Psychiatry EOR practice questions

Why Trauma-focused cognitive behavioral therapy is correct

• This patient meets criteria for acute stress disorder: characteristic intrusion, negative mood, dissociative, avoidance, and arousal symptoms occurring 3 days to 1 month after exposure to a traumatic event
• First-line management is trauma-focused cognitive behavioral therapy, which reduces symptom severity and lowers the risk of progression to PTSD

Why the others are wrong

• D) Long-term alprazolam — benzodiazepines such as alprazolam are not first-line and have been associated with worse PTSD outcomes, dependence, and impaired fear extinction
• B) Risperidone — antipsychotics such as risperidone are not first-line treatment for acute stress disorder in a patient without psychosis or refractory severe symptoms
• A) Electroconvulsive therapy — electroconvulsive therapy is reserved for severe treatment-resistant depression, catatonia, or psychosis and has no role in initial management of acute stress disorder

Why C) Fibromyalgia is correct

• Fibromyalgia presents with widespread musculoskeletal pain, fatigue, unrefreshing sleep, and cognitive symptoms ("fibro fog") for at least 3 months with no underlying disease.
• 2016 diagnostic criteria: widespread pain index (WPI) at least 7 + symptom severity scale (SSS) at least 5, or WPI 4–6 + SSS at least 9.

Why the others are wrong

• B) Rheumatoid arthritis — presents with symmetric joint swelling and elevated inflammatory markers; labs here are normal.
• D) Hypothyroidism — does not cause widespread pain; labs are normal in this patient.
• A) Chronic fatigue syndrome — defined by post-exertional malaise as the hallmark feature; the predominant symptom cluster here fits fibromyalgia.

Additional high-yield points

• Treatment: aerobic exercise has the most evidence.
• Cognitive behavioral therapy (CBT) is also first-line.
• FDA-approved pharmacotherapy: duloxetine (serotonin-norepinephrine reuptake inhibitor, SNRI), pregabalin, and milnacipran.
• Avoid opioids and NSAIDs (limited benefit, high harm).
• Sleep hygiene is an important component of management.

Why Postictal state is correct

• Postictal state is a period of confusion, drowsiness, and disorientation that follows a generalized tonic-clonic seizure
• The patient's epilepsy medical alert bracelet is a critical clue to the underlying diagnosis
• Mechanism: neuronal exhaustion, surges in inhibitory neurotransmitters (gamma-aminobutyric acid (GABA)), and transient metabolic dysfunction following excessive neuronal firing
• Duration is typically 5–30 minutes but may last hours in patients with structural epilepsy, prolonged seizures, or cumulative seizure burden
• Features include confusion, amnesia for the event, gradual recovery toward baseline, possible focal weakness (Todd paralysis) if the seizure was focal, and incontinence

Why the others are wrong

• D) Acute alcohol intoxication — less likely given normal glucose and the epilepsy medical alert bracelet pointing to a known seizure disorder
• C) First episode psychosis — typically includes hallucinations or delusions and does not explain the spontaneous gradual recovery toward baseline
• B) Malingering — does not explain the spontaneous gradual recovery observed over 45 minutes

Additional high-yield points

• Management: maintain airway, supportive care, check glucose, allow recovery, and evaluate for seizure trigger (missed medications, alcohol, metabolic disturbance, fever, head trauma)
• Electroencephalogram (EEG) in the postictal state may show diffuse slowing

Why Dental caries is correct

• Caries develops when cariogenic bacteria (Streptococcus mutans, Lactobacillus) ferment dietary sugars into acids that demineralize enamel
• Frequent juice exposure and poor oral hygiene are classic risk factors
• The characteristic progression is chalky white demineralized spot lesion → brown discoloration → cavitation detectable on visual and tactile probing

Why the others are wrong

• Dental fluorosis — presents with symmetric, diffuse white striations or mottling from excess fluoride during enamel development, not focal cavitation
• Enamel hypoplasia — a developmental defect producing pits or grooves in enamel, typically symmetric and present from eruption, without active demineralization
• Pulpitis — would cause spontaneous or thermal pain and is a complication of untreated caries reaching the pulp, not the initial clinical finding here

Additional high-yield points

• Definitive diagnosis is made by clinical inspection with probing; bitewing radiographs assess depth
• Management: referral to dentistry for restoration and caries-prevention counseling

Why Sertraline 50 mg daily is correct

• For moderate-to-severe major depressive disorder (MDD) (PHQ-9 10–19), combination of a selective serotonin reuptake inhibitor (SSRI) plus psychotherapy (cognitive behavioral therapy, CBT) is more effective than either alone
• Sertraline is a well-studied first-line SSRI

Why the others are wrong

• D) Bupropion 150 mg daily — an alternative antidepressant but not appropriate in patients with eating disorders, seizures, or history of purging
• C) Alprazolam 0.5 mg twice daily — benzodiazepines treat anxiety symptoms but not the underlying depressive disorder, and carry risk of dependence
• B) Lithium carbonate 900 mg daily — used for bipolar disorder or augmentation of antidepressants, not first-line monotherapy for MDD

Why Acute mania (bipolar I disorder) is correct

• Acute mania: elevated or irritable mood plus 3 or more DIGFAST criteria (Distractibility, Impulsivity, Grandiosity, Flight of ideas, Activity increase, Sleep decrease, Talkativeness), lasting at least 7 days or any duration if hospitalization is required
• Bipolar I disorder requires at least one manic episode
• Toxicology screen is negative, ruling out stimulant intoxication
• Management: hospitalize if dangerous to self/others or unable to care for self
• First-line medications include lithium, valproate, or atypical antipsychotics (quetiapine, olanzapine, risperidone)
• Antidepressants alone can trigger mixed episodes or cycling

Why the others are wrong

• B) Stimulant intoxication — ruled out by negative toxicology screen
• D) Schizophrenia — requires at least 1 month of psychosis without prominent mood symptoms
• C) Major depressive disorder with psychotic features — has prominent depressed mood, not elevated/irritable mood with the DIGFAST constellation