1-1 (101B56) Which of the following is true regarding the combination of life cycle stages and psychological tasks?

a) Early Childhood - Formation of self-identity

b) Childhood - Grief from the death of a family member or close acquaintance

c) Adolescence - Separation anxiety

d) Adulthood - Empty nest syndrome

e) Old age - Inferiority complex

The correct answer is:

d) Adulthood - Empty nest syndrome

Explanation:

• a) Early Childhood - Formation of self-identity: This is a fundamental task of early childhood, where individuals start to develop a sense of self. It is accurately matched with the developmental stage, emphasizing the emergence of personal identity.
• b) Childhood - Grief from the death of a family member or close acquaintance: While grief can occur at any age, its specific listing under "Childhood" doesn't align it as a primary developmental task. Childhood is more commonly associated with developing autonomy, competence, and social skills. However, the experience of grief can be significant and formative during this stage.
• c) Adolescence - Separation anxiety: Separation anxiety is more typical of early childhood, not adolescence. The primary psychological task of adolescence is forming one's identity and gaining independence, rather than experiencing separation anxiety, which would be considered atypical at this stage.
• d) Adulthood - Empty nest syndrome: This is correctly matched. Empty nest syndrome refers to feelings of sadness or loss parents may experience when their children leave home, a common phase during adulthood.
• e) Old age - Inferiority complex: While older adults may face challenges related to self-esteem and reflecting on their life's accomplishments, an inferiority complex is not a widely recognized primary task of old age. The stage is more associated with reflecting on life, achieving a sense of fulfillment, and dealing with physical decline and mortality.

1-2 (101B78) Which questions are appropriate for assessing orientation? Choose two.

a) "What is 100 minus 7?"

b) "What is today's year, month, and day?"

c) "Where are you now?"

d) "When is your birthday?"

e) "What is the address?"

The correct answers are:

b) "What is today's year, month, and day?"

c) "Where are you now?"

Explanation:

Orientation assessments are designed to evaluate a person's awareness of time, place, and person. These assessments are often used in medical and psychological evaluations to understand if an individual is fully oriented to their surroundings and the current time, which can indicate their cognitive functioning level. Based on the options provided:

• a) "What is 100 minus 7?" - This question tests basic arithmetic skills rather than orientation to time, place, or person.
• b) "What is today's year, month, and day?" - This is an appropriate question for assessing orientation, specifically to time. Knowing the current date demonstrates awareness of the passage of time.
• c) "Where are you now?" - This question assesses orientation to place. Being able to identify one's current location shows awareness of one's environment.
• d) "When is your birthday?" - While knowing one's birthday is related to personal information, it does not directly assess orientation to the current time or place.
• e) "What is the address?" - Without specifying "What is your address?" this question is too vague to be a clear assessment of orientation. If it meant "What is your address?" it could potentially assess orientation to place, but it's more about recalling specific personal information rather than understanding one's current location in a broader context.

1-3 (102E20) Which symptoms can differentiate Alzheimer's dementia from delirium?

a) Restlessness

b) Wandering

c) Impaired consciousness

d) Irritability

e) Memory loss

The correct answer is:

c) Impaired consciousness

Explanation:

To differentiate Alzheimer's dementia from delirium, it's essential to understand the characteristic features of each condition. Alzheimer's dementia is a progressive neurodegenerative disorder characterized by gradual memory loss, cognitive decline, and personality changes. Delirium, on the other hand, is an acute, fluctuating disturbance of consciousness and cognition that typically results from a medical condition, medication, substance abuse, or withdrawal.

• a) Restlessness - Both Alzheimer's patients and individuals with delirium can exhibit restlessness. It's not specific enough to differentiate between the two conditions.
• b) Wandering - Wandering can be a symptom of Alzheimer's as patients may become disoriented and roam aimlessly. While individuals with delirium might also wander due to confusion, wandering is more characteristic of Alzheimer’s dementia due to its association with cognitive decline over time.
• c) Impaired consciousness - This symptom is more indicative of delirium. Delirium involves a rapid onset of fluctuating levels of consciousness, which is not characteristic of Alzheimer’s dementia. Alzheimer's primarily affects memory, cognition, and executive function without the acute changes in consciousness seen in delirium.
• d) Irritability - Irritability can occur in both conditions but is not specific enough to serve as a differentiating symptom.
• e) Memory loss - Memory loss is a hallmark of Alzheimer’s dementia, particularly the progressive loss of the ability to remember new information. While individuals with delirium may also experience memory issues, these are usually due to fluctuations in attention and awareness rather than the progressive memory deterioration seen in Alzheimer's.

1-4 (104E3) Which of the statements about delusions is true?

a) In manic disorders, hypochondriacal delusions are common.

b) Delusions of grandeur are common in dementia.

c) In depression, delusions of sensitive relationships are common.

d) In schizophrenia, delusions of theft are common.

e) Delusions of jealousy are more common in alcohol-induced psychosis.

The correct answer is:

e) Delusions of jealousy are more common in alcohol-induced psychosis.

Explanation:

To identify the true statements about delusions within specific mental health disorders, let's analyze each option based on established psychiatric knowledge:

• a) In manic disorders, hypochondriacal delusions are common. - Hypochondriacal delusions, which involve an excessive preoccupation with having a serious illness, are more typically associated with hypochondriasis (illness anxiety disorder) rather than manic disorders. Manic episodes are characterized by elevated mood, increased activity or energy levels, and sometimes grandiose delusions, but not typically hypochondriacal delusions.
• b) Delusions of grandeur are common in dementia. - Delusions in dementia are more often characterized by paranoia or misidentification syndromes (such as thinking a spouse is an impostor), rather than delusions of grandeur. Delusions of grandeur are more commonly associated with manic phases of bipolar disorder or schizophrenia.
• c) In depression, delusions of sensitive relationships are common. - Major depressive disorder with psychotic features can include delusions, which are often mood-congruent (e.g., delusions of poverty, illness, or guilt). Delusions focusing on sensitive or interpersonal relationships can occur, but the descriptor "common" may not be as accurate as specifying that mood-congruent delusions are typical in severe depression.
• d) In schizophrenia, delusions of theft are common. - Schizophrenia can include a wide range of delusional themes, such as persecution, grandeur, or control. Delusions of theft could occur within the context of persecutory delusions, but they are not specifically highlighted as a common or defining feature of schizophrenia compared to other types of delusions.

• e) Delusions of jealousy are more common in alcohol-induced psychosis. - This statement correctly identifies a specific type of delusion that is notably more prevalent in the context of a particular disorder, aligning with clinical observations and research on the psychiatric effects of chronic alcohol use.

1-5 (104G12) Which one is correct? Choose two.

a) The ascending reticular activating system is located in the cerebrum.

b) Broca's area functions as a sensory-language cortex.

c) The medial temporal lobe is deeply involved in the formation of memory.

d) The innate traits that form the basis of personality are called temperament.

e) Intelligence quotient is calculated by dividing the living age by the mental age and multiplying by 100.

The correct answers are:

c) The medial temporal lobe is deeply involved in the formation of memory.

d) The innate traits that form the basis of personality are called temperament.

Explanation:

• a) The ascending reticular activating system is located in the brainstem. This system is crucial for regulating wakefulness and sleep-wake transitions, not in the cerebrum.
• b) Broca's area functions as a motor-language cortex. It is involved in the production of speech, making it a key component in expressive language, not sensory language processing.
• c) The medial temporal lobe is deeply involved in the formation of memory. This area, especially the hippocampus within the medial temporal lobe, plays a significant role in the consolidation of information from short-term memory to long-term memory, crucial for learning and memory.
• d) The innate traits that form the basis of personality are called temperament. Temperament refers to the biological foundation of personality, including innate predispositions and emotional responses, which is evident from early childhood.
• e) Intelligence quotient is calculated by dividing the mental age by the chronological age and multiplying by 100. This traditional method of calculating IQ involves comparing the test taker's performance (mental age) with the average performance of others at the same chronological age.

1-6 (110G34) Which of the following combinations of mental functions and psychiatric symptoms caused by their disorders is correct? Choose two.

a) Consciousness - Hallucinations

b) Emotion - Coma

c) Temperament - Emotional incontinence

d) Thought process - Associative loosening

e) Self-awareness - Depersonalization

The correct answers are:

d) Thought process - Associative loosening

e) Self-awareness - Depersonalization

Explanation:

• a) Consciousness - Hallucinations: Hallucinations are perceptual experiences without external stimuli, typically involving auditory or visual perceptions. They are more closely associated with disorders affecting perception or the sensory processing areas of the brain, not directly with consciousness. Consciousness refers to the level of awareness of oneself and the environment, so this pairing isn’t the most accurate.
• b) Emotion - Coma: A coma is a state of deep unconsciousness from which a person cannot be awakened; it pertains to the level of consciousness, not emotion. Emotional responses are not relevant in the context of a coma, making this combination incorrect.
• c) Temperament - Emotional incontinence: Emotional incontinence, or affective incontinence, refers to the uncontrollable expression of emotions, such as laughing or crying, disproportionate to the situation. It is related to neurological disorders rather than temperament, which is the innate predisposition towards emotional reactivity.
• d) Thought process - Associative loosening: Associative loosening, or loosening of associations, is a thought disorder characterized by a disorganized way of thinking, where ideas are poorly connected. This symptom is directly related to the thought process, making this combination correct. It is often observed in schizophrenia and other psychotic disorders.
• e) Self-awareness - Depersonalization: Depersonalization involves a feeling of detachment from oneself, where individuals may feel like an outside observer to their thoughts, body, or parts of their life. It is a disturbance in self-awareness, making this combination correct. Depersonalization can occur as part of depersonalization-derealization disorder or other mental health conditions.

1-7 (111E13) Which of the following is not a risk factor for delirium?

a) Pneumonia

b) Smoking

c) Hyponatremia

d) Urinary catheter placement

e) Benzodiazepine sleep aids

The correct answer is:

b) Smoking

Explanation:

Delirium is an acute confusional state characterized by altered consciousness, cognitive function, or perception, which is typically reversible and can be caused by a wide range of factors. To determine which of the listed options is not a risk factor for delirium, let's analyze each one:

• a) Pneumonia: Medical conditions, especially those that can lead to fever or systemic infection like pneumonia, are known risk factors for delirium. They can lead to altered mental states as the body responds to the infection.
• b) Smoking: Smoking itself is not directly listed as a common risk factor for delirium in the medical literature. While smoking can contribute to various health problems that might increase the risk of delirium indirectly (such as cardiovascular diseases), it is not directly implicated as a risk factor for delirium as the others are.
• c) Hyponatremia: Electrolyte imbalances, such as low sodium levels in the blood (hyponatremia), are significant risk factors for delirium. Hyponatremia can affect brain function, leading to symptoms of delirium.
• d) Urinary catheter placement: The placement of a urinary catheter can be associated with increased risk of delirium, especially in hospitalized or elderly patients, due to the potential for infection (like urinary tract infections) or the discomfort and stress it can cause, leading to sleep disturbances and delirium.
• e) Benzodiazepine sleep aids: The use of benzodiazepines is a well-established risk factor for delirium, particularly in the elderly. These medications can cause or worsen delirium due to their sedative properties and impact on cognitive function.

1-8 (111G12) Which of the following combinations of symptoms and disorders is correct?

a) Dissociation - Panic Disorder

b) Emotional incontinence - Personality Disorder

c) Flight of ideas - Attention Deficit Hyperactivity Disorder (ADHD)

d) Thought blocking - Schizophrenia

e) Somatic hallucinations - Anorexia Nervosa

The correct answer is:

d) Thought blocking - Schizophrenia

Explanation:

• a) Dissociation - Panic Disorder: Dissociation involves a disconnection and lack of continuity between thoughts, memories, surroundings, actions, and identity. While dissociation can occur in the context of severe stress or anxiety, it's not a hallmark symptom of panic disorder, which is characterized by sudden periods of intense fear or discomfort, palpitations, sweating, trembling, shortness of breath, and fear of dying or losing control.
• b) Emotional incontinence - Personality Disorder: Emotional incontinence, or the inability to control the expression of emotions (such as laughing or crying inappropriately), is not typically associated with personality disorders. Personality disorders involve enduring patterns of inner experience and behavior that deviate markedly from the expectations of the individual's culture, not necessarily emotional incontinence.
• c) Flight of ideas - Attention Deficit Hyperactivity Disorder (ADHD): Flight of ideas is a symptom where thoughts rapidly and often abruptly shift from one topic to another. While ADHD is characterized by inattention, hyperactivity, and impulsivity, flight of ideas is more commonly associated with bipolar disorder, especially during manic episodes, rather than ADHD.
• d) Thought blocking - Schizophrenia: Thought blocking, where a person suddenly stops speaking and appears to "lose their thought," is indeed a symptom that can be observed in schizophrenia. Schizophrenia is a chronic mental disorder characterized by delusions, hallucinations, disorganized speech, and significant impairment in daily functioning, making this combination correct.
• e) Somatic hallucinations - Anorexia Nervosa: Somatic hallucinations involve sensations or perceptions of bodily experiences that are not actually occurring. While individuals with anorexia nervosa may have a distorted body image, somatic hallucinations are not a defining feature of this eating disorder. Anorexia nervosa primarily involves an intense fear of gaining weight and a distorted body image, leading to severe restriction of food intake and weight loss.

1-9 (112F37) Which of the following is correct? Choose two.

a) Emotional incontinence is seen in adjustment disorders.

b) Ambivalence is characteristic of depression.

c) Autogenous thoughts are seen in obsessive-compulsive disorder.

d) Confabulation is seen in Korsakoff syndrome.

e) Word salad is characteristic of schizophrenia.

The correct answers are:

d) Confabulation is seen in Korsakoff syndrome.

e) Word salad is characteristic of schizophrenia.

Explanation:

• a) Emotional incontinence is seen in adjustment disorders. Emotional incontinence refers to a lack of control over emotional expressions, such as inappropriate laughing or crying. While it can occur in various neurological conditions and mental health disorders, it is not specifically characteristic of adjustment disorders. Adjustment disorders are stress-related conditions that cause emotional and behavioral symptoms, but emotional incontinence is not a defining feature.
• b) Ambivalence is characteristic of depression. Ambivalence, the state of having mixed feelings or contradictory ideas about something or someone, can indeed occur in depression, but it is not uniquely characteristic of depression. Ambivalence can be experienced in many mental health conditions and is not as specific to depression as other symptoms like persistent sadness, loss of interest, or feelings of worthlessness.
• c) Autogenous thoughts are seen in obsessive-compulsive disorder (OCD). Autogenous thoughts refer to intrusive thoughts that seem to come from nowhere and can be distressing to the individual. This feature is not typically seen in OCD, where individuals may experience unwanted intrusive thoughts that are distressing and may lead to compulsive behaviors to relieve the distress caused by these thoughts.
• d) Confabulation is seen in Korsakoff syndrome. This is accurate as confabulation is a notable symptom of Korsakoff syndrome, a condition often associated with chronic alcohol abuse that leads to significant memory issues, where individuals may unintentionally fabricate stories or facts to fill in memory gaps.
• e) Word salad is characteristic of schizophrenia. This is also correct. Word salad involves a mix of words and phrases that are incoherent and disjointed, reflecting the disorganized thinking and speech patterns that can occur in individuals with schizophrenia, a disorder that affects a person's ability to think, feel, and behave clearly.

