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• 4 A 35-year-old woman comes to the physician for a periodic health maintenance examination. She has no physical complaints, but she
• 5 is concerned that she hardly ever feels happy. She says that she has basically been "down" for at least 3 years. She rarely goes out
• 6 with friends, and basically keeps to herself at work. She states that her work performance has been stable, but she usually feels tired
• 7 and "blah." Which of the following is the most likely diagnosis?
• 8
• 9
0 A. Antisocial personality disorder
• 10
• 1i O B. Cyclothymic disorder
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• 13
oc. Depression

(I 0 0 . Dysthymic disorder

0 E. Schizoaffective disorder

0 F. Seasonal affective disorder

Explanation Rel<aps & Refs 6 Help 0 My Questions

The correct answer is D. This patient has dysthymia, which is a milder, chronic form of 53% of students got this correct.
depression. The diagnosis requires 2 years of a depressed mood. II may be associated with
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changes in appetite, sleep, and concentration, and with fatigue and hopelessness. Treatment is medFeedback@kaplan .com
psychotherapy or antidepressant therapy.
Please include QI O Q0754m
Antisocial personality disorder (choice A) is a pattern of behavior that is characterized by a
complete disregard to the rules of society. These individuals lie, steal, and endanger others.

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• 3
Rel<aps & Refs
• 4
• 5
The correct answer is D. This patient has dysthymia, which is a milder, chron ic form of 53% of students got th is correct
• 6
depression. The diagnosis requires 2 years of a depressed mood. It may be associated with
• 7 Send us your feedback at:
changes in appetite, sleep, and concentration, and with fatigue and hopelessness. Treatment is medFeedback@kaplan.com
• 8
psychotherapy or antidepressant therapy.
• 9 Please include QID Q0754m

• 10 Antisocial personality disorder (choice A) is a pattern of behavior that is characterized by a

complete disregard to the rules of society. These individuals lie, steal, and endanger others.
• 1i
They rarely feel remorse, and typically end up in prison.
• 12
• 13 Cyclothymic disorder (choice B) is characterized by recurrent and chronic episodes of
hypomania and depressed mood. It is a less severe form of bipolar disease and has r a duration
of at least 2 years.

Depression (choice C) is characterized by a depressed mood and changes in sleep, energy,

concentration, and appetite. Other findings are guilt, hopelessness, anhedonia, and
psychomotor agitation or retardation. A major depressive episode requires 5 or more of these
symptoms for at least 2 weeks. There is severe distress and functional impairment. It is more
severe than dysthymia.

Patients with schizoaffective disorder {choice E) have psychotic episodes with a mood
disturbance. This patient is not experienc ing psychotic episodes.

Seasonal affective disorder (choice F) is a type of depression that tends to occur (and recur)
as the days grow shorter in the fall and winter.

Reviewed on 12/10112

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•
• 4 An 8-year-old boy is brought to the office by his mother and father. The mother describes several episodes of sleep troubles over the

5 past few weeks. Her son has awakened screaming within a few hours of going to sleep, sits upright in bed, and looks frightened. She
•
has tried to comfort him at these times, but he does not respond to her questions and instead cries. The episodes last approximately
• 6
20 minutes. In the morning, he wakes up very tired and says that he doesn't remember the episode. Both parents do not believe him,
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which is one of the reasons they have brought him in today. A physical examination and baseline blood work are within normal limits.
• 8
Which of the following is the most likely diagnosis?
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• 10
• 1i 0 A. Narcolepsy
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0 B. Nightmare disorder

0 C. Seizure disorder
(I 0 D. Sleep terror d1sorder
0 E. Sleepwalking disorder

Explanation Rel<aps & Refs G Help Q My Questions

The correct answer is D. Sleep terrors are commonly seen in children aged 2 to 6 years, but 64% of students got this correct
they can be seen in older children also. They are recurrent episodes of abrupt awakening from
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sleep that usually occur during the first third of the night and often start with a scream. medFeedback@kaplan.com
Individuals are usually unresponsive to the efforts of others to comfort them during the episode
Please include QID m001044
and do not recall the episode in the morning. Treatment is supportive, and most children outgrow
these episodes over time.

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ReKaps & Refs
• 4
• 5
The correct answer is D. Sleep terrors are commonly seen in children aged 2 to 6 years, but 64% of students got th is correct
• 6
they can be seen in older children also. They are recurrent episodes of abrupt awakening from
• 7 Send us your feedback at:
sleep that usually occur during the first third of the night and often start with a scream. medFeedback@kaplan.com
• 8
Individuals are usually unresponsive to the efforts of others to comfort them during the episode
• 9 and do not recall the episode in the morning. Treatment is supportive, and most children outgrow Please include QID m001044
• 10 these episodes over time.
• 1i
Narcolepsy (choice A) is defined as "attacks" of sleep during the day that occur daily for at
• 12
least 3 months and the presence of one or both of the following: cataplexy (brief sudden
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episodes of loss of tone), or intrusions of elements of rapid eye movement sleep, such as
hypnopompic or hypnagogic hallucinations, or sleep paralysis into the transition between sleep
and wakefulness.

