Review Psychiatry Questions for SMLE

Collection of questions [2021 till September 2022] + interpretation

Version 2 2022

‫أ أ داف‬ ‫س ا رض‬ ‫رح أس ة ا صحة ا فس ة‬ ‫ا ا صحة ا فس ة ح‬ ‫ف‬ ‫ا طباء ا‬ ‫عة‬ ‫ص‬ ‫د‬ ‫ذا ا ع‬
.‫ربح ة‬
.‫ر عد است دا ف ا د رات ا ربح ة ا دف عة‬
.‫ت س ا دع ات ف ظ ر ا ب‬
) ‫طا‬ ‫ا‬ ‫فس‬ ‫إ أسأت أ أ طأت ف‬ ‫(إ أحس ت ف‬

:‫رسا ا س ة‬
Email: [email protected]
Telegram: https://t.me/psychsmlechannel

‫اط أ ا ص ذ ك س عت د ع ا ض ع ا ساس ف ا سؤا ع ا رح‬ ‫ر ا س ة ت ف ا ت عات ب‬ :‫ح ظة‬

‫ذا ا تبار ذ ك اعت د ا بعض ا صادر ا عت دة ف ا ب رد ا سع د صحة‬ ‫د صدر عت د ا ة ف ا ت‬ ،‫ا صادر‬
. ‫ا فس ة ا د ا‬
Resources:
Synopsis of Psychiatry Behavioral Sciences/Clinical Psychiatry
DSM-5
The Maudsley Prescribing Guidelines in Psychiatry
Toronto notes
Online sources: Uptodate, Medscape, Psychiatric Times, MDedge, AMBOOS

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History taking &Mental Status
Examination

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

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

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

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

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

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

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 Questions about history taking & mental status examination:

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

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

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6
Depression

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Review about Depression:

Summary for diagnosis depression – DSM-5:

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

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 Highlighted points about antidepressants in pregnancy:

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

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

1) Case of Depressed patient and the doctor will prescribe a drug for her. asking which
reuptake inhibitors should be prescribed?
A- DOPA
B- GABA
C- Serotonin
D- Acetylcholine
Answer is C
2) 55 years old patient C/O low mood, loss of appetite, insomnia, suicidal ideation, for 2
months dx?
A- Minor depression
B- Major depression
C- Bipolar disorder
Answer: A; as explained before, according to DSM-5 criteria:
2-4 symptoms for 2 weeks = minor depression “depressive episode”
>5 symptoms for 2 weeks = major depression
At least 2 symptoms for 2 years = Dysthymia
With clinically significant distress or impairment in social, occupational, or other important areas of
functioning.
symptoms regardless the number of them must continue for 2 weeks without being mixed or
interrupted with other manic or psychotic symptoms to make the diagnosis of depression. Of course
it can extend to longer period either because of not being treated or the respond to treatment
methods or continues of the underlying cause of depression.
So back to our scenario, 2 months mean it s extended more than 2 weeks but number of symptoms
are still 4 so the answer is minor depression.

3) Female lost her best friend and can’t sleep? “other recall: women with a history of
insomnia and crying for 5 days due to sibling death, what is the short course therapy?
“Duration is missing in the first question but important”
A- Lorazepam
B- Fluoxetine
C- Imipramine
D- Chlorpromazine
Answer: A; in general, Supportive psychotherapy is indicated for those individuals in acute crisis
or a temporary state of disorganization and inability to cope (including those who might otherwise be
well functioning) whose intolerable life circumstances have produced extreme anxiety or sudden
turmoil (e.g., individuals going through grief reactions, illness, divorce, job loss, or who were victims
of crime, abuse, natural disaster, or accident.
In this question the main complaint is sleeping issue due to current issue, so always treat the symptom
if needed. Giving short duration course of benzodiazepine can help to relieve the symptom, yet the
importance of supportive therapy must be involved. No SSRI or any other antidepressants are needed
unless low mood symptoms duration fit the criteria of depression.

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

5) 22 years female K/C/O severe depression, suicidal attempts, she is controlled on paroxetine.
Now, she is pregnant. What to do?
A- Stop paroxetine because of fetal malformation
B- Continue paroxetine and control her depression
C- Switch to others drug.
D- Stop paroxetine b/c of prematurity

Answer is B;
if she is currently pregnant and controlled on paroxetine (or any other antidepressants)
we have to continue using same medication because of the high risk of relapse and
educate the mother about the possible side effects to the baby, which is less in rate than
having maternal relapse [d n b eak he b a ]
if she is planning to be pregnant and still have time, you can switch to another
antidepressant safe for both baby and the mother with close follow up and assessment.
If untreated before and planning to be pregnant, Sertraline is a good choice to start with
and to be pregnant on it.

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

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

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

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

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

10) Pt diagnosed with major depressive disorder, what is true about SSRI?
A- Initiate one medication then follow up after 2 weeks.
B- Change the medication if there is no response
C- Not written
Answer: A: first assess side effects after 2 weeks, if not tolerated change it, then 3-4 weeks to
assess response if weak effect increases the dose, if no effect changes the medication.

