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15. A 43-year-old woman is brought in by family due to erratic behavior. She exhibits pressured speech, grandiosity, distractibility, and decreased need for sleep. She also reports auditory hallucinations. Symptoms have persisted for 4 weeks without depressive episodes. What is the most likely diagnosis?
A) Schizophrenia
B) Schizoaffective disorder
C) Bipolar I disorder with psychotic features
D) Brief psychotic disorder
E) Delusional disorder
Answer: C) Bipolar I disorder with psychotic features
Explanation: Psychosis occurring exclusively during mood episodes points toward bipolar I with psychotic features, not schizoaffective disorder (which requires psychosis outside of mood episodes).
14. A 27-year-old woman presents with recurrent episodes of intense fear accompanied by palpitations, nausea, dizziness, and fear of losing control. She now avoids grocery stores due to fear of having another episode in public. What is the most appropriate long-term treatment?
A) Clonazepam
B) Fluoxetine and CBT
C) Propranolol
D) Buspirone
E) Short-term benzodiazepines only
Answer: B) Fluoxetine and CBT
Explanation: This is panic disorder with agoraphobia. First-line treatment is SSRI + CBT. Benzos may be used acutely but not preferred long-term.
13. A 32-year-old woman is hospitalized for a suicide attempt. She describes unstable relationships, emotional lability, intense fear of abandonment, and a chronic sense of emptiness. She also reports impulsive behaviors including binge eating and reckless spending. What is the most appropriate long-term intervention?
A) Cognitive behavioral therapy
B) Dialectical behavior therapy
C) SSRI
D) Antipsychotic
E) Interpersonal therapy
Answer: B) Dialectical behavior therapy
Explanation: DBT is first-line psychotherapy for borderline personality disorder, targeting emotional regulation, distress tolerance, and interpersonal effectiveness.
12. A 55-year-old man with alcohol use disorder is admitted for confusion, ataxia, and horizontal nystagmus. His condition worsens after receiving IV fluids and glucose. What is the most likely mechanism of his worsening symptoms?
A) Acute hyponatremia
B) Hypoglycemia from insulin release
C) Precipitated Wernicke encephalopathy
D) Hepatic encephalopathy exacerbation
E) Central pontine myelinolysis
Answer: C) Precipitated Wernicke encephalopathy
Explanation: Giving glucose before thiamine in thiamine-deficient patients (e.g., alcoholics) can precipitate or worsen Wernicke encephalopathy.
11. A 34-year-old man is brought to the ED for bizarre behavior. He is agitated, violent, has vertical nystagmus, and does not respond to pain. Labs show elevated CPK. Which of the following substances is most likely responsible?
A) Cocaine
B) LSD
C) Methamphetamine
D) PCP
E) Heroin
Answer: D) PCP
Explanation: PCP intoxication is classically associated with violent behavior, nystagmus, analgesia, and rhabdomyolysis. It’s a dissociative anesthetic.
10. A 38-year-old man on haloperidol for schizophrenia develops fever, lead-pipe rigidity, autonomic instability, and altered mental status. What is the most appropriate next step in management?
A) Increase haloperidol dose
B) Discontinue antipsychotic and give dantrolene
C) Discontinue antipsychotic and give lorazepam
D) Switch to risperidone
E) Add benztropine
Answer: B) Discontinue antipsychotic and give dantrolene
Explanation: This is neuroleptic malignant syndrome (NMS). First-line is to stop the dopamine antagonist and initiate dantrolene or bromocriptine.
9. A 7-year-old girl is brought in for aggression and lying. She shows no remorse, has violated rules at school, and has hurt a family pet. Her behavior has persisted for over a year and is worsening. What is the most likely diagnosis?
A) ADHD
B) Oppositional defiant disorder
C) Conduct disorder
D) Intermittent explosive disorder
E) Reactive attachment disorder
Answer: C) Conduct disorder
Explanation: Conduct disorder involves a persistent pattern of violating others’ rights and societal rules. It may progress to antisocial personality disorder in adulthood.
8. A 23-year-old man is brought to the emergency department by his roommate due to bizarre behavior and auditory hallucinations. He is diagnosed with schizophrenia. Which of the following neurotransmitters is most likely involved in the pathophysiology of his condition?
