Módulo 1 Psiquiatra Flashcards
A 39-year-old African American man is an inpatient on a psychiatric ward. He was admitted because of concerns that his neighbors are spying on him and devising ways to kill him. He states that the neighbors have inserted cameras in several rooms of his house to monitor his activities. He claims to hear them through the walls saying they are going to kill him. The patient’s wife called the police when he bought a gun stating that he was going to kill the neighbors “in self-defense.” Which of the following is the most appropriate pharmacologic treatment?
(A) Benztropine
(B) Diazepam
(C) Fluoxetine
(D) Lithium
(E) Risperidone
Respuesta: E
The correct answer is E. This clinical vignette illustrates an individual with a primary psychotic disorder, probably schizophrenia. Risperidone, an atypical antipsychotic, would treat symptoms of paranoid delusions and auditory hallucinations.
Benztropine (Choice A) is an anticholinergic medication that is generally used with the typical antipsychotics (such as haloperidol) for the prophylaxis of extrapyramidal symptoms. It has no antipsychotic properties.
Diazepam (Choice B) is a long-acting benzodiazepine that would be appropriate in the management of an anxiety disorder. Shorter-acting benzodiazepines, such as lorazepam, are often used adjunctively in psychotic individuals for acute agitation.
Fluoxetine (Choice C) is a selective serotonin reuptake inhibitor (SSRI) used in depressive illnesses.
Lithium (Choice D) is used in bipolar disorder. Although individuals with bipolar disorder may have delusions, they are usually of a grandiose quality. In such individuals, antipsychotic medications like risperidone are often given as well, because lithium takes approximately 10 days to have a beneficial effect. This patient has profound paranoid delusions, suggestive of schizophrenia.
A 61-year-old man is brought to a physician for evaluation of his behavior. His family states that recently he has been yelling, spitting, and pulling other people’s noses or ears unexpectedly. He was always a fine man and devoted husband but now uses foul language and is openly promiscuous. He has no significant medical or psychiatric history. The family recalls that the patient’s uncle displayed similar behavior and was placed in a nursing home, where he quickly died. On examination, memory and visuospatial functions are intact, but the patient exhibits some word-finding difficulties. During the examination, the patient keeps repeating the doctor’s command and giggling inappropriately and loudly. Which of the following is the most likely diagnosis?
(A) Alzheimer disease
(B) Dementia pugilistica
(C) Multi-infarct dementia
(D) Neurosyphilis
(E) Pick disease
Respuesta: E
The correct answer is E. Pick disease is one in the spectrum of frontotemporal dementias. Unlike most other dementias, which present initially with cognitive changes, Pick disease presents insidiously with behavioral changes related to atrophy in frontotemporal regions. The cause is unknown. It is more common in men, especially those with an affected first-degree relative. In the early stages, it is more often characterized by personality and behavioral changes, such as disinhibition, impulsivity, repetitive behaviors, hypersexuality, and hyperorality. Treatment relies on behavior management.
Alzheimer disease (Choice A) is a progressive dementia with associated risk factors that include age, positive family history, head trauma, and Down syndrome. Typical first symptoms are a subtle loss of short-term memory, language difficulties, and apraxias, followed by impaired judgment and personality changes. Psychiatric symptoms are often prominent in the course of the illness. Treatment targets specific symptoms and includes psychosocial interventions and pharmacologic therapy.
Dementia pugilistica (Choice B) is a posttraumatic dementia that develops after blunt head trauma. It often occurs as a result of motor vehicle accident injuries and sports-related traumas. The clinical symptoms are dependent on the areas affected most (cortical versus subcortical). After a period of amnesia and recovery, the most common symptoms are decreased attention, slowed information processing, increased distractibility, and problems with memory. Behavioral changes include impulsivity, depression, aggression, and personality changes. Treatment is targeted at controlling the symptoms.
Multi-infarct dementia (Choice C), or vascular dementia, accounts for 20% of the cases of dementia. Typical features include progression of cognitive deficits and associated motor or sensory neurologic deficits. Risk factors are associated with vascular disease, vasculitis, or embolic disease. Treatment is focused on addressing risk factors.