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

12) Highest risk factors for

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

13) Pt after sleeve gastrectomy

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

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

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

16) Low mood, decreased interest and weight changes for

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

17) Alternative treatment of severe depression?

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

18) Old female pt with typical symptoms of depression, sadness, loss of interest, feeling
worthless and suicidal thoughts, which of the following mediators is responsible for her
symptoms?
A- DOPA
B- Serotonin
C- GABA
D- Acetylcholine
Answer: B ; FYI in (affective= mood) disorders, the stabilization of mood is working by balance
the combination of many chemicals, not a single chemical, and on the other hand, stabilization of
them help also to stabilize the psychotic symptoms and vice versa. Read the symptoms in the
question very well, it is not only serotonin!

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 19) Pt come with violence, which imbalance responsible for violence?
A- Testosterone
B- Low serotonin
Answer is A; Testosterone has more effect on violence
than serotonin
- Other recall with other choices:
A- Low serotonin
B- high serotonin.
C- low endorphin.
D- high endorphin
Answer is; A

20) drugs cause irritation and anxiety and insomnia?

another recall;
What drug cause insomnia and headache and n/v ?
Answer Fluoxetine; SSRI in general
A- Tricyclic antidepressant
B- tetracyclic antidepressant
C- MOI
D- SSRI
Answer D;
21) Side effect of Amitriptyline?
A- Dysphonia
B- Weight gain
C- Hyper-salivation
D- Hyperpigmentation
E- Constipation
Answer is B, then E; main common side effect of amitriptyline and the main concern from
the patient, constipation is also correct choose it if weight gain is not mentioned. ( in other
recall asking about Absolute side effect: Constipation
Other choices are wrong as this medication causes dry mouth, rash but not
hyperpigmentation, and unknown mechanism of treating vocal cord disease in low doses.

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22) Elderly on amitriptyline 30mg at night for insomnia, complained of drowsiness, what to
do?
A- Switch to SSRI
B- Change to morning dose
C- Divide the dose – take it TID
D- Decrease it to 10m
Answer: C. no need to change the dose or the timing plus SSRI can induce insomnia.
23) patient on amitriptyline daily, she complains from dizziness every morning. What to do?
A- change to SSRI
B- take the medication with food
-Answer preferred to change the timing of the dose to night dose.

24) Pt presented with insomnia started 2 months post MI, what is the best treatment for this
patient?
A- Zolpidem
B- Diazepam
C- Antihistamine
D- Nothing
Answer: A; First line treatment is CBT, however we can give short term medication just for
help, and we have to consider cardiac safety too. “short-term use of hypnotics can improve
sleep, long-term use has been associated with adverse effects, including tolerance, rebound
insomnia, daytime fatigue, and difficulty with memory and concentration.”

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

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

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27) Which among the following is NOT a side effect of bupropion?
A- Diarrhea
B- Blurred vision
C- increased sweating
D- dry mouth
Answer: A; all of them are reported side effects but diarrhea is less common.

28) Pt on antidepressant then developed constipation, what class of antidepressants?

A- SSRI
B- TCA
C- SNRI
D- MAOI
Answer: B, TCA more common in causing constipation then others.

29) Postpartum depression What to do beside psychotherapy:

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

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

32) 30yo female delivered her baby 1 week ago, presented with crying bouts associated with
decrease in appetite and self-neglect without any clear reason, what is the possible
diagnosis?
A- Postpartum depression
B- baby blues
C- Generalized anxiety
disorder
Answer is: B;

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

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 Anxiety Disorders

Obsessive-compulsive disorder (included in the obsessive-

compulsive and related disorders), acute stress disorder, and
posttraumatic stress disorder (included in the trauma and stress-
related disorders) are no longer considered anxiety
disorders according to DSM-5, yet we will answer them in the
same chapter. 19
 Criteria of most important anxiety disorders for the exam:

generalized anxiety disorder DSM-5

There is strong support for a variety of psychosocial

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

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 Specific Phobia

Evidence indicates that CBT

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

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

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Obsessive compulsive disorder DSM-5

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23
 Questions about Anxiety Disorders:
1) 19yo female, scared from dust storm, she gets out of home with her family, during sand
storm she get inside bed and cover her head with pillow, what is the most likely
diagnosis?
A- Generalized Anxiety Disorder
B- Social Phobia
C- Specific Phobia
Answer: C, for proper diagnosis to fit criteria we need more details
2) Patient diagnosed with generalized anxiety disorder the best drug is?
A- SSRI
B- Benzodiazepine
Answer: A;
Benzodiazepines should not be used except for crises.
An SSRI should be used as first-line treatment.
SNRIs and pregabalin are second and third choices, respectively.
High-intensity psychological intervention and self-help (based on CBT principles) should be
encouraged.
Antipsychotics should not be offered (presumably this includes quetiapine).