Nightmare disorder (choice B) is defined as repeated awakening from sleep with detailed
recall of frightening dreams, usually invoMng a threat to one's safety. The awakenings generally
occur during the second half of the night On awakening, individuals become alert and oriented.

Seizure disorders (choice C) can be accompanied by sleep disturbances, but this

presentation is more consistent with a diagnosis of a sleep terror disorder.

Sleepwalking disorder (choice E) is defined as repeated episodes of awakening and walking

about, usually occurring during the first third of the night While awake, the individual is
unresponsive to the efforts of others to communicate with him or her and cannot usually be
awakened. The individual usually has amnesia for the episode.

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A woman with severe depression attends weekly psychotherapy sessions and takes fluoxetine. She is doing well and is beginning to
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feel better, but she becomes furious at her psychiatrist, who is about to leave for vacation and is not willing to reveal where he is
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going. She angrily says that he is just like her father, who always had his own "own life" outside the family. Which of the following best
• 6
describes this patient's reaction?
• 7
• 8
• 9 0 A. Acting out
• 10
0 B. Countertransference
• 11
• 12 0 C. Identification
• 13
0 D. Projection
(I 0 E. Transference

Explanation ReKaps & Refs G Help Q My Questions

The correct answer is E. Transfe rence is defined by psychoanalysts as a patient's 70% of students got this correct.
unconscious feelings and behavior toward the analyst that are based on infantile wishes the
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patient has toward parental paras. medFeedback@kaplan.com
Acting out (choice A) is a defense mechanism by which a person expresses an unconscious Please include QID Q0073m
wish or impulse through action in order to avoid being consciously aware of the accompanying
effect. Giving in to an impulsive act relieves the tension and brings immediate gratification.

Countertransference (choice B) encompasses a spectrum of analyst's reactions to the patient

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Item: 3 of 13 <J C> il , . ~
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0 C. Identification
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• 5 0 D. Projection
• 6
f) 0 E. Transference
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10
Explanation ReKaps & Refs 6 Help Q My Questions
•
• 11
The correct answer is E. Transference is defined by psychoanalysts as a patient's 70% of students got this correct.
• 12
unconscious feelings and behavior toward the analyst that are based on infantile wishes the
• 13 Send us your feedback at:
patient has toward parental paras. medFeedback@kaplan.com

Acting out (choice A) is a defense mechanism by which a person expresses an unconscious Please include QID Q0073m
wish or impulse through action in order to avoid being consciously aware of the accompanying
effect. Giving in to an impulsive act relieves the tension and brings immediate gratification.

Countertransference (choice B) encompasses a spectrum of analyst's reactions to the patient

that are unconscious and based on personal conflicts of which the analyst may not be aware.

Identification (choice C) is a defense mechanism and also plays a role in normal ego
development. Identification with a loved object serves as a defense against pain or anxiety
related to threatened or real loss or to separation from the object.

Projection (choice D) is a defense mechanism by which inner unacceptable impulses are

perceived as though they were coming from the outside and are ascribed to someone else.

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An 8-year-old girl is admitted to the neurologic unit for the evaluation of fa inting spells that have been occurring for the past few
weeks. The neurologist wants to have the patient monitored in the hospital for the possibility of a seizure disorder. The physical
• 5
examination is unremarkable. The blood work is significant for mildly low serum glucose. After 2 days of video-EEG monitoring, no
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seizures are found , no fainting spells have occurred, and the neurologist comes by to order the discharge. The girl's mother is very
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upset and insists on a more extensive workup in the hospital to make sure that nothing is wrong with her child. She threatens to call the
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hospital legal department if she does not get her way. What is the most likely diagnosis?
• 9
• 10
• 11 0 A. Factitious disorder
• 12
0 B. Hypoglycemia
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0 C. Malingering
fl 0 0 . Munchhausen by proxy
0 E. MOnchhausen syndrome

0 F. Undiagnosed seizure disorder

Explanation ReKaps & Refs G Help Q My Questions

The correct answer is D. MUnchhausen by proxy occurs when a caretaker deliberately 61 % of students got this correct.
exaggerates, fabricates, or induces a physical or psychologic health problem in others. The
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primary purpose of this behavior is to gain some form of internal gratification, such as attention,
medFeedback@kaplan.com
for the parent or caretaker. Situations that should raise the suspicion of MOnchhausen by proxy
include a difference between reported history and what is found on physical examination or in Please include QID m001051

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• 1
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• 3

The correct answer is D. MOnchhausen by proxy occurs when a caretaker deliberately 61 % of students got this correct
• 5
exaggerates, fabricates, or induces a physical or psychologic health problem in others. The
• 6 Send us your feedback a t:
primary purpose of this behavior is to gain some form of internal gratification, such as attention,
• 7 medFeedback@kaplan.com
for the parent or caretaker. Situations that should raise the suspicion of MOnchhausen by proxy
• 8 Please include QID mOOlOSl
include a difference between reported history and what is found on physical examination or in
• 9
laboratory studies, a medical problem that does not respond to treatment as expected, and
• 10 symptoms that worsen in the presence of the perpetrator and improve in their absence.
• 11 MOnchhausen by proxy parents/gaurdians are usually (but not always) mothers and usually
• 12 present as normal, concerned, and good caretakers. They often have extensive healthcare
• 13 knowledge.