Neurosyphilis (Choice D) is a dementia of infectious origin, which is potentially reversible if diagnosed and treated early. It appears 10-15 years after the primary infection. It generally affects the frontal lobes, resulting in personality changes, poor judgment, irritability, and decreased care for oneself. Delusions of grandeur are seen in 10% to 20% of affected patients. The disease progresses into dementia with neurologic symptoms, such as tremor, Argyll-Robertson pupils, dysarthria, and hyperreflexia. Cerebrospinal fluid tests confirm the diagnosis. Treatment targets the infection and includes administration of IV penicillin G.
While on the Psychiatry Consult-Liaison Inpatient Service, a psychiatry intern is called to assess a patient on a general medical floor who has developed a muscle spasm causing her neck to twist uncontrollably to the left. She is also having difficulty speaking and is upset. The intern evaluates the patient’s list of medications and concludes that the her new symptoms may be due to one of them. Which of the following medications is most likely responsible for the patient’s symptoms?
(A) Aspirin
(B) Digoxin
(C) Erythromycin
(D) Fluoxetine
(E) Metoclopramide
Respuesta: E
The correct answer is E. Metoclopramide is used as a gastric motility agent, often in patients with diabetes who have gastric paresis. It has antidopaminergic properties and can cause acute dystonic reactions such as are occurring in this patient. A dystonia is a spontaneous contraction of individual muscles. Treatment includes cessation of the metoclopramide and providing an anticholinergic agent, such as benztropine, or an antihistamine, such as diphenhydramine, both of which are usually given in IM form for immediate effect.
Aspirin (choice A) is an analgesic, antipyretic, anti-inflammatory, and antiplatelet agent. It is widely used and does not cause acute dystonic reactions.
Digoxin (choice B) is a cardiac medication, specifically a steroid glycoside, used in the treatment of certain heart diseases, especially congestive heart failure. It does not cause acute dystonic reactions.
Erythromycin (choice C) is a macrolide antibiotic and does not cause acute dystonic reactions.
Fluoxetine (choice D) is an antidepressant medication. It is a selective serotonin reuptake inhibitor and has not generally been associated with acute dystonic reactions.
A 29-year-old woman was attacked, held at gunpoint, robbed, and beaten after leaving a restaurant in the evening. Despite this, she managed to report the incident to police and continue with her daily activities. Two months later, she seeks psychiatric help because she has been having difficulty going to work and participating in other activities. Which of the following constellation of symptoms would she most likely report to her psychiatrist?
(A) Confusion and disorientation
(B) Depression and suicidal thoughts
(C) Euphoria and racing thoughts
(D) Flashbacks and increased arousal
(E) Hyperphagia and hypersomnia
Respuesta: D
The correct answer is D. The patient is experiencing symptoms of acute posttraumatic stress disorder. The event is persistently reexperienced in flashbacks, nightmares, increased arousal, and avoidance of stimuli associated with trauma. The symptoms are of less than 3 months’ duration for the acute course, and the disturbances cause significant social or occupational impairment.
Confusion and disorientation (choice A) are symptoms usually seen in cognitive disorders (delirium, dementia) but can also be seen as a part of psychotic disorders.
Depression and suicidal thoughts (choice B) are symptoms seen in various mood disorders and in the depression associated with psychosis. They can also be associated with anxiety disorders and substance-induced mood disorders.
Euphoria and racing thoughts (choice C) are usually symptoms of bipolar disorder (manic or mixed type) or schizoaffective disorder. These symptoms can also be seen with substance abuse.
Hyperphagia and hypersomnia (choice E) are symptoms of major depressive disorder with atypical features, along with sensitivity to rejection and a heavy leaden feeling in limbs. They can also be symptoms of several medical conditions.
A 25-year-old man presents to the emergency department (ED) with a sore arm and difficulty using his hand. He has been evaluated multiple times in the ED for multiple somatic complaints, but medical evaluation has been consistently unrevealing. He also has a history of cocaine abuse, for which he was admitted to various substance abuse rehabilitation facilities. Often, his trips to the hospital coincided with scheduled court appearances after violating probation. Physical examination of the man’s arm does not show obvious injury or focal abnormalities, and an x-ray of the arm is normal. A urine toxicology screen is negative. The patient was offered ice, anti-inflammatory medication, and information concerning the benign nature of his pain. The patient was then told that he was to be discharged from the ED, at which point he stated that his pain was too great for him to leave the hospital and he demanded admission. Which of the following is the most likely diagnosis?
