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AMC RECALL PAPERS: PSYCHIATRY

2005
While shopping in a shopping centre a lady found that everything is moving around her. At
that time she felt herself separated from this world. These happened several occasions in
the past. In one occasion this happened when she was talking with her relatives and
uttered some un-recognizable words, which could not understand by them. WOF is next
appropriate step--a) talk to her relatives
b) CT scan of head
c) MRI of Brain
d) Measure BP in lying and standing position
e) EEG
Breaks of interpolations in the train of thought, resulting in incoherence or irrelevant speech
or neologisms (Unrecognizable words).
Blood tests Routine: U + E, LFT, calcium, FBC, glucose. When suggested by
history/examination: VDRLs, TFTs, PTH, cortisol, tumour markers.
Radiological
CT or MRI only in the presence of suggested neurological abnormality or persistent cognitive
impairment.
CXR only where examination/history suggests comorbid respiratory/cardiovascular
condition.
Urine Urine drugs screen (particularly stimulants and cannabis), microscopy and culture
(where history suggestive).
Other
EEG rarely necessary unless history of seizure or symptoms suggest TLE.
Special investigations 24hr collection for cortisol (if Cushing's disease suggested from
history/examination). 24hr catecholamine/5-HIAA collection for suspected
phaeochromocytoma/carcinoid syndrome respectively.

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Best possible answer is to asking the relatives and evaluates other symptoms and history of
Scizophrenia.

A young man was found by his parents agitated at night in his room. They told you that
their son did not sleep for last 3 nights and also has not taken food for 3 days. He used
cannabis and he is on lithium. The young man told you that he was complying with
lithium prescribe by the doctor. O/E you found tremor, agitation, arrhythmias and ataxia.
WOF is your next step---a) Electrolyte estimation
b) Urine test
c) Serum lithium level estimation
Toxicity Management of lithium:
Keeping plasma level below 1.5mEq/L is the major aim. Dehydration and hyponatremia can
aggravate the toxic symptoms. Tremors in therapeutic dosages respond further by
decreasing the dosage. Dividing the dose or slow release preparations is also helpful. See
p.95 Kaplan.
There are no withdrawal symptoms of Cannabis. See p.61 Kaplan and topic Cannabis and
Marijuana.

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About Core group to help alcoholics and addicts WOF is correct--- (Alcohol Anonymus).
a) Ask opinion and help from non-professionals
b) Co-operation and skill should be increased among members of the group.

Alcoholics anonymous (AA)

Alcoholics Anonymous (AA) is the best known and the most widespread of the voluntary
self-help organisations for problem drinkers. It was founded in 1935 in the USA by Bill
Wilson and Dr Bob Smith, themselves both problem drinkers. Currently there are -3000
groups in the UK and -88 000 groups worldwide. Associated organisations are Al-anon (for
relatives of problem drinkers); Al-Ateen (for teenage children of problem drinkers); and
Narcotics Anonymous (NA) (for addicts of illicit drugs).
AA views alcoholism as a lifelong, incurable disease whose symptoms can be arrested by
lifelong abstinence. Many other groups will use a variant of the AA model12-step
programme. AA is a useful and effective intervention in many problem drinkers and all
patients should be informed about AA and encouraged to consider attendance.
An AA meeting will generally follow a standard routine: there will be 1020 people in each
group, only first names are used; a rotating chairman will introduce himself with my
name is X, and I am an alcoholic, then will read the AA preamble; a number of speakers
are called from the floor who give an account of their stories and recovery if possible,
leading to general discussion; the meeting ends with a prayer and is followed by informal
discussions and contact between new members and sponsors who may offer emotional and
practical support and perhaps a phone number. Open meetings are held where friends,
family and interested professionals can attend. Closed meetings are for AA members only
(Oxford Handbook p.521).

Schizophrenic patient has good prognosis if they had--a) Prolong onset

b) Affected symptom
c) Family history
d) If all the relative help in psychotherapy
Poor prognostic indicators: Poor premorbid adjustment; insidious onset; early onset in
childhood/adolescence; cognitive impairment; enlarged ventricles; symptoms fulfil more
restrictive criteria (e.g. DSM-IV).

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Good prognostic factors: Marked mood disturbance, especially elation, during initial
presentation; family history of affective disorder; female sex; living in a developing country
(Oxford Hand book p.197).
Prolong onset is a bad prognostic factor. Family history of affective disorder is good
prognostic indicator.

A 60-year-old with Wernickes encephalopathy present to casualty. On examination he is

found to be hypoglycaemic, has nystagmus, drinks 6gm alcohol per day. What is your
initial management?

a) Normal saline (0.9%) & dextrose solution

b) Glucagon iv
c) 50% dextrose iv
d) Intravenous thiamine followed by dextrose solution
e) Insuline & dextrose iv
Begin thiamine administration prior to treating with IV glucose solutions. Glucose infusions
may precipitate Wernicke disease or acute cardiovascular beriberi in a previously unaffected
patient or cause rapid worsening of an early form of the disease. See topic Warnickes
Encephalopathy.