1-10 (114F10) Which of the following is a primary prevention of mental disorders?

a) Promotion of employment transition support

b) Promotion of advanced treatments in hospitals

c) Campaigns to spread knowledge about the harm of drinking

d) Rapid symptom improvement through the introduction of new antipsychotic drugs

e) Understanding mental states using new methods of brain function measurement

The correct answer is:

c) Campaigns to spread knowledge about the harm of drinking

Explanation:

• a) Promotion of employment transition support: While support for employment transition can help improve life outcomes for individuals with mental health conditions, it is more aligned with secondary or tertiary prevention, focusing on individuals already experiencing mental health issues or those at high risk, rather than preventing the onset of disorders in the general population.
• b) Promotion of advanced treatments in hospitals: This relates to treatment rather than prevention. It focuses on improving care for individuals who already have mental health conditions, which is not primary prevention.
• c) Campaigns to spread knowledge about the harm of drinking: This is a form of primary prevention. Educating the general public about the harmful effects of alcohol can reduce alcohol misuse and potentially prevent the development of substance-related disorders, as well as other mental health conditions influenced by heavy drinking.
• d) Rapid symptom improvement through the introduction of new antipsychotic drugs: This is related to the treatment of existing conditions, not preventing them. The use of antipsychotic drugs is aimed at individuals who have already been diagnosed with a mental disorder.
• e) Understanding mental states using new methods of brain function measurement: This approach is more about diagnosis and monitoring rather than prevention. It could potentially contribute to secondary prevention by identifying at-risk individuals early, but it does not prevent the initial development of mental disorders.

1-11 (115C33) Which of the following statements by a patient are considered primary delusions of schizophrenia? Choose three.

a) "Suddenly, I realized that I am a descendant of Prince Shotoku."

b) "Someone is poisoning my food while I eat."

c) "Vaguely, I feel something terrible is going to happen, and it scares me terribly."

d) "Watching passengers talk on the train, I know they are speaking ill of me."

e) "Looking at the neighbor's house, the shape of their entrance means I will die tomorrow."

The correct answers are:

a) "Suddenly, I realized that I am a descendant of Prince Shotoku."

c) "Vaguely, I feel something terrible is going to happen, and it scares me terribly."

e) "Looking at the neighbor's house, the shape of their entrance means I will die tomorrow."

Explanation:

Primary delusions are sudden, fully formed, and often bizarre beliefs that appear without a clear connection to any preceding thought or event. They are characteristic of schizophrenia and can provide significant insight into the disorder's diagnostic process:

• a) "Suddenly, I realized that I am a descendant of Prince Shotoku." This statement is an example of a primary delusion, specifically a delusion of grandeur. It arises spontaneously and involves an unrealistic belief about one's identity or importance, fitting the criteria for a primary delusion in schizophrenia.
• b) "Someone is poisoning my food while I eat."  This is an example of a delusion of reference, where the individual believes that ordinary events, remarks, or objects in the environment have particular and unusual meanings specifically for them. This kind of delusion is abrupt and indicative of schizophrenia.
• c) "Vaguely, I feel something terrible is going to happen, and it scares me terribly." A delusional mood is where an individual feels that something significant or catastrophic is about to occur without specific evidence or a clear idea of what it will be. This state can precede the formation of a more concrete delusion, reflecting a primary delusion in terms of its sudden, inexplicable onset and the profound impact on the individual's perception of reality.
• d) "Watching passengers talk on the train, I know they are speaking ill of me." This is an example of a delusion of reference, where the individual believes that ordinary events, remarks, or objects in the environment have particular and unusual meanings specifically for them. This kind of delusion is abrupt and indicative of schizophrenia.
• e) "Looking at the neighbor's house, the shape of their entrance means I will die tomorrow." This represents a bizarre and specific delusion with no logical basis, characteristic of a primary delusion. It's a sudden, irrational belief indicating a profound distortion of reality, typical in schizophrenia.

2-1, 2, 3 (100C28, 100C29, 100C30) A 56-year-old woman who was admitted to the surgical ward for the treatment of right breast cancer became suddenly agitated at night.

Current medical history: Three weeks ago, she underwent a right mastectomy and then started chemotherapy. Gradually, she began to experience discomfort in the upper abdomen, depressive mood, and insomnia, intensifying over time. She expressed a desire to die, saying, "I don't want to undergo treatment anymore," and stopped eating. At night, she suddenly became incoherent in her speech and attempted to remove her IV drip. When a nurse tried to stop her, she threw objects and shouted angrily, "You devil, don't kill my children."

Past medical history: Nothing notable.

Family history: Nothing notable.

Current condition: When the on-call doctor arrived and tried to speak with her, she was either distracted or agitated and seemed not to understand that she was in a hospital.

1. What is this condition?

a) Delirium

b) Grandiose delusion

c) Persecutory delusion

d) Psychogenic reaction

e) Stupor

2. The appropriate response to this condition is:

a) Isolate her.

b) Make her control her excitement.

c) Administer anti-anxiety medication.

d) Administer antipsychotic medication.

e) Administer antiepileptic medication.

3. The next day, she became calm and was able to converse with the attending physician and nurses, although her conversation content was pessimistic. She barely remembered the events of the previous night.

The appropriate response to this is:

a) Explain the events of the previous night thoroughly.

b) Aim to improve the depressive state.

c) Restrain her hands and feet at night.

d) Conduct a psychological test.

e) Consider discharge.

1. The correct answer is:

a) Delirium

Explanation:

The woman's presentation suggests a condition characterized by sudden agitation, disorientation, fluctuating levels of consciousness, and a change in cognitive function, which points to delirium. Delirium is an acute, confusional state that can result from a variety of causes, including medical conditions, changes in the environment, medications, and the stress of being in a hospital, especially after surgery and starting chemotherapy, which can be significant stressors.

2. The correct answer is:

d) Administer antipsychotic medication.

Explanation:

• The most immediate management of delirium involves addressing the underlying causes, ensuring the patient's safety, and sometimes using medication to manage agitation if it poses a risk to the patient or others. Among the options given, administering antipsychotic medication can help manage severe agitation and psychotic symptoms such as hallucinations or delusions commonly seen in delirium.
• Anti-anxiety medication (c) might help if anxiety is a significant component of the patient's presentation, but care must be taken due to potential side effects in the elderly and those with medical complications.

3. The correct answer is:

b) Aim to improve the depressive state.

Explanation:

The next day, when the patient is calm and able to converse but shows a pessimistic outlook and hardly remembers the previous night's events, it indicates a need to address her underlying mood and possible depressive symptoms, as well as to provide reassurance and information about her condition.

• Improving the depressive state is crucial, as it addresses a potential underlying cause of the delirium and can prevent future episodes. This involves both pharmacological treatment and psychological support.
•  Explaining the events of the previous night (a) is also important but should be done with sensitivity and in the context of overall supportive care, ensuring the patient understands her condition and the reasons for her experiences, without causing further distress.

2-4 (103B43) A 22-year-old man was born into a wealthy family in a provincial city and grew up without want. After graduating from a local high school, he entered a university in a major city. He studied moderately, participated in club activities, made close friends, and had girlfriends with whom he broke up, believing he was satisfied with his university life. However, when his friends started discussing job hunting, he became uncertain about what he wanted in life. His parents expected him to take over the family business, and he intended to do so, but he began to wonder if that was the right choice. He started feeling anxious about entering society.

The challenge this young man is facing is:

a) Acquisition of sociability

b) Overcoming separation anxiety

c) Formation of ego identity

d) Acquisition of egocentrism

e) Improvement of abstract thinking skills

The challenge the young man is facing is:

c) Formation of ego identity

Explanation:

Erik Erikson, a developmental psychologist, identified the formation of ego identity as a key task during adolescence and young adulthood. This stage involves exploring various possibilities and roles to develop a sense of self and direction in life. The young man's questioning of his life goals, especially in the context of career choices and the expectation to take over the family business, aligns with the struggle for identity versus role confusion, which Erikson described for this developmental stage. The man is trying to figure out who he is and what he wants from life, indicative of the process of forming an ego identity, rather than merely acquiring sociability (a), overcoming separation anxiety (b), becoming egocentric (d), or improving abstract thinking skills (e).

2-5 (104A59) A 73-year-old man was admitted to the ICU for pneumonia. Although his physical condition was good, starting from the fifth day of admission, he would try to remove his IV and become agitated at night. When nurses attempted to return him to his bed, he would become excited, asking "Where am I?" and "Why isn't my wife here?" During the day, he understood well that he was receiving hospital treatment and did not remember the events of the night.

What is the appropriate response to the psychiatric symptoms?

a) Transfer to a general ward.

b) Limit visits from family.

c) Keep the room bright at night.

d) Restrain physically as a preventative measure at night.

e) Encourage napping to maintain sleep hours.

The correct answer is:

a) Transfer to a general ward.

Explanation:

2-6 (108B47) A 14-year-old boy, noted for his defiant attitude at home and school, was recommended by his school to seek consultation, accompanied by his mother. For the past six months, he has been particularly defiant towards his mother, shouting and hitting furniture when cautioned. Although he sometimes shows a defiant attitude towards his homeroom teacher at school, he does not resort to violence. His attendance is good, his grades are average, and he participates actively in the basketball club. During the examination, he was polite and engaged in conversation calmly. No abnormalities were found in the physical examination.

Which of the following responses is appropriate?

a) Conduct counseling.

b) Prescribe central nervous system stimulants.

c) Prescribe benzodiazepines.

d) Prescribe norepinephrine reuptake inhibitors.

e) Prescribe selective serotonin reuptake inhibitors (SSRIs).

The most appropriate response is:

a) Conduct counseling.

Explanation:

• This boy's behavior, characterized by defiance towards authority figures both at home and in school, suggests possible behavioral issues, which could be addressed through counseling rather than immediate pharmacotherapy. His active participation in school activities like basketball and the absence of violence or academic failure indicate that his issues might be more related to emotional or developmental challenges common in adolescence. Counseling can provide a supportive environment to explore the underlying causes of his defiance, improve communication skills, and develop coping strategies for managing emotions and behavior. It can also offer guidance to his mother on how to effectively respond to and support her son during challenging interactions.
• Pharmacological treatments, such as prescribing central nervous system stimulants (b) , benzodiazepines (c) , norepinephrine reuptake inhibitors (d), or SSRIs (e), are generally considered when there's a clear diagnosis that warrants their use, such as ADHD, anxiety disorders, or depression. In this case, there's no indication from the description that the boy's behaviors are symptoms of a disorder requiring medication. Instead, his behaviors seem more aligned with typical adolescent challenges that could benefit from behavioral and supportive interventions like counseling.

2-7 (109B44) An 89-year-old woman is hospitalized for a femoral fracture. She was diagnosed with Alzheimer's disease 10 years ago and has been on medication for it. Two days ago, she fell in her room, became immobile, and was transported to the hospital by ambulance. She was found to have a fracture in the trochanteric region of the left femur and underwent osteosynthesis surgery yesterday. Her postoperative course was smooth, and she slept well through the night. From the evening of the first postoperative day, she became restless and tried to get up, calling out loudly for the nurse all night long.

Which of the following responses is appropriate?

a) Scold her strongly.

b) Review pain management.

c) Apply trunk restraints throughout the day.

d) Remove the nurse call button.

e) Place her in the same room as another patient who yells similarly.

The appropriate response is:

b) Review pain management.

Explanation:

• After surgery, especially in elderly patients with cognitive disorders like Alzheimer's disease, changes in behavior such as restlessness and calling out loudly can indicate unaddressed pain or discomfort. These patients may not be able to communicate their pain effectively due to their cognitive condition. Reviewing and possibly adjusting her pain management strategy could help alleviate her discomfort and reduce her restlessness and the need to call out for assistance.
• Options such as scolding the patient (a), applying trunk restraints throughout the day (c), removing the nurse call button (d), and placing her in the same room as another patient who yells similarly (e) are not appropriate and do not address the underlying issue, which is likely pain or discomfort. Furthermore, these options could compromise patient care and safety, and in the case of (a), (c), and (d), could be considered unethical.

3-1 (105I24) Which of the following is incorrect about Post-Traumatic Stress Disorder (PTSD)?

a) Autonomic hyperarousal occurs.

b) Emotional numbing and an inability to enjoy activities occur.

c) Stress reactions disappear within a month.

d) Situations leading to the recall of the traumatic experience are avoided.

e) The traumatic event is repeatedly re-experienced.

The incorrect statement about Post-Traumatic Stress Disorder (PTSD) is:

c) Stress reactions disappear within a month.

Explanation:

One of the diagnostic criteria for PTSD involves the persistence of symptoms for more than one month following the traumatic event. If stress reactions or symptoms disappear within a month, the condition might be classified as Acute Stress Disorder (ASD), not PTSD. PTSD is characterized by longer-lasting symptoms that significantly impair an individual's ability to function in daily life. The other statements accurately describe symptoms and behaviors associated with PTSD, such as autonomic hyperarousal (a), emotional numbing and an inability to enjoy activities (b), avoidance of situations that could lead to the recall of the traumatic experience (d), and the repeated re-experiencing of the traumatic event (e).

3-2 (106D12) Which of the following complaints is likely from a patient with Generalized Anxiety Disorder?

a) "My face turns red immediately when I speak in front of people."

b) "I'm worried that my stomach pain might be cancer."

c) "I'm always tense and never have a moment of rest."

d) "I'm worried about having an attack when nobody's around."

e) "I can't be at peace unless I check several times that I've locked the door."

The complaint likely from a patient with Generalized Anxiety Disorder is:

c) "I'm always tense and never have a moment of rest."

Explanation:

• Generalized Anxiety Disorder (GAD) is characterized by persistent and excessive worry about various topics, events, or activities. Patients with GAD often find it difficult to control the worry and may feel restless, keyed up, or on edge, leading to being easily fatigued, having difficulty concentrating, irritability, muscle tension, and sleep disturbance. The statement "I'm always tense and never have a moment of rest" captures the essence of GAD, which is a generalized, persistent anxiety not limited to specific situations or objects.
• The other options describe symptoms more specific to other anxiety disorders or conditions: a) Immediate facial reddening in social situations could be related to social anxiety disorder. b) Worrying specifically about stomach pain being cancer might be more indicative of health anxiety. d) Concerns about having an attack when alone might relate to panic disorder or agoraphobia. e) Needing to check several times that a door is locked is characteristic of obsessive-compulsive disorder.

3-3 (106I32) Which of the following are correct about social anxiety disorder? Choose two.

a) Develops into delusions of reference.

b) Accompanied by sweating and trembling.

c) Does not present with panic attacks.

d) Thinks they are ostracized by society.

e) Avoids situations where they are observed by others.

The correct statements about Social Anxiety Disorder (Social Phobia) are:

b) Accompanied by sweating and trembling.

e) Avoids situations where being watched by others.

Explanation:

• b) Social Anxiety Disorder is characterized by intense fear or anxiety in one or more social situations where the individual is exposed to possible scrutiny by others. Symptoms can include physical signs of anxiety, such as sweating and trembling, especially when faced with social interactions, performance situations, or when being observed while doing something.
• e) Individuals with Social Anxiety Disorder often go to great lengths to avoid social situations where they fear they may be judged, embarrassed, or humiliated. This includes situations where they feel they're being watched or observed by others, such as speaking in public, eating or drinking in public, or attending social gatherings.
• a) "Develops into delusions of reference" is incorrect because while individuals with Social Anxiety Disorder are overly concerned about being judged or embarrassed in social situations, these concerns do not typically develop into delusions of reference. Delusions of reference involve false beliefs that insignificant remarks, events, or objects in one's environment have a specific and unusual significance to oneself, which is more characteristic of psychotic disorders.
• c) "Does not experience panic attacks" is not entirely accurate because individuals with Social Anxiety Disorder can experience panic attacks specifically triggered by social exposure situations, though the core issue is the fear of social situations rather than the panic attacks themselves.
• d) "Thinks they are ostracized by society" might reflect feelings of individuals with Social Anxiety Disorder, but it is not a defining characteristic of the disorder. The primary issue is the intense fear of social situations, not necessarily a belief of being ostracized.