(A) Conversion disorder
(B) Dissociative identity disorder
(C) Factitious disorder
(D) Malingering
(E) Rheumatoid arthritis
Respuesta: D
The correct answer is D. This patient is malingering. He appears to be intentionally producing symptoms of arm pain in an attempt to gain admission to the hospital. His pattern has been such that his behavior is motivated by the external incentive of avoiding his legal responsibilities. His urine toxicology screen was negative, thereby eliminating the possibility that he was experiencing a substance-induced mood disorder. Further, there is a clear discrepancy between the patient’s complaint of arm pain and the objective physical examination and radiologic findings. This is characteristic of malingering.
Conversion disorder (choice A) differs from malingering in that the symptom is not intentionally produced and there is no obvious external incentive.
Dissociative identity disorder (choice B) involves the presence of two or more distinct, recurrent identities or personality states. This patient does not show features of this.
Factitious disorder (choice C) involves the intentional production of symptoms, but the motivation is to assume the sick role rather than gain external incentives.
Rheumatoid arthritis (choice E) is a chronic inflammatory disease affecting multiple joints. The patient’s presentation does not align with this condition.
A 23-year-old man is taking classes at a local community college. He had finished high school without difficulties and was voted “most popular” by his classmates. Three months ago, he started skipping classes after he had a “special revelation” that the “holy spirit” had a more important mission for him. He began worshipping computers, believing them to be sending him special, secret messages from the “holy spirit.” His family, alarmed by the change in his behavior, brings him to the local emergency department. His past history is significant for occasional alcohol and marijuana use. A urine toxicology screen is negative. The patient is admitted to the psychiatric ward of the hospital for further evaluation. In which of the following ways does this person’s presentation preclude a diagnosis of schizophrenia?
(A) Age of onset
(B) Duration of symptoms
(C) Presence of a mood disorder
(D) Severity of symptoms
(E) Type of auditory hallucinations
Respuesta: B
The correct answer is B. This patient has schizophreniform disorder. Except for its duration of symptoms, schizophreniform disorder is similar to schizophrenia in diagnostic criteria. Whereas the symptoms must be present for at least 6 months to establish a diagnosis of schizophrenia, an episode of schizophreniform disorder lasts at least 1 month but less than 6 months.
The average age of onset (choice A) for persons with schizophreniform disorder is the same as that for persons with schizophrenia.
One cannot simultaneously have a mood disorder (choice C) in the context of schizophreniform disorder. Only in schizoaffective disorder are symptoms that meet criteria for a mood disorder present.
The symptoms of schizophreniform disorder and schizophrenia may be of equal severity (choice D).
The frequency, character, and description of auditory hallucinations (choice E) may be identical in schizophreniform disorder and schizophrenia.
A 37-year-old man has a 2-year history of major depression that is managed with sertraline. Several attempts at discontinuing therapy resulted in relapses with major depressive symptoms and strong suicidal ideation. The man visits his psychiatrist to discuss management options. In particular, he discusses problems with his marriage because of sexual dysfunction. He describes a lack of libido that started when he began antidepressant therapy, and he believes that it is destroying his marriage. He discloses the presence of nocturnal erections but a lack of interest in sexual intimacy with his wife. Their relationship is otherwise well, and he doesn’t know what he should do. Which of the following medications is an appropriate antidepressant alternative for relieving his symptoms of sexual dysfunction?
(A) Amitriptyline
(B) Bupropion
(C) Fluoxetine
(D) Paroxetine
(E) Sildenafil
Respuesta: B
The correct answer is B. Antidepressant-induced sexual dysfunction is a common condition and can be a major obstacle to long-term therapy for major depression. Bupropion, a reuptake inhibitor of norepinephrine and dopamine, is an appropriate alternative to the major classes of antidepressants because it has a low-to-zero risk for sexual dysfunction.
