‫‪Review Psychiatry Questions for SMLE‬‬

‫‪Version 1 2024‬‬
‫‪Collection of questions [2021 till February 2024] + interpretation‬‬

‫هذا العمل مجهود شخصي من مجموعة من األطباء المقيمين في مجال الصحة النفسية لحل وشرح أسئلة الصحة النفسية وليس الغرض منه أي أهداف‬
‫ربحية‪.‬‬
‫يرجى عدم استخدامه في الدورات الربحية و المدفوعة‪.‬‬
‫ال تنسونا من دعواتكم في ظهر الغيب‪.‬‬
‫(إن أحسنت فمن هللا وإن أسأت أو أخطأت فمن نفسي والشيطان)‬

‫إلرسال االسئلة‪:‬‬
‫‪‬‬ ‫‪Email: psych.rs.sa2020@gmail.com‬‬
‫‪‬‬ ‫‪Telegram: https://t.me/psychsmlechannel‬‬

‫ملحوظة‪ :‬كثير من األسئلة نقلت في التجميعات بشكل خاطئ أو ناقص لذلك سنعتمد على الموضوع األساسي في السؤال مع الشرح من‬
‫المصادر‪ ،‬ال يوجد مصدر معتمد من الهيئة في قائمتهم لهذا االختبار لذلك اعتمدنا بعض المصادر المعتمدة في البورد السعودي للصحة‬
‫النفسية واإلدمان‪.‬‬

‫‪Resources:‬‬
‫‪‬‬ ‫‪Synopsis of Psychiatry Behavioral Sciences/Clinical Psychiatry‬‬
‫‪‬‬ ‫‪DSM-5‬‬
‫‪‬‬ ‫‪The Maudsley Prescribing Guidelines in Psychiatry‬‬
‫‪‬‬ ‫‪Toronto notes‬‬
‫‪‬‬ ‫‪Online sources: Uptodate, Medscape, Psychiatric Times, MDedge, AMBOOS and others..‬‬

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Basic psychology, Psych-Ethics,
History taking & Mental Status
Examination

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 The mental status examination (MSE) is an important diagnostic tool in both neurological and
psychiatric practice.
 MSE is used to describe a patient's mental state and behaviors, both quantitatively and
qualitatively, at a specific point in time.
 The findings of the MSE summarize the results of a psychiatric examination on a
comprehensive, cross-sectional level.
 When integrated with the interviewee's biographical information and psychiatric history, MSE
findings form the basis for diagnostic and therapeutic decisions
 Other factors that should be taken into account when conducting an MSE include the religious,
educational, and social backgrounds of the interviewed individuals.
 The MSE is not to be confused with the (MMSE), which is a screening tool for dementia but can
also be used as part of the MSE to assess sensorium and cognition.

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Components of MSE:

 Appearance and Behavior: Estimated age by physical appearance, Bodyweight, Physical

abnormalities, Posture, Hygiene, Dress, Wounds (e.g., burns, scratches, needle marks) and/or
scars Tattoos and/or body piercings Dental braces, jewelry, glasses..etc. Psychomotor agitation,
hallucinatory gesture, Abnormal motor activity, Gait, Apraxia Eye contact, Attitude toward the
interviewer, Level of distress.
 Language: based on the patient's ability to name objects, read, and write. Abnormalities including
(Aphasia, Agraphia, Alexia)
 Mood and Affect: Mood described using the patient's own words. Affect: Refers to the
physician's objective assessment of a patient's emotions conveyed both verbally and nonverbally
during an interview.
 Speech is the spontaneous production of the spoken language; rate, volume, quantity articulation
and fluency, speech latency. Abnormalities including (Mutism, Dysarthria, Echolalia, Palilalia,
Alogia/poverty of speech, Pressured speech, Neologisms, Word salad)
 Thoughts Process: the number of thoughts as well as their flow and coherence:

 Though content: explicitly to what an individual is thinking about (i.e., main themes and beliefs)
and is usually evaluated based on the presence of delusions, obsessions, compulsions, phobias and
homicidal or suicidal ideation. Consider the individual's social, cultural, and educational
background, since the understanding of normality varies among these things.

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  Perception: hallucination, illusion, dissociation, agnosia, hemi-neglect.

 Cognition and orientation: Cognition is mental process of gaining knowledge and understanding
via thinking, experiencing, and sensing, including attention and concentration, memory,
calculation, language, knowledge, abstract thinking, executive function. Orientation is assessing a
patient's level of consciousness and their orientation to time, place, and person in the same
sequence.
 Insight and Judgment: Insight is an individual's awareness and understanding of their current
medical problem, compliance to medications, and ability to relabel unusual mental events as
pathological. Judgment: The ability of an individual to make considerate decisions when
performing a task based on their understanding of the current circumstances and their problem-
solving abilities; a higher cortical function.
More details: https://www.amboss.com/us/knowledge/Mental_status_examination/

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  Questions about history taking & mental status examination:

1) Doctor asked his patient; “Do you think you are mentally retarded?” the doctor is
assessing what?
A- Insight
B- Judgment
C- Concentration
D- Perception
Answer is A, regardless it’s a wrong way to practice this part of MSE & no one is asking a
question like that!!!! Assessing insight of the patient about his problem is part of mental
status exam MSE while taking the history. Questions like: Do you think that you have a
mental illness? Why are you taking this medication? What would happen if you stopped
taking it? Why are you in the hospital?
Insight: patient’s ability to realize that he or she has a physical or mental illness and to
understand its implications (none, limited, partial, or full).
Judgment: patient’s ability to understand relationships between facts and draw conclusions
that determine one’s actions.

2) Patient came to the clinics, he speaks rapidly and jumping between topics, which of the
following describing his condition?
A- Flight of Ideas
B- loosening of associations
Other recall: Pt came to the clinic; he is talkative jumping from topic to topic without
completing each one. What is this called?
A- Flight of ideas
B- Thought insertion
C- Broadcasting
D- Thought withdrawal
Answer for both questions A: Jumping between ideas, rapid speech but coherent described
flight of ideas. Rapid speech frequently changing the topic but incoherent described as
loosening of association
3) 15yo, his friend died in a car accident and he told his mom her is thinking of suicide but
not going to act on it, what to do? Other recall (I wish I can die too but I will never do it)
A- Asking him directly about his suicidality is going to increase the risk of him acting on it.
B- Ask him details about his suicidal thoughts and feelings.
C- Reassurance and never mentioned suicide thoughts to patients
Answer is B; suicide thoughts and death wishes SHOULDN’T be ignored in any history
even it patient denied or normalized his answer, must take it seriously with detailed
information.

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4) Patient presented with psychomotor agitation, grandiose delusions, auditory
hallucinations, flight of ideas and lack of insight, what does he have?
A- Neurosis
B- Psychosis
C- Personality disorder
Answer is B

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5) 2 weeks after being diagnosed with small cell lung cancer, a 57 year old male return to his
oncologist for a follow visit, he has brought with him a large stack of research papers and
wants to discuss emerging therapeutic options whit his physician, while talking he
frequently quote survival statistics and discuses some of the histologic features associated
with improved outcome, this is an example of which of the following ego defenses?
A- Intellectualization
B- Rationalization
C- Denial
D- Suppression
Answer is A- review previous notes.

6) 50’s yo man works at an extremely stressful job and is yelled at by his boss daily for even
the smallest mistakes. When he gets home, the man is often abusive verbally and
sometimes physically to his wife and children. This example is which of a defenses
mechanism?
A- Displacement
B- Denial
C- Regression
D- Projection
Answer is A- review previous notes

7) 20s man is referred to a psychiatrist after receiving poor evaluation at work. He is an IM

resident currently complaining of training. Several medical students and interns have
complained about his behavior and accused him of being unnecessarily hostile towards
them. Recently he yelled at his intern in front of several colleagues after his supervising
attending expressed frustration about how large their inpatient census had become.
During discussion the patient admits to feeling very stressed at work and mentions several
instances of being verbally abused by his current attending physician for the quality of his
teams, He says that he is very angry at his current attending and feels that it is very
difficult to work with him. His behavior would be best described as which of the
following?
A- displacement
B- Projection
C- sublimation
D- splitting
Answer is A

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 Psych-Ethics:
1) Long scenario of a girl with lots of
depression symptoms and suicidal
attempts, the doctor said she needs to
be admitted and she got very angry
What's the ethical principle behind
wanting to admit the patient?
A. Justice
B. Beneficence
C. Non-maleficence
Answer is B; References: Synopsis of
Psychiatry

2) Women go for routine follow up with

her GP in clinic, he noticed that she has
severe depression symptoms and try to
prescribe anti-depressants for her, she
refused and she told him I don't need
drugs. She is already prescribed
vitamins so he added SSRI for her as
vitamin and he doesn't tell her. She gets
dramatically improved in the next visit
and her symptoms vanished. Which of
the following is correct or something
like that...

A-he should refer her to psychiatrist

before
B-He cannot prescribe her without
consent
C-He do the right thing because her symptoms improved now
D? ( excluded by your colleague)
Answer is B; Resources: synopsis of psychiatry

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3) Pregnant lady came to the hospital with broken arm caused by husband abuse.
Which of the following is the most likely time for increased intimate partner
violence?

A. After retirement
B. During pregnancy
C. At family visits
D. Holiday
Answer is B

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Depression

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 Review about Depression:

Summary for diagnosis depression – DSM-5:

Depression DSM-5 Diagnostic Criteria
The DSM-5 outlines the following criterion to make a diagnosis of depression. The
individual must be experiencing five or more symptoms during the same 2-week
period and at least one of the symptoms should be either (1) depressed mood or (2)
loss of interest or pleasure.
1. Depressed mood most of the day, nearly every day.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of
the day, nearly every day.
3. Significant weight loss when not dieting or weight gain, or decrease or increase
in appetite nearly every day.
4. A slowing down of thought and a reduction of physical movement (observable
by others, not merely subjective feelings of restlessness or being slowed
down).
5. Fatigue or loss of energy nearly every day.
6. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
7. Diminished ability to think or concentrate, or indecisiveness, nearly every day.
8. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan,
or a suicide attempt or a specific plan for committing suicide.
To receive a diagnosis of depression, these symptoms must cause the individual
clinically significant distress or impairment in social, occupational, or other important
areas of functioning. The symptoms must also not be a result of substance abuse or
another medical condition.
Note: 2-4 symptoms for 2 weeks = minor depression “depressive episode”
>5 symptoms for 2 weeks = major depression
At least 2 symptoms for 2 years = Dysthymia

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13
  Highlighted points about antidepressants in pregnancy:

 Paroxetine has been specifically associated with cardiac malformations particularly after high dose
(>25mg/day), first trimester exposure.
 Third-trimester use of paroxetine may give rise to neonatal complications, presumably related to abrupt
withdrawal.
 Sertraline appears to result in the least placental exposure.
 TCA use during pregnancy increases the risk of preterm delivery.
 Use of TCAs in the third trimester is well known to produce neonatal withdrawal effects; agitation,
irritability, seizures, respiratory distress and endocrine and metabolic disturbances. These are usually
mild and self-limiting.
 MAOIs should be avoided in pregnancy because of a suspected increased risk of congenital
malformations and because of the risk of hypertensive crisis
 SNRI: Venlafaxine has been associated with cardiac defects, anencephaly and cleft palate, neonatal
withdrawal and poor neonatal adaptation syndrome and PPH. Second trimester exposure to venlafaxine
has been associated with babies being born small for gestational age.
 Duloxetine is unlikely to be a major teratogen.
 Trazodone, bupropion and mirtazapine have few data supporting their safety. Data suggest that both
bupropion and mirtazapine are not associated with malformations but, like SSRIs, may be linked to an
increased rate of spontaneous abortion.

14
  Questions about Depression & medications “Reference: Kaplan& Maudsley”

1) Case of Depressed patient and the doctor will prescribe a drug for her. asking which
reuptake inhibitors should be prescribed?
A- DOPA
B- GABA
C- Serotonin
D- Acetylcholine
Answer is C
2) 55 years old patient C/O low mood, loss of appetite, insomnia, suicidal ideation, for 2
months dx?
A- Minor depression
B- Major depression
C- Bipolar disorder
Answer: A; 4 symptoms for 2 weeks = minor depression “depressive episode”.

3) A 40-year-old woman presents to the clinic with 2-month history of a sleep disturbance,
loss of interest, low energy. poor memory, and suicidal ideation. On examination, she
looks weak and inactive. Laboratory investigations are normal.
Which of the following is the most likely diagnosis?
A. Dysthymia
B. Bipolar disorder
C. Major depression
D. Minor depression
Answer is C; 5 symptoms of the criteria.

4) A 72-year-old man who lost his spouse 2 months ago after a prolonged illness, presents
with a sad mood, decreased appetite, and sleep disturbance.
Which of the following is the most likely diagnosis?
A. Dysthymia
B. Bereavement
C. Major depression
D. Minor depression
Answer is B; Normal duration of bereavement 6months to 1 year.

5) Female lost her best friend and can’t sleep? “other recall: women with a history of
insomnia and crying for 5 days due to sibling death, what is the short course therapy?
A- Lorazepam
B- Fluoxetine
C- Imipramine
D- Chlorpromazine
Answer: A; in general, Supportive psychotherapy is indicated for those individuals in acute crisis
or a temporary state of disorganization and inability to cope (including those who might otherwise be
well functioning) whose intolerable life circumstances have produced extreme anxiety or sudden
turmoil (e.g., individuals going through grief reactions, illness, divorce, job loss, or who were victims
of crime, abuse, natural disaster, or accident.

