NSG527 / NSG 527 Final Exam: Psychopathology,
Theories, & Advanced Clinical Modalities, Questions
& Answers (Verified Answers) Update - Wilkes
University
1. A patient with a history of recurrent major depressive episodes and a family history of bipolar I
disorder presents with a depressive episode that has not responded to two adequate trials of SSRIs.
The patient reports a previous hypomanic episode lasting 3 days while on an SSRI. Which of the
following is the most appropriate next step in pharmacotherapy?
A. Augment the current SSRI with aripiprazole
B. Switch to a monoamine oxidase inhibitor (MAOI)
C. Initiate lamotrigine as monotherapy
D. Discontinue the SSRI and start lithium
Answer: C
Rationale: The patient likely has bipolar II disorder given the SSRI-induced hypomania and family
history. Lamotrigine is first-line for bipolar depression due to its efficacy and lower risk of mood
destabilization. Aripiprazole augmentation may increase manic switch risk. MAOIs are not first-line due
to dietary restrictions and risk. Lithium is more effective for mania prophylaxis than acute bipolar
depression.
2. A patient diagnosed with schizophrenia has been adherent to clozapine for 6 months with
significant improvement in positive symptoms but continues to experience negative symptoms and
cognitive deficits. Which of the following augmentation strategies is most supported by current
evidence?
A. Adding a second antipsychotic such as risperidone
B. Adding a selective serotonin reuptake inhibitor (SSRI)
C. Adding a cognitive remediation therapy program
D. Adding a mood stabilizer such as valproate
Answer: C
Rationale: Cognitive remediation therapy has moderate evidence for improving cognitive deficits and
negative symptoms in schizophrenia. Adding a second antipsychotic increases side effects without clear
benefit. SSRIs may help depressive symptoms but not negative symptoms or cognition. Valproate lacks
evidence for negative symptoms and may increase metabolic side effects.
Page 1
,3. A 30-year-old patient with borderline personality disorder (BPD) presents with recurrent
self-harm behaviors and emotional dysregulation. The patient has not responded to dialectical
behavior therapy (DBT) after one year. Which of the following therapeutic approaches is most
appropriate to consider next?
A. Transference-focused psychotherapy (TFP)
B. Mentalization-based treatment (MBT)
C. Cognitive behavioral therapy (CBT) for BPD
D. Schema-focused therapy
Answer: B
Rationale: MBT is specifically designed for BPD and focuses on improving mentalization capacity. It has
strong evidence for reducing self-harm and improving emotional regulation. TFP is also evidence-based
but more intensive and less studied in non-responders to DBT. CBT for BPD has limited evidence.
Schema therapy is effective but less supported after DBT failure.
4. A patient with generalized anxiety disorder (GAD) has been on sertraline 200 mg daily for 12
weeks with partial response. The patient continues to have excessive worry and muscle tension.
Which of the following medication strategies is most consistent with current evidence-based
guidelines?
A. Augment with buspirone 15 mg twice daily
B. Switch to venlafaxine XR 225 mg daily
C. Add pregabalin 150 mg twice daily
D. Add a short course of lorazepam 0.5 mg as needed
Answer: A
Rationale: Buspirone augmentation of SSRIs has evidence for GAD with partial response. Venlafaxine is
first-line but switching after only one adequate trial is not optimal. Pregabalin is effective but not
first-line augmentation. Benzodiazepines are not recommended for long-term use due to dependence risk
and limited efficacy for core worry.
5. A patient with posttraumatic stress disorder (PTSD) has been receiving prolonged exposure
therapy but experiences significant dissociation during sessions, leading to poor engagement.
Which modification to the treatment approach is most indicated?
A. Switch to cognitive processing therapy (CPT)
B. Add a grounding technique before exposure
C. Increase the intensity of exposure to overcome avoidance
D. Discontinue exposure and use supportive therapy
Answer: B
Rationale: Grounding techniques help manage dissociation during exposure, allowing the patient to
remain present and engaged. CPT may also be effective but does not directly address dissociation
during sessions. Increasing intensity may worsen dissociation. Supportive therapy lacks evidence for
PTSD.
Page 2
,6. A patient with obsessive-compulsive disorder (OCD) has severe contamination fears and
compulsive hand washing. The patient has not responded to two adequate trials of SSRIs. Which of
the following is the most appropriate next step?