A man is brought to the hospital by the police. How will you different whether he has
schizophrenia or delirium?
a) Fluctuating level of consciousness
b) Hallucinations
c) Confusion
d) Irritability
e) Agitation
Delirium: Disturbances in alertness, confusion and a short fluctuating course (p.43 Kaplan).

A 33-year-old lady comes to see you at your practice with complaints of insomnia. In the
last 2 months she has lost 2 Kgs. She has 3 children aged 10, 7& 4 yrs. In the past few
months she doesnt feel as close she used to, to her husband. She feels more distant from
him. They have been living in a rented house for the last 10 yrs or so and have not been
able to go for a holiday due to financial difficulties. She also complains of heavy periods.

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You did a FBC (full blood count), thyroid hormone levels, etc and all came out within
normal range. Physical examination was unremarkable. What is your next step in
management for this woman?***
a) Refer to gynecologist
b) Refer to psychiatrist
c) Refer to marriage counselor
d) Interview husband
e) Suggest that she takes a holiday
Depression: 2 months (>2 weeks symptoms) history of Insomnia (or Hypersomnia),
disturbed interpersonal relation (or separation or divorce) and female gender all suggests
depressive disorder. Refer to Psychiatrist is the best possible answer (p.17 Kaplan).

Which of the following is reversible inhibitor of monoamine oxidase?

a) Phenelzine
b) Flouxitine
c) Moclobemide
d) Mianserin
e) Tranylcyclomine
Meclobemide is a reversible MAOI (p.440 KDT).

Anorexia Nervosa will have all except?

a) Flight of ideas
b) Hypokalemia
c) Lanugo hair
d) Mainly seen in females
e) Depression
Answer is Flight of ideas (p.67 Kaplan).
The Mental health Act was introduced approximately 20 years ago. Of the following,
which is true?
a) It is the same in all States & Territories in Australia
b) It can save lives
c) It takes away the individuals freedom
d) It can be involuntarily imposed on everyone
e) It needs six people to impose it

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The parents of an adopted girl, who has been diagnosed as schizophrenic, have come to
consult you about their own biological child. They inquire about the possibility of
schizophrenia developing in their child. You should tell them?
a) Nil
b) Less than 2%
c) 10%
d) 50%
e) 75%
Answer is less than 2% see previous answers.

In which of the following conditions is there dejavu?

a) Occipital lobe tumour
b) Temporal lobe tumour
c) Frontal lobe tumour
d) Raised intracranial pressure
e) Korsakoffs syndrome

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Temporal lobe tumour is associated with De ja vu phenomena. Others are: migraine, simple
partial seizures and anxiety disorders. Functional disorders located in Parieto-temporal or
limbic area can cause depersonalization phenomena (p.373 Oxford handbook).
http://en.diagnosispro.com/differential_diagnosis-for/deja-vu-phenomenon/25037154.html

A young woman who is an accountant in a bank, after experiencing bank robbery in which
she was taken as a hostage for several hours. After 3-4 weeks she returned to work. What
should you expect on her?
a) Erotic memories of the event
b) A brief psychotic reaction
c) Visual Hallucination of the event
d) Irritability and outbursts of anger
e) Hypersomnia
Diagnosis: persistence of symptoms beyond 3 to 4 weeks PTSD.
2 or more persistent symptoms of increased psychological sensitivity and arousal (not
present before exposure to the stressor):
o
o
o
o
o

Difficulty falling or staying asleep

Irritability or outbursts of anger
Difficulty in concentrating
Hypervigilance
Exaggerated startle response (p.369 Oxford hand book).

A 36 years old engineer is due to give a speech soon and is reluctant to be exposed to
people. At the same time, he does not want to sign cheques or write anything in public.
He also thinks his boss is controlling what he is doing although he knows that there is no
motive for that because he is a very good worker. He realizes there is no reason to act this
way. Lately he has been avoiding going to the canteen with his mates and takes alcohol to
cope with the situation. What he is suffering from--a) Social phobia
b) Agoraphobia
c) Antisocial personality disorder
d) Panic disorder
e) Paranoid disorder

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Answer is Social phobia (see p.34 Kaplan and p.353 Oxford hand book).
What is incorrect concerning Gille de la Tourette syndrome?
a) Associated with tics
b) Patient is not distressed by the tics
c) Patient utters obscene words in less than 10% of cases

Tourette disorder: childhood onset of multiple motor and vocal tics. AD pattern, common
association with: ADHD 50% and OCD 40% cases. Coprolalia (use of obscene words) and
Vocal tics (throat clearing and barking) present in 10% of cases. High potency antipsychotics
Haloperido, Pimozide and Risperidone are TX of choice (p.16 Kaplan).

WOF is most likely associated with Bulimia?

a) Cachexia is not present
b) Induced vomiting is one of the key symptoms.
c) Hallucination not seen in bulimia
d) Sexual disorder not seen.
e) Disturbed body image overvalued idea about body image.
Depressive symptoms, substance abuse and impulsivity (Kleptomania) are the common
association. Most common co-morbid illness is borderline PD seen in more than 50% of
cases (p.68 Kaplan).