Factitious disorder (choice A) is the intentional production or feigning of physical or

psychologic symptoms because the individual values the sick role. This would be the case if the
mother was feigning her own symptoms and asking for her own treatment

Although this young girl presents with mildly low serum glucose, hypoglycemia (choice B)
does not explain the complete picture, including the mother's reaction to her daughter's care
and her insistence on a larger, more extensive workup

Malingering (choice C) is defined as the intentional production or feigning of physical or

psychologic symptoms with the motivation of external incentives, including avoiding work,
monetary gain, or obtaining drugs.

MOnchhausen syndrome (choice E) occurs when a person induces physical symptoms on

oneself to get medical attention, and in this case it would be true if the mother induced the
fainting spells on herself, not on her daughter.

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for the parent or caretaker. Situations that should raise the suspicion of MOnchhausen by proxy
include a difference between reported history and what is found on physical examination or in Please include QID m00 1051
• 5
laboratory studies, a medical problem that does not respond to treatment as expected, and
• 6
symptoms that worsen in the presence of the perpetrator and improve in their absence.
• 7
MOnchhausen by proxy parents/gaurdians are usually (but not always) mothers and usually
• 8 present as nonnal, concerned, and good caretakers. They often have extensive healthcare
• 9 knowledge.
• 10
Factitious disorder (choice A} is the intentional production or feigning of physical or
• 11
psychologic symptoms because the indMdual values the sick role. This would be the case if the
• 12
mother was feigning her own symptoms and asking for her own treatment.
• 13
Although this young gil1 presents with mildly low serum glucose, hypoglycemia (choice B)
does not explain the complete picture, including the mother's reaction to her daughter's care
and her insistence on a larger, more extensive workup.

Malingering (choice C) is defined as the intentional production or feigning of physical or

psychologic symptoms with the motivation of external incentives, including avoiding work,
monetary gain, or obtaining drugs.

MOnchhausen syndrome (choice E) occurs when a person induces physical symptoms on

oneself to get medical attention, and in this case it would be true if the mother induced the
fa inting spells on herself, not on her daughter.

An undiagnosed seizure disorder (choice F) is highly unlikely, given the extensive neurologic
workup in the hospital. It also does not explain the mother's inappropriate behavior.

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A 74-year-old, right-handed man comes to see you in your office because of progressive gait dysfunction. He and his family report a
• 4
6- to 7-month history of gradually deteriorating, wide-based gait and increasing unsteadiness. He has gotten to the point of requiring
• 5
assistance while walking. His family also reports that he has had urinary "accidents" over the same time period. His past medical
• 6
history is significant for several episodes of genital herpes and one episode of meningitis as a child. He has had multiple sexual
• 7
partners. On examinalion he is awake and alert, but oriented only to person. Otherwise his examination is nonfocal, but when asked to
• 8
walk across the room he seems to be frozen to the spot on gait initiation, as if his feet were stuck to the floor. Which of the following
• 9
diagnostic tests would provide the most useful information regarding the patienrs diagnosis?
• 10
• 11
• 12 0 A. Brain MRI
• 13
0 B. RPR
0 C. Electroencephalogram
(I 0 0 . CT and lumbar puncture
0 E. Vitamin B12 level

Explanation Rel<aps & Refs G, Help Q My Questions

The correct answer is D. This patient has urinary incontinence, gait ataxia, and dementia, 56% of students got this correct
which is the classic triad of normal pressure hydrocephalus (NPH). NPH is caused by
Send us your feedback a t:
decreased resorption of cerebrospinal fluid (CSF) over the cerebral convexities. A history of
medFeedback@kaplan.com
previous meningitis or subarachnoid hemorrhage may be obtained in some patients. Diagnosis
Please include QID imq429m
can be made by seeing nonobstructive hydrocephalus on neuroimaging and obtaining a normal
,....rr- ----:- - ... ........... .............. •··-~-- .............. _... r"C" r ....................... ... L.. .......... ........... L. ... - - - - • "T'\... ...