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 In this question the main complaint is sleeping issue due to current issue, so always treat the symptom
if needed. Giving short duration course of benzodiazepine can help to relieve the symptom, yet the
importance of supportive therapy must be involved. No SSRI or any other antidepressants are needed
unless low mood symptoms duration fit the criteria of depression.

6) Patient wants to get pregnant and have severe depression on paroxetine, what you should do?
A- stop
B- decrease the dose
C- continue
Answer: A; Paroxetine is contraindicated in pregnancy (Category D)

7) 22 years female K/C/O severe depression, suicidal attempts, she is controlled on paroxetine.
Now, she is pregnant. What to do?
A- Stop paroxetine because of fetal malformation
B- Continue paroxetine and control her depression
C- Switch to others drug.
D- Stop paroxetine b/c of prematurity

Answer is B;
 if she is currently pregnant and controlled on paroxetine (or any other antidepressants)
we have to continue using same medication because of the high risk of relapse and
educate the mother about the possible side effects to the baby, which is less in rate than
having maternal relapse [don’t break the boat]
 if she is planning to be pregnant and still have time, you can switch to another
antidepressant safe for both baby and the mother with close follow up and assessment.
 If untreated before and planning to be pregnant, Sertraline is a good choice to start with
and to be pregnant on it.

8) TCA minimum fatal dose? (another recall with grams, Answer is 1 gm)
A- 10-20 mg \ kg
B- No more choices
Answer; A; Minimum fatal dose of TCA:
 >10mg/kg is potentially life threatening
 <5mg/kg = Minimal symptoms
 5-10mg/kg = Drowsiness and mild anticholinergic features
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  >10mg/kg = Potential for coma, hypotension, seizures, cardiac dysrhythmias. Anticholinergic
affects are often masked by the coma
 >30mg/kg = severe toxicity with pH-dependent cardiotoxicity and coma expected to last >24
hours

9) What is the one with the most serious side effects of the following SSRI medications?
A- Sertraline
B- Fluoxetine
C- paroxetine
Answer: C; Paroxetine is the one of the favorite SSRI used to treat depression, however;
comparing to other choices, it has more serious side effects due to its too many side effects produce
symptoms within a day or two, whereas symptoms with fluoxetine can be delayed by 2–6 weeks,
specially discontinuation syndrome associated with evidence of emergent suicidal thoughts, which
needs Cross-taper cautiously. Similar medication; Venlafaxine

10) Which one of these SSRI is the most toxic?

A- Sertraline
B- Fluoxetine
C- Citalopram
Answer: C; between these choices it’s the most toxic due to dose related cardiac side effects.

11) Which of these can be used in Children and even adult with depression?
A- Fluoxetine
B- Citalopram
Answer: A; same as previous note regarding safety and side effects.

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12) Depressed female. What is the most important risk factor of suicidal thoughts?
A- Age
B- Gender
C- Social isolation
D- Previous attempt.
Answer: D then C.

13) Highest risk factors for suicide?

A- Absence of medical illness
B- Social isolation
C- Age
D- Female
Answer is: B then C

Other recall: 38 yo female

medically free husband afraid she will commit suicide, which of the following has the
highest risk of committing suicide? Other recall; A husband brought his wife who has
depression for 2 years, he noticed that she became more isolated, at the clinic there
was no eye contact with the doctor, other hx was normal no history of chronic illnesses
and no abnormal FHx. what is highly associated with suicide?
A- Age
B- being female
C- socially isolated
D- has no medical disease
Answer is C

14) Pt after sleeve gastrectomy complains of low mood what to do?

A- Reassure the family
B- Give antidepressant
C- Admit to the hospital for evaluation
Answer A: duration of low mood is missing in the question, however encourage life style
modification, support groups and reassurance are important after surgery, if mood changes
persisted then start antidepressant.

15) Female with postpartum depression for 5 days, the baby is breastfed well, but she is sad
and cry, what is appropriate initial step?
A- discharge follow up after 1 week
B- SSRI
C- benzodiazepines
D- multivitamin
Answer is A; based on duration she is having postpartum blues, the first line therapy is
supportive and close observation.

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 16) Patient came to postpartum clinic after 2 weeks of delivering healthy baby she said she
was feeling moody, anxious and tearfulness after the delivery,, but now she is fine and
everything normal and she feeling well:
A- postpartum blues
B- postpartum psychosis
C-postpartum depression
Answer is A

17) Patient came to the ER with signs and symptoms of myocardial infarction he was going
for PCI, when the cardiologist was assessing his condition he notice the patient was
depressed with low mood, the patient refused the PCI he demonstrate good
understanding of his problem to the doctor what to do?
A- Treat the patient regardless of the consent
B- Refer the patient for psychiatric assessment then take the consent
C- Respect the patient choice after discussing the reasons of refusing
D- Take the consent from the patient relative
Answer is B; supportive therapy including assessment and psychotherapy, if no urgent
need of doing PCI now, and still in the window of 12 hrs.

18) Low mood, decreased interest and weight changes for

2 years. What is the Dx?
A- Major depressive disorder
B- Dysthymia
Answer B; hint is duration of symptoms →

19) Alternative treatment of severe depression?

A- Electroconvulsive therapy (ECT)
B- TCA
C- Electroencephalogram (EEG)
Answer: A; ECT: currently fastest and most effective
treatment for MDD. Consider in severe, psychotic or
treatment-resistant cases, TCA is used for severe
depression as monotherapy or in combination, however
the question is about alternative method of medications.

20) Old female pt with typical symptoms of depression, sadness, loss of interest, feeling
worthless and suicidal thoughts, which of the following mediators is responsible for her
symptoms?
A- DOPA
B- Serotonin
C- GABA
D- Acetylcholine
Answer: B

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 21) Pt come with violence, which imbalance responsible for violence?
A- Testosterone
B- Low serotonin
Answer is A; Testosterone has more effect on violence
than serotonin
- Other recall with other choices:
A- Low serotonin
B- high serotonin.
C- low endorphin.
D- high endorphin
Answer is; A
22) drugs cause irritation and anxiety and insomnia?
another recall;
What drug cause insomnia and headache and n/v ?
Answer Fluoxetine; SSRI in general
A- Tricyclic antidepressant
B- tetracyclic antidepressant
C- MOI
D- SSRI
Answer D;
23) Side effect of Amitriptyline?
A- Dysphonia
B- Weight gain
C- Hyper-salivation
D- Hyperpigmentation
E- Constipation
Answer is B, then E; main common side effect of amitriptyline and the main concern from
the patient, constipation is also correct choose it if weight gain is not mentioned. ( in other
recall asking about Absolute side effect: Constipation.
24) Elderly on amitriptyline 30mg at night for insomnia, complained of drowsiness, what to
do?
A- Switch to SSRI
B- Change to morning dose
C- Divide the dose – take it TID
D- Decrease it to 10mg
Answer is C

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25) 76 years old male diagnosed with depression and started on
amitriptyline 30 mg he take it every night. Early after starting
the meds he started to complain of early morning Dizziness, what
is the most appropriate next step?
A. Advice to take in the morning
B. Change it to 10 mg 3 times
C. Change to SSRI
D. Advise to take before food
Answer is B

26) Pt presented with insomnia started 2 months’ post MI, what is

the best treatment for this patient?
A- Zolpidem
B- Diazepam
C- Antihistamine
D- Nothing
Answer: A; First line treatment is CBT, however we can give short term medication just for
help, and we have to consider cardiac safety too. “short-term use of hypnotics can improve
sleep, long-term use has been associated with adverse effects, including tolerance, rebound
insomnia, daytime fatigue, and difficulty with memory and concentration.”

27) Pt k\c of a.fib, depression, and 3rd disease, on medications, complained of palpitation,
insomnia and irritability. He is vitally stable, what to do?
A- Give BB
B- Do TFT
C- d\c antidepressants
D- refer to psychiatrist
Answer: B; first rule out organic causes, review medications, then refer to psychiatrist if it’
anxiety related symptoms.

28) Which of the following is one of the characteristics of Major depression psychiatric
illness?
A- Hypomania
B- loses eye interest during talking
C- sleep problem
D- hallucination and delusion
Answer: C; sleeping problems such as insomnia or hypersomnia is one of the MDD criteria
based on DSM-5. avoiding eye contact is not specific for MDD yet we comment on it in
assessing the patient, don't confuse yourself with anhedonia (loss of interest in the daily
activity all or some of them), not only eye contact.

29) Which among the following is NOT a side effect of bupropion?

A- Diarrhea
B- Blurred vision
C- increased sweating
D- dry mouth
Answer: A; all of them are reported side effects but diarrhea is less common.
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30) Pt on antidepressant then developed constipation, what class of antidepressants?
A- SSRI
B- TCA
C- SNRI
D- MAOI
Answer: B, TCA more common in causing constipation then others.

31) Postpartum depression What to do beside psychotherapy:

A- Small dose of antidepressants
B- Mother breast feed the baby
C- involve family in therapy
Answer: C, although B is also correct to increase the bond of mother and her baby yet involving
the family is more important for support at this stage.
32) Female came with 5 depressive symptoms for 2 months; dx?
A- Major depression
B- Minor depression
C- Other options
Answer: A, check criteria box.

33) Pt presented with hopelessness, which of the following is likely to be with it?
A- Gender identity disorder
B- Impulse behavior
C- Suicidal behavior
D- Panic disorder
Answer: C; asking about depression criteria

34) 30yo female delivered her baby 1 week ago, presented with crying bouts associated with
decrease in appetite and self-neglect without any clear reason, what is the possible
diagnosis?
A- Postpartum depression
B- baby blues
C- Generalized anxiety
disorder
Answer is: B;

35) patient with severe

depression. With polyuria
in polydipsia and drinking
so much water. Urine diluted. What is the diagnosis
A-psychogenic polydipsia
B-diabetes insipidus
C- SIADH
Answer is A: based on medical explanation regardless the psych cause as pt is hyponatremic
so not DI & low urine osmolality so not SIADH

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36) Which of the following is correct regarding antidepressants medication?
A- Start any medication as they equal in efficacy
B- Start one and check response after 2 weeks
C- Stop medication when symptoms improve
D- Change medication if not effective.
Answer is B; Explanation: by Maudsly
Onset of action:
It is widely held that antidepressants do not exert their effects for 2–4 weeks. This is a
myth. All antidepressants show a pattern of response in which the rate of
improvement is highest during weeks 1–2 and lowest during weeks 4–6. … In
clinical practice using simple observations, an antidepressant effect in an individual is
usually seen by 2 weeks. It follows that in individuals where no antidepressant effect is
evident after 3–4 weeks’ treatment, a change in dose or drug should be considered. It is
important, however, to be clear about what constitutes ‘no effect’. Different patterns of
response have been identified and in some individuals’ response is slow to emerge.
However, in those ultimately responsive to treatment, all will very probably have begun
to show at least minor improvement at 3 weeks. Thus those showing no discernible
improvement at this time will very probably never respond to the prescribed drug at that
dose. In contrast, those showing small improvements at 3 weeks (that is, improvement
not meeting criteria for ‘response’) may well go on to respond fully
Duration of treatment:
Antidepressants relieve the symptoms of depression but do not treat the underlying
cause. They should therefore be taken for 6–9 months after recovery from a single
episode (to cover the assumed duration of most single untreated episodes). In those
patients who have had multiple episodes, there is evidence of benefit from
maintenance treatment for at least 2 years; no upper duration of treatment has been
identified.
37) Young woman with depression (and other symptoms) prior to her cycle every month it
is effecting her work what to give her?
A- SSRI
B- Medroxyprogesterone
C- Progesterone
D- Estrogen
Answer is A
38) Patient after being told by physician that he has lung cancer
he responds: “can it be a mistake?” What kind of response is
this?
A- Denial
B- Bargaining
C- Anger
D- Depression
Answer is A

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39) patient has advanced breast cancer with metastasis in her bones, brain, lungs and liver.
Which responses will the patient most likely make upon hearing these results?
A. “ Doctor, I think you need to re-run those test”
B. “I think I am dying now”
C.” can you make sure I’m alive for 3 months to see my son gets married?”
D.” I will take you to court
Answer is: A

40) 76yo woman, her husband states that she has been more and more forgetful over the
past few weeks, this situation is causing a strain on their marriage, he appears to be
frustrated with her memory troubles and states that he doesn’t want to start to dressing
her or bathing her if her mental capacity deteriorates further, at her last visit, she
seemed mildly impaired cognitively but at this visit she is withdrawn and does not make
eye contact with the physician or her husband, she lets her husband speak on her behalf
for the duration of the visit. Which of the following is the next step?
A- ask the husband to step out so you can speak with the patient alone
B- talk to the husband about marriage counseling.
C- assess the patients risk for depression
D- order an MRI
Asking about NEXT step: Answer is C, Doing MRI is correct but to be done later after
psychological assessment.
41) 31 yo F With emotional symptoms 3 days before her menstrual cycle, including low
mood, decreased activity, and severe lower abdominal and back pain first 3 days of
menstrual cycle affecting her work and social life.
What’s is the evidence base medication to prescribe (or best evidence based)?
A- oral combined contraceptive
B- progestin only pill
C- SSRI
D- NSAIDs
Answer is C; read about it:
https://www.mdedge.com/familymedicine/article/216331/womens-health/evidence-based-
tools-premenstrual-disorders
42) Case of Young man w/ a hx of IBD is brought to the ED after changes in his behavior,
his friend reported that the patient has not been sleeping, is acting irritable and
depressed, additionally, he has a rash on the dorsal surface of his hands, face and neck.
The patient appears apathetic and has episodes of diarrhea, vitamin deficiencies cause
his symptoms?
A-Niacin /vit B3
B-thiamine /vit-B1
C-vitamin C
D-vitamin B12
Answer is A; read about it:
https://www.ncbi.nlm.nih.gov/books/NBK557728/

24
43) Patient on depression medication, c/o perianal pain , and other other urinary tract
symptoms, he cannot pass urine for the past 12 hours ,
A . Prostatitis
B. BPH
C. Neurogenic bladder
D. Drug induced
Answer is D- anticholinergic effect of TCA
Other recall (medical) :
Middle age male on depression medication complaining of painful micturition, perianal
pain and inability to urinate for the past 12 hours, DRE shows palpable small tender
prostate, what is the most likely underlying cause?
A- Prostatitis
B- Neurogenic bladder
C-UTI
D-BPH
(no medication induced in the options)
Answer is A

44) A patient is brought to the emergency department after being found down by her
mother. She admits to the attending physician that she ingested a large dose of her
prescribed amitriptyline approximately seven hours prior. Which of the following pieces
of information would be MOST helpful in risk stratification of likelihood of having a
major cardiac or neurologic event due to her medication overdose?
A. Ingested dose
B. Peak serum amitriptyline concentration
C. Serum potassium level
D. QRS duration
Answer is D; To do ECG for QRS prolongation
If more than 100msec:
Stabilize the patient (ABC)
Give sodium bicarbonate
Benzodiazepines for TCA-associated convulsions

45) Cancer patient who seems depressed refuses treatment, how to

approach him?
A. Overrule
B. refer to psychiatry first
C. Respect his decision but ask why
D. I don't recall
Answer is B
Resource: Synopsis

25
46) Patient with 8 months history of low mood, anxiety,
irritability, difficultly in sleeping and concentration,
what is the diagnosis?
A- GAD
B- Undefined psychiatry problem
C- Mixed anxiety with depression
Answer is C
ICD-10 criteria is attached.