3) 27yo male after 12 months on war, he saw dead friends, and remembers difficult situations,
he is in low mood, and poor sleep, what is the most appropriate treatment?
A- Sertraline
B- Lorazepam
C- Amitriptyline
D- Lithium
Answer is A: explanation same as question 1, however; In this question case of PTSD and the
main complaint is mood affecting quality of life, and fit the criteria of depression so SSRI is the
choice. Giving short duration course of benzodiazepine can help to relieve poor sleep, yet the
importance of supportive therapy must be involved. Amitriptyline is good choice for mood +
poor sleep but not the first line of treating PTSD

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

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

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

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

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

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

Answer is D:

check
psychotic
disorders
chapter for
similar
scenario with
different
answer

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

7) 20 y old male, keeps counting blocks, walls, etc. he keeps repeat counting, He feels guilty
and anxiety when he stops counting, what is dx?
A- Depression
B- Obsession
C- Compulsion
Answer: C; by definition of compulsion vs obsession

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

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9) Women fear from fired from her job because she not sleep, not really during sleep
awake repetitively to check close door and look oven ask about dx?
A- Obsessive compulsive disorder
B- Anxiety
Answer is A, by exclusion. This is a bit confusing question started with anxiety and ended up
with OCD symptoms.
10) 20yo girl, BMI is normal, she has fear from eat to not increase weight?

A- Body dysmorphic
B- Bulimia nervosa

Answer is A

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

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

A- major depression
B- secondary depression
C- generalized anxiety disorder
D- social phobia
Answer is C

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

14) panic attack symptoms and asked about

symptoms reliever?

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

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

etc. and tried but cannot stop doing this Dx?

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

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

A- Trichotillomania
B- anxiety disorder
Answer is A

FYI: trichotillomania is categorized in dsm-5 as one of the OCDs and impulsive control
disorders. Unlike those with OCD, patients with hair-pulling disorder do not experience
obsessive thoughts, and the compulsive activity is limited to one act, hair pulling.
onset has been linked to stressful situations in more than one-fourth of all cases. Family
members of hair-pulling disorder patients often have a history of tics, impulse-control
disorders, and obsessive–compulsive symptoms, further supporting a possible genetic
predisposition.
Significant comorbidity is found between hair-pulling disorder and OCD; anxiety
disorders; Tourette’s syndrome; depressive disorders; eating disorders; and various
personality disorders—particularly obsessive–compulsive, borderline, and narcissistic
personality disorders.

29
Bipolar Affective Disorder

30
 Review about Bipolar Affective Disorder:

diagnosis depressive episode – DSM-5:

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

diagnosis manic episode – DSM-5:

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

31
\ diagnosis hypomania episode – DSM-5:
criterion A and B of a manic episode is met, but duration is _4 d
• episode associated with an uncharacteristic change in functioning that is observable by
others but not
severe enough to cause marked impairment in social or occupational functioning or to
necessitate
hospitalization
• absence of psychotic features (if these are present the episode is, by definition, manic)

diagnosis mixed episode – DSM-5:

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

Presence of psychotic symptoms

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

32
 Important notes about Bipolar treatment:
1) Monotherapy with antidepressants should be avoided in patients with bipolar depression as
patients can switch from depression into mania.
2) Summary of medications:

33
Questions about Bipolar Affective Disorder:

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

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

3) Most common disease has mania:

A- Bipolar
B- Schizophrenia
Answer: A

4) Case about a man with depressive symptoms and low mood, his wife said he was
very happy, 3 months ago he bought an expensive car and said he is rich, what to
give him?
A- Lithium
B- olanzpine
Answer: question needs better recall for duration and symptoms and choices to
confirm diagnosis of bipolar disorder with mixed features with or without psychosis,
and as mentioned before, lithium is a good mood stabilizer but not the first line
treatment.

34
Psychotic Disorder

35
 Review about psychotic disorder:
Definition of Psychotic disorder: characterized by a significant impairment in reality testing including:
A) Positive symptoms:
delusions or hallucinations (with or without insight into their pathological nature) disorganized
behaviors formal thought disorder
Delusions: fixed, false beliefs
Hallucinations: perceptual experiences without an external stimulus
B) Negative symptoms:
affective flattening anhedonia avolition alogia asociality
Schizophreniform: criteria A, D, and E of schizophrenia are met; an episode of the disorder lasts for at
least 1 mo but less than 6 mo.

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

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

Summary for diagnosis Schizophrenia– DSM-5:

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

36
 Important notes about medications:
atypical antipsychotics (second generation) are as effective as typical (first generation) antipsychotics but are thought
to have better adverse effect problems; main difference is lower risk of EPS and TD
if no response in 4-6 wk, switch drugs
duration: minimum 6 mo and usually for life in most patients with primary psychotic disorders; variable for other
indications.
Long acting injection indicated in individuals with schizophrenia or other chronic psychosis who relapse because of
non-adherence. should have been exposed to oral form prior to first injection. dosing: start at low dosages, then titrate
every 2-4 wk to maximize safety and minimize side effects. side effects: risk of EPS, parkinsonism, increased risk of
NMS

37
 Questions about psychotic disorders & medications“Reference: Kaplan& Maudsley”:

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

2) Poor prognosis of schizophrenia:

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

3) Regarding postpartum Psychosis:

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

4) Case of paranoid schizophrenia with positive and negative symptoms asking about treatment?
A- Fluphenazine
B- Clozapine
C- Chlorpromazine
Answer is B; in general, it s better to start with atypical antipsychotics, if not in the choices then
choose typical antipsychotic. Clozapine is last line used for resistant psychosis and refractory
cases.
- Fluphenazine is high potency typical dopaminergic D` and D2 receptors can worsen negative
symptoms
- Chlorpromazine is an atypical antipsychotic but has low potency.