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Item: 5 of 13 <J C> il , . ~
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• 4
• 5
• 6 Explanation ReKaps & Refs 6 Help 0 My Questions

• 7
• 8 The correct answer is D. This patient has urinary incontinence, gait ataxia, and dementia, 56% of students got this correct.
which is the classic triad of normal pressure hydrocephalus (NPH). NPH is caused by
• 9 Send us your feedback at:
decreased resorption of cerebrospinal fluid (CSF) over the cerebral convexities. A history of
• 10 medFeedback@kaplan.com
previous meningitis or subarachnoid hemorrhage may be obtained in some patients. Diagnosis
• 11 Please include QID imq429m
can be made by seeing nonobstructive hydrocephalus on neuroimaging and obtaining a normal
• 12
CSF opening pressure on lumbar puncture. CSF contents should also be normal. The
• 13
Miller-Fisher test is a method in which CSF is removed and the gait is re-evaluated .

A brain MRI (choice A) likely would not provide any additional diagnostic information in this
case.

RPR (choice B) is not useful because this patient presents with the classic triad of NPH. The
history of STD and sexual promiscuity are used as distractors.

In most patients with dementias, the electroencephalogram (choice C) is normal or diffusely

slowed, and the EEG findings alone cannot indicate whether a patient is demented, nor can
they distinguish between dementia and pseudodementia

Vitamin 612 (choice E) deficiency can present with cognitive and gait dysfunction and would
be worth checking in this patient Given the classical triad of NPH, however, 612 deficiency is
not likely to be the cause of this patient's problems.

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• 4 A 29-year-old woman comes to her new primary care physician requesting medication to help with her recent spells of anxiety and
• 5 depression. She wishes to be started on a medication that will not cause too much sedation. Examination of the patient's old records
reveal two previous hospitalizations for minor laceration repair on her left arm and treatment for accidental Tylenol overdose, for which

7 both times she was under close observation. She is otherwise healthy and does not smoke cigarettes or drink alcohol. She is not
•
currently taking any medication. Given this history, which of the following antidepressant medications would most likely be
• 8
contraindicated for this patient?
• 9
• 10
• 11 0 A. Buspirone
• 12
• 13 0 B. Fluoxetine
(I 0 C. Nortriptylme
0 D. Paroxetine

0 E. Sertraline

Explanation Rel<aps & Refs G Help Q My Questions

The correct answer is C. Nortriptyline is a tricycl ic antidepressant that is lethal in overdose 41% of students got this correct.
and is the leading cause of overdose-related deaths in the psychiatric population. Overdose is
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associated with prolongation of the QT interval, leading to cardiac arrhythmia and death. Given medFeedback@kaplan.com
this patient's history of previous suicide attempts, a tricyclic antidepressant would be
Please include QID Q016lm
contraindicated.

Busoirone (c hoice Al is used in patients with aeneral anxietv disorder (GAOl. which is

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Item: 6 of 13 <J C> il , . ~
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• 4 0 0 C. Nortriptyline
• 5
0 D. Paroxetine

• 7 0 E. Sertraline
• 8
• 9
• 10 Explanation ReKaps & Refs @ Help Q My Questions
• 11
• 12 The correct answer is C. Nortriptyline is a tricyclic antidepressant that is lethal in overdose 41% of students got this correct.

• 13 and is the leading cause of overdose-related deaths in the psychiatric population. Overdose is
Send us your feedback at:
associated with prolongation of the QT interval, leading to cardiac arrhythmia and death. Given medFeedback@kaplan.com
this patient's history of previous suicide attempts, a tricyclic antidepressant would be
Please include QID Q0 161m
contraindicated.

Buspirone (choice A} is used in patients with general anxiety disorder (GAD), which is
characterized by excessive, poorly controlled anxiety about life circumstances that lasts for at
least 6 months or more. Mhough it is not yet indicated in this patient, there are no
contraindications for its use in this case.

Fluoxetine (choice B) , paroxetine (choice D) , and sertraline (choice E) are all selective
serotonergic reuptake inhibitors. These antidepressant medications are generally safe and
effective and are not lethal, except in extremely high doses.

Reviewed on 1216/12

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• 3
A 50-year-old woman with a past history of 2-month episodes of depressed mood, feelings of guilt and hopelessness, difficulty
• 4
sleeping, and a decreased appetite is currently on medication. She has been well for the past 2 years. She is complaining to her
• 5
psychiatrist about her decreased ability to reach orgasm. The patient should be asked for a history of which of the following?
• 6
• 7
• 8 0 A. Benzodiazepine use
• 9
0 B. History of alcohol
• 10
• 11 0 C. Sexual abuse in childhood
• 12
0 D. Smoking history
• 13
fl 0 E. SSRI use

Explanation ReKaps & Refs 0 Help Q My Questions

The correct answer is E. This patient must have been on a selective serotonin reuptake 84% of students got this correct.
inhibitor (SSRI) for the treatment of depression SSRis can cause decreased libido and
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difficulties reaching orgasm. medFeedback@kaplan. com

Benzodiazepine use (choice A) is not associated with sexual dysfunction. Moreover, there Please include QIO Q0624m
would be no reason for this patient to be on benzodiazepine. II is not an antidepressant.