A) Serotonin
B) Norepinephrine
C) GABA
D) Dopamine
E) Acetylcholine
Answer: D) Dopamine
Explanation: Schizophrenia is associated with increased dopaminergic activity, particularly in the mesolimbic pathway.
7. A 25-year-old woman with schizophrenia is prescribed haloperidol. She returns to the clinic with muscle stiffness, tremor, and a shuffling gait. These symptoms are most likely due to antagonism of dopamine in which of the following pathways?
A) Mesolimbic
B) Mesocortical
C) Nigrostriatal
D) Tuberoinfundibular
E) Raphe nuclei
Answer: C) Nigrostriatal
Explanation: Extrapyramidal symptoms (EPS) result from dopamine blockade in the nigrostriatal pathway.
6. A new antipsychotic drug selectively blocks D2 receptors in the mesolimbic pathway with minimal effect on other dopamine pathways. Which of the following side effects is this drug most likely to avoid?
A) Galactorrhea
B) Akathisia
C) Sedation
D) Weight gain
E) Hyperglycemia
Answer: A) Galactorrhea
Explanation: Blocking dopamine in the tuberoinfundibular pathway can cause hyperprolactinemia leading to galactorrhea. A selective mesolimbic blocker would avoid this.
5. A 48-year-old woman with major depressive disorder presents after starting fluoxetine 3 weeks ago. She now reports increased agitation, insomnia, tremors, and myoclonic jerks. Vitals reveal a temperature of 38.7°C and BP of 160/98 mmHg. Which of the following is the next best step?
A) Increase the fluoxetine dose
B) Add a benzodiazepine
C) Discontinue fluoxetine and start cyproheptadine
D) Switch to bupropion
E) Administer naloxone
Answer: C) Discontinue fluoxetine and start cyproheptadine
Explanation: This is serotonin syndrome, often caused by serotonergic medications. Treatment includes discontinuation and cyproheptadine (a serotonin antagonist).
4. A 21-year-old man presents with 2 months of hearing voices telling him he is worthless. He appears disheveled and is socially withdrawn. He reports poor academic performance but no mood symptoms. What distinguishes schizophreniform disorder from schizophrenia?
A) Type of hallucination
B) Duration of symptoms
C) Presence of delusions
D) Family history of schizophrenia
E) Absence of negative symptoms
Answer: B) Duration of symptoms
Explanation: Schizophreniform disorder = 1–6 months of schizophrenia symptoms. Schizophrenia requires ≥6 months of symptoms.
3. A 62-year-old man recently started on risperidone for psychosis presents with restlessness and a strong urge to move. He paces frequently and feels unable to sit still. What is the most appropriate management?
A) Increase risperidone dose
B) Add propranolol
C) Switch to haloperidol
D) Add benztropine
E) Give diphenhydramine
Answer: B) Add propranolol
Explanation: This is akathisia, a common extrapyramidal symptom. First-line treatment is beta-blockers, such as propranolol.
2. A 33-year-old woman has recurrent episodes of binge eating followed by self-induced vomiting. She is concerned with body image but maintains a normal BMI. Labs show metabolic alkalosis and hypokalemia. What is the most evidence-based pharmacologic treatment?
A) Olanzapine
B) Bupropion
C) Fluoxetine
D) Lisdexamfetamine
E) Topiramate
Answer: C) Fluoxetine
Explanation: Fluoxetine is the only FDA-approved SSRI for bulimia nervosa and improves binge-purge frequency. Bupropion is contraindicated due to seizure risk.
1. A 4-year-old child who was previously meeting developmental milestones now exhibits loss of purposeful hand use, gait disturbances, and repetitive hand-wringing movements. Speech is significantly impaired. What is the most likely diagnosis?
A) Rett syndrome
B) Fragile X syndrome
C) Autism spectrum disorder
D) Childhood disintegrative disorder
E) Landau-Kleffner syndrome
Answer: A) Rett syndrome
Explanation: Rett syndrome, seen almost exclusively in girls, is caused by MECP2 mutation. It features regression, loss of hand skills, and hand-wringing.
Simon Downes, MD, PhD 