38
 5) 21-year-old college student, came with her parents, they said she had four months
ago auditory hallucinations, she believed that the TV inserted ideas in her brain and she had
social issues and withdrawn from the last semester, but no mood issues, then now she become
fine and retuned normal. What is the diagnosis?
A- Conversion disorder
B- Schizophrenia
C- Mania episode from bipolar
Answer is B regardless the wrong duration but the closet answer, according to the duration it should be
schizophreniform, no neurological symptoms so A is excluded, no mood symptoms so C is excluded.

6) 34yo male believed that his company implanted him with chip to steal his ideas, he denied low
mood. What is the most diagnosis?
A- Schizophrenia
B- Schizophreniform
C- Brief psychotic episode
D- Manic episode
Answer???: it depends on the duration too, it can be any of the first 3 answers, check the notes before
for clarification.

7) 56 yo newly diagnosed with schizophrenia prescribed new neuroleptics, he is at risk of what?

A- MI
B- Seizure
C- Hyperthermia
D- Akathisia
Answer is D; Extrapyramidal Symptoms common
side effects of antipsychotics;
incidence related to increased dose and potency.
- Acute (within 10 days, early-onset; reversible)
- Tardive (within 90 days, late-onset; often
irreversible)
- Acute: lorazepam, propranolol, or
diphenhydramine
- reduce dose or change antipsychotic to lower
potency.

8) Most common antipsychotics causes weight

gain:
Note: Risk of weight gain: Clozapine > Olanzapine >
Quetiapine > Risperidone

9) Clozapine is the best to treat child with:

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

39
10) What’s the effect of anti-psychotic drugs on schizophrenia?
A- Decrease delusions
B- increase apathy
C- improve communications
Answer: A; the goal of maintenance treatment of schizophrenia is to minimize symptoms
and functional impairments, minimize side effects of pharmacotherapy, avoid relapses, and
promote recovery that allows self-determination, full integration into society, and pursuit of
personal goals.

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

12) Women with schizophrenia (on two medications, i forgot name) had orofacial abnormal
movement taking two medications (metoclopramide, another drug):
A- catatonic movement
B- tardive dyskinesia
C- positive sum schizophrenia symptoms
Answer: B; metoclopramide interacts with antipsychotics (dopamine antagonists) cause
EPS & TD
13) Symptoms of delusion for 3 months then return to normal without any tx?
A- brief psychotic
B- schizophreniform
C- delusional disorder
D- Schizophrenia
Answer is C if the same scenario. Against choice A & D because of duration, might be
choice B if the scenario has more details about the symptoms positive or negative symptoms
14) patient has hallucinations and delusions for 6 months then get away without medication?
A- Schizophreniform
B- Schizophrenia
Answer is A based on duration
Summary for diagnosis Delusional Disorder– DSM-5:
A. the presence of one (or more) delusions with a duration of 1 mo or longer
B. criterion A for schizophrenia has never been met
Note: hallucinations, if present, are not prominent and are related to the delusional theme
C. apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and
behavior is not obviously bizarre or odd
D. if manic or major depressive episodes have occurred, these have been brief relative to the duration of
the delusional periods
E. the disturbance is not attributable to the physiological effects of a substance or another medical condition
and is not better explained by another mental disorder

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

16) Psychiatric case about a patient with bad hygiene, muttering, good memory, echolalia,
echopraxia and bad hygiene 2 months. Patient is oriented. How would you treat?
A- Lithium
B- Oxcarbazepine
C- Venlafaxine
D- Amisulpride
40
 Answer: D, one of the atypical antipsychotics effective in
argumentation, but remember the first line therapy for
catatonic schizophrenia is benzodiazepine.

17) 23 years old, he came complaining of the first time hearing

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

18) Patient admitted to Psychiatry with acute psychosis and

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

41
20) Pt at the clinic always looking the right direction and when asked he says my mother is
there and no one can see her except me, family stated she’s dead but he insisted that she is
there but comes and goes, what is your diagnosis?
A- Delusional disorder
B- Visual hallucination
C- Auditory hallucination
D- personality disorder
Answer is: B

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

22) Women just had her baby 3 months

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

23) Young person his father died for three days he had disorganized speak and behavior walk
outside without clothes and see his father then he returns to normal what is Dx?
A- Brief psychotic disease
B- schizophreniform disorder
C- Reactive psychosis
Answer: Answer might be C if it s an old
question; This question might be a bad
recall as A & C now are similar answers
according to DSM- 5 classifications brief
psychotic disorder with marked stressor
previously was called brief reactive
psychosis in DSM-4.