Taking a history of alcoholism (choice B) is not appropriate at this lime. This patient had
depression, for wh ich she was prescribed an SSRI, a side effect of which is anorgasmia.

Sexual abuse in childhood (choice C) is associated with sexual dysfunctions such as

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• 4 0 C. Sexual abuse in childhood
• 5
0 D. Smoking history
• 6
• 7 (I 0 E. SSRI use
• 8
• 9
• 10 Explanation ReKaps & Refs 6 Help 0 My Questions
• 11
• 12 The correct answer is E. This patient must have been on a selective serotonin reuptake 84% of students got this correct.

• 13 inhibitor (SSRI) for the treatment of depression. SSRis can cause decreased libido and
Send us your feedback at:
difficulties reaching orgasm. medFeedback@kaplan.com

Benzodiazepine use (choice A) is not associated with sexual dysfunction. Moreover, there Please include QID Q0624m
would be no reason for this patient to be on benzodiazepine. It is not an antidepressant.

Taking a history of alcoholism (choice B) is not appropriate at this time. This patient had
depression, for which she was prescribed an SSRI, a side effect of which is anorgasmia.

Sexual abuse in childhood (choice C) is associated with sexual dysfunctions such as

vaginismus and aversion, not with anorgasmia

Smoking history (choice D) may play an indirect role in the gradual development of impotence,
but not with the development of anorgasmia.

Reviewed on 1216112

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• 3
A 68-year-old man is admitted to the hospital for delirium associated with a urinary tract infection. Upon adequate treatment of the
• 4
infection, the patient's mental status improves significantly, though he is noted to remain partly disoriented. He also has an impairment
• 5
in short-term memory, difficulties in naming simple objects, and impaired concentration. His family members confirm an 8-month
• 6 history of gradual progressive decline in cognitive abilities, wh ich they attribute to old age. However, the man is no longer able to
• 7 manage his finances and has gotten lost while driving to the grocery store on two occasions. Prior to his discharge from the hospital,
the nursing staff reports that he continues to drip urine, although his infection has resolved. The nurses also notice that he cannot walk
• 9 straight and requires assistance when walking. No other obvious signs or symptoms are present. Which of the following will confirm
• 10 the diagnosis of this patienrs condition?
• 11
• 12
• 13 0 A. Brain biopsy
(I 0 B. CT followed by LP

0 C. No test is required , as the diagnosis is clinical

0 D. Urine examination and culture

Explanation ReKaps & Refs 8 Help 0 My Questions

The correct answer is B. The patient has normal pressure hydrocephalus (NPH), identified by 73% of students got this correct.
the classic triad of gait disturbance (unsteady or shuffling gait), urinary incontinence, and
Send us your feedback at:
dementia. NPH is a potentially reversible cause of dementia. Enlargement of the ventricles is
medFeedback@kaplan.com
observed on CT; and increased cerebrospinal flu id pressure is observed on LP, so lumbar
Please include QID QOS6Sm
puncture is both diagnostic and therapeutic for NPH.

Rr.,in hinn~v lr.hnir.P. A l i~ Inn inv::l~M:! "'nrl wnnlcl viAicl nn hAnAfil

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Item: 8 of 13 <J C> il , . ~
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• 3
• 4
0 A. Brain biopsy
• 5
• 6 (j 0 B. CT followed by LP
• 7
0 C. No test is requ ired, as the diagnosis is clinical

• 9 0 D. Urine examination and culture

• 10
• 11
• 12 Explanation ReKaps & Refs G Help Q My Questions

• 13
The correct answer is B. The patient has normal pressure hydrocephalus (NPH), identified by 73% of students got this correct.
the classic triad of gait disturbance (unsteady or shuffling gait), urinary incontinence, and
Send us your feedback at:
dementia. NPH is a potentially reversible cause of dementia. Enlargement of the ventricles is
medF eedback@kaplan. com
observed on CT; and increased cerebrospinal fluid pressure is observed on LP, so lumbar
Please include QID Q0565m
puncture is both diagnostic and therapeutic for NPH.

Brain biopsy (choice A) is too invasive and would yield no benefit.

II is not true for NPH that no test is required because the diagnosis is clinical (choice C) . II is
true for Parkinson disease, which presents with bradykinesia, flat fac ies, resting tremor,
shuffling gait, etc.

Urine examination and culture (choice E) will be of no help. This patient's urinary incontinence
is because of the NPH, not a UTI

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• 3
• 4 A 72-year-old African American woman is being readied for discharge from the hospital 2 weeks after a stroke affecting her right

5 occipital cortex. A psychiatric consultation is called to evaluate the patient for depression, as she has had decreased appetite, some
•
crying spells, and severe insomnia. After determining that the patient is not suffering from delirium, which of the following medications
• 6
would be most appropriate to treat her depressive symptoms?
• 7
• 8
• 9 0 A. Methylphenidate
• 10
• 11 0 B. Nortriptyline

• 12 0 C. Phenelzine
• 13
0 D. Sertraline

0 0 E. Trazodone

Explanation Rel<aps & Refs @ Help 0 My Questions

The correct answer is E. This patient has severe insomnia due to depression. Among the 68% of students got this correct.
answer choices, trazodone is the best choice since it causes significant sedation and is safe
Send us your feedback at:
after a stroke. Depression is one of the common symptoms in post-stroke patients. medFeedback@kaplan.com

In a patient with complications from a stroke, an SSRI such as sertraline (choice D ) has been Please include QIO Q0748m
demonstrated to be the safest and most effective medication for the treatment of clinical
depression. But since this patient has severe insomnia, trazodone is preferred over an SSRI.