3-4 (108D9) Which of the following is included in adjustment disorders?

a) Mood dysregulation

b) Brief depressive reaction

c) Depressive episode

d) Acute stress disorder

e) Post-traumatic stress disorder

The correct answer is:

b) Brief depressive reaction

Explanation:

Adjustment disorders are psychological responses to identifiable stressors occurring within 3 months of the onset of the stressor(s). These responses are characterized by emotional or behavioral symptoms that are out of proportion to the severity or intensity of the stressor, considering the cultural, social, and age-appropriate norms. Adjustment disorders can manifest with a variety of symptoms, including both depressive and anxious feelings, as well as disturbances in conduct.

• b) Brief depressive reaction is a type of adjustment disorder where the predominant manifestation is depression in response to a significant life change or stressor. The symptoms are less severe than those found in a major depressive episode and are directly related to the stressor.

The other options:

• a) Mood dysregulation is not specifically classified under adjustment disorders. It is more related to mood dysregulation disorder or other mood disorders.
• c) Depressive episode refers to a period characterized by severely depressed mood or loss of interest or pleasure in nearly all activities, which is a hallmark of major depressive disorder, not adjustment disorder.
• d) Acute stress disorder involves symptoms that occur immediately after exposure to a traumatic event, lasting from three days to one month. It is specifically related to trauma and is distinct from adjustment disorders, which are related to a wider range of stressors.
• e) Post-traumatic stress disorder (PTSD) develops after exposure to a traumatic event and involves symptoms that persist for more than a month and can last for years. PTSD is a separate diagnosis from adjustment disorder, which typically involves less severe symptoms that are more directly linked to a specific stressor and do not last as long.

3-5 (108D14) Regarding mental disorders due to psychological stress at work, which situation is considered to have the highest level of stress?

a) Received unreasonable demands from a customer.

b) Was pointed out by a colleague for missing documents.

c) Set performance goals that are difficult to achieve.

d) Had to give a presentation at a large briefing.

e) Caused an injury to a customer that requires hospitalization for more than two months.

3-6 (109I3) Which one involves symptoms that develop due to stress and disappear within a certain period after the stressor is gone?

a) Adjustment disorder

b) Somatoform disorder

c) Panic disorder

d) Social anxiety disorder

e) Post-traumatic stress disorder

3-7 (110I37) Which of the following are considered symptoms of Obsessive-Compulsive Disorder? Choose two.

a) Thoughts involuntarily pop into one's head.

b) There's no real feeling of being the one thinking.

c) Past scenes vividly come to mind.

d) Continuously thinking about possibly hitting someone.

e) Feeling uneasy unless objects on a desk are parallel to the edges of the desk.

The symptoms considered characteristic of Obsessive-Compulsive Disorder (OCD) are:

d) Continuously thinking about possibly hitting someone. e) Feeling uneasy unless objects on a desk are parallel to the edges of the desk.

Explanation:

• d) Continuously thinking about possibly hitting someone is indicative of obsessions, particularly those involving harm. This type of obsession involves persistent, unwanted thoughts about causing harm to others, which can cause significant anxiety due to the person's efforts to suppress or neutralize these thoughts with other thoughts or actions, known as compulsions.
• e) Feeling uneasy unless objects on a desk are parallel to the edges of the desk represents a compulsion for symmetry and order. This need for things to be just right or to perform actions until they feel perfect is a common symptom of OCD. The discomfort or unease felt unless certain actions are taken or conditions are met can significantly impact daily functioning.

4-1 (101G3) An 18-year-old female has been frequently absent from work, prompting her concerned family to accompany her to a visit. After graduating high school, she got a job at a department store but found it distressing to explain and sell products in front of many customers, leading to her frequent absences. There are no particularly unusual behaviors at home.

Which of the following is a possible diagnosis?

a) Depression

b) Anxiety disorder

c) Obsessive-compulsive disorder

d) Dissociative disorder

e) Schizophrenia

The most likely diagnosis is:

b) Anxiety disorder

Explanation:

• The description highlights that the young woman experiences significant distress specifically in social situations, such as explaining and selling products in front of many customers, which leads to her frequent absences from work. Her discomfort in social situations and the avoidance behavior (frequent absences) suggest an anxiety disorder, potentially Social Anxiety Disorder (Social Phobia). This disorder is characterized by intense fear or anxiety in social situations where the individual is exposed to possible scrutiny by others. The fear is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

The other options are less likely based on the information provided:

• a) Depression could manifest with avoidance of work or social situations, but the primary issue described here is the distress tied to specific social situations, not a general depressed mood or loss of interest in activities.
• c) Obsessive-compulsive disorder (OCD) involves repetitive thoughts (obsessions) and behaviors (compulsions) that the individual feels compelled to perform. There's no indication of such patterns in the brief description.
• d) Dissociative disorder involves disruptions and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. The scenario provided does not suggest such symptoms.
• e) Schizophrenia is a complex psychiatric disorder that involves a range of symptoms, including delusions, hallucinations, disorganized speech, and significant social/occupational dysfunction. The situation described does not include these hallmark symptoms.

4-2 (102A29) A 27-year-old woman was brought to the clinic by her concerned husband because she stares blankly at one point and seems indifferent to everything. Five weeks ago, she was sexually assaulted on her way home. Since then, she has been unable to leave the house and has been absent from work. She has not been able to sleep at all, has no appetite, and has lost a significant amount of weight rapidly. Her husband is worried and tries to talk to her, but she does not respond and just stares blankly.

Which of the following is a possible diagnosis?

a) Adjustment disorder

b) Obsessive-compulsive disorder

c) Social anxiety disorder

d) Generalized anxiety disorder

e) Post-traumatic stress disorder (PTSD)

The most likely diagnosis is:

e) Post-traumatic stress disorder (PTSD)

Explanation:

• The woman's symptoms began after a traumatic event (sexual assault), which is a key criterion for PTSD. Symptoms of PTSD include re-experiencing the traumatic event (through flashbacks, nightmares), avoidance of stimuli associated with the trauma (in this case, unable to leave the house), negative changes in thinking and mood (indifference, not responding to her husband), and marked alterations in arousal and reactivity (inability to sleep, rapid weight loss). Her behavior of staring blankly and being non-responsive could also be indicative of dissociation, a symptom associated with PTSD. The timing (symptoms beginning after the traumatic event and persisting for more than a month) and the nature of the symptoms fit the diagnosis of PTSD.

The other options do not fit as well based on the provided information:

• a) Adjustment disorder involves stress-related symptoms following a significant life event, but the symptoms are less severe and typically do not include the degree of functional impairment or specific symptoms such as re-experiencing the trauma or dissociation seen in PTSD.
• b) Obsessive-compulsive disorder (OCD) is characterized by unwanted, intrusive thoughts and repetitive behaviors or mental acts. The description does not mention any obsessions or compulsions.
• c) Social anxiety disorder involves intense fear or anxiety in social situations due to fear of being judged, embarrassed, or humiliated. While the woman is avoiding leaving the house, the primary reason appears to be trauma-related, not fear of social judgment.
• d) Generalized anxiety disorder (GAD) involves persistent and excessive worry about various aspects of life, not specifically related to a traumatic event, and does not typically include symptoms such as re-experiencing the trauma or dissociation.

4-3 (102A30) A 13-year-old boy visited the clinic with a chief complaint of headaches. He has been experiencing frequent headaches for the past month, which sometimes prevented him from going to school. The headaches feel like a tightening pain throughout the head but lessen after about an hour. The timing of the headaches is irregular, with no aura preceding them. There is no fever, but nausea sometimes accompanies the pain. There has been no change in symptoms over the month. Blood tests: red blood cells 5.1 million, white blood cells 3,800, platelets 170,000. CRP 0.2 mg/dL. No abnormalities were found on a plain head CT.

Which of the following is not an appropriate response at the first consultation?

a) Measure blood pressure.

b) Perform psychological testing.

c) Check for ophthalmological abnormalities.

d) Check for ENT (ear, nose, throat) abnormalities.

e) Advise not to go to school.

The inappropriate response at the first consultation is:

e) Advise not to go to school.

Explanation:

• At the initial consultation for a child presenting with headaches, the primary goal is to conduct a comprehensive assessment to determine the cause of the headaches. This includes measuring blood pressure (a) to rule out hypertension, examining for ophthalmological (c) and ENT (d) abnormalities to check for common causes of headaches such as vision problems or sinus issues, and even considering psychological factors (b) if stress or anxiety seems to be a contributing factor.
• Advising not to go to school (e) without a clear understanding of the cause of the headaches and without attempting interventions that might alleviate the symptoms is not appropriate. Such advice could unnecessarily interfere with the child's education and social development. It's important to address the underlying issue causing the headaches and to develop a management plan that allows the child to continue their daily activities, including school, as much as possible.

4-4 (102G60) A 32-year-old woman experienced severe palpitations, difficulty breathing, feelings of faintness, and her body going into a bow-like state of tension during a marital argument a year ago, for which she received treatment at a local clinic. Since then, the frequency and duration of similar episodes have increased. Recently, as her marital relationship cooled and divorce discussions began, each mention of divorce triggered repeated episodes, leading to outpatient visits. No physical abnormalities were found.

Which of the following treatments is appropriate?

a) Psychotherapy

b) Administration of antipsychotic medication

c) Electroconvulsive therapy

d) Administration of anticonvulsant medication

e) Social skills training (SST)

The appropriate treatment is:

a) Psychotherapy

Explanation:

• The woman's symptoms—severe palpitations, difficulty breathing, feelings of faintness, and her body going into a bow-like state of tension during stressful emotional situations—suggest a psychological rather than a physiological origin, particularly given the absence of physical abnormalities. These episodes could be indicative of panic attacks or anxiety related to her marital conflicts and discussions of divorce. Psychotherapy, particularly cognitive-behavioral therapy (CBT), is effective in treating anxiety disorders, including panic disorder, by helping individuals understand and change their thought patterns and behaviors that trigger anxiety and panic attacks.
• Option b) Administration of antipsychotic medication, is more suited for psychotic disorders, not primarily anxiety or panic disorders.
• Option c) Electroconvulsive therapy (ECT), is typically reserved for severe cases of depression or other mental health conditions unresponsive to other treatments, not first-line for anxiety or panic disorders.
• Option d) Administration of anticonvulsant medication, may be used in some cases of anxiety, but given the situational trigger of her symptoms and the absence of a diagnosis of a seizure disorder, this would not be the first choice.
• Option e) Social skills training (SST), is generally used to improve social interactions and communication skills, which could be beneficial in a broader treatment plan but does not directly address the acute symptoms or underlying causes of her panic or anxiety episodes.

4-5 (103A39) A 62-year-old woman visited the clinic alone, complaining of forgetfulness. She started taking notes for everything important about six months ago, fearing she would forget. Even after taking notes, she becomes anxious, worrying she might have forgotten something. She believes her memory is gradually deteriorating. She canceled a trip with a friend, which she had been looking forward to, because she worried about getting sick at the destination. The sound of an ambulance siren makes her anxious, fearing her grandchild might have been in an accident. She experiences palpitations and occasional dizziness but manages all household chores. Her appearance is neat, her movements are agile, and although she is somewhat nervous during the interview, her responses are appropriate.

Which of the following is a possible diagnosis?

a) Depression

b) Pick's disease

c) Generalized anxiety disorder

d) Somatic symptom disorder

e) Alzheimer's disease

The correct answer is:

c) Generalized anxiety disorder

Explanation:

Given the details provided, generalized anxiety disorder (GAD) is a plausible diagnosis. This condition is characterized by persistent and excessive worry about various aspects of daily life, not limited to one specific event or situation. The woman's behaviors and symptoms, such as worrying about forgetting important things, taking notes excessively out of fear of forgetting, feeling restless about potentially missed notes, and exhibiting undue concern over personal health and safety (e.g., canceling trips due to health worries, anxiety about her grandchild's safety upon hearing sirens), align with the hallmark features of GAD. Additionally, physical symptoms like palpitations and dizziness can accompany GAD, further supporting this diagnosis. While her actions and the level of care she maintains for herself suggest she is functioning relatively well in daily activities, the pervasive anxiety impacting her quality of life is characteristic of generalized anxiety disorder.

4-6, 7 (103G65, 103G67) A 33-year-old woman, accompanied by her husband, visited the clinic complaining of a lack of motivation to do anything.

Current medical history: At 31, while driving, she suddenly experienced shortness of breath, palpitations, cold sweat, and dizziness, felt faint, and was terrified she was going to die, leading her to seek medical attention nearby. After receiving treatment, the episode subsided, but similar episodes began occurring frequently afterward, leading her to visit internal medicine, neurosurgery, gynecology, and otolaryngology departments repeatedly. She became increasingly worried that another episode would occur. Gradually, she became unable to go out to banks, department stores, or supermarkets. Over the past year, she has minimized going out, effectively confining herself at home. Her mood has gradually declined, she has become pessimistic about the future, lost interest in things, and doesn't want to do household chores. She can't sleep well, her appetite has decreased, and she has lost 8kg in the past year. She still experiences episodes occasionally.

Past medical history: She tended to feel unwell before menstruation.

Life history: She has a naturally cheerful personality and had many friends. After graduating high school, she worked in an administrative position. She married at 22 and has been a stay-at-home mother raising two children.

Current condition: Conscious and alert. Height 162 cm, weight 45 kg. Body temperature 36.5°C. Pulse 72 beats per minute, regular. Blood pressure 120/76 mmHg.

1. Which two conditions are observed in this patient?

a) Regression

b) Dissociation

c) Agoraphobia

d) Anticipatory anxiety

e) Hysterical coma

2. Which two conditions could be considered?

a) Depression

b) Epilepsy

c) Eating disorder

d) Delusional disorder

e) Panic disorder

1. The two conditions observed in this patient are:

c) Agoraphobia

d) Anticipatory anxiety

Explanation:

• c) Agoraphobia is characterized by an intense fear or anxiety about being in places or situations from which escape might be difficult or help might not be available in the event of having panic-like symptoms or other embarrassing symptoms. The patient's avoidance of places like banks, department stores, and supermarkets, where such episodes could occur, aligns with agoraphobia.
• d) Anticipatory anxiety involves excessive worry about future panic attacks or the fear of experiencing the same distressing symptoms again, which is evident in the patient's concern about having another episode.

2. The two conditions that could be considered are:

a) Depression

e) Panic disorder

Explanation:

• a) Depression is suggested by the patient's loss of interest in activities, significant weight loss, sleep disturbances, and a pessimistic outlook on the future. These symptoms indicate a depressive disorder.
• e) Panic disorder is indicated by the sudden onset of palpitations, shortness of breath, dizziness, and a fear of dying, which are typical of panic attacks. The patient's frequent episodes and the severe worry about future attacks also point towards panic disorder.

4-8 (104I74) A 28-year-old woman visited the clinic complaining that she is unable to concentrate on her work. Two months ago, she was involved in a car accident while driving with her family, sustaining severe abdominal injuries but no head trauma. Her parents died instantly. Although her physical condition has improved, for the past month, she has frequently been haunted by visions of the accident during the day, which terrifies her.