Amitriptyline (choice A) is unlikely to alleviate the symptoms due to a similarly high risk for sexual side effects.
Fluoxetine (choice C) and paroxetine (choice D) are both SSRIs and are unlikely to change the symptoms of sexual dysfunction.
Sildenafil (choice E) may help reverse sexual dysfunction from antidepressant use in both men and women but does not address the patient’s ongoing need for antidepressant therapy.
A 28-year-old, malodorous woman in dirty clothing is brought by police into a psychiatric community crisis response center after being found shouting in the middle of a busy street. The woman reportedly was yelling about the end of the world coming soon and that all cars must be abandoned to save the earth from eternal destruction. She screamed at the police who brought her into custody, calling them “evil.” She visibly shook when taken by police car, crying out that “cars are the means to destruction.” Further, she was noted to stare off into the distance and talk to herself during the car ride. On her arrival at the crisis center, her behavior quickly escalated. She became belligerent, shouting obscenities and trying to hit everyone around her. To calm her down and in an attempt to speak with her in a less agitated fashion, the psychiatric intern on call ordered an intramuscular medication to be administered. Which of the following medications is the best choice for rapid tranquilization in this agitated patient?
(A) Clozapine
(B) Haloperidol
(C) Lithium
(D) Olanzapine
(E) Perphenazine
Respuesta:
The correct answer is B. This patient is clearly psychotic and shows evidence of a formal thought disorder. Her acute presentation in the crisis center demonstrates the agitation that often accompanies acute psychosis. Often, after calming a patient down with medication and perhaps allowing her to sleep for a short while, the patient is much more calm, cooperative, and redirectable. This not only enables the psychiatric intern to have an easier time with the interview, diagnosis, and immediate treatment planning, but also provides the most safety for the patient. Haloperidol is a typical high-potency antipsychotic: it has a quick onset of action, is reliably administered in all of its forms (i.e., PO, IM, and IV), and can temper the agitation of acute psychosis. It is not unusual for haloperidol to be given in conjunction with IM lorazepam in severe acute agitation.
Clozapine (Choice A) is not used in acutely agitated patients, and is associated with more frequent seizures unless the initial daily dose is minimal. This antipsychotic is very effective in patients who have treatment-resistant psychotic disorders, most often schizophrenia. It has been used to treat aggression in some patients with a broad variety of neuropsychiatric disorders, including traumatic brain injury and mental retardation, but is not used in acute, agitated psychosis as in this scenario.
Lithium (Choice C), an antimanic medication, is the most widely used treatment for the bipolar disorders. It has proved useful in the treatment of acute episodes of mania and depression and, perhaps most significantly, in the long-term prophylaxis of the bipolar disorders. It is not effective acutely.
Olanzapine (Choice D) is a newer, atypical antipsychotic that is not used in acute psychosis because of its delayed onset of action compared with haloperidol. This is mostly because olanzapine is not yet available in an IM formulation, and it undergoes first-pass metabolism before being systemically absorbed. Olanzapine is as effective as haloperidol in the treatment of both first-episode and chronic schizophrenia, but not for an acute presentation.
Perphenazine (Choice E) is a medium-potency, typical antipsychotic that is not used in the acute treatment of agitated psychosis. Like olanzapine, it is not available in IM form. Likewise, it is effective in first-episode and chronic schizophrenia. However, because of several undesirable side effects, it is not currently considered a first-line drug in the treatment of schizophrenia, including acutely agitated psychotic patients.
An emergency department physician orders a 5-mg haloperidol injection for a psychotic 30-year-old man. Six hours later, the patient’s temperature is 39.4 C (103.0 F), and there is diffuse muscular rigidity and diaphoresis. Over the next 24 hours, the patient becomes increasingly obtunded. He is put on a cardiac monitor, and his blood pressure is noted to fluctuate from 100/70 mm Hg to 170/96 mm Hg. Which of the following is the most likely diagnosis?