Methylphenidate (choice A) is a stimulant medication that has the potential to increase heart
--·- ___, -·--- -&L. . . &;. · --- . . .... : .... · · · - · ·' - ' - - · '-- - _ _,__ __ _ ... _ _ _ _ __ _ ; _ ...__ - - - · . _ _ _ ... _ _ · ·· - - · ·· - - =-:··-·

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Item: 9 of 13 <J C> il , . ~
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• 3
• 4 0 D. Sertraline
• 5
• 6
fl 0 E. Trazodone

• 7
• 8
• 9
Explanation ReKaps & Refs 0 Help Q My Questions

• 10
The c orrect answer is E. This patient has severe insomnia due to depression. Among the 68% of students got this correcL
• 11
answer choices, trazodone is the best choice since it causes significant sedation and is safe
• 12 Send us your feedback at:
after a stroke. Depression is one of the common symptoms in post-stroke patients. medFeedback@kaplan.com
• 13
In a patient with complications from a stroke, an SSRI such as sertraline (choice D) has been Please include QID Q074Bm
demonstrated to be the safest and most effective medication for the treatment of clinical
depression. But since this patient has severe insomnia, trazodone is preferred over an SSRI.

Methylphenidate (choice A) is a stimulant medication that has the potential to increase heart
rate and sympathetic tone, which would not be advantageous in the post-cerebrovascular injury
period.

Nortriptyline (choice B ) is a tricyclic antidepressant that also causes sedation but has the
potential for producing cardiac arrhythmias and vascular compromise in overdose.

Phenelzine (choice C) is a monoamine oxidase inhibitor, which would be contraindicated in a

patient with a history of recent vascular injury because the ingestion of tyramine with an MAO
inhibitor could induce a hypertensive crisis.

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• 3
A 32-year-old single mother of two is brought to the hospital after overdosing on over-the-counter sleeping medication. In talking to a
• 4
psychiatrist she denies any prior psychiatric problems. She admits that she was laid off from work the day before and that
• 5
approximately 2 weeks ago she discovered that her ex-husband, who was providing child support, had committed fraud and had lost all
• 6
of his money. She has no other family and was in foster care and shellers until she was 18 years old. She fell desperate when she
• 7
realized that she didn't have any money to pay the rent and buy food for the children. That is when she went to the pharmacy and
• 8
bought the medication. She tearfully admits that she has been selfish and really hasn't thought of her children. She feels guilty now
• 9 about the attempt. She has no prior medical or psychiatric history. Which of the following is the most likely diagnosis?

• 11
• 12 0 A. Acute stress disorder
• 13
(I 0 B. AdJUStment disorder
0 C. Antisocial personality disorder
0 D. Brief psychotic disorder

0 E. Major depressive disorder

Explanation Rel<aps & Refs 8 Help 0 My Questions

The correct answer is B . Adjustment disorder is a set of behavioral or emotional symptoms 76% of students got this correct.
that develop as a response to an identifiable stressor within 3 months after exposure to the
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stressor (i.e., ex-husband lost all his money). The symptoms are significantly in excess of what medFeedback@kaplan.com
one would expect from the exposure and cause marked impairment in social functioning .
Please include QID s2s177m
Acute stress disorder (choice A) is anxiety produced by extraordinary life stress. The event is

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• 4
• 5 Explanation ReKaps & Refs 6 Help 0 My Questions

• 6
• 7 The correct answer is B . Adjustment disorder is a set of behavioral or emotional symptoms 76% of students got this correct.

• 8 that develop as a response to an identifiable stressor within 3 months after exposure to the
Send us your feedback at:
stressor (i.e., ex-husband lost all his money). The symptoms are significantly in excess of what
• 9 medFeedback@kaplan.com
one would expect from the exposure and cause marked impairment in social functioning.
Please include QID s2sl77m
• 11 Acute stress disorder (choice A) is anxiety produced by extraordinary life stress. The event is
• 12 relived in dreams and waking thoughts. The symptoms include re-experiencing, avoidance, and
• 13 hyperarousallasting less than a month.

Antisocial personality disorder (choice C) involves a pervasive pattern of violation of rights of

others by a person older than 15 years as indicated by failure to conform to social norms,
deceitfulness, impulsivity, irritability, disregard for the safety of others, and lack of remorse .

