QUESTION 31: A 28-year-old woman washes her hands 50+ times a day due to intrusive thoughts about germs. Her hands are raw and bleeding. She knows the thoughts are excessive but cannot stop.
What is the most likely diagnosis?
A) GAD
B) OCD
C) Specific phobia
D) Illness anxiety disorder
Answer: B) Obsessive-compulsive disorder (OCD)
Explanation:
OCD is defined by:
1. Obsessions: Recurrent, intrusive, unwanted thoughts (Contamination).
2. Compulsions: Repetitive behaviors (Hand washing) aimed at reducing anxiety.
3. Time-consuming: Taking >1 hour per day.
Key Differentiator: OCD thoughts are ego-dystonic (the patient knows they are irrational/unwanted), whereas OCPD thoughts are ego-syntonic (the patient thinks their way is the ‘correct’ way).
QUESTION 32: A combat veteran has nightmares, avoids war movies, feels emotionally numb, and has an exaggerated startle response. Symptoms began 3 months after deployment and have persisted.
Most likely diagnosis?
A) Acute stress disorder
B) PTSD
C) Adjustment disorder
D) GAD
Answer: B) Post-traumatic stress disorder (PTSD)
Explanation:
PTSD requires 4 symptom clusters (lasting >1 month):
1. Intrusion (Nightmares/Flashbacks).
2. Avoidance (Avoiding movies/reminders).
3. Negative Cognition/Mood (Numbing/Detachment).
4. Hyperarousal (Startle response/Hypervigilance).
Why not Acute Stress Disorder? ASD is only diagnosed if symptoms last between 3 days and 1 month. Since these followed a 3-month delay and are ongoing, it is PTSD.
QUESTION 33: What is the ‘Gold Standard’ psychotherapy for OCD?
Answer: Exposure and Response Prevention (ERP).
Explanation:
ERP involves:
1. Exposure: Gradually confronting the obsession (e.g., touching a doorknob).
2. Response Prevention: Not performing the compulsion (e.g., not washing hands).
This leads to habituation, where the brain learns the ‘threat’ is not real without the ritual.
QUESTION 34: Which medication class and specific dosing rule applies to the treatment of OCD?
Answer: SSRIs at HIGH doses for a LONGER duration.
Explanation:
- OCD requires higher doses than depression (e.g., Sertraline 200mg vs 50mg).
- OCD requires a longer trial (10-12 weeks) to see a full response compared to 4-6 weeks for depression.
- Clomipramine (TCA) is highly effective but second-line due to side effects.
QUESTION 35: A patient with PTSD suffers from frequent, vivid nightmares that interrupt sleep. Which medication is the most appropriate adjunct for this specific symptom?
Answer: Prazosin.
Explanation:
- Prazosin is an alpha-1 adrenergic antagonist.
- It crosses the blood-brain barrier and reduces the sympathetic ‘overdrive’ that causes traumatic nightmares.
- Safety: Monitor for first-dose hypotension (syncope).
QUESTION 36: What is the primary first-line psychotherapy for PTSD?
Answer: Trauma-focused CBT (TF-CBT) or Eye Movement Desensitization and Reprocessing (EMDR).
Explanation:
- TF-CBT includes Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT).
- These treatments help the patient process the traumatic memory so it no longer triggers a ‘fight or flight’ response.
QUESTION 37: Why are Benzodiazepines generally NOT recommended in the long-term treatment of PTSD?
Answer: They interfere with recovery and increase risk of dependence.
Explanation:
1. They prevent ‘emotional processing’ of the trauma (numbing the patient).
2. They do not treat the core clusters (Avoidance/Cognition).
3. High comorbidity of PTSD with substance use increases the risk of addiction.
