29-1 (117A5) Which of the following is more common in women?

a) Bipolar I disorder

b) Alcohol dependence

c) Autism spectrum disorder

d) Anorexia nervosa

e) Antisocial personality disorder

The correct answer is:

d) Anorexia nervosa

Explanation:

• Anorexia nervosa is significantly more common in women than in men. This eating disorder is characterized by an intense fear of gaining weight and a distorted body image, leading to severe restriction of calorie intake and often excessive exercise. The prevalence of anorexia nervosa is higher among females, particularly in adolescent and young adult age groups, where societal and cultural pressures regarding body image can be especially influential. Studies and clinical observations consistently show a higher incidence of anorexia nervosa in females compared to males.

The other options have different gender prevalence patterns:

• a) Bipolar I disorder has a more equal gender distribution, affecting males and females at similar rates.
• b) Alcohol dependence is more common in men than in women, although the gap has been narrowing.
• c) Autism spectrum disorder is more frequently diagnosed in males, with a widely cited ratio of about 4 males for every female diagnosed, although this ratio varies and recent research suggests that autism may be underdiagnosed in females.
• e) Antisocial personality disorder is more commonly diagnosed in men than in women, according to DSM-5 criteria and epidemiological studies.

29-2 (117F5) Which of the following are true about delirium? Choose three.

a) Dehydration can be a causative factor.

b) It cannot improve without treatment.

c) It develops rapidly over a few hours to a few days.

d) Having an underlying physical illness is a requirement.

e) There are fluctuations throughout the day, often worsening at night.

The correct answers are:

a) Dehydration can be a causative factor.

c) It develops rapidly over a few hours to a few days.

e) There are fluctuations throughout the day, often worsening at night.

Explanation:

• a) Dehydration is a known risk factor for delirium, especially in elderly patients. Dehydration can lead to electrolyte imbalances and reduced cerebral perfusion, which can contribute to the development of delirium.
• c) Delirium is characterized by its acute onset, typically developing over a short period ranging from a few hours to a few days. This rapid onset distinguishes delirium from other cognitive disorders like dementia, which develops more gradually.
• e) Delirium often shows a diurnal variation, with symptoms fluctuating throughout the day and frequently becoming more severe during the night. This pattern can be particularly distressing for patients and challenging for caregivers.

The statements that are not correct:

• b) Delirium often improves with appropriate treatment, which includes addressing the underlying cause (such as infection, dehydration, or medication side effects), ensuring patient safety, and sometimes using medications to manage agitation or psychosis.
• d) While delirium is often associated with physical illness, it can also be triggered by surgery, medications, or even withdrawal from alcohol or drugs. An underlying physical illness is a common but not an absolute requirement for the diagnosis of delirium.

29-3 (117F22) Which of the following is incorrect regarding the grief reaction associated with the death of someone close?

a) It is a reaction unique to adults.

b) It is necessary to differentiate it from depression.

c) It can have physical effects.

d) The care provided is called grief care.

e) It lightens over time.

The incorrect statement is:

a) It is a reaction unique to adults.

Explanation:

• Grief reactions are not unique to adults; children also experience grief, though their understanding and expression of grief may differ from those of adults. Children's reactions to loss can vary widely, depending on their age, developmental stage, and the support they receive. While the manifestations of grief in children can differ from adult expressions of grief, both children and adults can experience profound sadness, changes in sleep and eating patterns, and physical symptoms in response to the death of someone close.
• b) It is indeed necessary to differentiate grief from depression, as both can share similar symptoms, but the approaches to support and treatment may differ.
• c) Grief can have physical effects, including changes in sleep patterns, appetite, and even physical pain or discomfort.
• d) The care provided to support someone experiencing grief is referred to as grief care or bereavement support, focusing on emotional and psychological well-being during the grieving process.
• e) Grief typically does lighten or change over time, as individuals process their loss and begin to adjust to life without the deceased. However, the timeline for this process can vary greatly among individuals.