Which of the following is likely to occur in this condition?

a) Nightmares

b) Hypersomnia

c) Hallucinations

d) Night terrors

e) Déjà vu

The condition likely to occur in this scenario is:

a) Nightmares

Explanation:

• The woman's symptoms, including being frequently haunted by visions of the traumatic car accident during the day and experiencing significant anxiety as a result, suggest that she is experiencing post-traumatic stress disorder (PTSD). A common symptom of PTSD is nightmares, where individuals relive the traumatic event in their dreams. These nightmares can cause significant distress and contribute to the fear and anxiety associated with the trauma. Given the description of her experiencing vivid, distressing recollections of the accident during waking hours, it's likely that her sleep could also be disturbed by nightmares related to the trauma.

The other options, while possible symptoms in various psychological conditions, are not as directly linked to the described symptoms:

• b) Hypersomnia might occur in various mood and anxiety disorders, but it is not specifically mentioned in the scenario.
• c) Hallucinations involve sensing things that are not present, which might occur in severe cases but are not as commonly associated with PTSD as nightmares are.
• d) Night terrors are episodes of screaming, intense fear, and flailing while still asleep, more common in children than adults, and not specifically related to reliving traumatic events.
• e) Déjà vu is a feeling that one has lived through the present situation before, not directly related to the traumatic experiences described.

4-9 (107A24) A 19-year-old male visited the clinic with the chief complaint of being unable to speak in front of others. He entered university last spring. During a club orientation, when asked to introduce himself, he felt everyone's gaze, became nervous, and his body trembled. Since then, he has avoided being in front of people, did not join the club he was interested in, and has continued his university life attending lectures only. No depressive symptoms are observed, and no clear hallucinations or delusions are present.

Which of the following treatments is most appropriate?

a) Art therapy

b) Family therapy

c) Play therapy

d) Cognitive-behavioral therapy

e) Psychoanalytic therapy

The most appropriate treatment is: d) Cognitive-behavioral therapy (CBT)

Explanation:

The description suggests the individual may be experiencing social anxiety disorder, characterized by intense fear or anxiety in social situations, especially where there is the possibility of being scrutinized by others. The physical symptoms of trembling when faced with public speaking and avoidance behavior (not joining the desired club and limiting university life to attending lectures) are indicative of this condition.

• Cognitive-behavioral therapy (CBT) is a highly effective treatment for social anxiety disorder. It involves identifying and challenging negative thought patterns and beliefs about social situations and gradually facing feared social situations in a controlled manner to reduce anxiety and avoidance behavior. CBT is practical and goal-oriented, making it suitable for addressing the specific fears and situations the individual is struggling with.

The other options, while beneficial for various conditions, are not as directly targeted to the symptoms and behaviors associated with social anxiety disorder as CBT:

• a) Art therapy can be a useful adjunctive treatment but does not directly address the cognitive and behavioral aspects of social anxiety.
• b) Family therapy can be helpful in cases where family dynamics contribute to an individual's issues but may not directly address the individual's social anxiety.
• c) Play therapy is typically used with children and may not be applicable or effective for a university student's social anxiety issues.

• e) Psychoanalytic therapy focuses on uncovering underlying psychological conflicts from early life experiences but may not be as effective as CBT for specific phobias and anxiety disorders like social anxiety disorder in a short-term context.

4-10 (107D22) A 32-year-old man visited the clinic complaining of insomnia. As a firefighter, he was dispatched the day after a major disaster occurred and spent two weeks on rescue operations under harsh conditions. Upon returning to his regular job, he initially did well, even working more earnestly than before. However, about two months after the rescue activities, he began waking up multiple times during the night, became irritable, and noticed a decline in concentration, leading him to consult with an occupational physician and seek an appointment. There is no notable past medical history. He is motivated to work, and there is no increase in fatigue.

Which question is important for diagnosis?

a) "Do you suddenly have unpleasant scenes flash into your mind?"

b) "Does talking about your difficult symptoms with family members make you feel somewhat relieved?"

c) "Are you anxious about not being able to sleep tonight?"

d) "Have you been feeling very down, and has it lasted for several days?"

e) "Do you feel like you no longer enjoy things you used to find pleasurable?"

The important question for diagnosis is:

a) "Do you suddenly have unpleasant scenes flash into your mind?"

Explanation:

• This question is critical for diagnosing Post-Traumatic Stress Disorder (PTSD), which the man's symptoms suggest he might be experiencing. PTSD can occur after exposure to a traumatic event, such as the intense and demanding rescue operations he was involved in following a major disaster. Symptoms of PTSD include re-experiencing the traumatic event through intrusive memories or flashbacks, which could contribute to his insomnia, irritability, and decreased concentration. Asking about the presence of intrusive memories or flashbacks can help identify whether his symptoms are related to PTSD, facilitating appropriate treatment planning.
• The other options, while relevant to his overall well-being and mental health, are not as directly diagnostic of PTSD as option a). They could help identify other issues like depression (d) and (e), anxiety about insomnia (c), or the potential benefits of social support (b), but the direct link to PTSD symptoms makes option a) the most important for diagnosing his condition.

4-11 (110E43) A 20-year-old woman, accompanied by a friend, visited the clinic because she lost her voice. This morning, she went to university as usual, but her voice started to become hoarse after the first lecture ended, and an hour later, she completely lost her voice. She consulted with the health management office at her university along with her friend, where they advised her to seek medical attention, leading to her visit. Since a year ago, following troubles in relationships within her club activities, she started experiencing anxiety and emotional instability, for which she had been receiving treatment. At the time of consultation, she was able to communicate via writing, her comprehension was intact, and she was considered to be alert and conscious. No neurological findings were observed except for the inability to produce voice. Blood biochemistry, EEG, and head CT scans showed no abnormalities.

Which of the following is observed in this patient?

a) Dissociation

b) Conversion

c) Depersonalization

d) Suggested experience

e) Induced experience

• Conversion disorder, part of what were historically referred to as "hysteria," is a psychological condition in which patients present with neurological symptoms, such as paralysis, blindness, or in this case, loss of voice (aphonia), that cannot be explained by medical evaluation. These symptoms are not intentionally produced and often occur in response to psychological stress or conflict. The sudden loss of voice following a period of emotional stress or anxiety, with no neurological or physical abnormalities found in examinations (blood tests, EEG, head CT scans), strongly suggests a conversion disorder. The fact that the patient had been experiencing anxiety and emotional instability for a year, likely exacerbated by interpersonal issues, supports this diagnosis. Conversion disorder is characterized by symptoms that affect voluntary motor or sensory functions, suggesting a psychological need or conflict is being expressed through physical symptoms.

The other options:

• a) Dissociation typically involves a disconnection between thoughts, identity, consciousness, and memory, not solely physical symptoms.
• c) Depersonalization involves feeling detached from oneself or one's body, not necessarily presenting with physical symptoms like voice loss.
• d) Suggested experience and e) Induced experience are not standard terms or diagnoses within the context of psychological disorders related to the symptoms described.

4-12 (111D54) A 22-year-old man visited the clinic because he felt fearful. In November of his third year in junior high, he was stressed about high school entrance exams. Around that time, while eating with a friend, he felt as though his throat was blocked and found it hard to swallow. This condition persisted during meals with friends, and he became unable to eat at all when dining out, feeling as if the food wouldn't go down his throat and his hands would tremble as if he was being watched. At home, he can eat normally. As a result, he has hardly gone out with friends since entering university. Now, with job-seeking ahead, he is concerned this will interfere with his work and decided to seek consultation. During the examination, he answered questions accurately and showed no signs of depression. He expressed, "Even though I know I shouldn't worry about it, I don't understand why I get so nervous that I can't eat." No abnormalities were found in the physical examination, including neurological findings.

Which two medications are appropriate for treatment?

a) Anti-anxiety medication

b) Mood stabilizers

c) Anti-Parkinson's medication

d) Atypical antipsychotics

e) Selective serotonin reuptake inhibitors (SSRIs)

The appropriate medications for treatment are:

a) Anti-anxiety medication

e) Selective serotonin reuptake inhibitors (SSRIs)

Explanation:

• a) Anti-anxiety medication: Given the man's symptoms of anxiety, particularly in social situations like eating out with friends, anti-anxiety medications can help alleviate the immediate symptoms of fear and physical manifestations of anxiety such as trembling hands. These medications are useful for short-term relief of anxiety symptoms.
• e) Selective serotonin reuptake inhibitors (SSRIs): SSRIs are commonly used for a range of anxiety disorders and are effective in managing symptoms of social anxiety disorder, which this man appears to be experiencing. SSRIs work by increasing the levels of serotonin in the brain, which can help improve mood and reduce anxiety. Given his ongoing issues with anxiety that interfere with social activities and concerns about future employment, SSRIs could provide longer-term management of his symptoms.

The other options are less appropriate given the presented symptoms

• b) Mood stabilizers are typically used for bipolar disorder or mood swings, which are not described in this scenario.
• c) Anti-Parkinson's medication is used to treat Parkinson’s disease and drug-induced extrapyramidal symptoms, which are not applicable here.
• d) Atypical antipsychotics are primarily used for treating psychosis, schizophrenia, and bipolar disorder, not for anxiety or specific phobias related to eating in public.

The man's difficulty with swallowing and fear of eating out, without any physical abnormalities found upon examination, suggests an anxiety-related condition rather than a neurological or mood disorder, making anti-anxiety medications and SSRIs the most appropriate choices.

4-13 (112A42) A 27-year-old woman visited the clinic complaining of sudden palpitations and difficulty breathing. About a month ago, while on the train to work, she suddenly started experiencing palpitations and cold sweat, and her breathing became labored, overwhelmed by the fear that she might suffocate to death. After getting off the train at an intermediate station, her symptoms eased within about 10 minutes. Since then, she has experienced similar symptoms once on the train and once at home. Despite thorough examinations including an electrocardiogram, no abnormalities were found. She continues to worry about the possibility of symptoms recurring, regardless of her location.

Which symptom of persistent worry is this?

a) Hypochondriacal delusion

b) Autogenous thoughts

c) Claustrophobia

d) Delusional mood

e) Anticipatory anxiety

The symptom of persistent worry described is:

e) Anticipatory anxiety

Explanation:

• Anticipatory anxiety refers to the fear and worry about facing a situation that might induce anxiety or panic attacks in the future. This condition is characterized by the persistent concern over the possibility of experiencing distressing symptoms again, regardless of the specific location or situation. The woman's experience of sudden palpitations and difficulty breathing, along with the fear of these symptoms recurring in any location, fits the description of anticipatory anxiety. This type of anxiety is common in individuals with panic disorder, where the person experiences repeated unexpected panic attacks and is persistently worried about having more panic attacks or their consequences.

The other options do not accurately describe the woman's symptoms:

• a) Hypochondriacal delusion involves a persistent belief in having a serious, undiagnosed medical illness despite medical evidence to the contrary.
• b) Autogenous thoughts are self-generated thoughts typical in OCD, unrelated to the fear of panic attacks.
• c) Claustrophobia is a specific fear of being in enclosed spaces, which does not fully capture her fear that is not limited to specific situations.
• d) Delusional mood refers to a general feeling that something is wrong or something bad is going to happen, often preceding delusions, but it does not specifically relate to the fear of recurring symptoms of panic or anxiety.

4-14 (113A25) An 18-year-old girl was brought to the clinic by her concerned mother because she was behaving differently than usual. Yesterday, she came home crying with a pained expression, having broken up with a boyfriend she had been dating for a while. Two hours later, when her mother spoke to her, she responded with an unusual, childlike, clingy demeanor, asking, "Mom, make me the usual sweets." When her mother asked about the distressed state she was in when she came home, she replied, "What are you talking about?" and had no memory of it. No abnormalities were found in the physical examination, including a neurological examination. Blood tests, brain imaging, and EEG showed no abnormalities.

Which of the following is correct about this patient?

a) She is in a comatose state.

b) Hospitalization is necessary.

c) Cognitive-behavioral therapy is effective.

d) There is a high possibility that this is the early stage of schizophrenia.

e) She is experiencing amnesia for the stressful event.

The correct statement about this patient is:

e) She is experiencing amnesia for the stressful event.

Explanation:

• The described behavior, including the sudden shift to a childlike demeanor and the inability to remember the distressing event she experienced when she came home, suggests an episode of dissociative amnesia. Dissociative amnesia is characterized by an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness. The situation of breaking up with a boyfriend and the subsequent emotional distress, followed by a period during which she acted in a manner inconsistent with her usual self and had no memory of the episode, aligns with this diagnosis.

The other options are less applicable based on the information provided:

• a) She is in a comatose state. - This is incorrect, as she is conscious and interacting with her mother, although in a childlike manner.
• b) Hospitalization is necessary. - Without further information indicating danger to herself or others, immediate hospitalization may not be necessary. The need for hospitalization would depend on a more comprehensive assessment of her mental state and safety.
• c) Cognitive-behavioral therapy is effective. - While CBT can be effective for a range of psychological disorders, including some forms of dissociative disorders, the specific statement is too broad without a clear diagnosis and understanding of her overall psychological condition.
• d) There is a high possibility that this is the early stage of schizophrenia. - The symptoms described do not specifically indicate schizophrenia, which is characterized by a range of symptoms including delusions, hallucinations, disorganized speech, and significant social/occupational dysfunction. The episode described seems more related to a dissociative reaction to a stressful event rather than symptoms of schizophrenia.

4-15 (116D17) A man, appearing to be in his early 40s, was found crouching on the street and taken into custody by a police officer because he claimed, "I don't know who I am," and was brought to the clinic accompanied by the officer. He had no possessions that could identify him. He was able to converse and spoke in a Kansai dialect, though he claimed to have no memory of living in the Kansai region. There were no signs of trauma, and physical examinations including blood tests, brain imaging, and EEG showed no abnormalities. He retained memories from after he was taken into custody.

The most likely characteristic seen in this patient is:

a) Capgras delusion is present.

b) He is capable of performing general actions like buying a ticket.

c) He is seriously troubled by the lack of memory.

d) There is a need to administer antipsychotic medication.

e) This is an early symptom of Alzheimer's disease.

The most likely characteristic seen in this patient is:

b) He is capable of performing general actions like buying a ticket.

Explanation:

• The scenario describes a man with apparent amnesia regarding his identity and past, including where he has lived. Despite this significant memory gap, there is no mention of him being unable to engage in normal, everyday activities or having cognitive impairments beyond his amnesia. The fact that physical examinations, including neuroimaging and blood tests, revealed no abnormalities, and he retained memories after being taken into custody, suggests his cognitive functions are intact for day-to-day activities. This situation is indicative of dissociative amnesia, a condition characterized by a sudden inability to recall personal information, usually of a traumatic or stressful nature, which is too extensive to be explained by ordinary forgetfulness.

The other options:

• a) Capgras delusion involves a belief that a familiar person or place has been replaced with an exact duplicate. This is not indicated in the scenario.
• c) He is seriously troubled by the lack of memory. While this may be true, the scenario does not provide enough information about his emotional or psychological state regarding his amnesia.
• d) There is a need to administer antipsychotic medication. This treatment would be more appropriate for psychotic disorders, which are not clearly indicated in the provided scenario.
• e) This is an early symptom of Alzheimer's disease. Alzheimer's typically presents with progressive memory loss and other cognitive declines, not sudden amnesia with retention of the ability to perform daily tasks and new memory formation, as described here.