42
24) 21 yo male complains of sounds tell him that “will stick out his thoughts “since 4 months
what is the diagnosis:
A- Mania
B- Schizophrenia
C- Mood disorder
Answer is: 4 months of auditory hallucination
only is schizophreniform, if not mentioned and
no other mood symptoms so schizophrenia is the
closest answer regardless the duration

25) 40 years old male pt come with his brother, he was completely healthy after that he
started 3 months ago to be aggressive and irritate everyone in house and work flight of
idea can’t complete sentence, diagnosis?
A- Dementia
B- Alzheimer s
C- Schizophrenia
D- Schizophreniform disorder
Answer is D; based on age, duration of symptoms and theses options.

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

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

28) Man put a cover on the television because he thinks the government is watching him, he
says god himself told him to that?
A- Schizophrenia
B- Mania
C- Depression
D- Delusional Disorder
Answer is D

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

43
30) elderly with psychosis came to ER they increased the dose of haloperidol then he
deteriorated what will u do?
A- intubate
B- Lavage
C- naloxone
missing too much information about vitals, kind of deterioration, the increased
dose was within normal range or toxic dose
If EPS - give Anticholinergic drugs; benzotropine
If NMS - give either bromocriptine, dantrolene or amantedine as antidote with
possible ICU admission
If toxicity: vitals & ECG, start ABC, gastric lavage or induction of emesis
followed by active charcoal, IV fluid
With possible include ECT in the management

44
Substance Abuse &
Smoking

45
 Review about addiction:

criteria for substance use disorders:

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

Drugs s\s of intoxication Withdrawal s\s

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

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

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

46
 - Antidotes of common drugs: Don’t forget ABC and hydration &
observation
1) Opioids, Heroin : naloxone hydrochloride
2) Cocaine: IV diazepam to control seizures, aspirin for chest pain and cooling
3) Amphetamine: antipsychotics for acute psychosis , benzodiazepines for agitation, -blockers
for tachycardia & hypertension
4) Hallucinogens: benzodiazepines or high potency small dose of antipsychotics seldom
5) Alcohol “ with specific criteria”: Fomepizole
6) Benzodiazepine: Flumazenil

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

47
Important notes about smoking cessation medications:
If patient anxious = avoid Bupropion.
If patient with Seizure, eating disorders and alcohol dependence = Avoid Bupropion.
Varenicline = FDA approved agent for smoking cessation. “safe in cardiac patient”, reduce rates
by 50%.
Although nicotine replacement therapy is the nicotine agent that double the cessation rate.
Nicotine replacement therapies increase the risk of birth defects and should not be used during
pregnancy. counselling is recommended as first line treatment ◆ nicotine replacement
therapy (NRT) should be made available to pregnant women who are unable to quit using non-
pharmacologic methods ◆ intermittent NRT use (lozenges, gum) is preferred over continuous
dosing of the patch ◆ no strong evidence that either major positive or negative outcomes were
associated with gestational use of bupropion or varenicline; consider using only if benefits
outweigh risk.
Buspirone not approved by FDA regardless the articles mentioned it decrease withdrawal
symptoms of nicotine anxiety for short period.

48
49
 Questions about Smoking & Addiction:

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

2) Pt is heavy smoker came for checkup, he has no intention for quitting at all, how to
manage?
A- Let him attend smoking cessation classes
B- Nicotine replacement therapy
C- Set a quit deadline
D- Personalized advice
Answer is D; Pre-contemplation stage, give advices about benefits of smoking cessation and
increase awareness

3) Female smoker wants to quit, what to give for smoke cessation;

A- nicotine patch
B- vareniclin
C- bupropion
Answer B
4) smoking cessation for pt with chest pain on exertion and relieved by rest on examination
he’s anxious with nicotine staining on fingers
A- buspirone
B- varenicline
C- nicotine replacement therapy
Answer: B

5) Smoker with anxiety wants to stop smoking intial mx :

A- bupropion
B- varencillen
C- nicotine replacement
D- motivational support
Answer: D then B (asking about initial)

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

50
7) Wants to quit smoking best initial intervention?
A- Nicotine replacement
B- motivation
C- bupropin
D- Varenicline ( Chantix)
Answer: B

8) pregnant smoker useful tool for smoking?

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

9) Pt has long history of cardiovascular disease with chest pain, on examination:

peripheral cyanosis, JVP around 8 cm above normal, nicotine stain on his fingers,
what is the next step:
A- Motivational therapy
B- Bupropion
C- Varenciline
D- Nicotine replacement therapy
Answer is: A; as the question about initial step

10) 53 years old male patient heavy smoker presented with sob cyanosis and distended jvp
the patient is heavy smoker for many years wants to quit now?
Answer:
Best: Vareniciline
Next step: Behavioral therapy

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

12) Drug abuser agitated and has palpitation for a couple of days, what is the cause of his
symptoms:
A- Cocaine withdrawal
B- Amphetamine toxicity
Answer is A;
Cocaine withdrawal: initial “crash” (1-48 h): increased sleep, increased appetite,
dysphoria • withdrawal (1-10 wk): dysphoric mood plus fatigue, irritability, vivid
unpleasant dreams, insomnia or hypersomnia, psychomotor agitation or retardation
Amphetamine toxicity: intoxication characterized by euphoria, improved
concentration, sympathetic and behavioral hyperactivity, can mimic psychosis.