29-4 (117F24) Which of the following is used as a comprehensive scale for assessing psychiatric symptoms, primarily targeting schizophrenia?

a) Rorschach Test

b) State-Trait Anxiety Inventory (STAI)

c) Rivermead Behavioural Memory Test (RBMT)

d) Mini-Mental State Examination (MMSE)

e) Brief Psychiatric Rating Scale (BPRS)

The correct answer is:

e) Brief Psychiatric Rating Scale (BPRS)

Explanation:

• The BPRS is a widely used instrument for assessing the severity of psychiatric symptoms, particularly in patients with schizophrenia. It provides a comprehensive evaluation of a broad range of psychiatric symptoms, including delusions, hallucinations, depressive symptoms, and anxiety, making it particularly useful for tracking symptom changes over time in individuals with schizophrenia or related disorders.
• a) The Rorschach Test is a projective psychological test consisting of inkblots to analyze a person's personality and emotional functioning. It is not specifically used for assessing psychiatric symptoms in schizophrenia.
• b) The State-Trait Anxiety Inventory (STAI) is designed to measure both state and trait anxiety in individuals, not the comprehensive range of psychiatric symptoms associated with schizophrenia.
• c) The Rivermead Behavioural Memory Test (RBMT) assesses memory function and is more suited for evaluating cognitive deficits following brain injury, not specifically for psychiatric symptom assessment in schizophrenia.
• d) The Mini-Mental State Examination (MMSE) is a brief 30-point questionnaire test that is used to screen for cognitive impairment. It assesses functions including arithmetic, memory, and orientation, but it is not comprehensive enough to evaluate the wide range of psychiatric symptoms seen in schizophrenia.

29-5 (117F32) Which of the following is not observed in a manic state?

a) Talkativeness

b) Extravagance

c) Irritability

d) Disorientation

e) Reduced need for sleep

The correct answer is:

d) Disorientation

Explanation:

• Disorientation, which involves confusion about time, place, or person, is generally not a characteristic of a manic state. Mania typically includes symptoms such as increased energy, reduced need for sleep, talkativeness, impulsivity including extravagant behaviors, and irritability. However, individuals experiencing mania are usually oriented to time, place, and person unless the mania is accompanied by psychotic features, but even then, disorientation is not typically a core feature.
• a) Talkativeness is a common symptom of mania, where individuals may experience pressured speech and feel a strong urge to keep talking.
• b) Extravagance or reckless spending is often seen in manic episodes, where individuals may make poor financial decisions due to increased impulsivity.
• c) Irritability is frequently observed in mania, especially when others do not share the manic individual's enthusiasm or when their plans are thwarted or questioned.
• e) A reduced need for sleep is one of the hallmark symptoms of mania, with individuals often feeling rested after only a few hours of sleep.

30-1 (117A18) A 7-year-old girl was brought to the clinic by her concerned parents because she has not been talking to teachers or other children since she started school two months ago. She barely spoke in kindergarten as well, but she was able to communicate through gestures. She has been speaking normally with her family since she was young, and there are no noticeable intellectual delays. Physical examination, including neurological assessment, showed no abnormalities.

Which of the following is a possible diagnosis?

a) Stuttering (childhood-onset fluency disorder)

b) Tourette syndrome

c) Learning disability

d) Selective mutism

e) Conduct disorder

The correct answer is:

d) Selective mutism

Explanation:

• Selective mutism is a complex anxiety disorder characterized by a child's inability to speak in certain social situations, such as at school or in the community, even though they may speak normally at home or in settings where they feel comfortable and secure. This condition perfectly aligns with the scenario described, where the girl speaks normally at home with her family but does not speak at school or with peers and teachers. Selective mutism often becomes apparent when children start school, where the demand for social interaction and performance increases significantly.
• a) Stuttering, or childhood-onset fluency disorder, involves disruptions in the flow of speech, such as repeating sounds, which is not mentioned in this scenario.
• b) Tourette syndrome is characterized by repetitive, stereotyped involuntary movements and vocalizations called tics, which is not relevant to the girl's described behavior.
• c) Learning disabilities involve difficulties in learning and using academic skills, not specifically related to the issue of not speaking in certain environments.
• e) Conduct disorder involves a range of behavioral and emotional problems, including aggressive behavior towards people or animals, destruction of property, deceitfulness, theft, and serious violation of rules, which does not reflect the girl's symptoms of non-communication in specific settings.