Brief psychotic disorder (choice D) requires one or more of the following to be present:
delusions, hallucinations, disorganized speech Duration of an episode is from 1 day to 1
month, and it is not caused by any other medical condition or substance abuse.

Major depressive disorder (choice E) involves the presence of depressed mood or anhedonia
for at least 2 weeks on a daily basis in the past month and additional symptoms of changes in
appetite, weight, sleep, energy, and concentration, together with the presence of guilt, suicidal
ideation, and changes in psychomotor activity. The symptoms are not caused by medical
condition or use of substances.

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• 2
• 3
A 45-year-old white woman comes to her primary care physician for her routine yearly examination. Her physician notices that she
• 4
has lost approximately 25 lbs over the past year. When asked about her weight loss, she states that she has not had much of an
• 5
appetite since her daughter left to go to college about 8 months ago. In describing this, she is somewhat tearful and complains of
• 6
loneliness, poor memory, decreased concentration, and feeling tired. Although she appears very sad, she denies feeling depressed
• 7
and states that she simply needs to become more socially active to distract herself from her worries, which keep her up at night. Her
• 8 physical examination is normal except for the noticeable weight loss. Her current weight is 1051b. Which of the following is the most
• 9 likely diagnosis?
• 10
• 1.1.
• 12 0 A. Adjustment disorder with depressive symptoms
• 13
0 B. Bereavement
0 C. Dependent personality disorder
0 D. Dysthymic disorder
f) 0 E. Major depresstve disorder

Explanation Rel<aps & Refs @ Help 0 My Questions

The correct answer is E. The probable diagnosis is major depressive disorder. In order to 25% of students got this correct.
meet the criteria for this disorder, the patient must have five or more symptoms during the same
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2-week period. This patient has several such symptoms: she appears sad (depressed affect),
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she has significant weight loss, she describes feeling fatigued, and she complains of poor
Please include QID Q0206m
concentration and inability to sleep. Other symptoms that she may be experiencing include:
r1iminic:.hot1 intoroc:.tc:. nr nlo~C:.11ro f~nhA<tnni~\ nc:.v,..hnmntnr ~nit~tinn nr rot~rr1"tinn foc.linnc:. nf

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• 4
• 5 The correct answer is E. The probable diagnosis is major depressive disorder. In order to 25% of students got this correct

• 6 meet the criteria for this disorder, the patient must have fwe or more symptoms during the same
Send us your feedback at:
• 7 2-week period. This patient has several such symptoms: she appears sad (depressed affect), medFeedback@kaplan.com
• 8 she has significant weight loss, she describes feeling fatigued , and she complains of poor
Please include QID Q0206m
• 9 concentration and inability to sleep. Other symptoms that she may be experiencing include:
diminished interests or pleasure (anhedonia), psychomotor agitation or retardation, feelings of
• 10
worthlessness or inappropriate guilt, and suicidal ideation.
• 1.1.
• 12 Adjustment disorder with depressive symptoms (choice A) is the diagnosis when the
• 13 development of significant symptoms of depression is in response to identifiable stressors within
3 months of the onset of the stressor. The stress-related disturbance does not meet criteria for
another specific Axis I disorder.

Bereavement (choice B) refers to the state of being deprived of someone by death, and it
refers to being in a state of mourning. Although the patient's daughter recently left for college,
the patient's symptoms cannot be accounted for by bereavement.

Dependent personality disorder (choice C) refers to a chronic and pervasive personality

structure in which the patient has an excessive need to be taken care of. This leads to
submissive and clinging behavior and fea rs of separation, beginning by early adulthood and
present in a variety of contexts. There is no evidence from this case that the patient has such
personality features.

Dysthymic disorder (choice D) refers to a milder form of depression that lasts for at least 2
years (or at least 1 year in children and adolescents). Patients exhibit 2 or more depressive
symptoms. There is no evidence that this patienfs symptoms are chronic.

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• 1
• 2
• 3 A 32-year-old man is in twice-weekly insight-oriented psychotherapy with a psychiatrist. Recently, the patient has been exploring his
• 4 thoughts and feelings around his wife's complaint that he is too restricted and inhibited in their sexual activity. The patient admits that
• 5 he wishes to be more sexually available for his wife, but finds himself maintaining a restricted stance. Which of the following defense
• 6 mechanisms would best describe this patient's tendency in his sexual relationship with his wife?
• 7
• 8
• 9 0 A. Projection
• 10
8 0 B. React1on formallon
• 11
0 C. Sexualization
• 13 0 D. Somatization
0 E. Sublimation

Explanation ReKaps & Refs ~ Help 0 My Questions

The co rrect answer is B . Reaction formation , often seen in obsessional characters, is the 69% of students got this correct.
term for the defense mechanism in which an unacceptable impulse is transformed into its
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opposite. In this case, during insight-oriented psychotherapy the patient realizes his wish to be
medFeedback@kaplan. com
freer in his sexual relationship with his wife (an impulse which he finds unacceptable on some
level) but finds himself responding in the opposite way (maintaining a restricted stance). Please include QID Q0639m

Inhibition may also partly account for this man's difficulty, in that a renunciation is used to evade
anxiety arising out of impulses.