51
13) 16yo boy came to ER with hx of euphoria, agitation and visual hallucination, what did he
take?
A- Cannabis
B- Amphetamine
C- Opioids
Answer is B

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

15) Nicotine Effects?

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

52
 According to Maudsly:
In those people wishing to make an attempt to give up there are three first line stop smoking
medications that are recommended by NICE: nicotine replacement therapy (NRT), varenicline
and bupropion, all of which at least double the chance of success- fully stopping. Quit rates can be
increased further if the smoker is also provided with behavioural support from a trained tobacco
dependence treatment advisor.
Combination NRT more effective than using a single NRT product and has a similar efficacy to
varenicline, and a greater efficacy than bupropion

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

53
Child & Adolescents
Psychiatry
Will explain based on the question as nothing specific in it

54
 Questions about Child psychiatry:
1) A 3-year-old male came with his mother complaining because he yelling, hitting and Say
“no”, your Dx.?
A- mental retardant
B- depression
C- temper tantrum
D- oppositional defiant disorder
Answer: C, if its repetitive with other features fit the criteria then D

2) A mother brought her 4 years old child because he frequently wakes up in the middle of the
night setting on the bed, eyes opened but unresponsive for 2-3 min then he goes back to sleep,
in the morning he doesn’t remember what happened?
A- night terror
B- night walking
C- nightmares
D- epilepsy
Answer: A, not B because he is not walking and no behavior, not C because he doesn t
remember or scared, and of course not D

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3) 12 y old female, acne, menorrhea, and 29 BMI, Agitated, not cooperative in examination You
have considered:
A- Mood
B- Behavior
C- Substance use
D- Anxiety
Answer is B, remember it s an age of puberty with multiple hormonal & body changes,
personality maturity, many factors can lead to behavioral issues. Mood swings associated with
hormonal changes but in certain patterns.

4) ADHD boy what is the management:

A- Paroxetine
B- Bupropion
C- Dextromephatamine
Answer is C.

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

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

Few notes about ADHD:

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

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7) baby with repetitive eye blinking (incomplete
question)
A- Tics
B- Tourette syndrome
C- ADHD
Answer: A
8) A mother presented to you with her 2 years’
child who was yelling and throwing himself on
the floor, how would you deal with her
A- Positive reinforcement counseling
B- Ignorance counseling
C- Strict and firm counseling
Answer: A: behavioral therapy and positive
reinforcement

9) 12y old obese patient came to the clinic crying

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

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

11) 7 yo child has recurrent abdominal pain and nausea, recently

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

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12) 13 years old male present with his parents complaining that he loves to set things on
fire, the noticed this behavior started 6 months ago, they also noticed that he extends his
arm in 45 degrees from time to time. On P/E looks well and quiet, no finding aside from
short mustache, what is the most likely diagnosis?
A- Pyromania
B- Schizophrenia
C- Borderline personality disorder
D- Mimic syndrome
Answer is A

13) Child started to develop sense of individuality,

awareness for strangers and separation anxiety,
how old is the child in months?
A- 6 months
B- 7 months
C- 10 months
D- 12 months
E- 24 months
Closet answer is C; 10 months
Child Develops stranger anxiety by (6–9 months) and separation anxiety starts by 8-9
months, peaks at 12-24 months, lasts till 3 years old.

59
Geriatric Psychiatry

60
Review about the common problems in geriatrics (focusing on the repeated topics in the questions)

61
62
Vascular dementia:

63
 Important notes about dementia, and if it’s associated with other neurological disease:
1) Dementia is a hallmark of Alzheimer s. Alzheimer s affects language and memory, while Parkinson s
affects problem solving (executive function), speed of thinking, memory and other cognitive
functions, as well as mood.
2) None of the following risk factors directly cause dementia, but the more of these factors that are
present, the higher the likelihood of developing dementia: Increasing age, Longer duration of disease
(advanced stage), Older age at onset of Parkinson s, Family history of dementia, more severe motor
symptoms, being male, Having visual hallucinations.
3) Symptoms of dementia: Difficulty concentrating, Memory problems, Difficulty learning new
material, Difficulty problem solving, Disorientation/confusion, Mood changes (for example,
irritability, impatience, aggression), Hallucinations (hearing/seeing things others do not), Paranoia
(feeling suspicious or distrustful of others), Delusions (false, unrealistic or strange beliefs.

4) Mini-Mental State Examination (MMSE) is not diagnostic of dementia and does not distinguish well
between various confusion states, it is useful for assessing cognitive function and documenting
subsequent decline.
5) 10 Warning signs:
Sign 1: Memory loss that affects day-to-day abilities: Are you, or the person you know, forgetting
things often or struggling to retain new information?

It's normal to occasionally forget appointments, colleagues names or a friend s phone number
only to remember them a short while later. However, a person living with dementia may forget
things more often or may have difficulty recalling information that has recently been learned.
Sign 2: Difficulty performing familiar tasks: Are you, or the person you know, forgetting how to do a
typical routine or task, such as preparing a meal or getting dressed?