47) 60-old man seems low mood and looks depressed but
surgeon needs consent for a surgical procedure
"didn't mention lifesaving" but old man refuses and
surgeon gets the idea that he's alert and knowing what he's talking about
A-Surgery any way
B-Don't do surgery after explaining refusal causes
C-Ask his son to obtain power of attorney for old man’s incompetent
D-Psychological assessment then consent or not according to patient's wish
Answer is D
48) Patient k/c of hypertension and depression on multiple medications c/o Irritability,
insomnia, palpitations.
what is the next step?
A- Thyroid profile
B- start thyroxine
C- start antidepressant
Answer is A
Other recall:
D- review medications
Answer is D as a first step then do thyroid profile.

26
 Anxiety Disorders

Obsessive-compulsive disorder (included in the obsessive-

compulsive and related disorders), acute stress disorder, and
posttraumatic stress disorder (included in the trauma and stress-
related disorders) are no longer considered anxiety
disorders according to DSM-5, yet we will answer them in the
same chapter. 27
 Criteria of most important anxiety disorders for the exam:

generalized anxiety disorder DSM-5

There is strong support for a variety of psychosocial

therapies for anxiety disorders, including cognitive-
behavioral therapy (CBT), behavioral therapies, and
interpersonal therapy.

28
 Specific Phobia

Evidence indicates that CBT

is helpful for phobias, with
exposure therapy being the
most efficacious technique. Benzodiazepines, although
effective in alleviating some
Pharmacologic interventions—
phobic symptoms, are not
specifically selective serotonin
reuptake inhibitors (SSRIs) and recommended per current
selective serotonin norepinephrine guidelines due to adverse
reuptake inhibitors (SNRIs)—have effects and potential
been effective in treating social exacerbation of the phobic
phobia and agoraphobia response once discontinued.

Agoraphobia refers to a fear of or anxiety regarding places from which escape might be difficult. It can be
the most disabling of the phobias because it can significantly interfere with a person’s ability to function in
work and social situations outside the home. Patients with agoraphobia rigidly avoid situations in which it
would be challenging to obtain help. They prefer to be accompanied by a friend or a family member when
leaving home, especially if their destination is crowded or closed-in. Severely affected patients may simply
refuse to leave the house.
Duration: > 6months.
Symptoms: Fear or anxiety from: Public transportation, Open spaces, Confined spaces, being in a line or in a
crowd, Being alone outside of home, Avoidance of the situations, due
to: Fear of having a panic attack while there or, no access to a companion to help withstand the situation. Fear
and avoidance is out of proportion to the potential threat.
At least 1 of the above sources of fear, Marked distress or impairment, This is for cases in which the
above occurs without a panic disorder, despite the fear of having one.

29
Obsessive compulsive disorder DSM-5

30
31
  Questions about Anxiety Disorders:
1) 19yo female, scared from dust storm, she gets out of home with her family, during sand
storm she get inside bed and cover her head with pillow, what is the most likely
diagnosis?
A- Generalized Anxiety Disorder
B- Social Phobia
C- Specific Phobia
Answer: C, for proper diagnosis to fit criteria we need more details
2) Patient diagnosed with generalized anxiety disorder the best drug is?
A- SSRI
B- Benzodiazepine
Answer: A;
■ Benzodiazepines should not be used except for crises.
■ An SSRI should be used as first-line treatment.
■ SNRIs and pregabalin are second and third choices, respectively.
■ High-intensity psychological intervention and self-help (based on CBT principles) should be
encouraged.
■ Antipsychotics should not be offered (presumably this includes quetiapine).

3) Patient with social phobia and fear of recurrent symptoms, first line management?
Answer is SSRI

4) 27yo male after 12 months on war, he saw dead friends, and remembers difficult situations,
he is in low mood, and poor sleep, what is the most appropriate treatment?
A- Sertraline
B- Lorazepam
C- Amitriptyline
D- Lithium
Answer is A: explanation same as question 1, however; In this question case of PTSD and the
main complaint is mood affecting quality of life, and fit the criteria of depression so SSRI is the
choice. Giving short duration course of benzodiazepine can help to relieve poor sleep, yet the
importance of supportive therapy must be involved. Amitriptyline is good choice for mood +
poor sleep but not the first line of treating PTSD

5) Adult female complains of lower abdominal pain since 4 months, she says previous doctors
told her that she didn’t have any disease, she had been examined and did abdomen urine,
pelvic investigations and were normal. What is the most helpful in this situation?
A- Refer to psychiatrist
B- Frequent follow up visits
C- Perform exam and order investigations
Answer: A; clear.

6) Female has headache, mastalgia, and behavioral changes 10 days before her periods, and she
is asymptotic for the rest of the cycle. What is the Dx?
A. Pre-menstrual syndrome\ another recall; premenstrual tension syndrome
B. pelvic congestion syndrome

32
Answer is A, regardless PMS it’s not a real mental illness or even at DSM-5 unless occurred
with other mental features, explanation is to differentiate between it and PMDD which is
considered at mental disorder:

 Premenstrual dysphoric disorder (PMDD) occurs exclusively in the luteal phase of the menstrual
cycle and remits with the onset of menses
 PMDD is associated with a level of impairment that is similar to major depressive disorder and
poorer quality of life compared with community norms and should therefore be considered a
serious health condition.
 PMDD is diagnosed as a comorbid condition when the specific constellation of symptoms occurs
during the luteal phase, ceases in the follicular phase, and does not replicate the comorbid
condition’s main symptoms.
 In the treatment of patients with PMDD and severe PMS, the SSRIs should be considered first-
line, with various dosing strategies to increase efficacy.
 If luteal symptoms persist, increase the dosage of the antidepressant for the whole cycle,
Alternatively, switch to semi-intermittent dosing by maintaining the follicular dosage and then
increasing it during the luteal phase only.

33
7) A mother of a 3 months old baby Telling the doctor she’s going crazy She thinks that there’s
a snake near her baby. She said that she didn’t see the snake and she knows it’s not true. She
checks on baby crib 50 times a day What’s the most likely diagnosis?

A- Delusional
B- Hallucination
C- Postpartum Psychosis
D- Postpartum Obsession

Answer is D:

check
psychotic
disorders
chapter for
similar
scenario with
different
answer

8) patient was diagnosed with generalized anxiety disorder and has difficulty sleeping. the
following is used for management?
A-Alprazolam
B-Bupropion
C-Haloperidol
Answer: A between these choices A in short term management with CBT regardless that in clinical
practice there are better choices and to avoid addiction. Bupropion is used for anxiety treatment as
NDRI but can induce insomnia more than SSRI.

9) 20 y old male, keeps counting blocks, walls, etc. he keeps repeat counting, He feels guilty
and anxiety when he stops counting, what is dx?
A- Depression
B- Obsession
C- Compulsion
Answer: C; by definition of compulsion vs obsession

10) Pt known to have panic attacks. She described her last panic attack as if she was not in
the world, the environment is strange, what can explain her symptom?
A- illusion
B- derealization
C- depersonalization
Answer is B; derealization, one of the symptoms come with panic attacks.

34
10) 20yo girl, BMI is normal, she has fear from eat to not increase weight?

A- Body dysmorphic
B- Bulimia nervosa
Answer is A
Hint: normal BMI, obsessive thoughts only.

11) 17yo girl with refusal to maintain a weight within a normal range for her height and
age, fear of weight gain, severe body-image disturbance and amenorrhea for >3
cycles, what is the diagnosis?
A- anorexia nervosa
B- bulimia nervosa
C- body dysmorphic disorder
D- obsessive compulsive disorder
Answer is A
Hint: low BMI , symptomatic
12) A 19-year-old woman presents to the clinic for a routine physical check-up. On examination,
she has fine hair all over the body She feels fat and subsequently diets, BMI 16.8 kg/m2.
Which of the following is the most likely diagnosis?

A- Bulimia nervosa
B- Anorexia nervosa
C- Body dysmorphic disorder
D- Generalized anxiety disorder
Answer is B

13) A 16-year-old girl presents for a follow-up visit complaining that she is unable to eat because
of an intense desire to reduce her weight. Some time she develops an impulse to eat
excessively and she then follows the impulse. She then intermittently self-induces vomiting.
On examination, she looked weak. Which of the following is the most likely diagnosis?
A- Bulimia nervosa
B- Anorexia nervosa
C- Personality disorder
D- Obsessive compulsive disorder
Answer is B
14) A 19-year -old girl presents with a 12 kg weight loss over the last 6 months. She feels fat with
an intense fear of gaining weight. Over the last 4 months, the patient has had amenorrhea.
On examination, she has lanugo hair distribution. Height 167 cm, weight 42 kg. Which of
the following is the most likely diagnosis?
A- Bulimia nervosa
B- Anorexia nervosa
C- Masked depression
D- Generalized anxiety disorder
Answer is B
15) A 15-year-old girl presents to the clinic with history of tetany, swollen glands, and eroded
dental enamel. Potassium 2.8 3.5-5.1 mmol/l. Which of the following is the most likely
diagnosis?
A- Bulimia nervosa
B- Substance abuse
C- Anorexia nervosa
35
 D- Alcohol withdrawal
Answer is A

Notes:

36
16) post-partum distressed afraid for her baby she thinks that she might lose him:
Answer is: postpartum Anxiety;
Treatment includes behavioral therapy and/or medication ( SSRI, SNRI, TCA..etc)

17) patient >2m history of anxiety, irritability, impotence, sleep disturbance, lose 10 kg, no
sexual history abnormalities what is the diagnosis? “another recall 9 months”

A- Major depression
B- Secondary depression
C- Generalized anxiety disorder
D- Social phobia
Answer is C

37
18) Who will get benefit from CBT?
A- Social phobia
B- Schizophrenia
C- Depression with hallucination
Answer is A

19) panic attack symptoms and asked about

symptoms reliever?

A- SSRI
B- Benzodiazepines
Answer is A; in general 1st line SSRI, 2nd
line benzodiazepines. If question asked about
the urgent intervention at ER choose B.

20) Pt counts everything, on dining table, stairs,

etc. and tried but cannot stop doing this Dx?

A- Obsession
B- Compulsive
Answer is B; Simply; Obsession = thoughts, Compulsive = actions directed by obsessive
thoughts.

21) Someone who is having THOUGHTS that aliens land in his backyard when he leaves
his home. Although he knows that aliens do not actually exist, be he always has this
thought. He said to the doctor that these overwhelming thoughts will make him
insane. Dx ?

A- Obsession
B- Compulsion
C- Delusions
D- Hallucinations

Answer is A

22) Old man has stress in his life and he pull his hair and he has empty hair spaces?

A- Trichotillomania
B- anxiety disorder
Answer is A

 FYI: trichotillomania is categorized in dsm-5 as one of the

OCDs and impulsive control disorders. Unlike those with
OCD, patients with hair-pulling disorder do not experience
obsessive thoughts, and the compulsive activity is limited to
one act, hair pulling.
 onset has been linked to stressful situations in more than
one-fourth of all cases. Family members of hair-pulling
disorder patients often have a history of tics, impulse-

38
 control disorders, and obsessive–compulsive symptoms, further supporting a possible
genetic predisposition.
 Significant comorbidity is found between hair-pulling disorder and OCD; anxiety
disorders; Tourette’s syndrome; depressive disorders; eating disorders; and various
personality disorders—particularly obsessive–compulsive, borderline, and narcissistic
personality disorders.

