USMLE USMLE Certifications USMLE-STEP-2 Questions & Answers

• Question 231:

  A middle-aged man with depression requests help for his symptoms of low self-esteem and feelings that "life is bad no matter what you do." He prefers to use no medication and expresses the desire to not be in therapy "for years." There is no previous psychiatric treatment. Which of the following therapies would be the most helpful?

  A. psychoanalysis

  B. behavioral therapy

  C. cognitive psychotherapy

  D. supportive psychotherapy

  E. group psychotherapy

  Correct Answer: C

  Cognitive psychotherapy would be helpful to this man to see and understand how cognitive distortions about himself, others, and the future bring about his depressive feelings. Psychoanalysis, a process lasting several years with a weekly commitment of three to four sessions, would require this person to be willing to explore and work through issues and conflicts that have their source in childhood. Behavioral therapy has as its goal the disruption of inappropriate behaviors with the substitute of more appropriate behaviors. It is intended for the treatment of phobias and various psychosomatic disorders (e.g., migraine, hypertension). Supportive psychotherapy could also be of some value. This is used frequently in conjunction with medication. Group therapy may be of some value after this patient has had the opportunity to work in a one-to-one situation in which understandings about himself have developed. Proper preparation is essential before entering group therapy.

• Question 232:

  Which of the following is considered a negative symptom of schizophrenia?

  A. anhedonia

  B. loose associations

  C. delusions of thought insertion

  D. incoherence

  E. stereotypic gestures

  Correct Answer: A

  Negative symptoms of schizophrenia reflect the absence or deficiency of a mental function that is normally present. Anhedonia, or the inability to experience pleasure, is an example of such. Positive symptoms of schizophrenia reflect aberrance or distortion of mental functions. Loose associations, delusions of thought, insertion, incoherence, and stereotypic gestures are all examples of these distortions.

• Question 233:

  A 40-year-old woman with no previous psychiatric history seeks help from her internist for a sleep problem. Initially, she is able to fall asleep but then sleeps fitfully, and finally around 4:00 a.m. decides to stay up. She averages approximately 34 hours of sleep per night, and this has been occurring for the last 3 weeks. She finds herself quite tired and "blue" during the day but is unable to nap. Mornings are "the worst" for her, but she feels better toward the end of the day. There has been a 15-lb weight loss because "I'm just not hungry." She denies any physical problems except for constipation. As a gradeschool teacher, she feels extremely stressed but sees no way out and no way to improve the situation. At times, suicide seems like a possible option, and she admits to spending long hours brooding on how to do it. A physical examination is unremarkable Which of the following is the most appropriate treatment choice?

  A. olanzapine

  B. paroxetine

  C. alprazolam

  D. tranylcypromine

  E. ECT

  Correct Answer: B

  For a first, relatively acute episode of major depression, a tricyclic or SSRI is usually considered a first-choice drug. The SSRIs, considered as effective as the tricyclics, are often favored by clinicians because of their greater safety profiles. Olanzapine is an example of an antipsychotic drug. Alprazolam is a benzodiazepine that does have some anxiolytic value in depression. Its addictive potential does not make it a drug of choice for depression. Tranylcypromine is an effective MAO inhibitor antidepressant selected for use after a depression has failed to respond to the tricyclics and SSRIs. ECT is also used after other treatments have failed. In very severe, debilitating depressions, however, a clinician may choose ECT as a first treatment.

• Question 234:

  A 40-year-old woman with no previous psychiatric history seeks help from her internist for a sleep problem.

  Initially, she is able to fall asleep but then sleeps fitfully, and finally around 4:00 a.m. decides to stay up.

  She averages approximately 34 hours of sleep per night, and this has been occurring for the last 3 weeks.

  She finds herself quite tired and "blue" during the day but is unable to nap. Mornings are "the worst" for

  her, but she feels better toward the end of the day. There has been a 15-lb weight loss because "I'm just

  not hungry." She denies any physical problems except for constipation. As a gradeschool teacher, she

  feels extremely stressed but sees no way out and no way to improve the situation. At times, suicide seems

  like a possible option, and she admits to spending long hours brooding on how to do it. A physical

  examination is unremarkable.

  Which of the following is the most likely diagnosis?

  A. borderline personality disorder

  B. major depression

  C. dysthymia

  D. Alzheimer's disease

  E. generalized anxiety disorder

  Correct Answer: B

  This woman's symptoms meet the criteria for a major depressive episode. She has had a depressed (blue) mood for at least a 2-week period, a significant weight loss, insomnia, fatigue and loss of energy, and thoughts of suicide. Because her symptoms seem to be limited to 3 weeks, dysthymic disorder would most likely not be considered. There are no indications for an organic mental disorder that would suggest Alzheimer's disease. Generalized anxiety disorder is characterized by excessive anxiety and worry for about 6 months. For a diagnosis of borderline personality disorder, patterns of instability in relationships, selfimage, affect, and impulsivity would have been present in early adulthood. None of that is described here.