30-2 (117A33) An 18-year-old male has been increasingly uncomfortable with perceived scrutiny from others when going out for the past three months. Over the last two weeks, even at home, he feels as though someone is peeping into his room and eavesdropping on his conversations, leading his parents to take him to a psychiatrist. Diagnosed with strong delusions, he was prescribed antipsychotic medication. Starting from the second day of medication, he began experiencing restless legs, causing him to walk around his room frequently, and at night, this restlessness has led to complaints of insomnia.

Which of the following is correct regarding this restlessness?

a) It is called dystonia.

b) It is accompanied by a decrease in sensation in both lower limbs.

c) It is accompanied by sleep apnea syndrome.

d) It is accompanied by abnormal EEG.

e) It can be alleviated by reducing the dosage of antipsychotic medication.

The correct answer is:

e) It can be alleviated by reducing the dosage of antipsychotic medication.

Explanation:

• The symptoms described—restlessness in the legs and an urge to move around, particularly worsening during periods of rest or inactivity at night—suggest a condition often referred to as "akathisia." Akathisia is a common side effect of many antipsychotic medications and is characterized by an inner restlessness and an inability to stay still. One of the most effective ways to manage akathisia is to adjust the dosage of the antipsychotic medication, either by reducing it or switching to a different type of medication less likely to cause this side effect.
• a) Dystonia refers to a different type of movement disorder characterized by involuntary muscle contractions that force the body into abnormal, sometimes painful, movements and postures, not the restlessness described.
• b) Decrease in sensation in the lower limbs is not typically associated with akathisia, which is more about movement and less about sensory changes.
• c) Sleep apnea syndrome involves breathing interruptions during sleep, which is unrelated to the restlessness caused by antipsychotic medications.
• d) An abnormal EEG, which measures electrical activity in the brain, is not specifically related to the symptoms of akathisia.

30-3 (117A34) A 7-year-old boy was brought to the clinic by his parents due to concerns about his restlessness. His teacher has noted that he is unable to sit still during class, often leaves his seat without permission, interferes with classmates which leads to conflicts, and frequently forgets things. At home, he struggles with tidying up and organizing, but he can concentrate well on his favorite games. There have been incidents where he has run into the street without checking for cars. No abnormalities were noted at birth, and no significant developmental delays were reported during infancy. No clear abnormalities were found in a physical examination, including a neurological assessment.

Which of the following is correct about the condition currently considered?

a) It involves intellectual disability.

b) Effective pharmacological treatment is available.

c) Symptoms disappear by adulthood.

d) Postnatal upbringing is a causal factor.

e) It is better to correct undesirable behavior than to praise desirable behavior.

The correct answer is:

b) Effective pharmacological treatment is available.

Explanation:

The symptoms described in the scenario — inability to sit still, impulsivity, lack of attention to safety, ability to focus well on preferred activities, and general inattention without significant developmental delays or neurological abnormalities — suggest a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). ADHD is a behavioral disorder characterized by patterns of inattention, hyperactivity, and impulsivity that are more severe than typically observed in individuals at a comparable level of development.

• b) Effective pharmacological treatments, such as stimulant medications (e.g., methylphenidate, amphetamine salts) and non-stimulant medications (e.g., atomoxetine), are well-established and can significantly improve symptoms of ADHD by enhancing concentration and decreasing impulsivity and hyperactivity.
• a) ADHD does not inherently involve intellectual disability, though it can coexist. The scenario provided does not specifically indicate intellectual disabilities.
• c) It is a misconception that ADHD symptoms always disappear by adulthood. While symptoms can change and sometimes lessen in intensity, many individuals continue to experience symptoms into adulthood.
• d) While environmental factors can influence the expression of symptoms, ADHD is primarily considered a neurodevelopmental disorder with a strong genetic component. Postnatal upbringing alone is not a causal factor for ADHD.
• e) Behavioral interventions for ADHD often focus on reinforcing positive behaviors through praise and rewards, rather than solely focusing on correcting undesirable behavior. This approach is generally more effective in promoting long-term positive behavior changes in children with ADHD.