23) Pt afraid from automobile started to feel anxious when she see a car ?
A- Panic attack
B- Specific phobia
C-Generalized phobia
D-Motor-phobia (fear of automobiles)
According to you colleague “ Not sure if D was there” Answer both B and D are correct,
so if D wasn’t there, choose B and we explained specific phobia in details in the booklet

24) young female presented to ER with tachypnea and tachycardia and hypercapnia, her
father mentioned that she recently failed in her math exam what is the diagnosis:
A- hyperventilating syndrome
B- Munchausen syndrome
C- anxiety disorder
Answer is A, Read more about it: https://www.msdmanuals.com/professional/pulmonary-
disorders/symptoms-of-pulmonary-disorders/hyperventilation-syndrome

25) A 22YO woman with a history of anxiety visits the dentist for a routine cleaning, in
the waiting room; she begins to complain to the receptionist that she feels extremely
dizzy and weak and that her vision is blurring, the receptionist realize she is having a
panic attack, which of the following is the most likely cause of this patient’s
symptoms?
A- decreased cerebral blood flow
B- oxygen toxicity
C- carotid artery occlusion
D- decreased respiratory rate
Answer is A; Anxiety & Panic attacks can cause hyperventilation which explained by
the physiological changes happened during the attack as fast breathing will decrease
CO2 in the blood and cause vasoconstriction so the blood flow decreases to the brain.

22) Female with increased anxiety and sleep disturbances, wakes up in the middle of
the night to check on her children, clean the house, and prepare lunch boxes, are
these activities causing her to feel relieved, what is your diagnosis? Other recall:
female asking for an antidepressant because she can’t sleep; she *repeatedly*
checks if the door is closed, if the oven is turned off, and checks her children's
school supply. She can’t control it, and if she does not do it, she can’t leave the
house
A. Delusional disorder
B. GAD
C. Compulsive - obsessive
Answer is B

39
23) Pt with irritability, excessive worrying, difficulty concentrating and sleeping. Which
of the following is the most likely diagnosis?
A- Mood disorder not otherwise specified
B- Major depression with anxiety
C- Anxiety with depression
D- Generalized anxiety disorder
Answer is D

24) A female patient counts the number of floor tiles and the number of steps she walks.
She is aware of her problem and when she tries to stop she gets mad and irritated.
What is the diagnosis?
A- Delusion.
B- Obsession.
C- Compulsion.
D- hallucination.
Answer is C

25) Female 20yr, she thinks that her nose need rhinoplasty. she absence many times
from classes, GP examine her and no abnormally detected, what to do?
A- refer to ENT
B- refer to psychotherapy
C- Reassure that she is normal
D- doesn’t remember
Answer is B

40
Bipolar Affective Disorder

41
  Review about Bipolar Affective Disorder:

diagnosis depressive episode – DSM-5:

Depression DSM-5 Diagnostic Criteria
A. 5 of the following symptoms have been present during the same 2 wk period and represent a
change from previous functioning; at least one of the symptoms is either 1) depressed mood
or 2) loss of interest or pleasure (anhedonia), not related to any other cause .
- depressed mood most of the day, nearly every day, as indicated by either subjective report or
observation made by others
- markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly
every day
- significant and unintentional weight loss/weight gain, or decrease/increase in appetite nearly
everyday
- insomnia or hypersomnia nearly every day
- psychomotor agitation or retardation nearly every day
- fatigue or loss of energy nearly every day
- feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly
every day (not merely self-reproach or guilt about being sick)
- diminished ability to think or concentrate, or indecisiveness, nearly every day
- recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific
plan, or a suicide attempt or a specific plan for committing suicide

diagnosis manic episode – DSM-5:

A. a distinct period of abnormally and persistently elevated, expansive, or irritable mood, and
abnormally and persistently increased goal-directed activity or energy, lasting 1 wk and
present most of the day, nearly every day (or any duration if hospitalization is
necessary)
B. during the period of mood disturbance and increased energy or activity, _3 of the following
symptoms have persisted (4 if the mood is only irritable) have been present to a significant
degree and represent a noticeable change from usual behavior
_ inflated self-esteem or grandiosity
_ decreased need for sleep (i.e. feels rested after only 3 h of sleep)
_ more talkative than usual or pressure to keep talking
_ flight of ideas or subjective experience that thoughts are racing
_ distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli)
_ increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor
agitation
_ excessive involvement in pleasurable activities that have a high potential for painful
consequences
(i.e. engaging in unrestrained shopping sprees, sexual indiscretions, or foolish business
investments)

42
\ diagnosis hypomania episode – DSM-5:
criterion A and B of a manic episode is met, but duration is _4 d
• episode associated with an uncharacteristic change in functioning that is observable by
others but not
severe enough to cause marked impairment in social or occupational functioning or to
necessitate
hospitalization
• absence of psychotic features (if these are present the episode is, by definition, manic)

diagnosis mixed episode – DSM-5:

an episode specifier in bipolar or depression that indicates the presence of both depressive and
manic symptoms concurrently, classified by the disorder and primary mood episode component
(i.e. bipolar disorder, current episode manic, with mixed features)
• clinical importance due to increased suicide risk and appropriate treatment
• if found in patient diagnosed with major depression, high index of suspicion for bipolar
disorder
• while meeting the full criteria for a major depressive episode, the patient has on most days
> 3 of criteria B for a manic episode
• while meeting the full criteria for a manic/hypomanic episode, the patient has on most
days >3 of criteria A for a depressive episode (the following criterion A cannot count:
psychomotor agitation, insomnia, difficulties concentrating, or weight changes)

Presence of psychotic symptoms

Mood + psychosis =
1) Schizoaffective if the psychotic symptoms are the prominent for 2 weeks or
more in absence of mood symptoms, and no underline stimulus or medical
issue.
2) Bipolar with psychotic features if the psychotic symptoms occur exclusively
during the mood episodes

43
 Important notes about Bipolar treatment:
1) Monotherapy with antidepressants should be avoided in patients with bipolar depression as
patients can switch from depression into mania.
2) Summary of medications:

44
 Questions about Bipolar Affective Disorder:

1) Bipolar Mx.
A- Bupropion
B- Lithium
C- Olanzapine
Answer: B, regardless no information in the question, if presence of psychotic symptoms
and prominent then chose olanzapine. In clinical practice the combination of mood
stabilizer and antipsychotics in such cases.

2) Bipolar disease feature in hypomania episode with weight gain & previous mania
episode what to give:
A- Lithium
B- Olanzapine
C- Mirtazapine
Answer: A, treat hypomania as mania, plus you need in this case to decrease recurrence
and avoid weight gain. Olanzapine is a good choice as antipsychotics but not needed in
this case and will increase weight.

3) Most common disease has mania:

A- Bipolar
B- Schizophrenia
Answer: A

4) Case about a man with depressive symptoms and low mood, his wife said he was
very happy, 3 months ago he bought an expensive car and said he is rich, what to
give him?
A- Lithium
B- olanzapine
Answer: question needs better recall for duration and symptoms and choices to
confirm diagnosis of bipolar disorder with mixed features with or without psychosis,
and as mentioned before, lithium is a good mood stabilizer but not the first line
treatment.
5) 32woman history of fatigue, often wakes up at 4:00 AM, unable to fall asleep again,
the patient has lost her usual interests, no appetite, she admits feeling guilty. stating
the patient recalls 2 episodes in the past 2 years when she felt “extremely well” and
very positive attitudes towards life, at that time, she slept only 4 hours a night but
did not feel tired, went to work early and very productive and made risky decisions
for her company, however she believes that she functioned well, never took excessive
risks and never experienced hallucinations. what is diagnosis?
A. Bipolar disease
b. Cyclothymic disorder
c. Dysthymic disorder
d. Major depressive disorder
Answer is B; Cyclothymic disorder is a milder form of bipolar disorder involving many
"mood swings," with hypomania and depressive symptoms that occur frequently. People
with cyclothymia experience emotional ups and downs but with less severe symptoms
than bipolar I or II disorder.

45
6) Pt is pregnant and using valproic acid, what is the recommended folic acid dose to be
used?
A- 1mg
B- 3mg
C- 5mg
Answer is C

7) Pregnant women on valproic acid, which of the following associated with it?
A. Polyhydramnios
B. Oligohydramnios
C. Neural tube defect
Answer is C

8) 28-year-old with bipolar disorder, treated for 6 months, presents for follow up visit.
On examination, she has 8 kg weight gain , generalized weakness and hair loss, What
of the following is the most likely cause ?
A- Hypothalamic disorder
B- hypothyroidism
C- verapamil
D- Lithium
Answer is D

46
Psychotic Disorder

47
  Review about psychotic disorder:
Definition of Psychotic disorder: characterized by a significant impairment in reality testing including:
A) Positive symptoms:
■ delusions or hallucinations (with or without insight into their pathological nature) ■ disorganized
behaviors ■ formal thought disorder
Delusions: fixed, false beliefs
Hallucinations: perceptual experiences without an external stimulus
B) Negative symptoms:
■ affective flattening ■ anhedonia ■ avolition ■ alogia ■ asociality
 Schizophreniform: criteria A, D, and E of schizophrenia are met; an episode of the disorder lasts for at
least 1 mo but less than 6 mo.

 Brief Psychotic Disorder: criteria A1-A4, D, and E of schizophrenia are met; an episode of the
disorder lasts for at least 1 d, but less than 1 mo with eventual full return to premorbid level of
functioning, can occur with a stressful event or postpartum

 Schizoaffective disorder: delusions or hallucinations for 2 or more wk in the absence of a major mood
episode during the lifetime duration of the illness. major mood episode symptoms are present for the
majority of the total duration of the active and residual periods of the illness

Summary for diagnosis Schizophrenia– DSM-5:

Schizophrenia DSM-5 Diagnostic Criteria
A. two (or more) of the following, each present for a significant portion of time
during a 1 mo period (or less if successfully treated). At least one of these must
be (1), (2), or (3):
1. delusions 2. hallucinations 3. disorganized speech (i.e. frequent derailment or
incoherence) 4. grossly disorganized or catatonic behaviour 5. negative
symptoms (i.e. diminished emotional expression or avolition)
B. decreased level of function
C. at least 6 mo of continuous signs of the disturbance. Must include at least 1
mo of symptoms (or less if successfully treated) that meet Criterion A
D. rule out mood symptoms or disorder
E. rule out medical causes or drug use

48
Summary for diagnosis Delusional Disorder– DSM-5:
A. the presence of one (or more) delusions with a duration of 1 mo or longer
B. criterion A for schizophrenia has never been met
Note: hallucinations, if present, are not prominent and are related to the delusional theme
C. apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired,
andbehavior is not obviously bizarre or odd
D. if manic or major depressive episodes have occurred, these have been brief relative to the duration
of the delusional periods
E. the disturbance is not attributable to the physiological effects of a substance or another medical
condition and is not better explained by another mental disorder

49
  Important notes about medications:
 atypical antipsychotics (second generation) are as effective as typical (first generation) antipsychotics but are thought
to have better adverse effect problems; main difference is lower risk of EPS and TD
 if no response in 4-6 wk, switch drugs
 duration: minimum 6 mo and usually for life in most patients with primary psychotic disorders; variable for other
indications.
 Long acting injection indicated in individuals with schizophrenia or other chronic psychosis who relapse because of
non-adherence. should have been exposed to oral form prior to first injection. dosing: start at low dosages, then titrate
every 2-4 wk to maximize safety and minimize side effects. side effects: risk of EPS, parkinsonism, increased risk of
NMS

50
  Questions about psychotic disorders & medications“Reference: Kaplan& Maudsley”:

1) Prognosis of schizophrenia:
A- 5% remission
B- 33% reduction of symptoms
C- 70% satisfied with their life
Answer is B: 60% manage their life relatively normal, remember rule of 1\3:
1\3 recover more or less completely, 1\3 episodic impairment, 1\3 chronic decline

2) Poor prognosis of schizophrenia:

A- Onset in adolescent years
B- Family History
C- Acute onset
D- Anxiety with flares
Answer: A, the early onset of the disease the poor prognosis and most of cases ends using
clozapine.
(positive – good prognostic factors: Acute onset, Female, living in developed country),
(Negative-poor prognosis factors: insidious symptoms, childhood and adulthood onset,
poor premorbid function, cognitive impairment)

3) Regarding postpartum Psychosis:

A- Recurrences are common in subsequent pregnancies
B- It often progresses to frank schizophrenia
C- It has good prognosis
D- It has insidious onset
E- It usually develops around the 3rd week postpartum
Answer: A & E both are correct!!
According to Kaplan: The symptoms of postpartum psychosis can often begin within days of the
delivery, although the mean time to onset is within 2 to 3 weeks and almost always within 8 weeks of
delivery. A favorable outcome is associated with a good premorbid adjustment and a supportive family
network. Subsequent pregnancies are associated with an increased risk of another episode, sometimes
as high as 50 percent.

4) Psychiatry Pt come to clinic talking to his mom who died when he was young saying she is
next to him no one can see her but him symptoms for 1 week?
A) Visual hallucinations
B) Auditory hallucinations
C) Acute psychosis
Answer is C

5) Case of paranoid schizophrenia with positive and negative symptoms asking about
treatment?
A- Fluphenazine
B- Clozapine
C- Chlorpromazine

51
 Answer is B; in general, it’s better to start with atypical antipsychotics, if not in the choices then
choose typical antipsychotic. Clozapine is last line used for resistant psychosis and refractory
cases.
-Fluphenazine is high potency typical dopaminergic D` and D2 receptors can worsen negative
symptoms
-Chlorpromazine is an atypical antipsychotic but has low potency.

6) 21-year-old college student, came with her parents, they said she had four months
ago auditory hallucinations, she believed that the TV inserted ideas in her brain and she had
social issues and withdrawn from the last semester, but no mood issues, then now she become
fine and retuned normal. What is the diagnosis?
A- Conversion disorder
B- Schizophrenia
C- Mania episode from bipolar
Answer is B regardless the wrong duration but the closet answer, according to the duration it should be
schizophreniform, no neurological symptoms so A is excluded, no mood symptoms so C is excluded.

