36 CASE FILES: PSYCHIATRY

COMPREHENSION QUESTIONS

II.1 A 43-year-old woman with a long history of schizophrenia complains of

a loss of night vision. Which of the following medications is most likely
responsible?
A. Haloperidol
B. Thioridazine
C. Risperidone
D. Chlorpromazine
E. Clozapine
II.2 A 28-year-old man with a history of a psychiatric admission 6 months previ-
ously is seen in the emergency department with a painful erection, which he
says has persisted for 18 hours. Which of the following is the best next step?
A. Epinephrine injection into the penis
B. Follow-up in 12 hours
C. Oral benzodiazepines and careful observation
D. Magnetic resonance imaging of the lumbosacral spine
E. IM injection of benztropine
II.3 A 57-year-old woman complains of feeling dizzy when she gets up in the
morning and when standing. She takes imipramine each evening for depres-
sion. Which of the following is the most likely cause of her symptoms?
A. Hypovolemia from decreased appetite
B. Hypoglycemia
C. Diabetes insipidus
D. Alpha-adrenergic blockade
E. Dehydration
II.4 A 34-year-old man is seen in the emergency department with a headache,
dizziness, and blood pressure of 210/150 mm Hg. He has no medical prob-
lems, states that he feels fine, and says that last night he even had a nice meal
with wine. Which of the following medications is he most likely taking?
A. Bupropion
B. Lithium
C. Amitriptyline
D. Phenelzine
E. Fluoxetine

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 SECTION II: PSYCHIATRIC THERAPEUTICS 37

II.5 A 22-year-old college student with a history of depression is being treated

with sertraline. He enjoys drinking beer on the weekends. Which of the fol-
lowing side effects is most likely to occur?
A. Alcohol potentiation
B. Alcohol withdrawal
C. Sexual dysfunction
D. Diabetes insipidus
E. Serotonin syndrome
II.6 Because of the side effects of his original antidepressant, the college student
in Question II.5 is switched to another agent. He comes to the emergency
department several days later with muscle spasms, confusion, fever, tachycar-
dia, and hypertension. Which of the following is the most likely cause?
A. Serotonin syndrome
B. Cocaine intoxication
C. Meningitis
D. Alcohol withdrawal (delirium tremens)
E. Neuroleptic malignant syndrome (NMS)
II.7 A 17-year-old adolescent suffers from bulimia nervosa and is very depressed.
She is also suffering from insomnia and apathy. Which of the following medi-
cations should be avoided?
A. Fluoxetine
B. Trazodone
C. Imipramine
D. Bupropion
E. Amitriptyline
II.8 A 32-year-old woman has been taking medication (the name of which she
does not remember) for her psychiatric condition. She complains of excessive
thirst and urinating “all the time.” Which of the following is the most likely
diagnosis?
A. Bipolar disorder
B. Major depression
C. Panic disorder
D. Schizophrenia
E. Social phobia

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 38 CASE FILES: PSYCHIATRY

II.9 A 29-year-old man who “hears voices” at times complains of fever and chills.
His temperature is 102°F (38.9°C) with no findings of infection. His white
blood cell count is 800 cells/mm3. Which of the following medications is
most likely responsible?
A. Haloperidol
B. Risperidone
C. Clozapine
D. Thioridazine
E. Fluphenazine
II.10 A 38-year-old woman is admitted to the hospital for an elective hysterectomy.
On hospital day 3, she experiences auditory and visual hallucinations, has
tremors, and is agitated. Which of the following would be the best therapy?
A. Selective serotonin reuptake inhibitor (SSRI)
B. Propranolol
C. Imipramine
D. Benzodiazepine
E. Atypical antipsychotic
II.11 A 35-year-old African American woman with bipolar disorder delivers a
male newborn who has spina bifida. Which of the following is the most
likely etiology?
A. Advanced maternal age
B. Mood-stabilizing medication
C. Folate excess
D. Ethnicity
E. Maternal malnutrition
II.12 A 39-year-old man tries to commit suicide by taking an overdose of amitrip-
tyline tablets. He is rushed to the emergency room where resuscitation is
attempted but fails. Which of the following is most likely to be noted during
the attempted resuscitation or the autopsy?
A. Massive coronary artery occlusion
B. Aortic valve stenosis
C. Electrocardiographic conduction abnormalities
D. Cardiac tamponade
E. Massive pulmonary embolism

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 SECTION II: PSYCHIATRIC THERAPEUTICS 39

Match the following therapies (A-F) to the clinical scenarios listed

(Questions II.13-II.18).
A. Benztropine
B. Propranolol
C. Amantadine
D. Dantrolene
E. Dialysis
F. Flumazenil
G. Methylphenidate
H. Modafinil
II.13 A 25-year-old man with bipolar disorder took too many pills, had two sei-
zures, and is now in a coma.
II.14 A 38-year-old schizophrenic woman feels restless and cannot sit still; her
physician states that this behavior is caused by her medication.
II.15 A 32-year-old woman with panic disorder and anxiety took an overdose of
diazepam and is taken to the emergency department with somnolence and
hypoventilation.
II.16 A 30-year-old man being treated for schizophrenia complains of tremor and
a slow gait.
II.17 A 14-year-old adolescent boy being treated for ADHD complains of not
being able to go to sleep at night.
II.18 A 56-year-old man on the night shift complains of excessive daytime
sleepiness.