A. Augment with a low-dose atypical antipsychotic
B. Initiate clomipramine
C. Add a D-cycloserine augmentation to exposure and response prevention (ERP)
D. Consider deep brain stimulation (DBS)
Answer: A
Rationale: Augmentation with an atypical antipsychotic (e.g., risperidone, aripiprazole) is
evidence-based for SSRI-resistant OCD. Clomipramine is effective but often poorly tolerated; it is
typically tried before augmentation. D-cycloserine has mixed evidence and is not first-line. DBS is
reserved for severe, treatment-refractory cases after multiple failed trials.
7. A patient with anorexia nervosa, restricting type, has a body mass index (BMI) of 15 kg/m² and
refuses to eat due to intense fear of weight gain. Which of the following is the most critical initial
intervention?
A. Initiate olanzapine to reduce anxiety and promote weight gain
B. Begin cognitive behavioral therapy for eating disorders (CBT-E)
C. Establish a structured refeeding protocol with close medical monitoring
D. Prescribe cyproheptadine as an appetite stimulant
Answer: C
Rationale: Medical stabilization and nutritional rehabilitation are paramount due to severe malnutrition
(BMI < 16). Olanzapine may help but is not first-line for acute refeeding. CBT-E is effective but not
appropriate until medical stability is achieved. Cyproheptadine has limited evidence and is not standard
care.
8. A patient with alcohol use disorder (AUD) has been abstinent for 5 days and is experiencing mild
withdrawal symptoms (CIWA-Ar score of 8). The patient has a history of seizures during previous
withdrawals. Which pharmacotherapy is most appropriate?
A. Naltrexone 50 mg daily
B. Chlordiazepoxide 50 mg every 6 hours as needed
C. Acamprosate 666 mg three times daily
D. Disulfiram 250 mg daily
Answer: B
Rationale: The patient has a history of withdrawal seizures, necessitating a benzodiazepine for seizure
prophylaxis. Chlordiazepoxide is a long-acting benzodiazepine recommended for alcohol withdrawal.
Naltrexone and acamprosate are for relapse prevention, not acute withdrawal. Disulfiram is
contraindicated during active drinking and early withdrawal.
9. A patient with major depressive disorder (MDD) and comorbid chronic kidney disease stage 4
(eGFR 25 mL/min) has failed sertraline and venlafaxine. Which antidepressant should be avoided
due to increased risk of seizures and accumulation?
Page 3
, A. Bupropion
B. Escitalopram
C. Duloxetine
D. Mirtazapine
Answer: A
Rationale: Bupropion is contraindicated in patients with renal impairment due to increased risk of
seizures and accumulation of its metabolites. Escitalopram and mirtazapine are safer options.
Duloxetine is not recommended in severe renal impairment but is less risky than bupropion.
10. A patient with schizophrenia is being treated with haloperidol 10 mg daily and develops acute
dystonia. The patient has a history of prolonged QTc interval (480 ms). Which of the following is
the most appropriate management?
A. Administer diphenhydramine 50 mg intramuscularly
B. Administer benztropine 2 mg intramuscularly
C. Switch to aripiprazole 15 mg daily
D. Reduce haloperidol to 5 mg daily
Answer: B
Rationale: Benztropine is an anticholinergic agent effective for acute dystonia and does not prolong QTc.
Diphenhydramine also treats dystonia but its sedative and anticholinergic effects are less preferred.
Switching antipsychotics may be considered but does not address the acute dystonia. Dose reduction is
not appropriate for acute management.
11. A 45-year-old individual with a history of recurrent major depressive episodes presents with
anhedonia, psychomotor retardation, and excessive guilt. Recent genetic testing reveals a
polymorphism in the serotonin transporter gene (5-HTTLPR) with two short alleles. Which
neurobiological mechanism is MOST likely contributing to this patient's treatment resistance to
selective serotonin reuptake inhibitors (SSRIs)?
A. Increased presynaptic serotonin synthesis due to upregulated tryptophan hydroxylase
B. Reduced serotonin transporter availability leading to decreased synaptic serotonin clearance
C. Enhanced negative feedback via somatodendritic 5-HT1A autoreceptors in the raphe nuclei
D. Downregulation of postsynaptic 5-HT2A receptors in the prefrontal cortex
Answer: C
Rationale: The short allele variant of 5-HTTLPR is associated with reduced serotonin transporter
expression, leading to higher baseline synaptic serotonin. This results in compensatory upregulation of
somatodendritic 5-HT1A autoreceptors, which inhibit raphe neuron firing and reduce serotonin release,
diminishing SSRI efficacy. Option A is incorrect because tryptophan hydroxylase is not directly affected
by 5-HTTLPR. Option B describes the opposite effect. Option D is not a primary consequence of this
polymorphism.