7) 34yo male believed that his company implanted him with chip to steal his ideas, he denied low
mood. What is the most diagnosis?
A- Schizophrenia
B- Schizophreniform
C- Brief psychotic episode
D- Manic episode
Answer???: it depends on the duration too, it can be any of the first 3 answers, check the notes before
for clarification.

8) 56 yo newly diagnosed with schizophrenia prescribed new neuroleptics, he is at risk of what?

A- MI – dose dependent, duration within a month of starting the medication, high risk with
FGA
B- Seizure
C- Hyperthermia\NMS- most dangerous, duration
in the first 2 weeks, life threatening
D- Akathisia\EPS – more common with variety
between FGA and SGA.
Answer is D; Extrapyramidal Symptoms common side
effects of antipsychotics;
incidence related to increased dose and potency.
- Acute (within 10 days, early-onset; reversible)
- Tardive (within 90 days, late-onset; often
irreversible)
- Acute: lorazepam, propranolol, or
diphenhydramine
- reduce dose or change antipsychotic to lower
potency.

52
9) Patient known case of schizophrenia on two medications had abnormal orofacial and limb
movements. What is the most likely explanation?
A. Positive Schizophrenia Symptoms
B. Tardive Dyskinesia
C. Catatonic Movement
Answer is B

10) Female patient known case of schizophrenia for years and on antipsychotic, complaining now
of abnormal facial movements, What is the dx?
Tardive dyskinesia; Long term use of antipsychotics.

11) 24yo newly started antipsychotic presented with neck stiffness, abnormal facial movements
and eye blinking, no other abnormalities in examination, what is your diagnosis?
Answer is: Acute dystonia “EXTRAPYRAMIDAL SIDE EFFECTS OF ANTIPSYCHOTIC DRUGS”
happens in short period after using antipsychotics.

53
12) Most common antipsychotics causes weight gain:
- Toronto notes: Risk of weight gain: Clozapine > Olanzapine > Quetiapine > Risperidone
- Maudsly:

13) Clozapine is the best to treat child with:

A- Bipolar
B- Schizophrenia
Answer: B, but not the first line to treat schizophrenia. FYI, the early onset of
schizophrenia the poor prognosis and most of them will be on clozapine.

14) What’s the effect of anti-psychotic drugs on schizophrenia?

A- Decrease delusions
B- increase apathy
C- improve communications
Answer: A; the goal of maintenance treatment of schizophrenia is to minimize symptoms
and functional impairments, minimize side effects of pharmacotherapy, avoid relapses, and
promote recovery that allows self-determination, full integration into society, and pursuit of
personal goals.

15) Schizophrenic pt with constipation and huge bowel what was the treatment?
Answer is Clozapine; Medications with anticholinergic activity: Antipsychotics (especially
clozapine), Antidepressants (especially TCAs), Opioids.

16) Women with schizophrenia (on two medications, i forgot name) had orofacial abnormal
movement taking two medications (metoclopramide, another drug):
A- Catatonic movement
B- Tardive dyskinesia
C- Positive schizophrenia symptoms
Answer: B; metoclopramide interacts with antipsychotics (dopamine antagonists) cause
EPS & TD
17) Symptoms of delusion for 3 months then return to normal without any tx?
A- brief psychotic
B- schizophreniform
C- delusional disorder
D- Schizophrenia
Answer is C if the same scenario. Against choice A & D because of duration, might be
choice B if the scenario has more details about the symptoms positive or negative symptoms

54
18) patient has hallucinations and delusions for 6 months then get away without
medication?
A- Schizophreniform
B- Schizophrenia
Answer is A based on duration

19) Patient turns to be erratic, for 4 months he said that's people in TV knows what he is
thinking about, in last 2 months he claim that he has special power that no one has
what is the most likely diagnosis?
A- Uni-polar
B- schizophrenia
C- Bipolar – mania
Other recall of different answers:
A) schizophrenia
B) conversion syndrome
C) manic episode of bipolar disorder
D) cyclic depression
Answer should be delusional disorder because of two types of delusions; thoughts broadcast
and grandiose delusions, however if not in the choices choose schizophrenia although even it
supposed to be Schizophreniform because of the duration.

20) Sever schizophrenia, how to manage? (no choices provided with the question)
Answer, always start with atypical antipsychotics then typical, last choice is clozapine. (check
notes about medications)

21) Psychiatric case about a patient with bad hygiene,

muttering, good memory, echolalia, echopraxia and bad
hygiene 2 months. Patient is oriented. How would you
treat?
A- Lithium
B- Oxcarbazepine
C- Venlafaxine
D- Amisulpride
Answer: D, one of the atypical antipsychotics effective in
argumentation, but remember the first line therapy for
catatonic schizophrenia is benzodiazepine. 

22) 23 years old, he came complaining of the first time

hearing sounds (auditory hallucinations) What is your
management?
A- Olanzapine
B- Fluoxetine
C- Antipsychotic & CBT
D- CBT
Answer: C: Brief psychotic episode: Antipsychotics important to balance the dopamine
irregularity caused hallucination and CBT is a technical way to improve quality of life as it
can be traumatic to some patients.

55
23) Patient admitted to Psychiatry with acute psychosis and eventually
schizophrenia as this was his first episode of psychosis, treated with antipsychotics, which
of the following statements regarding his prognosis is TRUE?
A- Antipsychotics are effective in treating 95% of patients with a first episode of psychosis.
(correct is 30-50%)
B- full remission from an episode of psychosis typically takes 3-6 months (Full recovery is
unusual, so no definitive period).
C- If medications are discontinued, the relapse rate is 60% at 6 months (Approximately 80%
of patients relapse within 1 year if antipsychotic medications are stopped, whereas only
20% relapse if treated)
D- More than 25% of schizophrenia patients commit suicide. (according to studies between
5-20%, greater risk of homicide during first episode psychosis that accounted for 38.5 per
cent of homicides)
E- Prognosis depends on severity of symptoms at initial presentation.
Answer: E. depends on the onset was it insidious or acute, and the type of symptoms positive
or negative or combined with the medication response, and presence of other prognostic factors.
(his question is based on many studies, not one source, I tried to explain each choice
individually).
24) Male patient said that aliens took him and put their thoughts in his mind, what is the
most appropriate management?
A- Antidepressants
B- Antipsychotic
C- bereavement encouragement
D- mood stabilizer
Answer is B
Other recall 29yrs. old male present complaining of repeated thoughts about aliens arriving
to his house, inserting their thoughts in his mind, which of the following describes what he
has?
A- Hallucination
B- Delusions
C- Obsessions
Answer is B

25) Pt at the clinic always looking the right direction and when asked he says my mother is
there and no one can see her except me, family stated she’s dead but he insisted that she
is there but comes and goes, what explained this condition?
A- Delusional disorder
B- Visual hallucination
C- Auditory hallucination
D- personality disorder
Answer is: B

56
26) A mother postpartum 3months, telling the doctor she sees snakes near her baby, what is
your diagnosis?
A- Hallucination
B- Postpartum psychosis
C- Delusion
D- Baby blues
Answer is B;  

27) Women just had her baby 3 months

ago claims that she sees snails at his crib at night:
A- Hallucinations check anxiety
B- Delusions disorders chapter for
C- Obsessions similar scenario with
D- postpartum psychosis different answer
Answer is D

28) Young person his father died for three days he had
disorganized speak and behavior walk outside
without clothes and see his father then he returns to
normal what is Dx?
A- Brief psychotic disease
B- schizophreniform disorder
C- Reactive psychosis
Answer: Answer might be C if it’s an old question;
This question might be a bad recall as A & C now
are similar answers according to DSM- 5
classifications brief psychotic disorder with marked
stressor previously was called brief reactive
psychosis in DSM-4.
Other recall:
Male lost his ability to speak after finding out about his
father's death, started to undress and run in the street
saying his father is telling him to do it to honor him, after
3 days he returned to being normal with hazy memory of
what happened, What is the dx?
A- Schizophrenia
B- Brief psychotic disorder
C- schizophreniform
Answer is B

29) 21 yo male complains of sounds tell him that “will stick out his thoughts “since 4 months
what is the diagnosis:
A- Mania
B- Schizophrenia
C- Mood disorder
Answer is: 4 months of auditory hallucination only is schizophreniform, if not
mentioned and no other mood symptoms so schizophrenia is the closest answer
regardless the duration

57
30) 40 years old male pt come with his brother, he was completely healthy after that he
started 3 months ago to be aggressive and irritate everyone in house and work flight of
idea can’t complete sentence, diagnosis?
A- Dementia
B- Alzheimer’s
C- Schizophrenia
D- Schizophreniform disorder
Answer is D; based on age, duration of symptoms and
theses options.

31) Man hears some voices from the toaster that the food is poisoned?
A- Auditory hallucination
B- Delusion
C- Visual hallucination
Answer is A

32) Female postpartum 2 weeks, disoriented confused said that the baby lucky to be alive,
saying inappropriate answers, and she says that her child won’t live long?
A- Postpartum depression
B- Postpartum neurosis
C- Postpartum blues
D- Postpartum psychosis
Answer is D

33) Man put a cover on the television because he thinks the government is watching him, he
says god himself told him to that?
A- Schizophrenia
B- Mania
C- Depression
D- Delusional Disorder
Answer is D
More explanation: Pt thinks government watching him = persecutory delusion
Pt hears voices like god talking to him= auditory hallucinations
So answer is schizophrenia

If:
Pt thinks government watching him = persecutory delusion
Pt believes god told him that cuz for example he is special and in contact with god but
didn’t hear a voice = grandiosity delusion
So answer is delusional disorder

34) Man get easily provoked, he thinks he has super power and he thinks the government is
watching him from TV, he says god himself told him to that, all this symptom for 4
months, what is your diagnosis?
A- Schizophrenia
B- Manic episode of bipolar
C- acute cyclic depression
D- conversion syndrome
the closet answer is A; preferred if there is an option of delusional disorder

58
35) elderly with psychosis came to ER they increased the dose of haloperidol then he
deteriorated what will u do?
A- Intubate
B- Lavage
C- Naloxone
missing too much information about vitals, kind of deterioration, the increased
dose was within normal range or toxic dose
 If EPS - give Anticholinergic drugs; benzotropine
 If NMS - give either bromocriptine, dantrolene or amantedine as antidote with
possible ICU admission
 If toxicity: vitals & ECG, start ABC, gastric lavage or induction of emesis
followed by active charcoal, IV fluid
 With possible include ECT in the management.

36) young patient hearing voices for 3 months, what is the diagnosis?
A-brief psychotic disorder
b) schizophrenia
c) schizophrenia spectrum disorder.
the right term is psychotic spectrum disorders;
spectrum of psychotic disorders are conditions share similar symptoms to schizophrenia but are
classified differently based on certain factors, such as the length of the psychotic symptoms and
the presence of mood disorder characteristics, including Schizophreniform
disorder, Schizoaffective disorder, Delusional disorder, Brief psychotic disorder.

37) Student experienced delusional thoughts hearing voices for 3 months that resolve
without med?
A. Schizophrenia
B. Schizophreniform
C. delusional disorder
D. Brief psychotic disorder
Answer is B due to duration and mix of hallucination and delusion symptoms

38) Women with Auditory hallucinations, starts to think that these voices tell others what
she thinks of. What's the most likely diagnosis?
A. Schizophrenia
B. Mania
C. Major depressive disorder
D. Bipolar disorder
Answer is A

39) 32yo female schizophrenic maintained on 225mg clozapine, went to do sleeve

gastrectomy without telling the doctor she is ill, 5days after the surgery she came with
her family to your clinic complaining of schizophrenia episode and they started her
medication gradually but no response, what should you do?
Answer: Referring her to psychiatrist would be a safest choice for GP level because this
medication needs close monitoring and routine investigation.