A person with hypnogogic hallucinations:

a) A feeling of insects crawling over the skin
b) Usually occurs at the beginning of sleep
c) Seen in schizophrenic patient
d) Seen in amphetamine entoxication
e) Seen with cannabis use
Answer is b.
Sleep-related hallucinations may occur at sleep onset (ie, hypnagogic) or awakening
(ie,hypnopompic) and are usually vivid (dreamlike) visual, auditory, or tactile in nature. See
p.78 Kaplan. Cataplexy is seen in about 70% of patients with narcolepsy, and its presence
with EDS strongly suggests the diagnosis of narcolepsy. See topic Narcolepsy.

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The classic tetrad consists of excessive daytime sleepiness (EDS), cataplexy, hypnagogic
hallucinations, and sleep paralysis. Children rarely manifest all 4 symptoms.

All the following can cause serotonin syndrome except?

a) Haloperidol ***
b) L Tryptophan
c) Clonazepam (benzodiazepine) ***
d) Moclobemide
e) Dextromethorphan
Serotonin syndrome: Oxford Hand book of Psychiatry p.870.
A rare but potentially fatal syndrome occurring in the context of initiation or dose increase
of a serotonergic agent, characterised by altered mental state, agitation, tremor, shivering,
diarrhoea, hyperreflexia, myoclonus, ataxia, and hyperthermia. Although SSRIs are
commonly linked to SS, many other drugs (e.g. amphetamines, MAOIs, TCAs, lithium) have
the potential of causing hyperserotonergic symptoms.

Defense mechanism has been classified as mature and immature. Which of the following
is an immature defense mechanism?
a) Projection
b) Sublimation
c) Identification
d) Dissociation

Defense mechanism:
They are psychological strategies used individuals (and by extension--groups of indidivuals
and even entire nations at times) to cope with reality and to maintain his/her self -image
intact.
Types of defense mechanism:
Level 1: Psychotic example: Danial, distortion and delusional projection.
Level 2: Immature example: Fantasy, projection, acting out behaviour, hypochondriasis and
passive aggressive behaviour.

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Level 3: Neurotic example: Displacement, dissociation, intellectualization, repression and
reaction formation.
Level 4: Mature example: Sublimation, suppression, humour, anticipation and altruism
http://drsanity.blogspot.com/2004/08/psychiatry-101-defense-mechanisms.html

Concrete interpretation of a proverb is characteristic of?

a) Dysthymia
b) Depersonalisation
c) Dementia
d) Delusional disorder
e) Depression

Bulimia nervosa
a) Hyperkalemia
b) Never occur in male
c) Associated with depression
Associated hypokalemia not hyperkalemia (p.68 Kaplan).

Contraindication to tricyclic therapy:

a) TCA
b) Alcohol
c) Lithium
d) MAOI
e) Antipsychotic drug
SSRIs and MAOIs: if they are used together can cause severe toxicity. Especially with MAOIs
can cause hypertensive crisis (p.444 KDT).

Halucination of miniature object or animal crawling occurs in

a) Schizophrenia

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b) Generalized Epilepsy
c) Delirium Tremens
Delirium Tremens: Acute confusional state secondary to alcohol withdrawal. A medical
emergency, requiring in patient medical care.

Occurs in 5% of episodes of withdrawal. Onset 1 to 7 days after the last drink with a
peak incidence at 48 hours.
Risk is increased by severe dependence, comorbid infection, and pre-existing liver
damage.
In addition to the features of uncomplicated withdrawal there is:
o Clouding of consciousness
o Disorientation
o Amnesia for recent events
o Marked psychomotor agitation
o Visual, auditory, and tactile hallucinations (characteristically of diminutive
people or animals eg. Lilliputian hallucinations).
o Marked fluctuations in severity hour by hour, usually worse at night.
o In severe cases: heavy sweating, fear, paranoid delusions, agitation,
suggestibility, raised temperature, sudden cardiovascular collapse.

Reported mortality of 5 to 10%. It is most risky when it develops unexpectedly and

its initial manifestations are misinterpreted (e.g. in a patient not known to be
alcohol-dependent developing symptoms post-operatively).
Differential diagnosis is hepatic encephalopathy, head injury, pneumonia, acute
psychotic illness, acute confusional state with other primary cause (p.517 Oxford
hand book).

Which of the following would give a better prognosis in Schizophrenia?

a) No precipitating features
b) Abrupt onset
c) Schizoid personality
d) Drug abuse
e) With affective symptoms
Poor prognostic indicators: Poor premorbid adjustment; insidious onset; early onset in
childhood/adolescence; cognitive impairment; enlarged ventricles; symptoms fulfil more
restrictive criteria (e.g. DSM-IV).
Good prognostic factors: Marked mood disturbance, especially elation, during initial
presentation; family history of affective disorder; female sex; living in a developing country
(Oxford Hand book p.197).