Busy people can be so distracted from time to time that they may forget to serve part of a meal,
only to remember about it later. However, a person living with dementia may have trouble
completing tasks that have been familiar to them all their lives, such as preparing a meal or
playing a game.
Sign 3: Problems with language: Are you, or the person you know, forgetting words or substituting
words that don t fit into a conversation?

Anyone can have trouble finding the right word to express what they want to say. However, a
person living with dementia may forget simple words or may substitute words such that what they
are saying is difficult to understand.
Sign 4: Disorientation in time and space: Are you, or the person you know, having problems knowing
what day of the week it is or getting lost in a familiar place?

64
 It's common to forget the day of the week or one's destination – for a moment. But people living
with dementia can become lost on their own street, not knowing how they got there or how to get
home.
Sign 5: Impaired judgement: Are you, or the person you know, not recognizing something that can put
health and safety at risk?

From time to time, people may make questionable decisions such as putting off seeing a doctor
when they are not feeling well. However, a person living with dementia may experience changes
in judgment or decision-making, such as not recognizing a medical problem that needs attention
or wearing heavy clothing on a hot day.
Sign 6: Problems with abstract thinking: Are you, or the person you know, having problems
understanding what numbers and symbols mean?

From time to time, people may have difficulty with tasks that require abstract thinking, such as
using a calculator or balancing a chequebook. However, someone living with dementia may have
significant difficulties with such tasks because of a loss of understanding what numbers are and
how they are used.
Sign 7: Misplacing things: Are you, or the person you know, putting things in places where they
shouldn't be?

Anyone can temporarily misplace a wallet or keys. However, a person living with dementia may
put things in inappropriate places. For example, an iron in the freezer, or a wristwatch in the sugar
bowl.
Sign 8: Changes in mood and behavior: Are you, or the person you know, exhibiting severe changes in
mood?

Anyone can feel sad or moody from time to time. However, someone living with dementia can
show varied mood swings – from calmness to tears to anger – for no apparent reason.
Sign 9: Changes in personality: Are you, or the person you know, behaving in a way that's out of
character?

Personalities can change in subtle ways over time. However, a person living with dementia may
experience more striking personality changes and can become confused, suspicious or withdrawn.
Changes may also include lack of interest or fearfulness.
Sign 10: Loss of initiative: Are you, or the person you know, losing interest in friends, family and
favorite activities?

It's normal to tire of housework, business activities or social obligations, but most people regain
their initiative. However, a person living with dementia may become passive and disinterested,
and require cues and prompting to become involved.
https://alzheimer.ca/en/about-dementia/do-i-have-dementia/10-warning-signs-dementia

Parkinson s dementia is diagnosed if the onset of dementia occurs a year or more after the onset of
motor symptoms. If symptoms of dementia appear before or at the same time as symptoms of
Parkinson s, it is called dementia with Lewy bodies.
Memory and thinking problems in Parkinson’s are caused by changes in the structure and
chemistry of the brain. Dementia describes a set of symptoms that are caused by a significant loss in
brain function.
Pathophysiology of PD psychosis: an interaction between extrinsic, drug-related and intrinsic, disease-
related components. The most important extrinsic factor is use of dopaminergic medication, which
65
plays a prominent role in PD psychosis. Intrinsic factors include visual processing deficits (e.g.
lower visual acuity, colour and contrast recognition deficits, ocular pathology and functional brain
abnormalities identified amongst hallucinating PD patients); sleep dysregulation (e.g. sleep
fragmentation and altered dream phenomena); neurochemical (dopamine, serotonin, acetylcholine,
etc.) and structural abnormalities involving site-specific Lewy body deposition; and genetics (e.g.
apolipoprotein E epsilon4 allele and tau H1H1 genotype).
Several atypical antipsychotic agents (i.e. clozapine, olanzapine) have been shown to be efficacious in
reducing psychotic symptoms in PD; however, use of clozapine requires cumbersome monitoring and
olanzapine leads to motor worsening. Studies of other antipsychotics are limited.

66
 Question in geriatric psychiatry:

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

3) Elderly 6 months was dx with parkinsonism, early dementia, (forget the third one)
A- Parkinson dementia
B- Lewy body dementia
C- Alzheimer disease
Answer B: Parkinson s dementia is diagnosed if the onset of dementia occurs a year
or more after the onset of motor symptoms. If symptoms of dementia appear before
or at the same time as symptoms of Parkinson s, it is called dementia with Lewy
bodies.

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

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

67
 6) pt diagnosed with Parkinson and hallucination which of the following is associated
with high risk of dementia:
A. Irritability
B. Difficulty finding word
C. forgetting future appointment
Answer is B. as explained due to structural changes. A & C are found in mild phase of
Parkinson disease.

7) Which of these symptoms suggest severity of dementia?

