Free Psychiatry Board Exam Sample Questions

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Your First Free Psychiatry Sample Question

A 28-year-old man presents to your office seeking treatment for PTSD. He returned from Iraq 4 months ago. He received some initial psychiatric care overseas, including a prescription for fluoxetine, which he said didn’t help his symptoms. He has not been able to get help at the VA due to staffing issues. He seeks ongoing treatment for PTSD. He describes a depressed mood with feelings of hopelessness but no thoughts of self-harm. He has anxiety which he says is constant; nightmares, restlessness, trouble focusing, social withdrawal, and inability to find work; and newer symptoms of agitation and auditory and visual hallucinations. He denies any alcohol or drug abuse which is confirmed by a tox screen. He states: “My buddy keeps coming over and telling me I should have saved his life. He is scared and yells all the time – I think he is angry that I screwed up.” Of the following, what is the BEST treatment option for this man’s immediate needs?

A) A different selective serotonin reuptake inhibitor (SSRI)

B) Cognitive behavioral therapy or immersion therapy

C) Group therapy with other veterans

D) Benzodiazepines

E) Antipsychotics

Answer and Explanations

This man describes classic features of PTSD, including depressed mood, hopelessness, anxiety, flashbacks, social withdrawal, difficulty focusing, and nightmares.  However, he is experiencing some new symptoms of agitation and auditory and visual hallucinations. He experiences these events as real and describes the hallucinations to you, by telling you that they happened, which is different from a flashback.

Given that he now has some psychotic features, regardless of other symptoms, this man needs to be treated with an antipsychotic. The literature also shows that treatment with an antipsychotic benefits all symptoms of PTSD in patients who are resistant to SSRIs. Regardless, his psychosis must be treated before other symptoms.

Did you get it right? The correct answer is: E

• Answer A: In patients resistant to SSRIs, especially with hallucinations, an antipsychotic is superior to an SSRI. Therefore, there is no benefit to initiating a different SSRI.
• Answer B: Cognitive behavioral therapy (CBT) or immersion therapy – These 2 therapies have been used in veterans of different conflicts with success. However, their use is limited and is not sufficient for treatment of severe depression especially with psychotic symptoms.
• Answer C: Group therapy with other veterans. This modality has been used for decades but works best in a VA setting (inpatient or outpatient), and this man does not have VA access. In addition, if symptoms of depression are severe, or psychosis has hit as in this case, an antipsychotic is imperative.
• Answer D: Some use benzodiazepines to treat the agitation and severe anxiety, as well as to treat sleep disturbance. However, when depression is severe, and when psychotic symptoms emerge, benzodiazepines will not suffice and an antipsychotic must be employed.

Bottom Line: Patients who suffer from combat-related PTSD, with SSRI resistance or the presence of psychotic symptoms will improve when treated with an antipsychotic.

For more information, see:

Stein, et al. (2001). Adjunctive olanzapine for SSRI-resistant combat-related PTSD: A double-blind placebo controlled study. Am J Psychiatry. 159:1777-1779.

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