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A 21 yrs old young girl was brought to you by her parents. She tells you that her friends
are putting message in her brain trying to disturb her. Today when she has appeared in
the tutorial class they tried to lock her thought and tried to influence her. WOF is your
next step?
a) CT scan
b) X-ray
c) Olanzapine
d) OCP
e) Full blood test

WOF is formal thought disorder?

a) Thought echoing
b) Over inclusiveness
c) Delusions
d) Hallucinations
e) All of the above
The symptoms of schizophrenia are conventionally divided into positive (new symptoms or
signs) and negative (loss of a previous function):

Positive symptoms Delusions (commonly persecutory, thought interference, or

passivity) and hallucinations (usually auditory hallucinations commenting on the
subject or referring to them in third person e.g. he looks like a fool).
Negative symptoms Loss of the normal level of motivation or drive, loss of
awareness of socially appropriate behaviour, flattening of mood, and difficulty in
abstract thinking.
Other symptoms Formal thought disorder (a loss of the normal flow of thinking
usually shown in the subject's speech or writing), agitation, depression, poor
concentration, poor sleep, soft non-localising neurological signs, cognitive
impairment.

Formal thought disorders:

The sensation of alien thoughts being put into the subject's mind by some external
agency (thought insertion) or of their own thoughts being taken away (thought
withdrawal).
The sensation that the subject's thinking is no longer confined to their own mind, but
is instead shared by, or accessible to, others (thought broadcasting).

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Which of the following is correct regarding Baby Blues?

a) Is present in more than 50% of women
b) Postpartum blues lasts for at least 3 months
c) Predisposes to postpartum psychosis
d) She requires antipsychotic medication
e) She requires ECT

Postpartum Blues
Up to 85% ofwomen experience postpartum affective instability.
Rapidly fluctuating mood, tearfulness, irritability, and anxiety are common symptoms.
Symptoms peak on the fourth or fifth day after delivery and last for several days, but they
are generally time-limited and spontaneously remit within the first 2 postpartum weeks.
Symptoms do not interfere with a mother's ability to function and to care for her child.
Women with more severe symptoms or symptoms persisting longer than 2 weeks should
be screened for postpartum depression. See topic post partum psychosis.

A lonely man was found to be semiconscious and had bilateral six nerve palsy. Likely
diagnosis is--a) Alcoholic toxicity
b) Delirium tremen
c) Wemickes encephalopathy
Warnickes Encephalopathy:
Ocular abnormalities are the hallmarks of Wernicke encephalopathy. The oculomotor signs
are nystagmus, bilateral lateral rectus palsies, and conjugate gaze palsies reflecting cranial
nerve involvement of the oculomotor, abducens, and vestibular nuclei. Less frequently
noted are pupillary abnormalities such as sluggishly reactive pupils, ptosis, scotomata, and
anisocoria. The most common ocular abnormality is nystagmus, not complete
ophthalmoplegia. See topic Warnickes encephalopathy.

Panic disorder: Exept--a) is equally frequent in men & women

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b) Patient should avoid trigger factors
c) Starts in the 20s
Prevalence is 2% in general population. Male to female ratio is 1:2. Often present in the 3rd
decade of life. Severity symptoms may wax and wane. Associated with triggers or stressors.
Attacks last for few minutes. Commonly associated with agoraphobia, depression, GAD and
substance abuse (p.33 Kaplan).
A 28-years old male presents with grandiose beliefs of his own importance, over concern
for his appearance and extreme sensitivity to others criticism. He likewise has unrealistic
fantasies of unlimited success, capabilities and power. He also lacks empathy and uses
other people for his own benefit. This history is suggestive of what type of personality?
a) Schizotypal personality
b) Antisocial personality
c) Narcissistic personality
d) Borderline personality
Answer is Narcissistic PD (p.73 Kaplan).

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2006
WOF is not a feature of Bulimia Nervosa?
a. Amenorohea
b. Dental decay
c. Swollen tonsils
d. Hirsutism
Answer is hirsutism. Amenorrhoea is seen in bulimia as in anorexia nervosa. Dental erosion
is due to excessive purging. Swelling of parotid and submandibular glands is usually seen.
Tonsils are not mentioned in Oxford handbook. Hirsutism is not a feature of bulimia nervosa
but lenugo hairs can be seen (Oxford handbook p.385).

You are called to see a psychotic patient. On your arrival you see a tall built strong man
threatening with a riffle to shoot anyone who approaches him. You shoulda. Command him to surrender
b. Subdue the pt. and snap the riffle
c. Call the Police informing the situation
Calling the police is the best possible answer.

A 5 yr old boy brought by his parents, who is suffering from delayed development of
speech after a period of normal development. O/E he avoids eye contact. Parents give h/o
his unusual love for a toy Turtle.WOF is most probable Dxa. Autism
b. ADHD
c. Deafness
Answer is Autism. Profound failure to develop social relationship, delayed or absent
development of language, ritualistic compulsive behaviour and stereotypic movement are
the major characteristics of autism. It can develop later following normal development but
presents before the age of 3 years (p.12 Kaplan and AMQ book).