ANSWERS
II.1 B. High doses of thioridazine are associated with irreversible pigmentation
of the retina, leading initially to symptoms of night vision difficulty and ulti-
mately to blindness.
II.2 A. This priapism is most likely caused by trazodone. One treatment is epi-
nephrine injected into the corpus of the penis.
II.3 D. The mechanism for orthostatic hypotension caused by tricyclic/hetero-
cyclic antidepressants is alpha-adrenergic blockade.
II.4 D. This patient probably experienced a hypertensive crisis induced by an
interaction between the wine and phenelzine, an MAOI.
II.5 C. Sexual dysfunction is a very common side effect of SSRI medications.
II.6 A. This patient was likely switched from an SSRI, sertraline, to an MAOI,
such as phenelzine. Because both agents increase serotonin levels, 5 weeks
should elapse between discontinuation of one medication and initiation of
the other. The danger is very serious serotonin syndrome, which has features
similar to those of NMS.

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 40 CASE FILES: PSYCHIATRY

II.7 D. Seizure disorders and eating disorders are contraindications for bupro-
pion because of its possible lowering of the seizure threshold and its anorec-
tic effects.
II.8 A. This patient has symptoms of diabetes insipidus, a side effect of lithium
used in the treatment of bipolar disease.
II.9 C. This individual has neutropenic fever as a result of agranulocytosis, a side
effect of the atypical antipsychotic agent clozapine.
II.10 D. This woman is probably experiencing either alcohol or benzodiazepine
withdrawal; in either case, benzodiazepines would be the treatment.
II.11 B. This woman was likely taking valproic acid, a mood stabilizer used in
treating bipolar disorder, which increases the risk for teratogenicity (eg, a
neural tube defect).
II.12 C. A tricyclic antidepressant overdose can lead to increased QT intervals and
ultimately to cardiac dysrhythmias.
II.13 E. Dialysis is used to treat lithium toxicity when it is severe and life threaten-
ing, such as causing seizures or coma.
II.14 B. Akathisia (restlessness) can be treated with propranolol.
II.15 F. A benzodiazepine overdose can be treated with flumazenil, which is a
benzodiazepine antagonist.
II.16 C. The parkinsonian-like symptoms of neuroleptic agents are treated with
amantadine or levodopa.
II.17 G. Methylphenidate, a common treatment for ADHD, has a common side
effect—insomnia. For this reason, it is rarely prescribed for patients to take
in the late afternoon or early evening.
II.18 H. Modafinil may be used for the treatment of excessive daytime sleepiness
in shift workers.

CLINICAL PEARLS
»» In general, the side effects of tricyclic/heterocyclic antidepressant agents
are anticholinergic effects, sedation, orthostatic hypotension, cardiac
rhythm disturbances, and weight gain.
»» Usually, tricyclic/heterocyclic antidepressants do not cause EPS. An
exception to this rule is amoxapine, which is a metabolite of the antipsy-
chotic loxapine.
»» Selective serotonin reuptake inhibitors are the most commonly used
medications for depression but should not be used in conjunction with
MAOIs. One medication should be discontinued for at least 5 weeks
before the other is initiated to avoid serotonin syndrome.
»» Serotonin syndrome is characterized by (in order of appearance) diar-
rhea, restlessness, extreme agitation, hyperreflexia, autonomic insta-
bility, myoclonus, seizures, hyperthermia, rigidity, delirium, coma, and
death.

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 SECTION II: PSYCHIATRIC THERAPEUTICS 41

»» The most common side effects of SSRIs are gastrointestinal disturbance

and sexual dysfunction.
»» Individuals taking MAOIs should avoid aged cheese, red wine, liver, and
smoked foods (tyramine) or an acute hypertensive crisis can ensue.
»» Trazodone can lead to priapism; a prolonged painful erection that is tra-
zodone induced is considered an emergency and is treated with an intra-
corporeal injection of epinephrine or drainage of blood from the penis.
»» Bupropion is used for smoking cessation but must be avoided in patients
with eating disorders or seizures.
»» Lithium has numerous side effects, including tremor, polyuria/diabe-
tes insipidus, acne, hypothyroidism, cardiac dysrhythmias, weight gain,
edema, and leukocytosis.
»» Lithium is cleared through the kidneys and must be used with caution in
older patients and in those with renal insufficiency.
»» Valproic acid can be teratogenic and must not be used in women of
childbearing age (switch to another mood stabilizer).
»» Antipsychotic agents produce many adverse effects, including EPS, seda-
tion, and orthostatic hypotension.
»» Neuroleptic malignant syndrome can be caused at any time by an anti-
psychotic agent. It typically includes a movement disorder (muscle rigid-
ity, dystonia, agitation) and autonomic symptoms (high fever, sweating,
tachycardia, hypertension). White blood cell (WBC) and creatine phos-
phokinase (CPK) levels are both typically high.
»» Clozapine can cause fatal agranulocytosis, and thus frequent leukocyte-
count monitoring is mandatory.
»» Benzodiazepine withdrawal resembles alcohol withdrawal and can be
fatal.

REFERENCES
Hales RE, Yudofsky SC, Roberts LW. The American Psychiatric Publishing Textbook of Psychiatry. 6th ed.
Washington, DC: American Psychiatric Publishing; 2014.
Higgins ES, George MS. The Neuroscience of Clinical Psychiatry. 2nd ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2013.
Stern TA, Herman JB, Gorrindo T. Massachusetts General Hospital Psychiatry. 3rd ed. Boston, MA:
MGH Psychiatry Academy Publishing; 2012.

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