• Question 235:

  A 40-year-old man has been unsuccessfully treated for depression with two different medications for the past 3 months. He has a number of medical problems, and he recently was hospitalized after threatening suicide. His psychiatrist is considering the use of ECT for the patient.

  The patient has consented to ECT, and the pre ECT workup has been completed. Which of the following medications could routinely be continued through a course of ECT?

  A. lithium

  B. divalproex

  C. bupropion

  D. clonazepam

  E. risperdal

  Correct Answer: E

  Risperdal and high potency neuroleptics slightly decrease the seizure threshold and would enhance the seizure and can typically be continued through a course of ECT. Lithium can result in increased postictal delirium, divalproex and clonazepam would typically be withdrawn due to their anticonvulsant effect. If a benzodiazepine is required a short-acting medication should be used. Bupropion has been associated with late appearing seizures.

• Question 236:

  A 78-year-old woman is seen by a psychiatrist for depression. She is fairly cooperative in responding to questions. She admits to feeling blue; she "catnaps" throughout the day and is up at night; and her appetite is very poor. She thinks of death frequently but denies feeling suicidal. There is no past psychiatric history. On the MMSE, she obtains a score of 14. Her depressive symptoms have been present for "several days." Which of the following is highly suggested by the findings?

  A. impaired cognitive functioning

  B. psychosis not otherwise specified

  C. bipolar disorder--manic

  D. dysthymia E. changes secondary to normal aging

  Correct Answer: A

  One of the most significant findings here is that the woman, cooperative with the examination, has the score of 14 on the MMSE. Ascore of 2530 indicates no cognitive impairment, 2025 suggests possible mild impairment, and less than 20 is very strongly suggestive of cognitive impairment. This degree of change on the MMSE is not a normal sign of aging. In addition, there are no signs of psychosis or mania. Even if there were, in this woman with no previous sychiatric history, one would not likely consider psychosis not otherwise specified or mania. The time frame for dysthymia is not met by the "several days" length described here.

• Question 237:

  A 40-year-old man has been unsuccessfully treated for depression with two different medications for the past 3 months. He has a number of medical problems, and he recently was hospitalized after threatening suicide. His psychiatrist is considering the use of ECT for the patient. Which of the following is a relative contraindication to ECT?

  A. hypertension

  B. history of seizures

  C. clinically significant space-occupying cerebral lesion

  D. degenerative joint disease of the spine

  E. suicidality

  Correct Answer: C

  ECT can be a life-saving tool in the treatment of depression, particularly in individuals who are very suicidal, because of its relatively quick onset of action. It is a relative contraindication to give patients with a clinically significant space-occupying cerebral lesion ECT because of the risk of brain stem herniation. ECT can be performed on patients with space-occupying lesions rarely, but the benefit needs to outweigh the risk, and it should be performed by experts. However, although hypertension and cardiovascular disease put patients at a higher risk for complications from ECT, they are not absolute contraindications to its use. With the use of muscle relaxants as part of the electroconvulsive technique, patients with degenerative joint disease of the spine can generally safely receive ECT. Seizures actually would typically decrease in frequency with the application of ECT.

• Question 238:

  A25-year-old man presents in the emergency department for a 2-week problem of worsening urinary hesitancy. He has had problems getting his urine stream started and has noted a decrease in the force of the stream. Now it seems to just "dribble out." He denies any pain or burning, any medical problems, and any exposure to sexually transmitted diseases. For approximately 1 month, he has been taking thioridazine, 200 mg bid, and benztropine, 2 mg qid, and "sometimes one or two benztropine" prn.Given the above information, which of the following is the most likely cause of this man's problem?

  Which of the following is a safer choice of medication for this man?