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Parents of a 6 yr old boy complain that their son is overactive, not cooperative enough
with other children at kindergarten, also of destructive behaviour. But when kept alone,
was found to be playing happily with toys and other children.WOF is correct- ***
a. It is a normal variant
b. ADHD
c. Autism
d. Poor parenting

WOF is true about ADHDa.Children has reading disability

b.The child responds to cognitive therapy
c.They responds very well to behavioural therapy
d.Commonly seen in pre-school age (5-7 yrs)
The accepted definition of ADHD is: a persistent pattern of inattention and/or
hyperactivity that is developmentally inappropriate. DSM-IV specifies that at least some
of the symptoms must have their onset before 7 yrs of age ( preschool age).
50% risk in MZ twins; 2x risk in siblings; CD and substance abuse in parents; genes 5, 6,
and 11 implicated.
ADHD is highly comorbid with 5080% of children having a comorbid disorder: specific
learning disorders (60%) but not reading disabilty; CD and ODD (40%); substance abuse;
depression; bipolar disorder2 (NB Overlap in symptomatology).
Approximately 20% develop dissocial personality traits; 1520% develop substance
misuse problems; high rates of suicidality, poor self-esteem, unemployment. ADHD
symptoms may persist into adulthood (2030% with full ADHD syndrome and -60% with 1
or more core symptoms). Impulsivity-hyperactivity remits early, while inattention often
persists. Studies show a pattern of psychopathology, cognition, and functioning in adults
similar to that in children and adolescents.3
Treatment with methylphenidate should only be initiated by C&A psychiatrists or
paediatricians with expertise in ADHD, but continued prescribing and monitoring may be
performed by GPs, under shared care arrangements with specialists.
A comprehensive treatment programme should involve advice and support to parents and
teachers, and could, but does not need to, include specific psychological treatment (such as
behavioural therapy). While this wider service is desirable, any shortfall in its provision
should not be used as a reason for delaying the appropriate use of medication (Oxford
handbook p.580).
Answer is commonly seen in preschool children.

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Ecstasy is very popular in Australia, commonly used by youngs; its properties are similar
toa.Cocaine
b.LSD
c.Methamphetamines
d.Diazepam
MDMA was first synthesized in Europe as a possible appetite suppressant but never caught
on because of its side effects. MDMA (3, 4-Methylenedioxymethamphetamine) is a
psychoactive synthetic drug possessing stimulant and hallucinogenic properties. The drug is
analogous to amphetamine and LSD in terms of its hallucinogenic properties. Ecstasy is a
slang or street name for MDMA. The drug has a tendency to alter perception of time and
distance.
http://www.addictionsearch.com/treatment_articles/article/ecstasy-addiction-abuse-andtreatment_31.html

Two sisters are living together in a house. Elder sister thinks that their neighbours are
trying to poison them with germs, so they have sealed their house. Younger sister believes
what her sister says. But she is normal when she is away from her elder sister. This is an
example ofa.de clerabault syndrome (Oct.-2004)
b.Induced delusion
c.Capgras syndrome
d.Folieodoux syndrome
Folie a Deux syndrome: Two people share the same delusion or delusional system and
support one another in this belief. They have an unusually close relationship. Temporal or
contextual evidence exists that indicates the delusion was induced in the passive member
by contact with the active partner. See topic shared psychotic disease.

A girl lost her father 6 months ago. She cannot get over it. She lost weight 10 kg. Most
important thing you need to enquire about her:
a. Eating pattern (May05)
b. Suicidal ideas
c. Menstrual regularity
Ans: Suicidal ideas

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Rx of ADHD: Dexa amphetamine

In minimental examination WOF indicate severe outcome for the patient:

a. Unable to recognize you
b. Unable to recall own identity
Ans: B.

After his baby sister was born, a 6 yr old boy began suck his thumb and wetting his bed,
behaviour he had grown out of long before. This is an instance ofa. Regression

132.In senile dementia WOF would be least likely to be lost(last to lose) :

a.Memory for faces
b.Memory fpr neighbourhood
c.Arithmetic memory
d.Language memory(vocabulary)
e.Short term memory

Psychodynamic therapy
a)Schizophrenia
b)Borderline personality disorder
c)OCD

Ans: Borderline personality disorder

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http://books.google.com.au/books?id=95weyTTuKvgC&pg=PA90&dq=psychodynamic+psyc
hotherapy+indication#v=onepage&q=&f=false

2007
What is the use of Psychodynamic psychotherapy in Australia?
A. Phobia
B. Anxiety disorder
C. schizophrenia
D. OCD
One of your colleague is taking anti psychotic medication for her own psychiatric illness. what
should be your advice to her??

A. she should refrain from seeing pt. until she is asymptomatic

B. she should take specialist review
C. you should contact the medical advisory board

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2009
A man could not keep his legs in one place. Always wanted to walk. There s a need to
move his leg when he watches a film?
A.Restless leg Syndrome
Ans: JM p.787.
Akathisia: Typical antipsychotics.