5-1 (100G113) Which is the most appropriate medication for depression?

a) Monoamine reuptake inhibitor

b) Benzodiazepine

c) Barbiturate

d) Antihistamine

e) Anticholinergic

The most appropriate medication for depression is:

a) Monoamine reuptake inhibitor

Explanation:

• Monoamine reuptake inhibitors, including selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and tricyclic antidepressants (TCAs), are considered first-line treatments for depression. These medications work by increasing the levels of neurotransmitters (such as serotonin, norepinephrine, and dopamine) in the brain, which are often imbalanced in people with depression. By preventing the reuptake of these neurotransmitters into neurons, monoamine reuptake inhibitors help enhance mood and alleviate depressive symptoms.

The other options are less appropriate for the treatment of depression:

• b) Benzodiazepine: Mainly used for anxiety, insomnia, and agitation. While they can provide symptomatic relief for these conditions in depression, they do not treat the underlying depressive symptoms and have a potential for dependence.
• c) Barbiturate: Primarily used for sedation, anesthesia, and seizure disorders. They are not recommended for depression due to their high potential for dependence and overdose.
• d) Antihistamine: Often used for allergy relief and sometimes for insomnia. They are not effective in treating the core symptoms of depression.
• e) Anticholinergic: Used for various conditions, including gastrointestinal disorders, Parkinson's disease, and to reduce side effects of antipsychotic medications. They are not used for treating depression due to their potential side effects and lack of efficacy in addressing depressive symptoms.

5-2 (104B19) Which of the following are prone to presenting with a depressive state? Choose two.

a) Pick's disease

b) Tabes dorsalis

c) Cerebrovascular accident

d) Parkinson's disease

e) Creutzfeldt-Jakob disease

The two conditions prone to presenting with a depressive state are:

c) Cerebrovascular accident d) Parkinson's disease

Explanation:

• c) Cerebrovascular accident (CVA), also known as a stroke, can lead to depressive states in individuals due to the sudden changes in their physical health, mobility, and independence. The impact of a stroke on the brain can also directly affect mood and cognitive function, leading to depression.
• d) Parkinson's disease is a neurodegenerative disorder characterized by motor symptoms such as tremors, stiffness, and bradykinesia (slowness of movement), as well as non-motor symptoms including depression. Depression in Parkinson's disease can be related to the psychological impact of dealing with a chronic, progressive illness, as well as neurobiological changes caused by the disease itself.

The other options:

• a) Pick's disease, a type of frontotemporal dementia, primarily affects behavior and language. While changes in mood can occur, it is not specifically known for presenting with a depressive state.
• b) Tabes dorsalis, a late manifestation of untreated syphilis affecting the dorsal columns of the spinal cord, is primarily characterized by sensory disturbances and poor coordination, not typically depression.
• e) Creutzfeldt-Jakob disease (CJD) is a rare, degenerative, invariably fatal brain disorder. While it leads to rapid neurological decline, depression is not a defining feature of CJD, although behavioral changes can occur.

5-3 (107I20) Which of the following statements is likely to be made by a patient in a manic state?

a) "I have trouble falling asleep at night."

b) "I wake up several times in the middle of the night."

c) "I experience sleep paralysis when I'm asleep."

d) "I'm fine without sleeping at night."

e) "My legs feel restless, and I can't sleep well."

A statement that could be made by a patient in a manic state is:

d) "I'm fine without sleeping at night."

Explanation:

During a manic episode, individuals often experience a decreased need for sleep. They may feel rested after only a few hours of sleep or claim they do not need to sleep at all, as they might have an abundance of energy. This symptom is characteristic of mania and distinguishes it from other conditions that affect sleep.

The other options describe symptoms associated with sleep disturbances that are not specifically indicative of a manic state. These statements are more likely to describe issues with sleep quality or disorders like insomnia or restless legs syndrome, rather than the decreased need for sleep seen in mania.

6-1 (102A27) A 35-year-old man, accompanied by his wife, visited the clinic complaining of fatigue and a lack of motivation. He started worrying about whether his job was suitable for him around three months ago when there was a reassignment at work. He has noticed feelings of fatigue and a loss of appetite, resulting in a weight loss of about 3 kg. Although he falls asleep easily, he wakes up in the middle of the night. When at home, he spends a lot of time worrying, and his smile has completely disappeared. He believes that the cause is his workplace and insists that resigning is the only solution to his condition.

The most appropriate medication is:

a) Sleeping pills

b) Antidepressants

c) Anti-anxiety medication

d) Antipsychotic medication

e) Antiepileptic medication

The most appropriate medication for this patient is:

b) Antidepressants

Explanation:

• The patient's symptoms, including fatigue, loss of appetite, weight loss, disrupted sleep (specifically waking up in the middle of the night), persistent worrying, and a noticeable change in mood (loss of smile and enjoyment), are indicative of depression. The onset of these symptoms appears to correlate with a significant life stressor (job reassignment), which has led to increased stress and worry about his job suitability and overall satisfaction. Antidepressants are effective in treating the core symptoms of depression by correcting the imbalance of neurotransmitters in the brain, which can improve mood, increase energy levels, restore appetite, and normalize sleep patterns.

The other options, while useful in specific contexts, are less appropriate given the primary diagnosis:

• a) Sleeping pills could temporarily improve his sleep but would not address the underlying depression and could potentially lead to dependency.
• c) Anti-anxiety medication could help reduce anxiety symptoms but might not adequately address the broader range of depressive symptoms the patient is experiencing.
• d) Antipsychotic medication is used to treat conditions like schizophrenia and severe bipolar disorder and is not indicated for primary treatment of depression without psychotic features.
• e) Antiepileptic medication is primarily used for seizure disorders and certain types of pain management and is not a standard treatment for depression.

6-2 (102A28) A 32-year-old man was brought to the clinic by his parents because he had been verbally abusive towards his wife and children. When he was a sophomore in high school, he became lethargic for no apparent reason and missed school for three months but recovered without any specific treatment and had been doing well since then. Starting three months ago, he began arguing more with his superiors and colleagues at work, becoming sullen and defiant when corrected. He has been going out more at nights and on weekends, and his spending has significantly increased. While usually in a good mood and talkative, he easily becomes irritated and utters abuses over minor things. He yells at his wife when she points out his spending habits and screams at his young children when they do not stop crying. Although he used to drink socially, his alcohol consumption has recently increased. He has no awareness of his physical or mental health issues and visited the clinic reluctantly at his parents' urging.

Which of the following is a possible diagnosis?

a) Personality disorder

b) Bipolar disorder (manic-depressive illness)

c) Schizophrenia

d) Alcohol dependence

e) Attention-deficit/hyperactivity disorder (ADHD)

The most likely diagnosis for this patient is:

b) Bipolar disorder (manic-depressive illness)

Explanation:

• The patient's history of mood changes, from experiencing a period of lethargy in high school (suggestive of a depressive episode) to recent increased irritability, defiance, increased spending, and increased social outings (suggestive of a manic or hypomanic episode), aligns with the characteristics of bipolar disorder. Bipolar disorder involves episodes of mood swings ranging from depressive lows to manic or hypomanic highs. The patient's lack of insight into his condition, elevated mood contrasted with irritability and aggression, and increased alcohol use are common in manic phases.

The other options:

• a) Personality disorder might be considered given the behavioral issues, but the episodic nature of the symptoms more strongly suggests bipolar disorder.
• c) Schizophrenia is characterized by delusions, hallucinations, disorganized thinking, and significant social/occupational dysfunction, which are not described here.
• d) Alcohol dependence is a possibility, considering his increased drinking, but it seems more likely to be a symptom rather than the root cause of his behavioral changes.
• e) Attention-deficit/hyperactivity disorder (ADHD) typically presents with inattention, hyperactivity, and impulsivity that are consistent across different contexts and from a young age, not episodic mood swings.

6-3 (107I43) A 55-year-old man was found standing still on a train platform and taken into custody with a suicide note in his possession; he was brought in for consultation accompanied by his company supervisor. He has been feeling depressed all day and struggling with his work for the past two months. He expresses a desire to go home, saying, "I don't have the courage to die" and "I don't want to bother anyone, so I'd rather be alone."

The first step to take is:

a) Let him go home alone.

b) Hospitalize him in psychiatry.

c) Contact the police immediately.

d) Administer antidepressants via IV drip.

e) Ask specifically about suicidal thoughts.

The first step that should be taken is:

e) Ask specifically about suicidal thoughts.

Explanation:

• Given the context of the man being found with a suicide note and expressing feelings of not wanting to cause trouble by wishing to be left alone, it's crucial to directly and empathetically inquire about his suicidal thoughts, plans, and intentions. This approach is essential for assessing his immediate risk of suicide and understanding the severity of his ideation, which will guide further necessary actions to ensure his safety. It's a critical step in determining the level of care he needs, such as immediate hospitalization or other interventions.

The other options:

• a) Let him go home alone. This would be highly inappropriate and unsafe given his current state and suicidal ideation.
• b) Admit him to a psychiatric unit. While hospitalization may indeed be necessary to ensure his safety and provide treatment, the decision should come after a thorough assessment, including directly inquiring about his suicidal thoughts.
• c) Contact the police immediately. While involving the police might be necessary in some cases to ensure the individual's safety, the initial approach should focus on a medical assessment and establishing a therapeutic rapport to gauge the immediate risk of suicide.
• d) Administer antidepressants via IV. Immediate pharmacological intervention might be part of his treatment plan, but only after a thorough assessment. The first response should be to assess his immediate risk of suicide and ensure his safety.

6-4 (108I60) A 48-year-old man visited the clinic complaining of insomnia. He had been recognized for his long-standing achievements at a branch office and was promoted to the headquarters six months ago. Although initially pleased, he struggled to adapt to the new environment and blamed himself for not being able to meet expectations, leading to persistent low mood and inability to sleep at night. A month ago, he became unable to concentrate on work and offered his resignation, but his boss recommended that he seek medical advice. He was diagnosed with depression based on symptoms of depressed mood, decreased motivation, and a general lack of interest or pleasure, with no abnormalities found in the physical examination.

Which of the following is an appropriate response?

a) Do not bring up the topic of suicide.

b) Recommend a small amount of drinking before bedtime.

c) Explain that the symptoms are due to the illness.

d) Immediately suggest to the boss that he should be returned to his previous job.

e) Have him discuss the reasons he cannot work with his boss.

The appropriate response is:

c) Explain that the symptoms are due to the illness.

Explanation:

• Educating the patient about the nature of his symptoms as manifestations of depression is crucial for several reasons. It helps in destigmatizing the condition, enhances the patient's understanding and acceptance of the illness, and fosters cooperation with treatment plans. Understanding that their symptoms have a medical basis can also alleviate self-blame and provide hope that with appropriate treatment, improvement is possible.

The other options:

• a) Do not bring up the topic of suicide. It's important to assess for suicidal thoughts or plans, especially in individuals diagnosed with depression, as they are at increased risk for suicide. Avoiding the topic can miss an opportunity for vital intervention.
• b) Recommend a small amount of drinking before bedtime. Alcohol can interfere with sleep architecture and worsen sleep quality, and it may also interact negatively with medications or exacerbate depressive symptoms.
• d) Immediately suggest to the boss that he should be returned to his previous job. While workplace stressors need to be addressed, suggesting an immediate return to the previous position without a comprehensive plan to manage the patient's depression and adjustment issues might not be beneficial.
• e) Have him discuss the reasons he cannot work with his boss. While open communication can be part of a broader management strategy for work-related stress, it's essential first to address the depression medically and ensure the patient is in a stable state to engage in such discussions constructively.

6-5 (111B47) A 45-year-old male office worker started experiencing difficulty falling asleep and making careless mistakes at work about six months after being promoted to section chief. He then developed dizziness, fatigue, and loss of appetite and was advised to seek medical consultation by the company's occupational physician. He lives with his wife and child. Diagnosed with depression due to a depressive state with mild suicidal ideation, he was hospitalized. After 4 weeks of treatment with antidepressants, his symptoms disappeared, and he was deemed ready for discharge.

The most appropriate next step for the attending physician is:

a) Reduce the dosage of antidepressants before discharge.

b) Instruct the company to change his job assignment.

c) Advise him to return to work immediately after discharge.

d) Advise his family on how to interact with him.

e) Encourage him to resume work at the pace before the onset of his illness.

The most appropriate next step for the attending physician is:

d) Advise his family on how to interact with him.

Explanation:

• After a patient is discharged from the hospital following treatment for depression, it is crucial to prepare both the patient and their family for the transition back to daily life. Advising the family on how to interact with him can provide a supportive home environment, which is vital for his ongoing recovery. Understanding depression, recognizing signs of potential relapse, and knowing how to encourage appropriate support without applying undue pressure are important for family members. This approach helps in facilitating a smoother reintegration into home life and can contribute to the patient's long-term well-being.

The other options:

• a) Reduce the dosage of antidepressants before discharge. It is generally not advisable to reduce the dosage of antidepressants immediately before discharge, as maintaining stability is crucial during the transition period. Dosage adjustments should be based on a careful assessment of the patient's condition over time.
• b) Instruct the company to change his job assignment. While job stressors need to be managed, such direct instructions from a physician to the company may not be practical or within the physician's remit. Discussions about work adjustments should involve the patient, their employer, and possibly occupational health professionals.
• c) Advise him to return to work immediately after discharge. Returning to work immediately after discharge may not be suitable for everyone. The decision should be individualized based on the patient's readiness, the nature of their job, and the availability of a supportive work environment.
• e) Encourage him to resume work at the pace before the onset of his illness. While encouragement is important, it is essential to recognize that the patient may need time to adjust and gradually return to their previous level of functioning. Unrealistic expectations can lead to increased stress and potential relapse.

6-6 (112D46) A 75-year-old woman, accompanied by a concerned neighbor, visited the clinic complaining of a depressive mood. She has gradually become more forgetful over the past three years and was diagnosed with Alzheimer's disease two years ago, for which she has been taking donepezil. Five months ago, her eldest son died in a traffic accident, and since then, she has shown a marked tendency towards depression, frequently saying, "There's no point in living." Her husband died ten years ago, and she currently lives alone. During the consultation, she stated, "I just keep thinking about my dead son, so I don't need treatment. I also don't want you to contact my family." No abnormalities were found in the physical examination. Her score on the Revised Hasegawa's Dementia Scale (HDS-R) is 19 out of 30.

Which of the following responses is appropriate?

a) Increase the dose of donepezil.

b) Instruct her to rest as much as possible.

c) Persuade her to consent to contact her family.

d) Report her condition to the local mental health and welfare center.

e) Admit her for medical protection with the consent of the accompanying neighbor.

The most appropriate response is:

c) Persuade her to consent to contact her family.

Explanation:

• Given the woman's significant depressive symptoms following her son's death, on top of her pre-existing Alzheimer's diagnosis, it's crucial to ensure she receives a support network that can provide both emotional and practical assistance. Her statement of not wanting treatment or family contact may reflect her depressive state rather than her best interests. Persuading her to allow contact with her family could open up avenues for support and treatment options, including addressing her depression and managing her Alzheimer's disease more effectively. Family involvement is often essential in the care plan for individuals with dementia, especially when they are showing signs of significant mental health issues.

The other options:

• a) Increase the dose of donepezil. While donepezil is used to manage symptoms of Alzheimer's disease, adjusting its dosage would not directly address her acute depressive symptoms.
• b) Instruct her to rest as much as possible. While rest is important, this advice does not address the underlying issues of her depression and isolation.
• d) Report her condition to the local mental health and welfare center. While involving community resources can be beneficial, the first step should be to try and involve her immediate support system, such as family, to ensure a personalized and comprehensive approach to her care.
• e) Admit her for medical protection with the consent of the accompanying neighbor. Medical protection or hospitalization might be necessary in cases where there's a significant risk to the patient's health or safety. However, this decision should be made with the consent and involvement of her family (if possible) and after thorough assessment of her condition and needs, not solely based on the neighbor's consent.