  A. amitriptyline

  B. risperidone

  C. chlorpromazine

  D. mesoridazine

  E. imipramine

  Correct Answer: B

  Given the temporal relationship in the start of two anticholinergic drugs and the onset of the urinary hesitancy in an otherwise healthy young male, it would be reasonable to conclude that he drugs are causing the problem. Certainly, a rapid assessment regarding the possibility of other causes (e.g., infection, trauma, stricture) is important. Careful, attentive listening for any hint of psychotic delusion involving urination is important to screen for. The manner in which the patient describes his symptoms is invaluable in facilitating diagnosis. Also remember that a real medical condition can be described in bizarre, distorted terms, making assessment more difficult and complicated. Drug-induced urinary hesitancy may be treated by discontinuing the causative medications. In addition, bethanechol, 1030 mg three to four times each day, may be administered. Bethanechol acts by stimulating the parasympathetic nervous system. The tone of the detrusor urinae muscle increases, producing a contraction strong enough to initiatemicturition and emptying of the bladder. Giving benztropine, an anticholinergic, would only heighten the problem. Unfortunately, some patients understand that benztropine is "for the side effect" of their antipsychotic medication but do not understand the difference between the extrapyramidal effect and the anticholinergic effects. Increased thioridazine would also increase the urinary problem. Calling in a urologist would be indicated if the initial treatment failed to work or if the emergency department physician were not able to "get beyond" an extremely distorted, disorganized presentation by the patient. If the bladder were extremely distended and the patient very uncomfortable, insertion of a urinary catheter would be a reasonable course of action. In the patient described, the bladder is not distended.

  Of the medications listed, risperidone is a reasonable and safe choice because its anticholinergic effects are low compared to the other drugs listed, and much lower than thioridazine. Chlorpromazine and mesoridazine have substantial anticholinergic effects. Amitriptyline and imipramine have substantial anticholinergic effects, and, in addition, they are tricyclic antidepressants, not antipsychotics.

• Question 239:

  A 30-year-old woman complains that she has had sleep disturbances since the start of her depression 2 months ago. Which of the following is an accurate description of typical sleep abnormalities in depression?

  A. Sleep latency (the period of time between going to bed and falling asleep) is shortened.

  B. REM latency (the period of time from the onset of sleep to the first REM period) is shortened.

  C. Wakefulness is decreased.

  D. The arousal threshold is increased.

  E. Stage 3 and stage 4 sleep are increased.

  Correct Answer: B

  One of the earliest findings in biological psychiatry was the abnormal sleep pattern of depressed patients. Electroencephalographic monitoring of sleep divides sleep into REM and non-REM sleep. Sleep latency is generally prolonged in depression, while REM latency is shortened. General wakefulness is increased, with a decreased arousal threshold. There tends to be a reduction in stage 3 and stage 4 sleep in depression.

• Question 240:

  A25-year-old man presents in the emergency department for a 2-week problem of worsening urinary hesitancy. He has had problems getting his urine stream started and has noted a decrease in the force of the stream. Now it seems to just "dribble out." He denies any pain or burning, any medical problems, and any exposure to sexually transmitted diseases. For approximately 1 month, he has been taking thioridazine, 200 mg bid, and benztropine, 2 mg qid, and "sometimes one or two benztropine" prn.Given the above information, which of the following is the most likely cause of this man's problem?

  A. anticholinergic side effects to the thioridazine and benztropine

  B. urethral stricture

  C. breakthrough of a psychotic delusion that he cannot urinate

  D. injury from a perverse sexual practice he is not admitting to

  E. infection of the urethra

  Correct Answer: A

  Given the temporal relationship in the start of two anticholinergic drugs and the onset of the urinary hesitancy in an otherwise healthy young male, it would be reasonable to conclude that he drugs are causing the problem. Certainly, a rapid assessment regarding the possibility of other causes (e.g., infection, trauma, stricture) is important. Careful, attentive listening for any hint of psychotic delusion involving urination is important to screen for. The manner in which the patient describes his symptoms is invaluable in facilitating diagnosis. Also remember that a real medical condition can be described in bizarre, distorted terms, making assessment more difficult and complicated. Drug-induced urinary hesitancy may be treated by discontinuing the causative medications. In addition, bethanechol, 1030 mg three to four times each day, may be administered. Bethanechol acts by stimulating the parasympathetic nervous system. The tone of the detrusor urinae muscle increases, producing a contraction strong enough to initiatemicturition and emptying of the bladder. Giving benztropine, an anticholinergic, would only heighten the problem. Unfortunately, some patients understand that benztropine is "for the side effect" of their antipsychotic medication but do not understand the difference between the extrapyramidal effect and the anticholinergic effects. Increased thioridazine would also increase the urinary problem. Calling in a urologist would be indicated if the initial treatment failed to work or if the emergency department physician were not able to "get beyond" an extremely distorted, disorganized presentation by the patient. If the bladder were extremely distended and the patient very uncomfortable, insertion of a urinary catheter would be a reasonable course of action. In the patient described, the bladder is not distended.

  Of the medications listed, risperidone is a reasonable and safe choice because its anticholinergic effects are low compared to the other drugs listed, and much lower than thioridazine. Chlorpromazine and mesoridazine have substantial anticholinergic effects. Amitriptyline and imipramine have substantial anticholinergic effects, and, in addition, they are tricyclic antidepressants, not antipsychotics.