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USMLE World:
You are an internist making your rounds at a nursing home in the locality. You find the
nurses complaining about a 72-year-old male patient, who frequently masturbates in front
of them. He has been on treatment with olanzapine for years, for schizophrenia. He
frequently gets agitated and bangs his head against the wall. On interviewing him, you find
his thought process devoid of any hallucinations or delusions. He laughs inappropriately
when questioned during the interview. Based on his presentation, he falls into the category
of:
A. Schizophrenia, catatonic type
B. Schizophrenia, undifferentiated type
C. Schizophrenia, disorganized type
D. Schizophrenia, paranoid type
E. Schizophrenia, residual type
Explanation:
Schizophrenia is divided into subtypes based on the predominant symptoms that the patient
presents within the active phase of the illness. Schizophrenia of disorganized type is
characterized by disorganized behavior, disorganized speech and flat or inappropriate
affect. This subtype is devoid of any catatonic symptoms.
Choice A: Schizophrenia of catatonic type is characterized by bizarre posturing, muscular
rigidity, decreased reactivity to the environment and extreme negativism or mutism.
Choice B: Patients belonging to the subtype of schizophrenia of undifferentiated type have
symptoms that do not meet the criteria for catatonic, disorganized, or paranoid types.
Choice D: Schizophrenia of paranoid type is characterized by the presence of hallucinations
or delusions in the active phase of the illness. There are no disorganized or catatonic
symptoms.
Choice E: In patients belonging to the subtype of schizophrenia of residual type, delusions,
hallucinations, disorganized behavior or speech and catatonic symptoms are all absent.
Educational objective:
The different subtypes of schizophrenia are:
1). Catatonic, 2). Paranoid, 3). Undifferentiated, 4). Disorganized, and 5). Residual, classified
on the basis of the presenting symptoms.

Kevin, a 19-year-old white male, is brought to your clinic by his roommate. On questioning,
his roommate says that Kevin has been acting strange, since the past 10 days. He has been
sleeping about 2 hours/day and has been spending excessive amounts of money on buying
expensive clothes and shoes. When questioned about this, Kevin said that he's not worried,

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because he's going to hit a million dollar lottery soon. He also revealed to his roommate that
he has had sex with six different women, in the last 10 days. Examination of Kevin's old
medical records confirms your suspected diagnosis of BipolarI disorder, Manic episode. He
has been on Lithium, for the same, since the past 6 months. Physical examination reveals no
abnormalities. His vital signs are as follows: BP: 138/80 mm Hg; RR: 20/min; PR: 90/min. You
order a urine toxicology screen, which turns out negative. The next step in management
would be:
A. Increase the dose of lithium
B. Administer haloperidol
C. Order blood lithium levels
D. Switch over to valproate
E. Start fluoxetine
Explanation:
This patient has been on Lithium since the past 6 months, and is currently experiencing a
manic episode. Although he has an established diagnosis of Bipolar disorder, a urine
toxicology screen would be essential in order to rule out recent use of cocaine or
amphetamines, which can have a similar presentation. In the presence of a negative
toxicology screen, it becomes imperative to check for lithium levels as the next step in order
to confirm compliance with therapy or the need for an increased dose of lithium. Checking
for lithium levels (Choice C) would definitely precede Choice A, of directly increasing the
dose of Lithium.
Choice B. Haloperidol would be an appropriate choice if this patient had exhibited violent,
agitated or uncontrolled behavior. In the absence of these features, haloperidol need not be
included in the management, at this point.
Choice D. Switching over to Valproate would definitely be mandatory after confirming that
Lithium is definitely not working for him, in spite of compliance with the medication. In this
case, ordering lithium levels seems the most appropriate choice.
Choice E. Fluoxetine is an SSRI antidepressant drug. It has no role in the treatment of this
patient, who is currently exhibiting features of mania.
Educational Objective:
In a patient presenting with uncontrolled refractory mania in spite of therapy (in this case
Lithium), checking for levels of the drug would be the first step.

James, a 34-year-old male, calls his primary care physician, in her office saying that he needs
to see her urgently regarding a personal problem. She politely informs him that shes getting
ready to leave as its near closing time, but can arrange for an appointment to see him
tomorrow morning. Fifteen minutes later, when shes just about to leave her office, James

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shows up and insists that he should be seen right away. He says he has a rash on his
genitals and would like her to examine him. What should she tell him at this point?
A. Its totally inappropriate on your part to come here in spite of me asking you not to.
B. Alright, Id like to see your rash.
C. Your rash can definitely wait until tomorrow.
D. Didnt I already inform you that its closing time?
Mr. James, I understand your concern, but we can deal with this tomorrow, as there
E.
seems to be no emergency.
Explanation:
Although all patients have a right to treatment, this patient James is being demanding of his
physician for a trivial concern. He also demonstrates no respect for his physicians time. In
spite of her informing him that its closing time, he still shows up at her office, demanding
that she examine his genitals. In the absence of a real emergency, the physician is at no
obligation to see this patient at this very moment.
Choice A. Telling him that its totally inappropriate of him to come here in spite of being told
not to, would not be the best answer to this question. The physician should be firm but
polite in this case. If the patient misbehaves and continues to be demanding, then she may
retort to more aggressive means of dealing with him.
Choice B. Agreeing to examine him at this point would be a personal decision of the
physician concerned, but would set the foundation for a similar pattern of behavior in the
future. In order to avoid that, the physician should politely give him an appointment for the
next day.
Choice C. Your rash can wait until tomorrow would not be the most appropriate thing to
say at this time. The physicians demeanor should be firm but polite in this case.
Choice D. For the same reason as above, this response would not be the most appropriate
at this point. The physician should politely give him an appointment for the next day.
Educational Objective:
Even with a demanding patient, a physicians first response should always be polite but firm.