59
40) A girl is experiencing changes in the voices she hear, and she thinks they're able to '
suck out her thoughts':
A- schizophrenia
B- Mania
C- Mood disorder
Answer is A

60
Substance Abuse &
Smoking

61
  Review about addiction:

criteria for substance use disorders:

criteria for substance use disorders (PEC WITH MCAT)
■ use despite Physical or psychological problem (i.e. alcoholic liver disease or cocaine
related nasal problems)
■ failures to full External roles at work/school/home
■ Craving or a strong desire to use substance
■ Withdrawal
■ continued use despite Interpersonal problems
■ Tolerance, needing to use more substance to get same effect
■ use in physically Hazardous situations
■ More substance used or for longer period than intended
■ unsuccessful attempts to Cut down
■ Activities given up due to substance
■ excessive Time spent on using or finding substance

Drugs s\s of intoxication Withdrawal s\s

Depressants Alcohol, opioids, Euphoria, slurred Anxiety, anhedonia,
barbiturates, speech, disinhibition, tremor, seizures,
benzodiazepines, GHB confusion, poor insomnia, psychosis,
coordination, coma delirium, death
(severe
Stimulants Amphetamines, Euphoria, mania, ‘Crash’, craving,
methylphenidate, psychomotor dysphoria, suicidality
MDMA, cocaine agitation, anxiety,
psychosis (especially
paranoia), insomnia,
cardiovascular
complications (stroke,
MI, arrhythmias),
seizure
Hallucinogens LSD, mescaline, Distortion of sensory Usually absent
psilocybin, PCP, stimuli and
ketamine, ibogaine, enhancement of
salvia feelings, psychosis (++
visual hallucinations),
delirium, anxiety
(panic), poor
coordination

Euphoria occurs in (Intoxication) almost 4 substances: Amphetamine “Stimulants”- Cannabis/Marijuana

- Opioid / Heroin – Inhalant, but always the other sx differentiates them.
 Amphetamine (Euphoria + poor appetite so wt. decrease + it causes Nausea & Vomit) and hallucinations
 Cannabis: increase appetite and high mood + Red eye + hallucination.
 Opioid: slurred speech + Drowsiness
 Inhalant: drowsy, unsteady gait + nystagmus

62
 - Antidotes of common drugs: Don’t forget ABC and hydration &
observation
1) Opioids, Heroin : naloxone hydrochloride
2) Cocaine: IV diazepam to control seizures, aspirin for chest pain and cooling
3) Amphetamine: antipsychotics for acute psychosis , benzodiazepines for agitation, β-blockers
for tachycardia & hypertension
4) Hallucinogens: benzodiazepines or high potency small dose of antipsychotics seldom
5) Alcohol “ with specific criteria”: Fomepizole
6) Benzodiazepine: Flumazenil

Smoking cessation:
In patients willing to quit apply 5A’s rule + motivational behavior therapy ± medications
Ask if the patient smokes, Advise patients to quit, Assess willingness to quit, Assist in quit attempt,
Arrange follow-up

63
Important notes about smoking cessation medications:
 If patient anxious = avoid Bupropion.
 If patient with Seizure, eating disorders and alcohol dependence = Avoid Bupropion.
 Varenicline = FDA approved agent for smoking cessation. “safe in cardiac patient”, reduce rates
by 50%.
 Although nicotine replacement therapy is the nicotine agent that double the cessation rate.
 Nicotine replacement therapies increase the risk of birth defects and should not be used during
pregnancy. counselling is recommended as first line treatment ◆ nicotine replacement
therapy (NRT) should be made available to pregnant women who are unable to quit using non-
pharmacologic methods ◆ intermittent NRT use (lozenges, gum) is preferred over continuous
dosing of the patch ◆ no strong evidence that either major positive or negative outcomes were
associated with gestational use of bupropion or varenicline; consider using only if benefits
outweigh risk.
 Buspirone not approved by FDA regardless the articles mentioned it decrease withdrawal
symptoms of nicotine anxiety for short period.

64
65
 Questions about Smoking & Addiction:

1) 45 yo smoker came to clinic for his diabetes checkup. During session he acknowledged that
smoking is not good for his health. He plans to quit this year. According to the stages of
change model, at which stage of change is this patient?
A- Pre-contemplation
B- Contemplation
C- Preparation
D- Maintenance
Answer is B; check previous notes for explanation

2) A patient has recently stopped smoking and has started using nicotine replacement patches.
The patient is motivated to quit smoking and is actively taking steps towards achieving that
goal. Which stage of smoking cessation is the patient currently in?
A- Action
B- Preparation
C- Contemplation
D- Pre-contemplation
Answer is A; Action

3) Pt is heavy smoker came for checkup, he has no intention for quitting at all, how to
manage? Other recall: A guy came for follow up and he has been smoking for 20 years and
feels fine. What to do?
A- Let him attend smoking cessation classes
B- Nicotine replacement therapy
C- Set a quit deadline
D- Personalized advice
Answer is D; Pre-contemplation stage, give advices about benefits of smoking cessation and
increase awareness

4) Man came to smoking cessation clinic welling for quitting after buying nicotine patch .
What stage ?
A- Action
B-Preparation
C-Contemplation
D-Pre-contemplation
Answer is B; He didn’t stop smoking yet and took a step and planning to quit.

5) Female smoker wants to quit\ A 35 years old male he came for smoking cessation, what is
most appropriate to give for smoke cessation?
A- Nicotine patch
B- Varenicline
C- Bupropion
D- Amitriptyline
Answer B

66
6) smoking cessation for pt with chest pain on exertion and relieved by rest on examination
he’s anxious with nicotine staining on fingers
A- Buspirone
B- Varenicline
C- Nicotine replacement therapy
Answer: B

7) Smoker with anxiety wants to stop smoking initial mx :

A- Bupropion
B- Varenicline
C- Nicotine replacement
D- Motivational support
Answer: D then B (asking about initial)

8) Male patient is heavy smoker and he is known to have epilepsy which is well controlled on
carbamazepine. Patient is counseled for smoking cessation. Which of the following is
contraindicated in this patient?
A- Nicotine replacement therapy
B- Varenicline
C- Bupropion
Answer: C

9) Wants to quit smoking best initial intervention?

A- Nicotine replacement
B- motivation
C- bupropin
D- Varenicline ( Chantix)
Answer: B

10) pregnant smoker useful tool for smoking?

A- Bupropion
B- Varenicline
C- Behavior therapy
D- Nicotine replacement therapy
Answer: C

11) Pregnant woman on her antenatal visit she is smoker for long time, she now concerned
about the complications of smoking on her fetus, what is counseling advise to quit
smoking?
A- Continue smoking
B- Non nicotine chewing gums
C- Nicotine patches
D- Advise her to stop smoking

Answer is D as an initial management and counseling. If failed to quit, Answer is B

67
12) A pregnant lady and smoker, failed to quit smoking what would you do?
A. Advice to have a small amount of cigarettes.
B. Bupropion.
C. nicotinic gum.
D. Nicotine patch
Other recall: C- non-nicotine chewing gum.
Answer is C
Smoking small amounts of cigarettes is like smoking regularly in the same risk on fetus and
can’t be used with NRT.
Nicotine patches are not ideal for pregnant women as they deliver a stronger flow of
nicotine in comparison to nicotine gum.
Bupropion .. not fully studied but some research suggests that taking bupropion during
pregnancy might be associated with miscarriage or heart defects.

13) Pt has long history of cardiovascular disease with chest pain, on examination:
peripheral cyanosis, JVP around 8 cm above normal, nicotine stain on his fingers,
what is the next step:
A- Motivational therapy
B- Bupropion
C- Varenciline
D- Nicotine replacement therapy
Answer is: A; as the question about initial step

14) 53 years old male patient heavy smoker presented with sob cyanosis and distended jvp
the patient is heavy smoker for many years wants to quit now?
Answer:
Best: Vareniciline
Next step: Behavioral therapy

15) Pt with symptoms of Opioid withdrawal, asking how to prevent such case?
A- Naloxon
B- Methadone
C- Cefdoxacod
Answer: B

16) Which of the following is the peak of nicotine withdrawal symptoms after smoking
cessation?
A- A day
B- 2 to 4 days
C- 5 to 7 days
D- 8 to 10 days
Answer is B
Withdrawal symptoms start (8-24hrs), Peak at first 3 days (48-72hrs), End at 4-10
days.
17) Drug abuser agitated and has palpitation for a couple of days, what is the cause of his
symptoms:
A- Cocaine withdrawal
B- Amphetamine toxicity
Answer is A;

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  Cocaine withdrawal: initial “crash” (1-48 h): increased sleep, increased appetite,
dysphoria • withdrawal (1-10 wk): dysphoric mood plus fatigue, irritability, vivid
unpleasant dreams, insomnia or hypersomnia, psychomotor agitation or retardation
 Amphetamine toxicity: intoxication characterized by euphoria, improved
concentration, sympathetic and behavioral hyperactivity, can mimic psychosis.
18) 16yo boy came to ER with hx of euphoria, agitation and visual hallucination, what did he
take?
A- Cannabis
B- Amphetamine
C- Opioids
Answer is B

19) 18 years old male presenting with 1 week history of euphoria, nausea vomiting, weight loss,
agitation, hallucinations. What is the diagnosis?:
A. cannabis intoxication
B. Amphetamine intoxication
C. Cocaine withdrawal
D. Schizophrenia
Answer is B

20) A 33yo drug addict wants to quit. She says she is ready to stop the drug abuse. She is
supported by her friends and family. What drug tx would you give her?
A- Benzodiazepines
B- Diazipoxide
C- Lithium
D- Methadone
E- Disulfiram
Answer: A by exclusion; B & E can reduce withdrawal symptoms specially for alcohol, & D for
opioids, but A reduce withdrawal symptoms in general; irritability & anxiety with withdrawal
symptoms as she is having good family support to control other symptoms I think
Benzodiazepines is the best answer by exclusion. C is used for controlling mood swing but not the
first choice.

21) Nicotine Effects?

A- lung cancer
B- Addiction
C- HTN
Answer B; as they can't easily stop smoking, and not all smokers have HTN but they are at
risk of it, and lung cancer is a late risk.
22) Heroin addict want to start a program to eliminate the addiction, which drug would you
choose?
A- Naloxone
B- Methadone
Answer is; B
Naloxone: used in case of overdose of opioids , short acting, rapid intervention.
Methadone: used to help to reduce or quit use of heroin or other opiates, long acting, control
withdrawal symptoms.
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23) Which among the following is not a side effect of bupropion?
A- Diarrhea
B- Dry mouth
C- Increased sweating
D- Blurred vision
Answer is; A
24) Patient want to start smoking cessation, which of the following has the most successful rate?
“incomplete choices”
 Explanation:
Most successful rate based on studies:
1) Combination of behavioral therapy with pharmacological therapy
2) Combination NRT (short and long acting)
3) Varenicline (the answer of other recall asking about most successful rate between drugs )
4) Combination varenicline and nicotine patch
5) Bupropion

According to Maudsly:
 In those people wishing to make an attempt to give up there are three first‐line stop‐smoking
medications that are recommended by NICE: nicotine replacement therapy (NRT), varenicline
and bupropion, all of which at least double the chance of success- fully stopping. Quit rates can be
increased further if the smoker is also provided with behavioural support from a trained tobacco
dependence treatment advisor.
 Combination NRT more effective than using a single NRT product and has a similar efficacy to
varenicline, and a greater efficacy than bupropion

25) An IV drug addict (they didn't mention the exact substance) was brought to the ER. The
patient is unconscious, had a very low RR, pupils were pinpoint. What is the most
appropriate management?
A- Atropine
B- Naloxone
Answer is B, & if asked about initial management
so ABC
Narcotic drugs, either legal or illicit, can constrict
pupils. These include heroin, morphine,
hydrocodone, and fentanyl. Overdose on these
drugs can also lead to pinpoint pupils.

70
26) 55yo man was referred for further assessment of his intentional tremors. What physical
examination will support the diagnosis of alcohol related tremor?
A- Aphasia
B- Hypertonia
C- Narrow steps gait
D- Dysdiadochokinesia
Answer is D; Cerebellar ataxia is
associated with alcohol use.

27) paramedics were called to the

home of a 19yr young man who
was found lying on the floor of
his apartment, unresponsive. At
the scene the patient’s blood
pressure was 102/80, his pulse
was 60 and respirations rate was 12 and shallow. The patient’s pupils were constricted and
non-reactive, his skin was cool and cyanotic, at the hospital, physicians were able to
resuscitate the patient and he eventually maintained normal, vital signs after several hours
of treatment, which of the following most likely caused this patient’s initial symptoms?
A- Cocaine
B- Phencyclidine.
C- Methamphetamine
D- Heroin
Answer is D

28) man presents to the emergency department with perspiration, euphoria and confusion. His
vitals are as follows, BP is 80/55, respiration is 10 and pulse 60 irregular with pupillary
constriction and clouded sensorium, which of the medication is the appropriate antidote in
this emergency?
A. Naloxone
B. Bupropion
C. Acamprosate
D. Chlordiazepoxide
Answer is A- opioid toxicity
29) A 40yo drug addict man presents to ER with 1hr history of unconsciousness. On
examination he has pinpoint pupils and respiratory rate of 8\ minute, which of the following
is the most appropriate treatment?
A- Atropine
B- Naloxone
C- Furosemide
D- N-acetylcystein
Answer is B – opioid toxicity

71
Child & Adolescents
Psychiatry
Will explain based on the question as nothing specific in it

72
  Questions about Child psychiatry:
1) A 3-year-old male came with his mother complaining because he yelling, hitting and Say
“no”, your Dx.?
Other recall:
A- mental retardant
B- depression A- Temper tantrum
C- temper tantrum B- Depression
C- Major anxiety disorder
D- oppositional defiant disorder
D- Anxiety with depression
Answer: C, if its repetitive with other features fit the criteria then D

2) Child 3 years presented with his mother to the clinic complaining of night walking after 3
hours of sleep and agitation, screaming and tachycardia.
A-Reassure
B- Brain imaging
C- EEG
Answer is A.
3) A mother brought her 4 years old child because he frequently wakes up in the middle of the
night setting on the bed, eyes opened but unresponsive for 2-3 min then he goes back to sleep,
in the morning he doesn’t remember what happened?
A- night terror
B- night walking
C- nightmares
D- epilepsy
Answer: A, not B because he is not walking and no behavior, not C because he doesn’t
remember or scared, and of course not D

73
4) 12 y old female, acne, menorrhea, and 29 BMI, Agitated, not cooperative in examination You
have considered:
A- Mood
B- Behavior
C- Substance use
D- Anxiety
Answer is B, remember it’s an age of puberty with multiple hormonal & body changes,
personality maturity, many factors can lead to behavioral issues. Mood swings associated with
hormonal changes but in certain patterns.