30-4 (117A59) A 35-year-old man visited the clinic with the complaint that he "keeps checking the locks and ends up being late almost every day." He lives alone, but since hearing news about a burglary in his neighborhood about three months ago, he has been unable to stop checking the locks, even though he thinks it's excessive. At work, he has also become noticeably more concerned about losing documents and checks them repeatedly. He has no problems with concentration or motivation.

Which of the following is a possible diagnosis?

a) Adjustment disorder

b) Dissociative disorder

c) Obsessive-compulsive disorder

d) Somatization disorder

e) Social (social anxiety) disorder

The correct answer is:

c) Obsessive-compulsive disorder (OCD)

Explanation:

• Obsessive-compulsive disorder is characterized by the presence of obsessions (intrusive, unwanted thoughts that repeatedly occur) and compulsions (repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession or according to rules that must be applied rigidly). In this scenario, the man's excessive checking of locks and concern over losing documents at work are indicative of compulsive behaviors. These actions are performed in an attempt to alleviate anxiety caused by his obsessions about safety and security, typical features of OCD.
• a) Adjustment disorder involves emotional or behavioral symptoms in response to a stressor, but it does not typically include compulsive behaviors related to intrusive thoughts.
• b) Dissociative disorders involve a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. This man’s symptoms do not suggest such disruptions.
• d) Somatization disorder, now more commonly referred to under the term Somatic Symptom Disorder, involves experiencing and becoming significantly distressed by physical symptoms that are not fully explained by a medical condition, which is not applicable here.
• e) Social anxiety disorder (social phobia) is characterized by significant anxiety and discomfort about being embarrassed, humiliated, rejected, or looked down on in social interactions. This does not relate directly to his symptoms of compulsive checking.

30-5 (117B37) An 18-year-old female visited the emergency department complaining of difficulty breathing. She suddenly felt breathless and her breathing became rapid while on a crowded bus on her way to school. She has been diagnosed with panic disorder and has been visiting a local clinic, but has no other underlying diseases. She is conscious and clear. Body temperature 36.8°C. Pulse 104/min, regular. Blood pressure 112/72 mmHg. Respiratory rate 48/min. SpO2 100% (room air). No jugular vein distension is observed. No abnormalities in heart sounds or breath sounds. The abdomen is flat, soft, and non-tender. No cyanosis in the limbs. The patient says, "I can't breathe. My fingertips and around my mouth are numb."

Which of the following is the correct approach to take in the emergency department for this patient?

a) Administer an antipsychotic medication.

b) Send her to school as usual.

c) Administer low-flow oxygen.

d) Have her breathe into a paper bag.

e) Instruct her to breathe slowly.

The correct answer is:

e) Instruct her to breathe slowly.

Explanation:

The symptoms described, including sudden onset of difficulty breathing, numbness around the mouth and fingertips, and a high respiratory rate, are typical of hyperventilation often associated with a panic attack. Given that the patient's SpO2 is 100% and there are no signs of respiratory distress such as cyanosis or abnormal heart and lung sounds, this suggests that the patient does not have a physical respiratory condition but is experiencing a panic-induced hyperventilation.