You are the psychiatry resident covering the ER when a 28-year-old man is brought in by the
police, for bizarre behavior. He was found naked at the traffic signal, abusing and
assaulting an innocent pedestrian. He has a long history of polysubstance abuse and has
been admitted several times to the hospital with a similar presentation, after illicit drug use.
You are unable to elicit any history from the patient, as he is extremely combative. He keeps
repeating Theyre all out to get me. I can see them coming to kill me. On examination you
notice ataxia, nystagmus and muscle rigidity. His vital signs are as follows: Temperature:
36.5C(97.8F); PR: 84/min; BP: 150/100 mm Hg; RR: 16/min. This patient is exhibiting
features of intoxication from:

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A. Alcohol
B. Heroin
C. LSD
D. Phencyclidine
E. Cocaine
Explanation:
Patients with PCP intoxication usually present with behavioral changes such as
impulsiveness, marked agitation, impaired judgment, psychosis, paranoia, hallucinations,
and assaultiveness shortly after using the drug. In addition, they can present with 2 or more
of: nystagmus, hypertension or tachycardia, ataxia, dysarthria, muscle rigidity, seizures or
coma.
Choice A. Alcohol intoxication can also present with ataxia, nystagmus and aggressiveness,
with impaired judgment. Hallucinations are a feature of alcohol withdrawal, not
intoxication.
Choice B. Heroin intoxication would present with pinpoint pupils, drowsiness, constipation,
and CNS depression in addition to behavioral changes.
Choice C. LSD is a hallucinogen, which can present with: mood impairment, hallucinations,
subjective intensification of perceptions (colors are richer, sensation is enhanced, and
tastes are heightened), depersonalization, and illusions shortly after drug use. In addition,
two or more of the following signs may be present: tachycardia, sweating, pupillary
dilatation, palpitations, tremors and incoordination.
Choice E. Patients with cocaine intoxication present with anxiety, aggressiveness, agitation,
psychosis or delirium in the setting of a recent cocaine use. In addition, they could develop
elevated or low blood pressure, tachycardia or bradycardia, sweating, pupillary dilatation,
nausea or vomiting, and insomnia. Overdoses can be fatal as these patients can develop
cardiac arrhythmias, myocardial infarcts, seizures or stroke. Not very frequently, these
patients present with formication also known as cocaine bugs, where the patient thinks
that there are bugs crawling all over him. Nosebleeds can occur in patients who snort
cocaine.
Educational Objective:
PCP and LSD intoxication both present with similar features, except that agitation and
aggressiveness is prominent in patients with PCP use. Hallucinations (visual) are a prominent
feature with LSD use.

A 64-year-old lady is brought in to your office by her daughter. According to the daughter,
her mother has become increasingly forgetful and irritable over the past two years. She also
adds that shes not much concerned about her mothers forgetfulness, as it is normal with
aging, but shes concerned about her mothers mood swings. You strongly suspect

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dementia in this patient. After ruling out the presence of any medical or psychiatric
conditions for her symptoms, you make a diagnosis of Alzheimers dementia. Which one of
these would you consider in the treatment of this patient?
A. Sertraline
B. Risperidone
C. Donepezil
D. Lorazepam
E. Bupropion
Explanation:
Although the etiology of Alzheimers dementia has not been completely understood, there
is a definitive selective loss of cholinergic neurons, as seen in the histopathological findings
in the brains of patients with this condition. Hence drugs like donepezil and tacrine, which
are reversible acetylcholinesterase inhibitors, are effective in slowing the cognitive decline
in some patients. Other therapies that can be beneficial in these patients are selegiline and
vitamin E. The goals of therapy in these patients are to improve mood, to ensure adequate
nutritional intake, to provide assistance with activities of daily living (if required), to educate
caregivers about the illness, and to provide them emotional support to cope with the
patients illness.
Choices A and E, are both antidepressants, and have no role to play in the therapy of
patients with Alzheimers dementia, in spite of frequent mood disturbances in these
patients.
Choice B: Risperidone could be used in patients with Alzheimers, who are agitated and
psychotic. This patient does not have any psychotic symptoms that would warrant initiation
of risperidone in her treatment.
Choice D: Lorazepam would be useful in reducing agitation in a patient with Alzheimers
dementia. This patient does not demonstrate any agitation, making this choice incorrect.

Educational objective:
Donepezil and tacrine, both reversible acetylcholinesterase inhibitors, are thought to be
useful in decreasing the cognitive decline in patients with Alzheimers dementia.

