SPEX Psychiatry 4 — Questions and Answers
Question 1: A 16-year-old girl has not eaten adequate calories for 8 months, fears weight gain, and has a BMI of 15.5. She denies body image distortion. Which DSM-5 diagnosis applies?
- Bulimia nervosa
- Avoidant/restrictive food intake disorder
- Anorexia nervosa, restricting type (Correct answer)
- Binge-eating disorder
Correct answer: Anorexia nervosa, restricting type
DSM-5 anorexia nervosa no longer requires insight into body image distortion; food restriction, low weight, and intense fear of gaining weight are sufficient.
Question 2: A psychiatrist evaluates a patient who tells her that a neighbor is 'controlling his mind through the walls.' The neighbor is real, but the belief is fixed and false. This is best described as:
- An overvalued idea
- A delusion of reference
- A delusion of control (thought insertion/passivity) (Correct answer)
- An auditory hallucination
Correct answer: A delusion of control (thought insertion/passivity)
A fixed false belief that an external agent is controlling one's thoughts or actions is a delusion of control, also called a passivity experience.
Question 3: Which of the following is the MOST important predictor of completed suicide in a clinical risk assessment?
- History of a prior suicide attempt (Correct answer)
- Current passive suicidal ideation
- Family history of depression
- Recent loss of employment
Correct answer: History of a prior suicide attempt
A prior suicide attempt is the single strongest predictor of future completed suicide, conferring an approximately 40-fold increased risk.
Question 4: A 55-year-old woman with no prior psychiatric history presents with new onset auditory hallucinations and paranoid delusions. Physical exam shows cogwheel rigidity and a resting tremor. MRI shows cortical and subcortical atrophy. What is the most likely etiology?
- Schizophrenia, late onset
- Dementia with Lewy bodies (Correct answer)
- Parkinson disease dementia
- Frontotemporal dementia
Correct answer: Dementia with Lewy bodies
Dementia with Lewy bodies classically presents with fluctuating cognition, recurrent visual hallucinations, and spontaneous parkinsonism, and can present with prominent psychiatric symptoms.
Question 5: A patient taking phenelzine (an MAOI) eats aged cheese and develops a severe occipital headache, hypertension (BP 210/120), and diaphoresis. What is the mechanism?
- Serotonin syndrome from dietary tryptophan
- Tyramine-induced hypertensive crisis (Correct answer)
- Anticholinergic toxidrome
- Norepinephrine reuptake blockade
Correct answer: Tyramine-induced hypertensive crisis
MAOIs block intestinal MAO-A, allowing dietary tyramine to enter systemic circulation and trigger massive norepinephrine release from sympathetic terminals.
Question 6: Which of the following is consistent with bulimia nervosa but NOT with anorexia nervosa, binge-purge type?
- Compensatory purging behavior
- Binge eating episodes
- Body weight within or above normal range (Correct answer)
- Distorted body image
Correct answer: Body weight within or above normal range
By definition, bulimia nervosa requires that binge-purge behavior occur in the context of a body weight NOT significantly low; anorexia nervosa binge-purge subtype occurs at low weight.
Question 7: A 30-year-old man has been involuntarily committed for acute psychosis. He regains capacity after 48 hours of antipsychotic treatment and refuses further medication. What is the appropriate next step?
- Continue involuntary medication as he was committed
- Obtain a court order for forced medication if he remains dangerous (Correct answer)
- Immediately discharge him per his autonomous request
- Administer medication covertly in food
Correct answer: Obtain a court order for forced medication if he remains dangerous
Involuntary commitment authorizes detention for safety evaluation but does not automatically authorize forced medication; a separate court order is required to treat a refusing, capacitated patient.
SPEX Psychiatry 4
A 16-year-old girl has not eaten adequate calories for 8 months, fears weight gain, and has a BMI of 15.5.
She denies body image distortion.
Which DSM-5 diagnosis applies?