5) A 7-year-old boy is brought by his mother because he was unable to sit in school without
interrupting the class, wandering around the classroom or poking his neighbors. On
examination, he has normal growth parameters. Which of the following is the best
management?
A- Bupropion
B- Paroxetine

74
 C- Guanfacine
D- Dextroamphetamine
Answer is D

6) Mother with an ADHD kid, complaining of his behavior, she was told to do positive
reinforcement of good things and ignoring bad things, which of the following would help her
to achieve the advice?
A- Mother training program
B- Behavior management
C- Timeout to positive reinforcement
D- Family therapy
Answer: A (focusing in the question about the mother, if about the child then B)

7) Child with suspension of ADHD, the mother complains that he’s making so much trouble and
has difficulty concentrating but at the clinic he was calm and cooperative what to do?
A- Ask more information from teachers and parents
B- Tell the mother it’s normal for his age
C- Reassurance and discharge
D- Stimulating therapy
Answer is A; (symptoms must be present in 2 settings)

8) Child had difficulty in concentrating, talkativeness (mentioned 4 features of ADHD ), what is

an appropriate way of preventing this condition?
A- pre-school screening
B- refer to special education classes
C- avoid prenatal use of stimulants / neurotoxins
D- limit TV watching and fast response video game
Answer is B ( child is already diagnosed and symptomatic)
Answer will be C if asking about prenatal prevention method for next baby for example.

Few notes about ADHD:

 non-pharmacological:
psychoeducation,
behavioral management
i.e. parent training,
classroom management,
social skills training
 pharmacological: 1st line
stimulants
(methylphenidate,
amphetamines); 2nd line
atomoxetine; 3rd line/
adjunct non-stimulants
(guanfacine, clonidine,
buproprion).

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  for comorbid symptoms: antidepressants, antipsychotics

 primary prevention initiatives include programs that promote maternal health during pregnancy,
such as warnings against alcohol and cigarette use, as well as initiatives to reduce environmental
toxins, such as lead and mercury. These initiatives will not eradicate ADHD, but they may lower
incidence rates.
 secondary preventive interventions include: Early detection, prior to the onset of serious (or in
some cases any) symptomatology, leads to the implementation of an intervention designed to
reduce (or eliminate) the likelihood of severe consequences in the future.
 tertiary prevention psychostimulants or parent training for individuals with ADHD.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3441940/

9) 5 yrs old child brought by his parent to

pediatric clinic , he have rapid eyes blinking for
2 weeks, the episode is not associated with
redness, pain, tearing or discharge. He was
communicating well when he talk to his parents
, all physical exam and labs normal .
what the most likely have ? other recall: 2 years
old child with history of repetitive eye blinking
few times per day and last few days and then
resolved. He is conscious between attacks?
A- Tics
B- Tourette syndrome
C- ADHD
D- Dry eye syndrome
Answer: A 
10) A mother presented to you with her 2 years’
child who was yelling and throwing himself on the floor, how would you deal with her
A- Positive reinforcement counseling
B- Ignorance counseling
C- Strict and firm counseling
Answer: A: behavioral therapy and positive reinforcement

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11) 12y old obese patient came to the clinic crying and saying he “want to take pills to die
“because his friends bullying him. what you should do:
A- Give him a plan to reduce weight
B- Discharge and advice
C- urgent referral to psychiatrist.
D- give fast acting antidepressant
Answer: A, reassurance and behavioral therapy in addition to medical management,
then if no improvement or high risk then referee him to
psychiatrist.
Not D as some antidepressants can increase weight and
appetite and there are limited choices for pediatric age, plus
nothing is fast acting.

12) Child has moved to other city, when school started he feels
down and finds it’s difficult to make friends, what’s dx?
A- Adjustment disorder
B- Dysthymia
C- Hypomania
Answer is A; 

13) 7 yo child has recurrent abdominal pain and nausea, recently

starting school, social and school phobia is suspected, what
should you do?
A- Amitriptyline
B- Domperidone
C- Keep him away from school for 3 months
D- Let him engage in age specific activities.
Answer is D

14) 13 years old male present with his parents complaining that he loves to set things on
fire, the noticed this behavior started 6 months ago, they also noticed that he extends his
arm in 45 degrees from time to time. On P/E looks well and quiet, no finding aside from
short mustache, what is the most likely diagnosis?
A- Pyromania
B- Schizophrenia
C- Borderline personality disorder
D- Mimic syndrome
Answer is A

15) Child started to develop sense of individuality,

awareness for strangers and separation anxiety,
how old is the child in months?
A- 6 months
B- 7 months
C- 10 months
D- 12 months
E- 24 months

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Closet answer is C; 10 months
Child Develops stranger anxiety by (6–9 months) and separation anxiety starts by 8-9 months,
peaks at 12-24 months, lasts till 3 years old.
Other recall: At what age in months children typically manifest anxiety towards strangers?
A. 3
B. 6
C.8
D.12
Answer is B
16) Child present with periumblical pain nausea and vomiting in the morning related to
school and separation anxiety?
A- stop school for 3 month
B- involve the child with peers’ activity
C- start citalopram
D- other psycho med
Answer is B
17) 16yo and plays sport, has erratic behavior, extreme mood swings. Irritability, feelings of
aggression toward his parents and teachers and feelings of invincibility, says he feels like
he could fly and his mom says that he has never acted like this before. The patient
denies depressive feelings, states that in general he feels really good, Denies suicidal
idea. He seems unworried about his own state of mind. mother is concerned about his
sport practice what condition is likely to present in this way?
A- anabolic steroid abuse.
B- marijuana intoxication
C- normal teen age development
D- viral encephalopathy
Answer is A. read more about it https://www.ccjm.org/content/ccjom/74/5/341.full.pdf

18) Pediatric patient came to clinic look not clean wearing old
clothes what is type of abuse?
Answer is Neglect abuse

19) 7-year-old child is reported to be hyperactive, restless, talks

rapidly, and has violent outbursts. What intervention can help
mitigate these issues?
A- Regular preschool examinations
B- Decreasing time spent on video games and watching television
C- Parenting classes for behavior management
D- Special education resources
Answer is C- Question about mitigate method.

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 Notes:
Preschool examination and collateral history for identifying and diagnosing
Video games and watching television by studies has no role in violence and regular parental
ways can escalate the issue.
Special educational resources can be used later to the parents and child after confirmation the
mental issue.

20) 8 yrs old referred due to moderate failure to thrive in divorce parent , lives w mother
who has social and financial issues and she’s on antidepressants works 6 days a week
What’s the most appropriate next step in management?
A. Reassurance
B. Increase caloric intake
C. TPN
D. Multidisciplinary team
Answer is D
https://www.msdmanuals.com/professional/pediatrics/miscellaneous-disorders-in-infants-
and-children/failure-to-thrive-ftt-in-children

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Geriatric Psychiatry

80
 Review about the common problems in geriatrics (focusing on the repeated topics in the questions)

81
82
Vascular dementia:

83
  Important notes about dementia, and if it’s associated with other neurological disease:
1) Dementia is a hallmark of Alzheimer’s. Alzheimer’s affects language and memory, while Parkinson’s
affects problem solving (executive function), speed of thinking, memory and other cognitive
functions, as well as mood.
2) None of the following risk factors directly cause dementia, but the more of these factors that are
present, the higher the likelihood of developing dementia: Increasing age, Longer duration of disease
(advanced stage), Older age at onset of Parkinson’s, Family history of dementia, more severe motor
symptoms, being male, Having visual hallucinations.
3) Symptoms of dementia: Difficulty concentrating, Memory problems, Difficulty learning new
material, Difficulty problem solving, Disorientation/confusion, Mood changes (for example,
irritability, impatience, aggression), Hallucinations (hearing/seeing things others do not), Paranoia
(feeling suspicious or distrustful of others), Delusions (false, unrealistic or strange beliefs.

4) Mini-Mental State Examination (MMSE) is not diagnostic of dementia and does not distinguish well
between various confusion states, it is useful for assessing cognitive function and documenting
subsequent decline.

 Parkinson’s dementia is diagnosed if the onset of dementia occurs a year or more after the onset of
motor symptoms. If symptoms of dementia appear before or at the same time as symptoms of
Parkinson’s, it is called dementia with Lewy bodies.
 Memory and thinking problems in Parkinson’s are caused by changes in the structure and
chemistry of the brain. Dementia describes a set of symptoms that are caused by a significant loss in
brain function.
 Pathophysiology of PD psychosis: an interaction between extrinsic, drug-related and intrinsic, disease-
related components. The most important extrinsic factor is use of dopaminergic medication, which
plays a prominent role in PD psychosis. Intrinsic factors include visual processing deficits (e.g.
lower visual acuity, colour and contrast recognition deficits, ocular pathology and functional brain
abnormalities identified amongst hallucinating PD patients); sleep dysregulation (e.g. sleep
fragmentation and altered dream phenomena); neurochemical (dopamine, serotonin, acetylcholine,
etc.) and structural abnormalities involving site-specific Lewy body deposition; and genetics (e.g.
apolipoprotein E epsilon4 allele and tau H1H1 genotype).
 Several atypical antipsychotic agents (i.e. clozapine, olanzapine) have been shown to be efficacious in
reducing psychotic symptoms in PD; however, use of clozapine requires cumbersome monitoring and
olanzapine leads to motor worsening. Studies of other antipsychotics are limited.

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85
  Question in geriatric psychiatry:

1) Elderly patient with progressive memory loss for one year. Patient is diagnosed clinically
as Alzheimer dementia. What test would confirm diagnosis?
A. MRI
B. EEG
C. Mental status examination
Answer is A
2) A 76 years old female complaining of memory impairment in the last 12 months.
Which of the following is the most ( sensitive) for Alzheimer disease:
A. Watch drawing test
B. MMSE
C. MoCA
D. History of stroke in the last 5 years
Answer is C
https://pubmed.ncbi.nlm.nih.gov/15817019/#:~:text=In%20the%20mild%20AD%20group,and%
2087%25%2C%20respectively).

3) Family notices that their grandfather is starting to gradually forget important events and
basic things in his life, like the directions in his house and the name of his children. The
family is concerned he might have Alzheimer’s. What is the most likely diagnosis of this
presentation?
A- Normal aging
B- Alzheimer
C- Vascular dementia
D- Lewy Body dementia
Answer is B; Difference b\w A & B based on function and quality of life and remembering after
forgetting, which is present in normal aging and lost in Alzheimer. If there is a choice of benign
forgetfulness in this scenario I will choose it better than jumping to Alzheimer’s disease
4) Old man says he sometimes forgets his friends’ names or celebrities in his community and
phone numbers. His wife is worried he has Alzheimer’s. Labs normal. He has tender knees
(not something amazing just cause he’s old). No mention how it affects his daily life.
Other recall: old man with tender joints, forgets his friends’ names, his wife is worried, not
affecting his daily activities?
A- Alzheimer’s
B- Benign forgetfulness
Answer B; mild cognitive decline based on symptoms.

5) 70 years old came with his family due to "memory issue". He has memory
impairment including difficulty with remembering objects, places, and aphasia. His
condition progressively becoming worse with time. He has good assessment and
functioning. He is not aware about his condition. What is the most likely diagnosis?
A. Dementia
B. B12 Deficiency
C. Parkinson Disease
D. Cortico-basal Disease/syndrome
Answer is A

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6) Elderly 6 months was dx with parkinsonism, early dementia, (forget the third one);
Other recall: Elderly 77 years old medical and surgical history were normal not
taking any medication brought by his wife complaining from gradual memory loss
and tremor, but can take care of himself dressing and eating and personal care were
not affected there was also personality change he became more aggressive and
agitated, examination showed normal findings. What is the diagnosis?
A- Parkinson dementia
B- Lewy body dementia
C- Alzheimer disease
Answer B: Parkinson’s dementia is diagnosed if the onset of dementia occurs a year
or more after the onset of motor symptoms. If symptoms of dementia appear before
or at the same time as symptoms of Parkinson’s, it is called dementia with Lewy
bodies, also check previous explanation.

7) Case of Parkinson disease, which of the following factors presents in patients who are
at risk of developing dementia
A- Forgetting future appointments
B- Word finding with talking
Answer: A in early stages

8) Elderly with symptoms of dementia what is the earliest symptom confirm the
diagnosis?
A- Irritability
B- Difficulty finding words
C- Forgetting places of things
D- Forgotten future appointment
Answer: D, as explained in the warning signs

9) pt diagnosed with Parkinson and hallucination which of the following is associated

with high risk of dementia:
A. Irritability
B. Difficulty finding word
C. forgetting future appointment
Answer is C.

10) Which of these symptoms suggest severity of dementia?

A- Increase irritability
B- Difficulty finding word
C- Forget appointment
D- Difficulty in reading
Answer: A; Individuals lose the ability to respond to their environment, to carry on a
conversation and, eventually, to control movement. They may still say words or phrases, but
communicating pain becomes difficult. As memory and cognitive skills continue to worsen,
significant personality and mood changes may take place and individuals need extensive care

11) Elderly, recently transferred to a nursing home for 3 months, lost interest activity,
cries every day, decrease appetite, along with short memory impairment, what is the
diagnosis? Other recall: Old man came with loss of interest low mood and loss of
appetite he lost 7kg and he controlled hypertension the symptoms get worse in the

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 morning and when it becomes he loss of short memory and forget a lot of things he
has these symptoms from 3 months what is the diagnosis??
A- Depression
B- Alzheimer disease
C- Vascular dementia
Answer: A; clear question, the short memory loss need more details but excepted to
be mild cognitive issue, polypharmacy, mental health issue or stress related lead to too
much cortisol in the morning.
12) Old age with HTN, DM, presented with progressive loss of memory, CT scan showed
hyper-intensity, dx?
A- Alzheimer disease
B- Vascular dementia
Answer B;CT findings and underline medical issues.