6-7 (113D73) A 44-year-old man was brought to the clinic by his wife, who was concerned about his hyperactivity. He has been complaining of unrelenting fatigue for the past three months, finding it difficult to get up in the morning and starting to arrive late at work. Two weeks ago, he suddenly became very energetic without any particular trigger. He claims to feel so well that he doesn't need to sleep and doesn't feel tired at all, spending nights on international calls with colleagues from the European branch and going to work almost without any sleep. He speaks rapidly and volubly, frequently changing topics. When his wife talks about his behavior at home, he quickly becomes irritable. His consciousness is clear, and no abnormalities were found in the physical examination.

Which two medications are appropriate for treatment?

a) Valproic acid

b) Diazepam

c) Lithium carbonate

d) Imipramine

e) Paroxetine

The appropriate medications for treatment are: a) Valproic acid c) Lithium carbonate

Explanation:

The patient's symptoms suggest a manic episode, characterized by increased energy, reduced need for sleep, rapid and pressured speech, irritability, and possibly grandiose ideas or behaviors. This presentation is consistent with bipolar disorder, specifically a manic phase.

• a) Valproic acid and c) Lithium carbonate are mood stabilizers commonly used in the treatment of bipolar disorder to control manic episodes and prevent future episodes of mania and depression. These medications can help balance mood and reduce the intensity of manic symptoms.

The other options are less appropriate for the primary treatment of a manic episode:

• b) Diazepam is a benzodiazepine used for anxiety, muscle relaxation, and sedation, but it's not a first-line treatment for managing manic episodes in bipolar disorder.
• d) Imipramine is a tricyclic antidepressant, and while it may be used in treating depressive episodes of bipolar disorder, using antidepressants in a manic phase can potentially exacerbate manic symptoms.
• e) Paroxetine is an SSRI antidepressant, which also carries the risk of exacerbating manic symptoms if used during a manic phase without adequate mood-stabilizing coverage.

6-8 (113F67) A 50-year-old woman was brought to the clinic by her concerned husband due to a decrease in her activities. Two months ago, she started waking up in the morning but couldn't prepare breakfast, sitting idly instead. She also stopped watching the news and reading the newspaper, which she used to enjoy. Although she goes shopping, she can't decide what to buy and often returns home empty-handed. Two weeks ago, she became unable to do household chores such as laundry and cleaning, which led her husband to bring her in for a consultation. Her consciousness is clear, and there are no abnormalities in orientation, memory, or physical examination findings.

The complaints that are expected from this patient are likely to be:

a) "I feel like I am causing trouble for my family because of me."

b) "Suddenly my mind goes blank."

c) "I get teary when watching TV dramas."

d) "I feel like there's a hidden meaning behind things, which is creepy."

e) "I can no longer enjoy my hobbies or things I used to like."

The complaints expected from this patient are:

a) "I feel like I am causing trouble for my family because of me."

e) "I can no longer enjoy my hobbies or things I used to like."

Explanation:

• a) Feeling like a burden to others or causing trouble for the family is a common concern among individuals with depression. This sense of guilt and worthlessness is a characteristic symptom of depressive disorders.
• e) Loss of interest or pleasure in hobbies and activities that one used to enjoy is known as anhedonia, which is a core symptom of depression. This symptom reflects the decreased ability to experience pleasure, leading to a disinterest in previously enjoyable activities.

The other options, while they can be symptoms associated with various mental health conditions, are less directly connected to the described scenario of decreased activity and loss of interest:

• b) "Suddenly my mind goes blank." This could be related to anxiety or cognitive disorders but doesn't specifically align with the symptoms described.
• c) "I get teary when watching TV dramas." While emotional sensitivity can occur in depression, the specific activities and behaviors mentioned don't directly suggest this symptom.
• d) "I feel like there's a hidden meaning behind things, which is creepy." This is more indicative of paranoid or delusional thinking, which isn't directly suggested by the patient's described behavior and symptoms.

6-9 (116A26) A 30-year-old man expressed a desire for a consultation with the occupational physician, complaining, "I've been concerned about my poor work efficiency for about three months." With the outbreak of COVID-19, he has been working from home, conducting meetings online for about half a year. He lives with his wife and a 3-year-old son, but he gets irritated by the noise around his home and the care of his son, which distracts him from his work. About a month ago, he started drinking alcohol to sleep, but since then, he has often felt depressed upon waking up in the morning. He feels tired every day and finds himself lost in thought without focus.

Which of the following responses by the occupational physician is not appropriate?

a) Recommend a consultation with a psychiatrist.

b) Advise stopping the use of alcohol as a sleep aid.

c) Obtain the person's consent to discuss the situation with his supervisor.

d) Ask in detail about his work methods and content.

e) Encourage him to endure until the end of the pandemic outbreak.

The response by the occupational physician that is not appropriate is:

e) Encourage him to endure until the end of the pandemic outbreak.

Explanation:

• Encouraging the patient to "endure until the end of the pandemic outbreak" does not address the immediate concerns and mental health issues he is facing. It overlooks the impact of his current work environment, his use of alcohol as a sleep aid, and his feelings of depression in the morning. It's essential to provide support and actionable advice that can help improve his situation now, rather than suggesting passive endurance of potentially harmful conditions.

The other options are constructive and focus on addressing the root causes of his concerns:

• a) Recommend a consultation with a psychiatrist could help address any underlying mental health issues, including depression or anxiety that may be contributing to his work inefficiency and alcohol use.
• b) Advise stopping the use of alcohol as a sleep aid is appropriate because alcohol can disrupt sleep patterns and contribute to feelings of depression.
• c) Obtain the person's consent to discuss the situation with his supervisor could facilitate adjustments in his work environment or schedule to reduce stress.
• d) Ask in detail about his work methods and content can help identify specific work-related stressors or inefficiencies that can be addressed to improve his work-life balance and overall well-being.

6-10 (116F56) A 34-year-old woman was brought to the clinic by her mother because she persistently "calls anyone in the middle of the night." For the past two weeks, her conversations have been disorganized, and she has exhibited unusual behavior such as laughing uncontrollably at minor things, which is out of character for her. She has been sleeping very little, yet she does not feel tired. She has been talking about plans to buy apartments and cars with relatives and friends over the phone, and when they oppose her plans, she becomes extremely angry. Blood tests, brain imaging, EEG, and cerebrospinal fluid tests showed no abnormalities, and there was no intake of illegal drugs.

Which symptoms are observed in this patient? Choose two.

a) Flight of ideas

b) Echolalia

c) Grandiose delusions

d) Made experiences

e) Cataplexy

The symptoms observed in this patient are:

a) Flight of ideas c) Grandiose delusions

Explanation:

• a) Flight of ideas is characterized by rapid, continuous verbalizations or speech in which the person jumps quickly from one idea to another. This symptom is consistent with the patient's disorganized talking and inability to stick to a single topic, which is commonly seen in manic episodes of bipolar disorder.
• c) Grandiose delusions involve an exaggerated sense of one's importance, power, knowledge, or identity. The patient's discussions about buying apartments and cars, likely without the means to do so, and her reactions when opposed, suggest she might be experiencing grandiose delusions, another symptom often present in manic episodes.

The other options are less relevant to the symptoms described:

• b) Echolalia refers to the automatic repetition of another person's spoken words and is more commonly associated with conditions such as autism spectrum disorder, Tourette syndrome, or after a stroke.
• d) Made experiences (or "passivity experiences") involve the belief that one's thoughts, feelings, or actions are not one's own but are being imposed by some external force. This symptom is more typically associated with schizophrenia.

• e) Cataplexy is a sudden and transient episode of muscle weakness accompanied by full conscious awareness, typically triggered by emotions such as laughing, crying, or terror. It is associated with narcolepsy, not the behaviors or symptoms described for this patient.

7-1 (100B7) Which of the following is correct about schizophrenia?

a) The onset is sudden.

b) There are no brain function abnormalities.

c) It often involves disturbances in consciousness.

d) It is almost completely cured through psychiatric rehabilitation.

e) The effectiveness of drug therapy is higher in the initial stages than in the chronic phase.

The correct statement about schizophrenia is:

e) The effectiveness of drug therapy is higher in the initial stages than in the chronic phase.

Explanation:

• The effectiveness of pharmacological treatment for schizophrenia is generally higher when initiated early in the course of the illness. Early intervention can help manage symptoms more effectively, potentially reduce the severity of the illness, and improve the long-term prognosis. Early treatment can also help prevent the progression to a more chronic state, where symptoms may become more resistant to medication.

The other statements are incorrect or misleading regarding schizophrenia:

• a) The onset is sudden. Schizophrenia can have a gradual onset, with early signs preceding the first acute episode.
• b) There are no brain function abnormalities. Research shows that schizophrenia involves abnormalities in brain structure and function, including changes in neurotransmitter systems.
• c) It often involves disturbances in consciousness. Schizophrenia does not typically involve disturbances in consciousness; patients are usually aware of their surroundings but may have delusions or hallucinations.
• d) It is almost completely cured through psychiatric rehabilitation. While psychiatric rehabilitation can significantly improve functioning and quality of life, schizophrenia is considered a chronic condition that can be managed but not cured.

7-2 (102A5) Which of the following is correct about schizophrenia? Choose two.

a) Monoamines are involved.

b) There are inflammatory changes in the cerebrum.

c) The effect of medication on negative symptoms is high.

d) Early aggressive therapeutic intervention is important.

e) The prevalence rate is about 10 per 100,000 population.

The correct statements about schizophrenia are:

a) Monoamines are involved. d) Early aggressive therapeutic intervention is important.

Explanation:

• a) Monoamines are involved. Schizophrenia is associated with dysregulation of monoamine neurotransmitters, including dopamine, serotonin, and to some extent, norepinephrine. The dopamine hypothesis is one of the most researched theories, suggesting that an overactivity of dopamine neurotransmission in certain brain regions contributes to psychotic symptoms.
• d) Early aggressive therapeutic intervention is important. Early intervention in schizophrenia, including pharmacotherapy, psychotherapy, and social support, can significantly affect the course of the disease. Initiating treatment soon after the onset of symptoms can help to reduce the severity of the illness, improve long-term outcomes, and may even delay or prevent the progression to a more severe form of the disease.

The other options:

• b) There are inflammatory changes in the cerebrum. While recent research has suggested potential roles for inflammation in schizophrenia, saying there are definitive inflammatory changes in the cerebrum is an oversimplification. The pathology of schizophrenia involves complex interactions of genetic, environmental, and neurobiological factors.
• c) The effect of medication on negative symptoms is high. Unfortunately, the efficacy of medications, especially typical antipsychotics, is more limited for negative symptoms (such as apathy, social withdrawal, and anhedonia) compared to positive symptoms (such as hallucinations and delusions). Newer antipsychotics may have some efficacy against negative symptoms, but the challenge remains significant.
• e) The prevalence rate is about 10 per 100,000 population. The estimated prevalence of schizophrenia is higher, about 1% of the population worldwide, which would be 1,000 per 100,000 people, not 10.

7-3 (102G6) Which of the following is correct? Choose two.

a) Ambivalence is characteristic of depression.

b) Word salad is observed in thought disorders.

c) Catatonic syndrome is seen in anxiety disorders.

d) Confabulation is observed in Korsakoff syndrome.

e) Emotional incontinence is characteristic of schizophrenia.

The correct statements are:

b) Word salad is observed in thought disorders. d) Confabulation is observed in Korsakoff syndrome.

Explanation:

• b) Word salad refers to a jumble of words and phrases that lack logical coherence or meaning, often seen in severe thought disorders. This symptom is typically associated with conditions like schizophrenia, where individuals may have significant disorganization in their thinking.
• d) Confabulation is a symptom of Korsakoff syndrome, a chronic memory disorder caused by severe deficiency of thiamine (vitamin B1) most commonly caused by alcohol misuse. Patients with Korsakoff syndrome may make up stories (confabulate) to fill gaps in their memory, not with the intent to deceive but rather as an automatic response to memory loss.

The other options:

• a) Ambivalence, the state of having mixed feelings or contradictory ideas about something or someone, is not specifically characteristic of depression alone; it can occur in many psychiatric conditions, including schizophrenia.
• c) Catatonic syndrome is not typically seen in anxiety disorders. Catatonia, which involves motor immobility, excessive motor activity, extreme negativism, or peculiarities of movement, is more commonly associated with mood disorders (both depressive and manic episodes) and schizophrenia.

• e) Emotional incontinence, or the inability to control the expression of emotions, is not characteristic of schizophrenia specifically. It can be seen in various neurological conditions, such as stroke or dementia, affecting brain regions that regulate emotion.

7-4 (104D8) Which of the following is characteristic of schizophrenia? Choose two.

a) Being afraid of speaking in public.

b) Hearing multiple voices criticizing oneself.

c) The topic jumps, conversation lacks coherence, and is incomprehensible.

d) Feeling as if there is a veil between oneself and the external world, lacking a sense of reality towards surroundings.

e) Looking at a man standing in front of the house and being convinced that he is being targeted.

The correct characteristics of schizophrenia are:

b) Hearing multiple voices criticizing oneself.

e) Looking at a man standing in front of the house and being convinced that he is being targeted.

Explanation:

• b) Hearing multiple voices criticizing oneself directly pertains to auditory hallucinations, which are a common and significant symptom of schizophrenia. These hallucinations often involve hearing voices that are not present, which can comment negatively on the person's actions or thoughts.
• e) Looking at a man standing in front of the house and being convinced that he is being targeted reflects delusional thinking, specifically persecutory delusions. Such delusions involve a strong belief that one is going to be harmed by others, which is also a key symptom of schizophrenia. Delusions are false beliefs that are not based in reality and are a core feature of schizophrenia, affecting how the person thinks and acts.

7-5 (107B15) Which complaint is related to ego disturbances?

a) "My brain is melting."

b) "My thoughts are being removed."

c) "Everyone is talking badly about me."

d) "Strange things are being put in my food."

e) "Something terrible is going to happen."

The complaint related to ego disturbances is:

b) "My thoughts are being removed."

Explanation:

• Ego disturbances are often characterized by a profound disruption in the sense of self and the boundary between self and others. "My thoughts are being removed" reflects a type of thought interference or withdrawal, where the individual perceives their thoughts as being accessed or taken away by external forces. This symptom is indicative of a breakdown in the personal sense of agency and ownership over one's mental processes, a core aspect of ego functioning.

The other options, while indicative of psychiatric symptoms, are less specific to ego disturbances:

• a) "My brain is melting." could be an expression of a somatic hallucination or a metaphorical description of feeling mentally unwell.
• c) "Everyone is talking badly about me." suggests paranoia or persecutory delusions.
• d) "Strange things are being put in my food." is indicative of a specific type of delusion, often related to poisoning.
• e) "Something terrible is going to happen." might reflect general anxiety or a sense of impending doom, common in various anxiety and mood disorders.