(A) Catatonia
(B) Malignant hyperthermia
(C) Neuroleptic malignant syndrome
(D) Serotonin syndrome
(E) Tardive dyskinesia
Respuesta: C
The correct answer is C. Neuroleptic malignant syndrome is a life-threatening adverse reaction to antipsychotic medications. It typically develops early in the course of treatment, although it can occur at any point, including after prolonged treatment. It is believed to be caused by impairment of CNS dopamine systems, either from dopamine receptor blockade or following treatment with a presynaptic dopamine depleting-agent like tetrabenazine. In addition to fever, muscle rigidity, and mental status changes, patients may develop autonomic instability, tremor, or dystonia. The most common laboratory abnormality is an elevated creatine kinase. Treatment involves discontinuation of the drug and supportive care, usually in an intensive care unit. Dopamine agonists, such as bromocriptine, are often given in conjunction with dantrolene, which acts as a muscle relaxant. Mortality can be as high as 25% without specific treatment. Symptoms resolve within 10 days.
Catatonia (Choice A) is characterized by mutism and stupor, and may be present in patients with schizophrenia or other psychotic disorders. It may also include bizarre motor behavior, such as sustained postures and stereotypies. Catatonia may respond acutely to treatment with benzodiazepines or electroconvulsive therapy.
Malignant hyperthermia (Choice B) follows administration of general anesthetic agents, not neuroleptics. It is believed to be caused by excessive release of calcium by the sarcoplasmic reticulum, resulting in severe, sustained muscle contraction. Dantrolene is also used to treat this disorder.
Serotonin syndrome (Choice D) is a potentially lethal reaction due to excess serotonin activity associated with combined use of a selective serotonin reuptake inhibitor (SSRI) and an MAO inhibitor or overdosage with an SSRI. It shares certain features of the neuroleptic malignant syndrome, including confusion and diaphoresis. Patients may also be hypertensive and tachycardic.
Tardive dyskinesia (Choice E) presents as a movement disorder developing many months to years after chronic antipsychotic use. It would not develop acutely and would not have any effect on temperature or mental status. Involuntary movements classically involve the oro-buccal-lingual musculature in this condition.
A 22-year-old college student presents to her physician complaining of increasing apathy and lethargy over the past several weeks. She has also been eating and sleeping more, and her grades have begun to drop. She also states that some of her classmates find her a bit overbearing and irritating, particularly when she goes for days at a time without sleeping while participating in her many student activities. She states that her alcohol intake is limited to two or three beers on occasional weekends while socializing with friends, and she denies any other substance use. Around 6 months ago, she spent almost $1000 on clothing and other gifts for her boyfriend, and she spent another large amount of money on a computer to use to write her latest novel. She states that she was put on paroxetine as a teenager and she “didn’t sleep for days.” Which of the following is the most appropriate single agent to use for pharmacotherapy in this case?
(A) Alprazolam
(B) Amitriptyline
(C) Bupropion
(D) Fluoxetine
(E) Lithium carbonate
Respuesta: E
The correct answer is E. The most likely diagnosis is bipolar disorder, most recent episode depressed. The patient’s recent symptoms suggest that she previously had an episode of mania, and this is supported by her description of disinhibition when started on a traditional selective serotonin reuptake inhibitor (SSRI) as a teenager—an event that is sometimes reported when patients with bipolar disorder are started on these agents. Lithium carbonate is more effective in treating bipolar disorder than is an SSRI, particularly in dealing with the cycles of depression and mania. Her hypersomnia and atypical symptoms of depression, combined with her gender, younger age of onset, and history of a manic episode, point to the depression of bipolar disorder rather than major depressive disorder. Therefore, lithium would be the most effective treatment.
Alprazolam (Choice A) is a short-acting benzodiazepine, which is not used to treat depression.
Amitriptyline (Choice B) is a tricyclic antidepressant, which would not treat the mood instability that the patient describes previously having.
Bupropion (Choice C) is a dopamine-norepinephrine reuptake inhibitor used to treat major depressive disorder, not as a single agent in the depression of bipolar disorder.
Fluoxetine (Choice D) is an SSRI similar to paroxetine used to treat depression, and would not be appropriate as a single agent in this case to treat a patient with a history of mania.