Projection (choice A) occurs when an unacceptable inner impulse is perceived and reacted to

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• 3 g
• 4 term for the defense mechanism in which an unacceptable impulse is transformed into its
• 5 Send us your feedback a t:
opposite. In this case, during insight-oriented psychotherapy the patient realizes his wish to be
medFeedback@kaplan.com
• 6 freer in his sexual relationship with his wife (an impulse which he finds unacceptable on some
• 7 Please include QID Q0639m
level) but finds himself responding in the opposite way (maintaining a restricted stance).
• 8 Inhibition may also partly account for this man's difficulty, in that a renunciation is used to evade
• 9 anxiety arising out of impulses.
• 10
Projection (choi ce A) occurs when an unacceptable inner impulse is perceived and reacted to
• 11
as though it was outside oneself. On the psychotic level, this takes the fonn of delusions and
hallucinations.
• 13
Sexualization (choice C) occurs when an object or function is endowed with sexual
significance that it did not previously have in order to ward off anxieties associated with
prohibited impulses.

Somatization (choice D) describes the defense mechanism that occurs when emotional
concerns are converted into bodily symptoms, and the person tends to react with somatic
manifestations. If the patient in this case had a tendency to use somatization, he might
unconsciously use physical symptoms to get rid of the anxiety around his conflicted sexual
thoughts.

Sublimation (choice E) is a mature defense mechanism that occurs when a socially

acceptable means of expressing an impulse replaces one that would be socially unacceptable.
Sublimation allows instincts to be channeled, rather than blocked or diverted. Feelings are
acknowledged, modified, and directed toward a significant object or goal, and modest
instinctual satisfaction occurs.

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• 2
• 3
An 18-year-old girl with no known past medical history comes to the university health center complaining of fatigue. She says that she
• 4 feels as if she has barely enough energy to finish her classwork, has been having tension headaches, and has been feeling somewhat
• 5 anxious about how these problems may affect her academic progress at her new school, to which she transferred last month. Physical
• 6 examination and laboratory studies, including complete blood count, thyroid studies, serum chemistries, and testing for
• 7 mononucleosis, are all within normal limits. When discussing the results of these studies she admits to feeling homesick, and states,
• 8 "I'm worried that I'm not good enough to make it here." Sleep and appetite are normal. Despite these problems, she has made many
• 9 friends and goes out most weekends. She does not drink or use any illicit drugs. Which of the following is the most likely diagnosis?
• 10
• 11
• 12 fl 0 A. Adjustment disorder
• 13 0 B. Bipolar disorder
0 C. Generalized anxiety disorder
0 D. Major depressive disorder
0 E. Panic disorder

Explanation Rel<aps & Refs 0 Help 0 My Questions

The correct answer is A. The patient is experienc ing a difficulty adjusting to life in college that 40% of students got this correct.
is manifested by feelings of sadness and mental and physical symptoms of anxiety. The patient's
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symptoms include both depressive and anxiety- related symptoms that do not meet the criteria for
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a major depression or anxiety diagnosis such as panic disorder or generalized anxiety disorder.
Please include QID Q1008m
The criteria for the diagnosis of adjustment disorder are:

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• 4 The correct answer is A. The patient is experiencing a difficulty adjusting to life in college that 40% of students got this correct.
• 5 is manifested by feelings of sadness and mental and physical symptoms of anxiety. The patient's
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• 6 symptoms include both depressive and anxiety-related symptoms that do not meet the criteria for
medFeedback@kaplan.com
• 7 a major depression or anxiety diagnosis such as panic disorder or generalized anxiety disorder.
Please include QID QlOOSm
• 8
The criteria for the diagnosis of adjustment disorder are:
• 9
• 10 • presence of an identifiable psychosocial stressor or stressors
• 11 • maladaptive reaction to the stressor(s)
• 12 • a time frame of within 3 months after onset of the stressor(s)
• symptoms that do not meet the criteria of any other psychiatric disorder
• 13
This patient has no past or present history to indicate a history of mania or hypomania.
Therefore, bipolar disorder (choice B) is incorrect.

The patient has symptoms that can be seen in generalized anxiety disorder (choice C) , such
as tension headaches. However, the chronicity of symptoms and a history of constant anxiety,
poor concentration, and insomnia are not suggestive of a diagnosis of generalized anxiety
disorder.

The patient's symptoms do not include neuro-vegetative symptoms or such severity of

depressive symptoms as to warrant a diagnosis of major depressive disorder. Therefore, major
depressive disorder (choice D) is incorrect.

The clinical vignette gives no history to suggest a problem with recurrent panic attacks.
Therefore, a diagnosis of panic disorder (choice E) is incorrect.

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