7-6 (107D20) Which of the following are associated with a favorable prognosis in schizophrenia? Choose three.

a) Gradual onset

b) Onset during adolescence

c) Good social adjustment before the illness

d) The presence of precipitating factors at the onset

e) Premorbid cyclothymic tendencies

The factors associated with a favorable prognosis in schizophrenia are:

c) Good social adjustment before the illness

d) The presence of precipitating factors at the onset

e) Premorbid cyclothymic tendencies

Explanation:

• c) Good social adjustment before the illness: Individuals who have shown good social functioning, including maintaining relationships and fulfilling responsibilities, before the onset of schizophrenia tend to have a better prognosis. This pre-illness social competence often correlates with a greater ability to engage in treatment and rehabilitation efforts, leading to better outcomes.
• d) The presence of precipitating factors at the onset: When the onset of schizophrenia can be linked to specific precipitating factors (such as a stressful life event), the prognosis is generally more favorable. This association suggests that addressing or resolving these factors may lead to improvements in symptoms.
• e) Premorbid cyclothymic tendencies: Individuals who exhibited cyclothymic tendencies (characterized by fluctuations between mild depressive and hypomanic states) before the onset of schizophrenia may have a more favorable prognosis. This personality type may be associated with a higher level of functioning and better adaptation to the illness.

The other options:

• a) Gradual onset: Contrary to the correct options, a sudden (acute) onset of schizophrenia, rather than a gradual one, is typically associated with a more favorable prognosis. Sudden onset may respond better to treatment and may be linked to more specific precipitating factors.
• b) Onset during adolescence: Early onset of schizophrenia (childhood or adolescence) is generally considered to have a poorer prognosis compared to adult-onset schizophrenia. Early onset can interfere with educational and social development, complicating recovery and adaptation.

7-7 (110D16) Which side effects are related to the anti-dopaminergic action of schizophrenia treatment drugs? Choose two.

a) Vomiting

b) Dry mouth

c) Amenorrhea

d) Tremors of the hands

e) Weight loss

The side effects related to the anti-dopaminergic action of schizophrenia treatment drugs are:

c) Amenorrhea d) Tremors of the hands

Explanation:

• c) Amenorrhea: Anti-dopaminergic drugs, especially traditional antipsychotics, can lead to amenorrhea (absence of menstruation) as a side effect. This is because dopamine antagonism affects the pituitary gland's regulation of prolactin, leading to elevated prolactin levels, which can disrupt the menstrual cycle.
• d) Tremors of the hands: Dopamine blockade can also contribute to extrapyramidal symptoms, such as tremors, which are movement disorders commonly associated with antipsychotic medication. These symptoms resemble those seen in Parkinson's disease, which is also related to dopamine deficiency.

The other options are less directly related to the anti-dopaminergic action of schizophrenia medications:

• a) Vomiting: While anti-dopaminergic action can affect the chemoreceptor trigger zone and cause nausea and vomiting, it is not as specifically associated with long-term treatment side effects as amenorrhea and tremors.
• b) Dry mouth: This is more commonly a side effect of medications with anticholinergic properties rather than those with primarily anti-dopaminergic actions.
• e) Weight loss: Antipsychotic medications, particularly those with anti-dopaminergic action, are more often associated with weight gain rather than weight loss.

7-8 (111I29) Which of the following is correct about schizophrenia? Choose two.

a) The incidence rate varies greatly by country.

b) The incidence rate is higher in cases with a family history.

c) It is caused by the accumulation of abnormal proteins in the brain.

d) The prognosis varies depending on when treatment is started.

e) Selective serotonin reuptake inhibitors (SSRIs) are effective for negative symptoms.

The correct statements about schizophrenia are:

b) The incidence rate is higher in cases with a family history.

d) The prognosis varies depending on when treatment is started.

Explanation:

• b) The incidence rate is higher in cases with a family history. Genetic factors play a significant role in schizophrenia. Individuals with a family history of schizophrenia have a higher risk of developing the disorder compared to the general population. This increased risk is due to the heritability of susceptibility to the disease.
• d) The prognosis varies depending on when treatment is started. Early intervention and the initiation of treatment soon after the onset of schizophrenia symptoms are associated with a better prognosis. Early treatment can help reduce the severity of symptoms, improve the long-term course of the disease, and enhance the quality of life for individuals with schizophrenia.

The other options:

• a) The incidence rate varies greatly by country. Epidemiological studies have shown that the incidence rates of schizophrenia are relatively consistent worldwide, challenging the notion of significant variation by country.
• c) It is caused by the accumulation of abnormal proteins in the brain. This statement more accurately describes neurodegenerative disorders such as Alzheimer's disease, not schizophrenia. The etiology of schizophrenia involves a complex interplay of genetic, environmental, and neurobiological factors but not specifically the accumulation of abnormal proteins.
• e) Selective serotonin reuptake inhibitors (SSRIs) are effective for negative symptoms. SSRIs are primarily used to treat depression and are not the first-line treatment for the negative symptoms of schizophrenia. While they may be used adjunctively in some cases, their effectiveness for negative symptoms specifically is limited and not well-established.

7-9 (116D2) Which statement made by a patient strongly suggests schizophrenia?

a) "I am being controlled by radio waves."

b) "The bugs are crawling on the wall stain" (pointing to the stain).

c) "I am worried about having a seizure on the train."

d) "I get nervous and can't speak my mind in front of people."

e) "I have to check multiple times whether I locked the door or not."

The statement that strongly suggests schizophrenia is:

a) "I am being controlled by radio waves."

Explanation:

• a) "I am being controlled by radio waves." This statement reflects a delusional belief, specifically a delusion of control, where the individual believes their thoughts, feelings, or actions are being controlled by external forces. This type of delusion is characteristic of schizophrenia, indicating a break from reality.

The other options are indicative of different issues:

• b) "The bugs are crawling on the wall stain" might suggest hallucinations, which can be a part of schizophrenia, but without additional context, it could also indicate other conditions, such as a delirious state or substance use.
• c) "I am worried about having a seizure on the train." This concern is more indicative of anxiety regarding a specific health condition (such as epilepsy) rather than schizophrenia.
• d) "I get nervous and can't speak my mind in front of people." This is indicative of social anxiety or performance anxiety, rather than the psychotic symptoms typical of schizophrenia.
• e) "I have to check multiple times whether I locked the door or not." This behavior is characteristic of obsessive-compulsive disorder (OCD), where repetitive checking is a common compulsion, rather than schizophrenia.

8-1 (100H31) An 18-year-old girl, shortly after starting high school, stopped attending due to abdominal pain triggered by trivial matters at school. Following family persuasion, her attendance became intermittent, and she eventually dropped out a year later. She spent about a year isolated in her room, barely communicating with her family, and reacted with agitation to attempts to encourage her to go outside. Recently, she began expressing thoughts like "my thoughts are being transmitted to others" and "my family will become unhappy."

The most likely diagnosis is:

a) School refusal

b) Borderline personality disorder

c) Depression

d) Delusional disorder

e) Schizophrenia

The most likely diagnosis is: e) Schizophrenia

Explanation:

• e) Schizophrenia is characterized by a range of symptoms, including withdrawal from social interactions, significant changes in behavior, and delusions or unusual beliefs, such as believing one's thoughts are being transmitted to others or that one's actions could result in family unhappiness. These symptoms align with the girl's behavior and expressed concerns.
• a) School refusal - This condition involves reluctance or refusal to go to school due to emotional distress but doesn't fully account for the later symptoms described.
• b) Borderline Personality Disorder (BPD) - BPD involves a pattern of unstable interpersonal relationships, self-image, and affects, and marked impulsivity, not specifically aligned with the symptoms described.
• c) Depression - While depression can cause withdrawal and a decrease in social interactions, the specific delusions mentioned are more characteristic of a psychotic disorder.
• d) Delusional Disorder - This disorder involves the presence of one or more delusions without other symptoms of schizophrenia. The range and nature of the girl's symptoms suggest a broader disorder than delusional disorder alone.

8-2 (101A5) An 18-year-old male, who has been living a nocturnal lifestyle for the past year, was brought to the clinic by his concerned mother. Until his sophomore year in high school, he had many friends and was actively involved in club activities. Over the past year, he gradually became less talkative, and recently, he has almost stopped speaking altogether. He started claiming that the neighbors are watching him, keeps the curtains in his room closed all day, and has begun speaking ill of the neighbors. He is conscious and alert, 175 cm tall, weighs 56 kg, has a stiff facial expression, and hardly responds to questions.

Which is the appropriate medication?

a) Antiepileptic

b) Antipsychotic

c) Anti-anxiety

d) Antidepressant

e) Sleep aid

The appropriate medication is:

b) Antipsychotic

Explanation:

• The symptoms described, including significant social withdrawal, reduction in speech, paranoid thoughts about neighbors watching him, and his overall presentation, suggest the onset of a psychotic disorder, possibly schizophrenia. Antipsychotic medications are the treatment of choice for managing psychosis, including delusions and hallucinations. These medications can help reduce the intensity of his symptoms, improve his ability to communicate, and potentially restore some of his previous levels of functioning.

The other options are less suited to his primary symptoms:

• a) Antiepileptic drugs are primarily used for seizure disorders, not psychosis.
• c) Anti-anxiety medications may relieve anxiety but won't address the core psychotic symptoms.
• d) Antidepressants treat depression, and while they could be helpful if he has comorbid depression, they are not the primary treatment for his current symptoms.
• e) Sleep aid could help regulate his sleep patterns but would not address the underlying psychotic symptoms.

8-3 (104E59) A 72-year-old woman was brought to the clinic by her family, concerned about changes in her speech and behavior. She has been living alone since her husband passed away three years ago and had never shown psychiatric symptoms before. Three months ago, she began to isolate herself more at home. When her eldest daughter visited her due to concern, she found that the patient continuously said, "When I go outside, everyone speaks ill of me," and "The neighbor is always watching me." During the examination, her expression was cheerful, and no depressive mood was observed. Communication was good. No hallucinations were noted, and she scored 30 out of 30 on the Revised Hasegawa's Dementia Scale.

The most likely diagnosis is:

a) Depression

b) Delusional disorder

c) Schizophrenia

d) Obsessive-compulsive disorder

e) Social anxiety disorder

The most likely diagnosis is:

b) Delusional disorder

Explanation:

• b) Delusional disorder is characterized by the presence of one or more delusions without other significant psychotic symptoms. In this case, the woman's belief that she is being talked about negatively by everyone and that her neighbor is always watching her suggests delusions of persecution, which are common in delusional disorder. The absence of depressive mood, good communication skills, and a perfect score on a cognitive function test further support this diagnosis over others.

Other options:

• a) Depression might involve social withdrawal and negative beliefs about oneself, but the absence of a depressive mood makes this less likely.
• c) Schizophrenia typically includes a broader range of psychotic symptoms beyond delusions, such as hallucinations and disorganized thinking, which are not reported here.
• d) Obsessive-compulsive disorder (OCD) involves repetitive thoughts (obsessions) and behaviors (compulsions), not primarily delusions.
• e) Social anxiety disorder involves intense fear of social situations due to concerns about being embarrassed or judged negatively, which does not fully explain the patient's delusional beliefs.

8-4, 5, 6 (104E61, 104E62, 104E63) A 17-year-old boy was brought to the clinic by his concerned parents due to changes in his speech and behavior.

Current medical history: For about a year, he has increasingly skipped school and spends most of his day in his room. He struggles to wake up in the morning, only getting up past noon. When his mother tries to speak to him, he becomes defiant, saying, "Shut up." A month ago, he began to smile without reason and suddenly shout expletives like "Damn it" and "Idiot." His personal hygiene has deteriorated; he has become unkempt and stopped bathing.

Past medical history: Nothing noteworthy.

Life history: Born as the second of two siblings without any abnormalities in psychomotor development and was an easy child to care for. Until junior high, he was a bright student with excellent grades. After entering high school, he stopped participating in extracurricular activities, and his grades gradually declined.

Family history: An uncle on his mother's side is currently hospitalized in a psychiatric facility.

Current condition: Conscious and alert. Height 175 cm, weight 63 kg. Body temperature 36.2°C, pulse 72 bpm, regular. Blood pressure 112/68 mmHg. His expression is stiff and tense. He does not initiate conversation and takes time to respond to questions, with short answers. Occasionally, he stares at one point unresponsively and sometimes appears to be listening intently. No abnormalities in neurological findings. When hospitalization is recommended, he shouts, "I'd rather be dead," becomes agitated, and refuses hospitalization, requesting to go home.

1. Which response is appropriate?

a) Immediately arrange for emergency hospitalization.

b) Respect the patient's wishes and allow him to go home.

c) Proceed with voluntary hospitalization.

d) Obtain the parents' consent for medical protective hospitalization.

e) Hospitalize based on a judge's decision.

2. What is the first treatment to undertake?

a) Pharmacotherapy

b) Morita therapy

c) Autogenic training

d) Psychoanalytic therapy

e) Cognitive-behavioral therapy

3. After two months of hospitalization, his symptoms have stabilized, and he is seen playing video games and reading books with other patients.

What is most appropriate for his reintegration into society after discharge?

a) Daycare

b) Sheltered workshop

c) Welfare factory

d) Welfare home

e) Small-scale workshop

1. Appropriate response to his condition:

d) Obtain the parents' consent for medical protective hospitalization.

Explanation:

• Given the severity of his symptoms, including social withdrawal, aggressive outbursts, and refusal of care, along with a lack of insight into his condition ("I'd rather be dead"), medical protective hospitalization is necessary. This approach ensures his safety and begins immediate treatment, even if he is reluctant or unable to consent due to his mental state.

2. First treatment to undertake:

a) Pharmacotherapy

Explanation:

• Given his symptoms, which suggest a severe psychiatric condition potentially like schizophrenia or a severe mood disorder with psychotic features (evidenced by drastic behavioral changes, defiance, unsocial behavior, and possibly auditory hallucinations or delusions), pharmacotherapy is the first line of treatment. This would typically involve antipsychotic medications to stabilize his mood and manage psychosis.

3. Most appropriate for his reintegration into society after discharge:

a) Daycare

Explanation:

• Daycare offers a structured but flexible environment for the boy to continue recovering while engaging in social and therapeutic activities. It supports reintegration by providing a bridge between hospital care and returning to everyday life, allowing him to rebuild social skills, gain support, and continue therapeutic engagement in a less intensive setting than hospitalization but more supportive than immediate full return to regular life.

8-7 (105A23) A 35-year-old man was brought to the clinic by his concerned company supervisor due to his sluggish responses and strange postures. He had been complaining for the past six months that, even when no one was around, he could hear coworkers at his job speaking ill of him. Since yesterday, he had intermittently been muttering to himself about fears of being killed by the company and concerns that his thoughts were transparent to the company, then would become silent and unresponsive, staring blankly. During the examination, when his right hand is lifted, he maintains the position indefinitely.

The most likely diagnosis is:

a) Depression

b) Adjustment disorder

c) Catatonic syndrome

d) Pervasive developmental disorder

e) Korsakoff syndrome

The most likely diagnosis is: c) Catatonic syndrome

Explanation:

• The man's symptoms include hearing coworkers speak ill of him when no one is around, suggesting auditory hallucinations, and his belief that his thoughts are known to the company, indicating delusions. Additionally, the peculiar behavior of maintaining a raised hand indefinitely and periods of mutism and unresponsiveness align with catatonia, which is characterized by abnormal motor behavior and stupor. Catatonic syndrome can be associated with various psychiatric disorders, including schizophrenia, mood disorders, and other mental health conditions. The combination of auditory hallucinations, delusions, and catatonic behavior strongly points toward a severe psychiatric disorder with catatonic features rather than the other options listed:
• a) Depression can involve psychomotor retardation, but the specific catatonic postures and the nature of the delusions and hallucinations described are not typical features.
• b) Adjustment disorder involves difficulty coping with stressors and does not typically include severe symptoms like hallucinations, delusions, or catatonia.
• d) Pervasive developmental disorder encompasses a group of disorders characterized by delays in the development of socialization and communication skills, not acute psychotic symptoms or catatonia.
• e) Korsakoff syndrome is related to chronic memory disorders due to thiamine deficiency, often associated with alcohol misuse, and does not typically present with catatonia or the acute psychotic symptoms described.