Parents of a 3-year-old boy take their child to the pediatrician for evaluation of what they consider to be “abnormal” behavior. They describe their son as never wanting to be held, even as a baby, not making good eye contact with anyone, crying whenever he is bathed, and having no interest in playing with other children. He does not have any favorite toys, security play items, or any known make-believe friends. He has minimal ability to speak in a coherent language, although the parents believe that they can understand him when he is trying to communicate. The pediatrician observes the boy in the office playroom. He is sitting alone in the corner of the playroom, carefully piling blocks one on top of the other. He is noted to make occasional circular gestures with his left hand. There are four other children, aged 2-4 years, waiting to be seen by the pediatrician; these children are playing together, apart from the boy. In which of the following areas is this boy most likely to have difficulty?
(A) Attention
(B) Concentration
(C) Intelligence
(D) Interpersonal relations
(E) Urinary incontinence
Respuesta: D
The correct answer is D. This boy likely has autistic disorder, which affects 3-5 per 10,000 persons. The male-to-female ratio is 3:1. This boy demonstrates a qualitative impairment in social interaction as manifested by nonverbal behaviors, such as poor eye contact and lack of desire to be touched. He has failed to develop peer relationships appropriate to his developmental level and does not seek enjoyment or shared pleasure with anyone. He lacks emotional reciprocity to his parents, has a marked delay in the development of spoken language, and demonstrates a stereotyped and repetitive mannerism. These are all attributes of autism. Also, since the boy’s behavior was described as chronic, his impairments cannot be better accounted for by childhood disintegrative disorder. Children with autistic disorder do not know how to regulate social interaction. They often are not interested in others, cannot accurately interpret the facial expressions and body postures of others, and do not understand social reciprocity.
Difficulty in attention (Choice A) is not prototypical for children with autistic disorder. Their attention span is variable and more often is affected by intelligence level rather than the autistic disorder itself.
Inability to concentrate (Choice B) is also not a characteristic marker of children with autistic disorder. Such children are often preoccupied with aspects of their inner world and with one or more stereotyped and restricted patterns of interest. This is often abnormal either in intensity or in focus. They may concentrate more on one area of focus than another, but this is common for normal children as well and is not viewed as a diagnostic component of autistic disorder.
Intelligence (Choice C) is variable in autistic disorder. Children can be high or low functioning depending on several variables, including intelligence, ability to communicate, and severity of repetitive behaviors, as well as other symptoms. Seventy percent of affected children have IQs measured below 70, and 50% have IQs below 50. Autistic disorder is considered to have an organic basis with no specific site of organic damage. The autistic character portrayed by Dustin Hoffman in the movie “Rainman,” an idiot savant with talents at the genius level, is very rare.
Urinary incontinence (Choice E) is no more prevalent in children with autistic disorder than in normal children.
A 15-year-old boy is brought in by his mother to see a psychiatrist for “strange behavior.” She reports that her son is often late for school because he spends more than an hour in the shower every morning. When asked about this, he says that he takes a long time because he feels compelled to wash himself in a certain manner, and has to repeat the whole process if he makes a mistake. He knows it sounds ridiculous, and that it makes him late for school and other activities, but he cannot seem to stop himself. In addition, he has found it difficult to fall asleep at night because he needs to constantly check that he has set his alarm for the morning. Which of the following is the most likely diagnosis?
(A) Attention deficit/hyperactivity disorder
(B) Bipolar disorder
(C) Generalized anxiety disorder
(D) Major depressive disorder
(E) Obsessive-compulsive disorder
Respuesta: E
The correct answer is E. In obsessive-compulsive disorder (OCD), patients may either experience intrusive thoughts (obsessions) or perform ritualized activities (compulsions), or do both. Obsessions with cleanliness and orderliness, as illustrated by the patient’s showering ritual, are common in OCD. Obsessions and compulsions (such as clock checking) can be so severe that they impact on functions of daily living.
Although OCD and attention deficit/hyperactivity disorder (ADHD; Choice A) may co-exist, this vignette does not demonstrate ADHD, which is characterized by an inability to maintain focus, easy distractibility, and difficulty with behavioral control.
Bipolar disorder (Choice B) is a mood disorder characterized by sustained extremes of mood states (depression and mania). Obsessions and compulsions are not features of bipolar disorder.