13) 76YO man with progressively worsening memory and language difficulties. The patient
first started having memory problems and word finding difficulties 5 years ago and the
patient became lost while driving to mosque last year. the patient’s personality has
changed from seeming apathetic to become more paranoid and agitated; he frequently
claims to have seen her niece stealing from her purse. The patient recently developed
urinary incontinence. He has a history of hypertension, hyperlipidemia and osteoarthritis
of the left hip and both knees. deep tendon reflexes are 2+ throughout and he has
preserved motor strength. The patient recalls none of 3 objects on memory testing and
cannot draw a clock. Laboratory studies show normal, diagnosis?
a. Alzheimer's disease
b. vascular dementia
c. front temporal dementia
d. dementia of lewy bodies
Answer is A

14) 71 Years Old Male Came to Clinic with 2 Year History of Slow and Progressive Memory
Loss, He can do his daily chores and wear clothes independently, He used to be a kind and
caring person, But in the last 3 months his personality changed and he became aggressive,
What is the Likely Diagnosis for This Patient?
A. multi vascular dementia
B. Major depression
C. Mixed dementia
D. Alzheimer’s Disease
Answer is D.
15) Patient known case of Alzheimer's came with severe agitation. What is the treatment
A- Olanzapine
B- Haloperidol
C- Buspurone
D- Thioridazine
Answer is A, although better to use quetiapine or clozapine. In addition to that; olanzapine and
haloperidol can treat agitation but we start with atypical antipsychotics (Olanzapine, risperidone,
quetiapine) because of less side effects, if not improving then we choose typical antipsychotics
(haloperidol).

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16) Elderly patient with Alzheimer’s disease fall down from the stairs thankfully nothing
happened to him what will you do to prevent this from happening again:
A- light to the stairs
B- increase the dose of antipsychotic
C- increase the calcium
D- I don’t remember
Answer A

17) 67 male lives in nursing home since two months he started to lose weight, sad and cry
almost all the time, forget simple daily things especially at the beginning of morning what’s
the diagnosis?
A- Depression
B- Hypothyroidism
C- Multi-infract dementia
D- Alzheimer’s disease
Answer is A.

18) An 81yo male presenting with memory loss and difficulty remembering grandsons’ names,
medically free apart from occasional alcohol intake. What is the likely diagnosis for this
presentation?
A- Multi-infarcts dementia
B- Alzheimer’s disease
C- Alcohol induced encephalopathy
D- Parkinsonism with dementia
Answer is B.

19) Lady in the 70s has type 2 DM on metformin 1 g BID had problem in naming and
calling things lately. For example, she says animal instead of cat when she sees a cat.
She has no memory impairment or personality changes. Her family are worried
about her. What is the most likely diagnosis?
A. Vascular dementia
B. Alzheimer’s dementia
C. Frontotemporal dementia
D. B12 deficiency with cognitive features
Answer is A
Simply; diabetes is high risk factor for vascular dementia, isolated symptom presentation (
based on scenario), personality and memory are intact till current presentation.
Alzheimer’s is progressive memory loss affecting orientation and daily activities
Frontotemporal dementia associated with personality changes
Vit b12 def with cognitive impairment will be associated with other neurological
symptoms like numbness and demyelination effect before hitting the cognitive level.

20) A 70-year-old male patient known case of HTN was brought to ER by his son, his son
reported that the patient had a change in behaviors besides his memory loss, he is
fighting with everyone in the street, what is the most likely diagnosis?
A.Frontotemporal dementia
B. Dementia of Lewy body
C. Parkinson disease
D. Alzheimer disease

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 Answer is D; Memory loss started first then personality changes happened
While in FTD apathy and personality changes occur earlier

21) Pt is known case of Alzheimer came to ER with severe agitation the doctor gives him
a big dose of Haloperidol and he develops side effects I don’t remember what r they
exactly, what u should give him now? They mean what is the antidote of haloperidol?
A- Naloxone
B- bromocriptine
C- Glycogen
Answer B

22) Elderly k\c of dementia, presented at ER and was agitated. He received Haloperidol
injection, then he became feverish with leukocytosis, what should you do? (duration is
missing)
A- Give antibiotics
B- Give Naloxone
C- Give Bromocriptine
Answer: C; case of neuroleptic malignant syndrome;

23) Treatment of Alzheimer disease with 10/30 score:

A- Rivastagmine
B- Memantine
C- Donepezil
D- Ginki pilopa
Answer is B; Score: severe stage

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24) 65 years old female with a recent difficulty to describe the things, she cannot describe
the items probably (she called an dogs as cat), with no hx of behavioral changes or
memory loss or head trauma. neurologist ordered an MRI what do expect in MRI
findings?
A. Hippocampal atrophy
B. Temporal atrophy
C. Caudate atrophy
Answer is B, to be more specific it’s unilateral anterior temporal lobe, Dx: semantic
dementia
Other recall:
Women 54 y , her family bring her because she can’t call them by their names and
has difficulty finding words, after sometime she can say general words (eg. calling the
cat Animal) Function intact. And there’s family history of the same problem
(I remember that she’s medically free); What do you expect to see in the MRI
A-Hippocampal atrophy
B-Caudate atrophy
C-Multiple hyper intensities
D-Temporal atrophy
Answer is D
Onset of symptoms , limited to aphasia, while memory, function & behavior are intact
Dx: primary progressive aphasia
Read more about it:
https://www.jneurosci.org/content/31/9/3344

25) Old age with 2 year history of progressive memory loss, had multiple attacks of
weakness, decline in abilities and cognitive function, he was diagnosed with HIV 3
years ago, diagnosis?
A. Vascular dementia
B. Lewy’s body
C. Alzheimer
D. HIV related dementia
Answer is D

Other scenario:
70ish year old male came to clinic with 2 year history of Slow and Progressive
Memory Loss, then the question mention hx of hypertension and diabetes. Hx of
multiple TIA. Then find out 3 years ago he has HIV through routine screening.
Lastly, he has apraxia, abnormal gait, and other neurological symptoms What is the
diagnosis?
A. lewy body dementia
B. alzheimer's disease
C. HIV related dementia
D. Vascular dementia
Answer is C

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 Few notes about HIV related dementia: HIV-associated dementia should be
suspected in patients who have: Symptoms of dementia & Known HIV infection or
symptoms or risk factors suggesting HIV infection.
 Criteria of diagnosis:
Cognitive or behavioral (neuropsychiatric) symptoms interfere with the ability to function at
work or do usual daily activities.
These symptoms represent a decline from previous levels of functioning.
These symptoms are not explained by delirium or a major psychiatric disorder
CD4 and HIV viral load:
 In patients with HIV infection or suspected HIV-associated dementia: CD4 count and
HIV viral load are measured. In patients with suspected or confirmed HIV and dementia,
these values help determine how likely HIV-associated dementia (and CNS lymphoma and
other HIV-associated CNS infections) is to be contributing to dementia. In patients who
have HIV infection but not dementia, these values help determine how likely HIV-
associated dementia is to develop.
 If patients with symptoms of dementia are not known to have HIV infection but have
risk factors for HIV infection: they are tested for HIV.
 Late-stage findings of HIV-associated dementia may include diffuse non-enhancing white
matter hyper-intensities, cerebral atrophy, and ventricular enlargement.

 Signs and symptoms: Symptoms and signs of HIV-associated dementia may be similar to
those of other dementias. Early manifestations include:
- Slowed thinking and expression, Difficulty concentrating, Apathy.
- Insight is preserved, and manifestations of depression are few.
- Motor movements are slowed; ataxia and weakness may be evident.
- Abnormal neurologic signs may include: Paraparesis, Lower-extremity spasticity,
Ataxia, Extensor-plantar responses
- Mania or psychosis is sometimes present.
 Workup: clinical evaluation, Measurement of CD4 count and HIV viral load, MRI and
usually lumbar puncture, when deterioration is acute.
 Management: antiviral primarily, supportive treatment methods, symptoms based
treatment.
read more about it: https://www.msdmanuals.com/professional/neurologic-disorders/delirium-
and-dementia/hiv-associated-dementia
 Types FYI:

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26) A 72-year-old man experiences inability to sustain attention, disorganized thinking,
hallucinations, and disorientation commencing 12 hours after an aortic femoral
popliteal bypass. The symptoms fluctuated during the next 2 days. Which of the
following is the most likely diagnosis?
A- Multi-infract dementia
B- Depression
C- Delirium
D- Mania
Answer is C

27) 45 year old male known case of HTN , DM , sudden agitation Decrease attention and
cognitive for one day, he is on atorvastatin, Aspirin antihypertensive (ACEI ) and
statin, Vitals given all was normal even BP, what to do?
A. EEG
B. This symptom due to medication use
C. anti-psychotic
D. pelvic Us
- In other recall:
A- Absence of fever preclude infection
B- Start antipsychotic
C- medications are the most common cause
D- urgent electroencephalography
Answer is “This symptom due to medication use” It can be simply a side effect of
medication or condition could be explained by delirium.

28) 80 years old male only have hypertension came to the hospital due to visual
hallucination along with attack of hypoglycemia and dysphagia and decrease
sweating, the memory is intact. he is only on amlodipine what is the diagnosis?
A- Alzheimer’s dementia
B- lewy body dementia
C- multi infarct
D- Prion disease
Answer is B; Confirmed by neurologist too

29) 65 female presented with progressive loss of recent memory, can't remember place,
time or person, can't remember names. Loss of skilled motor skills. No change in
personality or social behavior. Lack of insight. What's the diagnosis?
A- Alzheimer disease
B- Prion disease
C- Lewy body dementia
D- Multiple-infarct dementia
Answer is A

93
Personality Disorders

94
 Review about personality disorders:
 Personality disorders are common and chronic. They occur in 10 to 20 percent of the
general population, and their duration is expressed in decades.
 Approximately 50 percent of all psychiatric patients have a personality disorder, which is
frequently comorbid with other clinical syndromes.
 Personality disorder is also a predisposing factor for other psychiatric disorders (e.g.,
substance use, suicide, affective disorders, impulse-control disorders, eating disorders, and
anxiety disorders) in which it interferes with treatment outcomes of many clinical
syndromes and increases personal incapacitation, morbidity, and mortality of these patients.
 Persons with personality disorders are far more likely to refuse psychiatric help and to
deny their problems than persons with anxiety disorders, depressive disorders, or obsessive-
compulsive disorder.
 personality disorder symptoms are ego syntonic (i.e., acceptable to the ego, as opposed to
ego dystonic) and alloplastic (i.e., adapt by trying to alter the external environment rather
than themselves)
 Classifications: “WEIRD, WILD, & WORRIED”

 Diagnosis must be confirmed after ruling out any other causes such as substance use, brain
injury, etc. and have personality assessment and tests. (Don’t rush!!)
 Personality disorders respond better to psychotherapy and support rather than with
medications alone.
 These patients are usually very alert and orientated to name, date, location, or in other
words, mentally competent and have the right to REFUSE medications or treatment, thus
emotional support/therapy is the most important.

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 Questions about somatic & personality disorders “Reference: Kaplan& Maudsley”:
1. Pt did superficial scratches in her right hand because her physician abandoned
her, she also has labiality of mood. What type of personality disorder?
Other recall: female with self-inflicted injuries on the wrist because she thought her
therapist abandoned her. He claims she her voices but when asked her she denied. She
caused problem between resident and psychiatrist and head nurse over her condition.
What type of personality?
A- Borderline personality
B- Schizoid personality
C- Obsessive
Answer A: Borderline personality

2. Young adult, drug addict came to the hospital acting like he was sick and when the
doctor looked away he was acting fine, what is this?
Other recall: 30 years old male, hx of drug abuse visit clinic weekly with
exaggerated symptoms and when no one observing symptoms appears to be
revealed?
A- Malingering
B- Somatization
Answer is A

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3. female nurse is brought to the emergency department in comatose state, she was
found on the floor by her husband, and the patient’s past medical history is
significant for several admissions to the ED due to various symptoms, which had
no discovered a cause despite diagnostic workup, on presentation, the patient is
comatose with blood
pressure is normal, heart rate of 140 and respiratory rate of 16 . her blood glucose
at admission is 50 mg/dl. Treatment with dextrose immediately improves her
symptoms and she emerges from her coma, her insulin levels are high but c-
peptide is low, the patient states “that she wants to be taken care of in the ICU”
and is “really sick”, diagnosis?
a. factitious disorder
b. malingering
c. illness anxiety disorder
d. conversion disorder
Answer is A
This case is a typical scenario of factitious hypoglycemia as a result of self-injection of insulin
to induce hypoglycemia
Read more about it:
https://www.ncbi.nlm.nih.gov/books/NBK542310/

4. Personality disorder associated with which hormone?

A- Serotonin
B- androphine
C- Ach
Answer: specify the type of personality disorder and symptom.
- Borderline personality disorder (BPD) : serotonin, dopamine, oxytocin, endogenous,
glutamate.
- antisocial personality disorder (ASPD): serotonin and dopamine, endogenous
-schizotypal personality disorder (SPD): dopamine
- obsessive–compulsive personality disorder (OCPD): serotonin
Reference: personality disorders chapter; new Oxford textbook for psychiatry.

97
5. A 23 years old male known case of
dysthymic depression referred
from neuro-clinic. He had a
history of 3 tonic-colonic seizures,
but he can remember what
happened then. The neurologist
perform EEG and MRI both were
normal.
What do you suspect?
A. Conversion disorder
B. Panic disorder
C. Space occupying lesion
D. Partial seizure
Answer is A

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‫بموضوعات مختلفة‪.‬‬
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‫إلرسال األسئلة الجديدة‪:‬‬

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