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

8) Elderly, recently transferred to a nursing home for 3 months, lost interest activity,
cries every day, decrease appetite, along with short memory impairment, what is the
diagnosis?
A- Depression
B- Alzheimer disease
C- Vascular dementia
Answer: A; clear question, the short memory loss need more details but excepted to
be mild cognitive issue, polypharmacy, stress related, or any other cause not related to
other choices in the question.

d 9) Old age with HTN, DM, presented with progressive loss of memory, CT scan showed
hyper intensity, dx?
A- Alzheimer disease
B- Vascular dementia
Answer B; clear history not gradual onset of memory loss, underline medical issues.

10) Elderly with 2 years history of progressive memory loss, he can do his daily activities and
wear his clothes independently, he used to be kind and a caring person, last 3 months his
personality changes and he became aggressive, dx?
A- Vascular dementia
B- Major depression
C- Mixed dementia
D- Alzheimer
Answer: A and preferred if it s frontotemporal lobe due to behavioral changes which is commonly related to
that brain region. Patient is still able to function and be dependent on his daily activity, the main concern
currently is his behavior, so I exclude other choices. In dementia, changes in personality and behavioral
disturbances tend to develop early or late. Psychosis, hallucinations, delusions, and paranoia can occur in
approximately 10% of patients with dementia; these symptoms may occur only temporarily in a higher
percentage of patients.3 Behaviors such as agitation, paranoia, and physical aggression often replace clear verbal
communication in people with Alzheimer s disease, Lewy body dementia, or frontotemporal dementia.
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 11) Patient known case of Alzheimer's came with severe agitation. What is the treatment
A- Olanzapine
B- Haloperidol
C- Buspurone
D- Thioridazine
Answer is A, although better to use quetiapine or clozapine. In addition to that; olanzapine and
haloperidol can treat agitation but we start with atypical antipsychotics (Olanzapine, risperidone,
quetiapine) because of less side effects, if not improving then we choose typical antipsychotics
(haloperidol).
12) Elderly patient with Alzheimer’s disease fall down from the stairs thankfully nothing
happened to him what will you do to prevent this from happening again:
A- light to the stairs
B- increase the dose of antipsychotic
C- increase the calcium
D- I don t remember
Answer A

13) 67 male lives in nursing home since two months he started to lose weight, sad and cry
almost all the time, forget simple daily things especially at the beginning of morning what’s
the diagnosis?
A- Depression
B- Hypothyroidism
C- Multi-infract dementia
D- Alzheimer s disease
Answer is A.

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

15) 71yo male came to clinic with 2 years’ history of slow progressive memory loss. Patient is
able to perform activity of daily living such as dressing himself. He was kind but previous 3
months he was agitated and aggressive. What is the likely diagnosis for this presentation?
A- Lewy Body dementia
B- Alzheimer s disease
C- Multi-infarcts dementia
Answer is: C, because of his behavioral changes + intact daily activity
performance.

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16) Pt is known case of Alzheimer came to ER with severe agitation the doctor gives him
a big dose of Haloperidol and he develops side effects I don t remember what r they
exactly, what u should give him now? They mean what is the antidote of haloperidol?
A- Naloxone
B- bromocriptine
C- Glycogen
Answer B

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

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

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

70
Personality Disorders

71
Review about personality disorders:
Personality disorders are common and chronic. They occur in 10 to 20 percent of the
general population, and their duration is expressed in decades.
Approximately 50 percent of all psychiatric patients have a personality disorder, which is
frequently comorbid with other clinical syndromes.
Personality disorder is also a predisposing factor for other psychiatric disorders (e.g.,
substance use, suicide, affective disorders, impulse-control disorders, eating disorders, and
anxiety disorders) in which it interferes with treatment outcomes of many clinical
syndromes and increases personal incapacitation, morbidity, and mortality of these patients.
Persons with personality disorders are far more likely to refuse psychiatric help and to
deny their problems than persons with anxiety disorders, depressive disorders, or obsessive-
compulsive disorder.
personality disorder symptoms are ego syntonic (i.e., acceptable to the ego, as opposed to
ego dystonic) and alloplastic (i.e., adapt by trying to alter the external environment rather
than themselves)
Classifications: “ EI D, ILD, & O IED

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

72
 Questions about personality disorders “Reference: Kaplan& Maudsley”:
1) Pt did superficial scratches in her right hand because her physician abandoned her, she
also has labiality of mood. What type of personality disorder?
Other recall: female with self-inflicted injuries on the wrist because she thought her
therapist abandoned her. He claims she her voices but when asked her she denied. She
caused problem between resident and psychiatrist and head nurse over her condition.
What type of personality?
A- Borderline personality
B- Schizoid personality
C- Obsessive
Answer A: Borderline personality

2) Young adult, drug addict came to the hospital acting like he was sick and when the
doctor looked away he was acting fine, what is this?
A- Malingering
B- Somatization
Answer is A

73
‫ر م م الد اء الت ر ال اح‬ ‫د ات ا ل م الت‬
‫تم تحد ث المذ رة ل د ر إذا دت أ لة‬
‫ات م تل ة‪.‬‬ ‫م‬
‫طا )‬ ‫ا‬ ‫فس‬ ‫إ أسأت أ أ طأت ف‬ ‫(إ أحس ت ف‬

‫رسا ا س ة ا د دة‪:‬‬
‫‪Email: [email protected]‬‬
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