8-8 (105E57) A 30-year-old man is currently hospitalized in a psychiatric ward. He had been leading a reclusive life at home for several years. Two months ago, he was hospitalized due to a state of hallucinations and delusions, but he improved with pharmacotherapy. Recently, he has been calm, yet his expression is sparse, and he spends most of the day in bed with very little interaction with others.

The appropriate challenges for this patient's rehabilitation include choosing two:

a) Self-management of medication

b) Modification of negative emotions

c) Evaluation of unconscious conflicts

d) Acceptance as is

e) Acquisition of communication skills

The appropriate challenges for this patient's rehabilitation are:

a) Self-management of medication

e) Acquisition of communication skills

Explanation:

• Self-management of medication is a key rehabilitation goal for individuals who have shown improvement with pharmacotherapy. It empowers the patient, promotes independence, and contributes to long-term management of the condition.

• Acquisition of communication skills addresses the current lack of interaction with others and can significantly impact the patient's quality of life and social reintegration. It's a practical approach to rehabilitation that focuses on improving daily functioning and social participation.

The other options, while potentially valuable in certain contexts, are less directly related to the immediate rehabilitation goals for this patient:

• b) Modification of negative emotions could be part of broader psychotherapy but is less specific than communication skills for addressing social withdrawal and isolation.
• c) Evaluation of unconscious conflicts pertains more to psychoanalytic therapy, which may not be the primary focus in the acute rehabilitation phase.
• d) Acceptance as is could be a part of therapeutic approaches like mindfulness or acceptance and commitment therapy but doesn't directly address the key issues of medication management and social skills.

8-9 (108A39) A 63-year-old woman was brought to the clinic by her family due to issues with a neighboring house. After graduating from university and getting married, she had been living without issues as a housewife. Starting around the age of 60, without any clear cause, she began to claim that a man from the neighboring house was peeping into her home and even consulted the police about it. Furthermore, she started alleging that the neighbor was sending strange drugs into her house to kill her, often protesting against the neighbor's house and sometimes verbally abusing them in front of their home. Yesterday, she entered the neighbor's house with a kitchen knife, leading to police involvement. At the time of consultation, she lacked insight into her illness. No clear physical issues were identified. She was admitted for medical protective hospitalization, and although initially refusing medication, antipsychotic treatment over approximately a month led to a reduction in her pathological experiences. She did not exhibit any problematic behaviors during two trial leaves and was able to perform household tasks as before, leading to her discharge.

The appropriate explanation to the family at the time of discharge is:

a) "Psychiatric symptoms may recur."

b) "It's okay to leave medication management up to the patient herself."

c) "It's likely that she will show tendencies of becoming more withdrawn in the future."

d) "You should continue to convince her that her delusions are not real."

e) "She must attend daycare for rehabilitation purposes."

The appropriate explanation to the family at the time of discharge is:

a) "Psychiatric symptoms may recur."

Explanation:

• Given the severity of the woman's delusions that led to police involvement and her initial lack of insight into her illness, it's crucial for the family to understand that psychiatric symptoms, especially delusions, may recur. Although she responded well to antipsychotic medication, the nature of her condition suggests a risk of relapse, particularly if medication adherence fluctuates or if there are changes in her environment or stress levels. Families play a critical role in monitoring the patient's mental state, supporting medication adherence, and ensuring that the patient continues to engage in follow-up care. This advice prepares the family to respond proactively should symptoms reappear, emphasizing the importance of ongoing vigilance and support for the patient's mental health.

The other options are less appropriate due to various reasons:

• b) Leaving medication management solely to the patient may not be advisable if the patient has previously shown a lack of illness insight or if there's a risk of non-adherence.
• c) Predicting an increase in withdrawn tendencies might not be directly related to her condition's course, especially without evidence suggesting this outcome.
• d) Continuously attempting to persuade the patient that her delusions are not real can be confrontational and may not be effective without professional guidance.
• e) Recommending daycare for rehabilitation might be beneficial but is not directly related to the warning about the potential recurrence of symptoms, which is a more immediate concern for the family to understand and monitor.

8-10 (108G52) A father shared his concerns with his family doctor: "My son, who will be 30 this year, has been almost entirely homebound for the past three years. There's hardly any conversation with the family, and he frequently talks or laughs to himself. While he doesn't resort to violence, he occasionally yells 'Idiot!' towards the outside from a window." When the parents suggest he see a psychiatrist, the son refuses, sometimes leading to arguments.

The appropriate advice for the father is:

a) Request the police station to proceed with involuntary hospitalization.

b) Request emergency transport to a hospital through the fire department.

c) Consult the public health center on how to persuade the individual to seek a medical consultation.

d) Have the family or relatives physically restrain him and take him to the hospital.

e) Obtain medication from a medical institution and administer it to the person without their knowledge.

The most suitable advice for the father is:

c) Consult the public health center on how to persuade the individual to seek a medical consultation.

Explanation:

• Consulting a public health center can offer guidance and resources on the best approach to encourage the son to voluntarily seek psychiatric evaluation and treatment. This option respects the individual's autonomy while also addressing the family's concern for his mental health in a non-confrontational and supportive manner.

The other options are generally less appropriate due to ethical, legal, and safety concerns:

• a) and d) involve coercive measures that could traumatize the son and potentially breach his rights.
• b) is usually reserved for immediate, life-threatening emergencies.
• e) is unethical and could erode trust, besides posing health risks if the medication is not administered under professional supervision.

8-11 (110B42) A 34-year-old man is hospitalized for schizophrenia. He was diagnosed with schizophrenia three years ago and was admitted for medical protective hospitalization with his father's consent. His psychiatric symptoms have been difficult to manage, and he lacks insight into his condition with no intention of undergoing psychiatric treatment, resulting in continued medical protective hospitalization. Two weeks ago, he was diagnosed with lung cancer requiring surgery. When informed, he expressed, "I understand that surgery is necessary, but I'm scared. I'm okay with dying from cancer," and refused the surgery. On the other hand, his father wishes for him to have the surgery.

The appropriate course of action at this point is:

a) Increase the dosage of antipsychotic medication.

b) Proceed with the surgery despite the patient's refusal.

c) Persuade the father to give up on the idea of surgery.

d) Continue efforts to obtain the patient's consent for the surgery.

e) Seek a decision from the local mental health and welfare center.

The appropriate course of action at this point is:

d) Continue efforts to obtain the patient's consent for the surgery.

Explanation:

• Respecting the patient's autonomy is paramount, even when the patient has a psychiatric condition like schizophrenia. The refusal of surgery, especially for something as serious as lung cancer, presents a complex situation where the patient's understanding of his health and the consequences of his decisions need careful consideration. Continuing efforts to gain his consent involves providing him with information about the surgery in an accessible and understandable manner, addressing his fears, and involving him in the decision-making process. This approach respects his rights and supports informed consent, emphasizing the importance of his autonomy in medical decisions.
• a) Increasing the dosage of antipsychotic medication does not directly address the issue at hand, which is the patient's refusal of surgery for lung cancer. It might be relevant for managing his psychiatric symptoms but won't solve the ethical dilemma of consent for the surgery.
• b) Proceeding with the surgery despite the patient's refusal would violate his rights and autonomy. It could only be considered if the patient was deemed legally incompetent to make medical decisions, and even then, it would require legal proceedings.
• c) Persuading the father to give up on the idea of surgery disregards the medical necessity of the operation and does not prioritize the patient's health outcomes.
• e) Seeking a decision from the local mental health and welfare center may offer additional support or advice but does not replace the need for the patient's consent or address how to engage with him about his treatment options directly.

8-12 (111D39)  A 22-year-old man was brought to the clinic by his family, presenting with disorganized speech and actions. He had been working normally after graduating from university and starting a job two months ago, but suddenly, a month prior, his speech and actions became disorganized. He started expressing a sense of impending doom, restlessness, anxiety, and that he was hearing voices commanding him and felt as if he was being controlled by someone, which led him to recuperate at home. He responds cooperatively during the examination but insists, "I am not ill." No abnormalities were found in the physical examination.

The first intervention to introduce is:

a) Psychoeducation

b) Behavioral therapy

c) Art therapy

d) Hypnotherapy

e) Autogenic training

The first intervention to introduce is:

a) Psychoeducation

Explanation:

• Psychoeducation is a vital initial step in managing a condition like this, where the patient experiences disorganized speech and actions, anxiety, and auditory hallucinations but lacks insight into his illness. It involves educating the patient and his family about the nature of the illness, its symptoms, and the importance of treatment, including medication and therapy. Psychoeducation can help bridge the gap between the patient's current lack of insight ("I am not ill") and understanding the need for and benefits of treatment. This foundational knowledge is crucial for engaging the patient in further therapeutic interventions and promoting adherence to treatment plans.

The other options, while potentially beneficial as part of a broader treatment plan, are not the primary interventions to introduce at this stage:

8-13 (112D35) A 21-year-old man was brought to the hospital by his parents due to strange behavior. Since taking his graduate school entrance exam a week ago, he has been experiencing insomnia. This morning, he was found walking in circles and talking to himself around a bench in front of the station for about 3 hours, which led to him being taken into custody by the police and then brought to a nearby general hospital by his parents. His gestures and facial expressions are limited, and he avoids eye contact, staring at one point. Suddenly, he might smile or look scared. He nods as if listening to something silently and does not respond to questions, but abruptly he might say "I see" or "So that's why," as if having a short dialogue with someone. There have been no developmental or adaptation problems previously. Blood biochemistry, brain MRI, and EEG show no abnormalities.

Which symptom is observed in this condition?

a) Sensory aphasia

b) Behavioral compulsion

c) Associative loosening

d) Micropsia

e) Memory impairment

8-14 (114D60) A 20-year-old man was brought in for consultation by his concerned parents due to abnormal behavior. Since entering university two years ago and living alone in an apartment, he returned home a month ago claiming to be unwell and has since mostly secluded himself in his room. A week ago, he began claiming that "the TV broadcasts things about me every day," "TV show hosts are sending signals only I can understand," and "people around me are speaking ill of me." Consequently, he has been observed shouting towards the neighboring house at night. Because of these behaviors, he was brought to a psychiatric clinic by his parents. During the examination, he displayed limited facial expressions and avoided eye contact, answering questions in a low and brief manner. There were no developmental or adaptation issues before his university enrollment. Blood tests, brain MRI, and EEG showed no abnormalities.

Which medication is appropriate for treatment?

a) Imipramine

b) Lithium Carbonate

c) Phenytoin

d) Risperidone

e) Carbamazepine

The appropriate medication for treatment is:

d) Risperidone

10-1 (101A3) A 52-year-old man has been feeling less energetic for about half a year. He used to be considerate and polite, but he has become more self-centered and rude.

Which conditions could be considered? Choose two.

a) Pick's disease

b) Neurosyphilis

c) Personality disorder

d) Vascular dementia

e) Alzheimer's disease

The correct answers are:

a) Pick's disease

b) Neurosyphilis

Explanation:

Pick's disease, a type of frontotemporal dementia, leads to changes in personality and behavior due to atrophy in specific brain regions. Neurosyphilis can also cause significant neurological and psychiatric symptoms, including changes in behavior and personality, due to syphilis infection affecting the brain. While vascular dementia (d) and Alzheimer's disease (e) affect cognitive functions, the specific changes in behavior and self-centered actions described in the question are more characteristic of Pick's disease and can also be seen in neurosyphilis when it affects brain function. Personality disorders (c) typically involve long-standing patterns of behavior and are less likely to present with a sudden onset in middle age.

10-2 (105D22) A 60-year-old man was brought to the clinic by his family, who were concerned about his increasingly self-centered speech and actions, a marked change from his previously considerate behavior. Over the past year, he has lost motivation and often stands around blankly. His room is filled with piles of plastic bottles he has been collecting for several months.

The most likely disease is:

a) Alzheimer's disease

b) Lewy body dementia

c) Frontotemporal dementia

d) Obsessive-compulsive disorder

e) Schizophrenia

The most likely diagnosis is:

c) Frontotemporal dementia

Explanation:

Frontotemporal dementia (FTD) is characterized by progressive changes in personality, behavior, and language due to degeneration of the frontal and/or temporal lobes of the brain. The symptoms described in this scenario, such as a marked shift towards self-centered behavior, loss of motivation, and the accumulation of items like plastic bottles (which can indicate a compulsive behavior or a significant change in personal habits), align well with the behavioral variant of FTD. This form of dementia often leads to noticeable changes in social conduct and personality early in the disease process, differentiating it from Alzheimer's disease (a), which more typically begins with memory loss. Lewy body dementia (b) and Alzheimer's disease could also cause changes in behavior and cognition, but the specific behaviors mentioned are more characteristic of FTD. Obsessive-compulsive disorder (OCD) (d) and schizophrenia (e) might involve some similar behaviors but would not typically account for the described decline in motivation and personality change in the context of the patient's age and the absence of a prior history of these disorders.

10-3 (106G52) A 68-year-old woman was brought to the clinic by her husband due to forgetfulness. She has increasingly been forgetting conversations over the past year. Although she was skilled in cooking, recently the variety of her dishes has decreased, and she tends to prepare only simple meals. There is nothing notable in her medical history.

Which symptom is observed in this patient?

a) Aphasia

b) Apraxia

c) Agnosia

d) Attentional deficits

e) Executive dysfunction

The symptom observed in this patient is:

e) Executive dysfunction

10-4 (107A23) A 78-year-old man came to the clinic complaining, "I see strangers in my room when no one is there." According to his wife, he has often appeared drowsy and vacant during the day for several years, and his forgetfulness has gradually become more noticeable. His movements are slow, and he walks with a shuffle.

Which condition is observed in this disease?

a) Perseverative behavior

b) Persistent speech

c) Speech ataxia

d) Total life amnesia

e) REM sleep behavior disorder

The symptom observed in this disorder is:

e) REM sleep behavior disorder

Explanation:

REM sleep behavior disorder condition involves episodes where a person physically acts out vivid dreams with vocal sounds and sudden, often violent arm and leg movements during REM sleep — the stage in which dreaming occurs. It's more common in older adults and can be associated with neurodegenerative disorders, which might also explain the gradual cognitive decline and movement changes noted in the description. The mention of seeing strangers could relate to hallucinations, which are sometimes associated with conditions that also have REM sleep behavior disorder as a symptom, like Parkinson's disease or Lewy body dementia.

10-5 (114A70) A 76-year-old woman came to the clinic accompanied by her family, who were concerned about her increasing forgetfulness and repetitive questioning. About a year ago, a slight decrease in motivation was noted, and in the last three months, she has been preparing the same meals repeatedly over several days. No abnormalities were found in the physical examination. Her score on the Hamilton Depression Rating Scale is 4 points (0 to 7 points is considered normal), and her Mini-Mental State Examination (MMSE) score is 16 points (out of a maximum of 30 points). Mild hippocampal atrophy was observed on brain MRI.

Which tests are useful for evaluating this patient's functions? Choose two.

a) Rorschach Test

b) Tsumori-Inage Developmental Test

c) Frontal Assessment Battery (FAB)

d) State-Trait Anxiety Inventory (STAI)

e) Wechsler Memory Scale - Revised (WMS-R)