Q- A 30-year-old woman has had depressed mood, loss of interest, insomnia, poor concentration, and feelings of guilt for 2 months. She has no history of mania. What is the first-line medication?
A- A selective serotonin reuptake inhibitor (SSRI)
B- A monoamine oxidase inhibitor
C- Lithium
D- A benzodiazepine
A- An SSRI. This is major depressive disorder. SSRIs such as sertraline or escitalopram are first-line because they are effective and well tolerated. Psychotherapy (such as CBT) is also first-line, and the combination works best. MAOIs require dietary restriction because of the risk of hypertensive crisis.
Q- A 40-year-old man with bipolar disorder who takes lithium has excessive thirst and passes large volumes of dilute urine. What is the most likely cause?
A- Nephrogenic diabetes insipidus
B- SIADH
C- Central diabetes insipidus
D- Hyperthyroidism
A- Nephrogenic diabetes insipidus. Lithium makes the collecting ducts resistant to ADH. It is treated with amiloride. Other lithium adverse effects are hypothyroidism, tremor, and Ebstein anomaly when used in pregnancy. Lithium has a narrow therapeutic index, so levels must be monitored.
Q- A man with schizophrenia was started on haloperidol 3 days ago. He now has a fever of 40°C, “lead-pipe” muscle rigidity, confusion, unstable blood pressure, and a very high creatine kinase. Besides stopping haloperidol, which drug is used to treat this condition?
A- Dantrolene
B- Cyproheptadine
C- Physostigmine
D- Higher dose of haloperidol
A- Dantrolene. This is neuroleptic malignant syndrome. Stop the antipsychotic, give supportive care and cooling, and use dantrolene (a muscle relaxant) or bromocriptine (a dopamine agonist). Cyproheptadine treats serotonin syndrome, which causes hyperreflexia, clonus, and diarrhea rather than lead-pipe rigidity.
Q- A man is angry at his boss for criticizing him at work. When he comes home, he yells at his wife. Which defense mechanism is he using?
A- Displacement
B- Projection
C- Reaction formation
D- Sublimation
A- Displacement: redirecting feelings from their real target to a safer one. Projection is attributing one’s own unacceptable feelings to others, reaction formation is behaving the opposite of one’s true feelings, and sublimation is channeling impulses into socially acceptable activities (a mature defense).
Q- A 50-year-old man is admitted for a broken leg. Three days later, he is agitated and confused, sees insects on the walls, and has a fever, tachycardia, and tremor. What is the treatment of choice?
A- Benzodiazepines
B- Haloperidol alone
C- Naltrexone
D- Disulfiram
A- Benzodiazepines. This is delirium tremens from alcohol withdrawal, which usually begins 48 to 96 hours after the last drink and can be fatal. Long-acting benzodiazepines (chlordiazepoxide, diazepam) are used, or lorazepam in liver disease. Also give thiamine. Naltrexone and disulfiram are used later to maintain abstinence.
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