Page 4
Theories, & Advanced Clinical Modalities, Questions
& Answers (Verified Answers) Update - Wilkes
University
1. A patient with a history of recurrent major depressive episodes and a family history of bipolar I
disorder presents with a depressive episode that has not responded to two adequate trials of SSRIs.
The patient reports a previous hypomanic episode lasting 3 days while on an SSRI. Which of the
following is the most appropriate next step in pharmacotherapy?
A. Augment the current SSRI with aripiprazole
B. Switch to a monoamine oxidase inhibitor (MAOI)
C. Initiate lamotrigine as monotherapy
D. Discontinue the SSRI and start lithium
Answer: C
Rationale: The patient likely has bipolar II disorder given the SSRI-induced hypomania and family
history. Lamotrigine is first-line for bipolar depression due to its efficacy and lower risk of mood
destabilization. Aripiprazole augmentation may increase manic switch risk. MAOIs are not first-line due
to dietary restrictions and risk. Lithium is more effective for mania prophylaxis than acute bipolar
depression.
2. A patient diagnosed with schizophrenia has been adherent to clozapine for 6 months with
significant improvement in positive symptoms but continues to experience negative symptoms and
cognitive deficits. Which of the following augmentation strategies is most supported by current
evidence?
A. Adding a second antipsychotic such as risperidone
B. Adding a selective serotonin reuptake inhibitor (SSRI)
C. Adding a cognitive remediation therapy program
D. Adding a mood stabilizer such as valproate
Answer: C
Rationale: Cognitive remediation therapy has moderate evidence for improving cognitive deficits and
negative symptoms in schizophrenia. Adding a second antipsychotic increases side effects without clear
benefit. SSRIs may help depressive symptoms but not negative symptoms or cognition. Valproate lacks
evidence for negative symptoms and may increase metabolic side effects.
Page 1
,3. A 30-year-old patient with borderline personality disorder (BPD) presents with recurrent
self-harm behaviors and emotional dysregulation. The patient has not responded to dialectical
behavior therapy (DBT) after one year. Which of the following therapeutic approaches is most
appropriate to consider next?
A. Transference-focused psychotherapy (TFP)
B. Mentalization-based treatment (MBT)
C. Cognitive behavioral therapy (CBT) for BPD
D. Schema-focused therapy
Answer: B
Rationale: MBT is specifically designed for BPD and focuses on improving mentalization capacity. It has
strong evidence for reducing self-harm and improving emotional regulation. TFP is also evidence-based
but more intensive and less studied in non-responders to DBT. CBT for BPD has limited evidence.
Schema therapy is effective but less supported after DBT failure.
4. A patient with generalized anxiety disorder (GAD) has been on sertraline 200 mg daily for 12
weeks with partial response. The patient continues to have excessive worry and muscle tension.
Which of the following medication strategies is most consistent with current evidence-based
guidelines?
A. Augment with buspirone 15 mg twice daily
B. Switch to venlafaxine XR 225 mg daily
C. Add pregabalin 150 mg twice daily
D. Add a short course of lorazepam 0.5 mg as needed
Answer: A
Rationale: Buspirone augmentation of SSRIs has evidence for GAD with partial response. Venlafaxine is
first-line but switching after only one adequate trial is not optimal. Pregabalin is effective but not
first-line augmentation. Benzodiazepines are not recommended for long-term use due to dependence risk
and limited efficacy for core worry.
5. A patient with posttraumatic stress disorder (PTSD) has been receiving prolonged exposure
therapy but experiences significant dissociation during sessions, leading to poor engagement.
Which modification to the treatment approach is most indicated?
A. Switch to cognitive processing therapy (CPT)
B. Add a grounding technique before exposure
C. Increase the intensity of exposure to overcome avoidance
D. Discontinue exposure and use supportive therapy
Answer: B
Rationale: Grounding techniques help manage dissociation during exposure, allowing the patient to
remain present and engaged. CPT may also be effective but does not directly address dissociation
during sessions. Increasing intensity may worsen dissociation. Supportive therapy lacks evidence for
PTSD.
Page 2
,6. A patient with obsessive-compulsive disorder (OCD) has severe contamination fears and
compulsive hand washing. The patient has not responded to two adequate trials of SSRIs. Which of
the following is the most appropriate next step?