A 26-year-old lady presents to you with severe pain during intercourse. She tells you that
she has been married for the past two years and still continues to experience severe "genital
pain" during the act. As a result, she avoids becoming sexually intimate with her husband.
This is causing them interpersonal problems. She also complains of severe dysmenorrhea
and pain while passing stools. She further adds that she experiences pelvic pain, off and on.
Which one of these therapies would most likely be effective in this patient?

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A. Use of vaginal dilators

B. Pain management training
C. Oral contraceptive pills
D. Regularly scheduled follow up visits
E. Psychotherapy and sexual education
Explanation:
The patient in this case is exhibiting features of endometriosis. This condition is
characterized by the presence of the three Ds: i.e., dyspareunia, dysmenorrhea, and
dyschezia (painful defecation). Other features of this disorder are pelvic pain and infertility.
It usually occurs in women between 20 and 30 years of age. There are various treatment
modalities for this condition, one of them being combined estrogen and progestin pills.
(Choice A) Vaginal dilators are a useful therapy for patients with vaginismus. This disorder is
characterized by the involuntary contraction of the vaginal musculature, resulting in
interference with sexual intercourse. Patients with this disorder present with unsuccessful
attempts at intercourse.
(Choice B) Pain management training would be a treatment option for patients with pain
disorder. Pain disorder is characterized by the presence of pain in one or more anatomical
locations. This patient is presenting with dysmenorrhea, dyspareunia, dyschezia and
intermittent pelvic pain. Although pain disorder could be a possibility, a general medical
condition should always be ruled out before making a diagnosis. This question asks for the
therapy that is most likely to be effective in this patient. Although a laparoscopy would be
required before making a diagnosis of endometriosis, based on her presentation, Choice C
seems the most likely option.
(Choice D) Regularly scheduled follow-up visits are very effective for patients with
somatization disorder. Patients with this disorder present with multiple medical complaints
including four pain symptoms, two gastrointestinal symptoms, one sexual symptom and one
pseudo-neurological symptom. This patient does not meet the criteria for somatization
disorder. Also, she gives no history of multiple visits to physicians or extensive work-ups
with no concrete diagnosis, features which are characteristic of somatization disorder.
(Choice E) Patients with dyspareunia (pain during intercourse, not attributed to any medical
condition), benefit from sexual education and psychotherapy aimed at resolving the
underlying psychological conflicts. Sexual education for the couple, with a focus on
education about the female genital anatomy, phases of sexual response and the need for
adequate lubrication prior to intercourse, are essential in the treatment of these patients.
Educational Objective:
In a patient presenting with dyspareunia, it is essential to rule out whether it stems from a
general medical condition or the presence of underlying psychological stressors. Medical
causes of dyspareunia are endometriosis, local infections, vulvar or vaginal growths.
Estrogen deficiency in post-menopausal women can also lead to dyspareunia. Psychological

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causes could be due to somatization disorder, pain disorder or an isolated diagnosis of
dyspareunia without any other symptoms. Then, treatment can be targeted toward the
underlying cause.

You have just reviewed the MRI reports of a 37-year-old Mrs. Smith, who consulted you for
a low back pain one week ago. After obtaining minimal relief from a trial with 2 weeks of
bed rest and NSAID therapy, she was scheduled for an MRI. Her MRI reveals metastatic
deposits in her spine; the primary being uncertain at this stage. You are now to convey the
results of the MRI to her. What would be the most appropriate sentence to begin with?
A. You have cancer, which has metastasized to your back.
B. You should have come at an early stage for a medical check up. Its already too late.
C. We will try our best but once the tumour metastasizes, the prognosis is bad.
D. How are you feeling right now?
E. You do not have simple back strain.
F. The test results are not good. Do you want to know about them?
Explanation:
Breaking bad news can be one of the most awkward situations for a physician. A sensitive
yet efficient approach can make all the difference in the way a patient might react to the
news. Often the opening statement has to be carefully chosen. Asking the patient "How do
you feel right now? helps the patient feel at ease and sets up a two-way conversation,
rather than directly revealing the diagnosis to the patient. It is also helpful to enquire if the
patient would like anyone else to be present at that point. It is important to enquire the
patient about his feelings after you've revealed the diagnosis. Once that is done, it is
imperative to clearly indicate what the plan for further treatment involves.
Choice A. Directly stating the diagnosis would not be the most appropriate way to begin the
discussion with your patient in this case.
Choice B. Physicians should use a sensitive approach to breaking bad news. Blaming the
patient for not coming to you earlier would be an inappropriate approach.
Choice C. It is extremely imperative on your part as a physician, to make the patient
understand that you will do your best and extend your help at all times. It is also important
to give details about the prognosis of the disorder; but the discussion should not be initiated
with discussing the prognosis.
Choice E. Telling the patient that she does not have simple back strain will not be the best
initial approach. Although it will be essential eventually to reveal the diagnosis to her, this
question asks for the best initial statement, making Choice D the most appropriate option.
Choice F. It is important to make the patient feel at ease first and then reveal the diagnosis.
Beginning the discussion with The test results are not good will make the patient

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uncomfortable.
Educational Objective:
While breaking bad news, physicians have to begin with an appropriate initial sentence,
which would help the patient feel at ease.

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