• Instructing her to breathe slowly is an effective method to help control her breathing, reduce the hyperventilation, and alleviate the symptoms of a panic attack. This approach focuses on calming the patient and stabilizing her respiratory rate without the need for medical intervention like medication or oxygen, which are not indicated in this scenario as there is no evidence of oxygen saturation deficit or psychosis.
• a) Antipsychotic medication is not appropriate as this situation is more related to anxiety rather than a psychotic disorder.
• b) Sending her to school would ignore her acute distress and could potentially worsen her symptoms.
• c) Administering low-flow oxygen is not necessary since her oxygen saturation is at 100%, indicating she is not suffering from an oxygen deficit.
• d) Having her breathe into a paper bag is an old method once used for hyperventilation; however, it is not generally recommended anymore as it could potentially increase carbon dioxide levels too quickly.

30-6 (117C46) A 16-year-old male has been experiencing feelings of being watched in his room and hearing friends speak ill of him at home for about two months. Concerned, his parents took him to see a psychiatrist. The psychiatrist, recognizing that the boy was not willing to undergo treatment, admitted him to a medical care facility with the consent of his parents. On the seventh day of his hospitalization, he stated, "I am not sick and want to be discharged." When his doctor recommended continuing the hospitalization, he expressed a desire to initiate discharge procedures, mentioning something about a "discharge request."

Which of the following is correct about making a discharge request?

a) The permission of the hospital director is required.

b) It cannot be made verbally.

c) It can only be made if the patient is in a locked ward.

d) A lawyer can act as a proxy to make the request.

e) It cannot be made if the medical care admission was consented to by both parents.

The correct answer is:

d) A lawyer can act as a proxy to make the request.

Explanation:

• In the context of a patient under involuntary hospitalization, the patient has the right to request discharge, even if they were initially admitted with the consent of guardians or under medical advisement. This right ensures that patients have a means to assert their autonomy and seek a review of their involuntary status.
• a) The hospital director’s permission is not required for a patient to request a discharge; rather, such requests typically initiate a review process which may involve multiple healthcare professionals, but the initial request does not require approval.
• b) A discharge request does not necessarily have to be in writing; patients can make their wishes known verbally, which must then be formally documented and processed by the hospital staff.
• c) Discharge requests are not limited to those in locked wards; any patient who is under involuntary admission has the right to request a discharge.
• e) The fact that both parents consented to the medical protective admission does not negate the patient's right to request discharge. The laws are designed to protect the patient's rights irrespective of parental consent once admitted.

30-7 (117D35) A 10-year-old boy has developed behaviors of arching his back and repetitively uttering meaningless words, prompting a visit to the clinic with his parents. Since around the age of 6, he has been repeatedly distorting his face and shaking his head, suddenly shouting or coughing. After turning 8, he started to repeat more complex movements like clapping and jumping. He also occasionally repeats obscene words.

Which disorder is most likely in this child?

a) Separation anxiety disorder

b) Tourette syndrome

c) Autism spectrum disorder

d) Stuttering (childhood-onset fluency disorder)

e) Attention-deficit/hyperactivity disorder (ADHD)

The correct answer is:

b) Tourette syndrome

Explanation:

• Tourette syndrome is characterized by multiple motor tics and at least one vocal tic. These tics typically appear in childhood, often before the age of 18. The description of the child's behaviors — including repetitive movements such as arching the back, facial grimacing, head shaking, and more complex tics like clapping and jumping, along with vocal tics such as meaningless words, shouting, and even using obscene language (coprolalia) — fits the profile of Tourette syndrome.
• a) Separation anxiety disorder primarily involves excessive fear or anxiety about separation from home or attachment figures, which is not indicated in the described behaviors.
• c) Autism spectrum disorder includes challenges with social interaction, restricted interests, and repetitive behaviors, but the specific tic behaviors described are more characteristic of Tourette syndrome.
• d) Stuttering, or childhood-onset fluency disorder, involves disturbances in the normal fluency and time patterning of speech (such as sound repetitions, prolongations) and does not involve the motor tics or variety of vocal tics described.
• e) Attention-deficit/hyperactivity disorder (ADHD) is characterized by inattention, hyperactivity, and impulsivity. While children with ADHD might display some overlapping behaviors such as restlessness, the specific repetitive and involuntary tic behaviors described are hallmark features of Tourette syndrome rather than ADHD.