A. Augment with a low-dose atypical antipsychotic
B. Initiate clomipramine
C. Add a D-cycloserine augmentation to exposure and response prevention (ERP)
D. Consider deep brain stimulation (DBS)
Answer: A
Rationale: Augmentation with an atypical antipsychotic (e.g., risperidone, aripiprazole) is
evidence-based for SSRI-resistant OCD. Clomipramine is effective but often poorly tolerated; it is
typically tried before augmentation. D-cycloserine has mixed evidence and is not first-line. DBS is
reserved for severe, treatment-refractory cases after multiple failed trials.
7. A patient with anorexia nervosa, restricting type, has a body mass index (BMI) of 15 kg/m² and
refuses to eat due to intense fear of weight gain. Which of the following is the most critical initial
intervention?
A. Initiate olanzapine to reduce anxiety and promote weight gain
B. Begin cognitive behavioral therapy for eating disorders (CBT-E)
C. Establish a structured refeeding protocol with close medical monitoring
D. Prescribe cyproheptadine as an appetite stimulant
Answer: C
Rationale: Medical stabilization and nutritional rehabilitation are paramount due to severe malnutrition
(BMI < 16). Olanzapine may help but is not first-line for acute refeeding. CBT-E is effective but not
appropriate until medical stability is achieved. Cyproheptadine has limited evidence and is not standard
care.
8. A patient with alcohol use disorder (AUD) has been abstinent for 5 days and is experiencing mild
withdrawal symptoms (CIWA-Ar score of 8). The patient has a history of seizures during previous
withdrawals. Which pharmacotherapy is most appropriate?
A. Naltrexone 50 mg daily
B. Chlordiazepoxide 50 mg every 6 hours as needed
C. Acamprosate 666 mg three times daily
D. Disulfiram 250 mg daily
Answer: B
Rationale: The patient has a history of withdrawal seizures, necessitating a benzodiazepine for seizure
prophylaxis. Chlordiazepoxide is a long-acting benzodiazepine recommended for alcohol withdrawal.
Naltrexone and acamprosate are for relapse prevention, not acute withdrawal. Disulfiram is
contraindicated during active drinking and early withdrawal.
9. A patient with major depressive disorder (MDD) and comorbid chronic kidney disease stage 4
(eGFR 25 mL/min) has failed sertraline and venlafaxine. Which antidepressant should be avoided
due to increased risk of seizures and accumulation?
Page 3
, A. Bupropion
B. Escitalopram
C. Duloxetine
D. Mirtazapine
Answer: A
Rationale: Bupropion is contraindicated in patients with renal impairment due to increased risk of
seizures and accumulation of its metabolites. Escitalopram and mirtazapine are safer options.
Duloxetine is not recommended in severe renal impairment but is less risky than bupropion.
10. A patient with schizophrenia is being treated with haloperidol 10 mg daily and develops acute
dystonia. The patient has a history of prolonged QTc interval (480 ms). Which of the following is
the most appropriate management?
A. Administer diphenhydramine 50 mg intramuscularly
B. Administer benztropine 2 mg intramuscularly
C. Switch to aripiprazole 15 mg daily
D. Reduce haloperidol to 5 mg daily
Answer: B
Rationale: Benztropine is an anticholinergic agent effective for acute dystonia and does not prolong QTc.
Diphenhydramine also treats dystonia but its sedative and anticholinergic effects are less preferred.
Switching antipsychotics may be considered but does not address the acute dystonia. Dose reduction is
not appropriate for acute management.
11. A 45-year-old individual with a history of recurrent major depressive episodes presents with
anhedonia, psychomotor retardation, and excessive guilt. Recent genetic testing reveals a
polymorphism in the serotonin transporter gene (5-HTTLPR) with two short alleles. Which
neurobiological mechanism is MOST likely contributing to this patient's treatment resistance to
selective serotonin reuptake inhibitors (SSRIs)?
A. Increased presynaptic serotonin synthesis due to upregulated tryptophan hydroxylase
B. Reduced serotonin transporter availability leading to decreased synaptic serotonin clearance
C. Enhanced negative feedback via somatodendritic 5-HT1A autoreceptors in the raphe nuclei
D. Downregulation of postsynaptic 5-HT2A receptors in the prefrontal cortex
Answer: C
Rationale: The short allele variant of 5-HTTLPR is associated with reduced serotonin transporter
expression, leading to higher baseline synaptic serotonin. This results in compensatory upregulation of
somatodendritic 5-HT1A autoreceptors, which inhibit raphe neuron firing and reduce serotonin release,
diminishing SSRI efficacy. Option A is incorrect because tryptophan hydroxylase is not directly affected
by 5-HTTLPR. Option B describes the opposite effect. Option D is not a primary consequence of this
polymorphism.
Page 4