Although OCD is categorized as an anxiety disorder, it is distinct from generalized anxiety disorder (Choice C), which is characterized by excessive worry about several different events and activities. These patients may worry about things that elicit anxiety, but they do not experience obsessions or perform compulsions.
Patients with major depressive disorder (Choice D) have either depressed mood or anhedonia (loss of interest) and a constellation of other symptoms, including change in appetite, disturbance in sleep, loss of energy, and decreased concentration. Many patients with OCD develop major depressive disorder, and pharmacotherapy is the same in most cases; however, the case illustrated above is not consistent with major depression.
A 75-year-old woman experiences several episodes of syncope. She is evaluated and found to have critical aortic stenosis. She is otherwise healthy and, with the advice of her cardiologist, decides to undergo valve replacement surgery. Three days after the surgery the patient is found to be irritable, have a labile mood, and be awake for much of the night. She yells at the nurses at 4 AM one morning for not helping her get into her street clothes; however, the next morning at 8 AM, when the surgical intern came to see her, she was calm and cooperative. She did not remember the events of the previous night. The patient had no known psychiatric history and got a 30/30 on the Folstein Mini-Mental State Examination 1 week prior to the surgery. Which of the following is the most likely diagnosis?
(A) Adjustment disorder
(B) Cyclothymia
(C) Delirium
(D) Dementia
(E) Malingering
Respuesta: C
The correct answer is C. This patient is delirious. Delirium is a transient disorder of brain function that results in global cognitive impairment and other behavioral phenomena. It is a common disorder, with its main features being impairment of consciousness, attentional deficit, and a fluctuating course. An estimated 10 to 15% of general medical inpatients are delirious at any given time, and studies show that as many as 30 to 50% of acutely ill geriatric patients become delirious at some point during their hospital stay. Risk factors for delirium include new or worsened medical illness, older age, and baseline cognitive impairments, usually secondary to dementia. The syndrome of delirium is almost always due to an identifiable cause, such as systemic or cerebral disease or drug intoxication or withdrawal.
Adjustment disorder (Choice A) is characterized by the development of emotional or behavioral symptoms, often related to anxiety or depression, in the context of a psychosocial stressor. The symptoms resolve when the stressor ends, or when the patient learns to adapt to them better. Symptoms of severe confusion, as were present in this patient, are unusual in adjustment disorders, as is the sudden resolution of symptoms despite the continuing stressor.
Cyclothymia (Choice B) is a disorder characterized by symptoms that have occurred for at least 2 years. This patient has been suffering for only 3 days. In cyclothymia, there are numerous periods of hypomanic, but not manic, symptoms and of depressive symptoms that do not meet criteria for a major depressive episode. By definition, the person has not been symptom-free for more than 2 months at a time.
Dementia (Choice D) is characterized by the development of multiple cognitive deficits manifested by memory impairment, and by one or more of the following features: aphasia (language disturbance), apraxia (impairment in carrying out motor activities), agnosia (failure to recognize or identify objects), or disturbance in executive functioning. The onset is usually gradual and cannot occur exclusively during the course of a delirium. As stated above, a person with dementia is more susceptible to delirium.
The characteristic feature of malingering (Choice E) is the intentional production of false or markedly exaggerated physical or psychological symptoms as motivated by external incentives. This woman is unlikely to be producing her symptoms intentionally, and there is no obvious external incentive to do so.
A 52-year-old man is seen for the first time by a psychiatrist. He states that he always feels “keyed up” and “on edge” and has been having nightmares about combat experience from the Vietnam War, from which he is a veteran. He states that he witnessed several of his fellow soldiers get killed in combat and he has since experienced what he describes as “movies of it all happening over again” while awake. He reports that he has difficulty discussing these events because they are so distressing. Prior to Vietnam, he was happily married and had several friends; now he feels that he cannot get close to other people and oftentimes gets angry with people for no apparent reason. Which of the following is the most likely diagnosis?
(A) Acute stress disorder
(B) Generalized anxiety disorder
(C) Posttraumatic stress disorder
(D) Schizoid personality disorder
(E) Sleep terror disorder
Respuesta: C
The correct answer is C. The patient describes classic symptoms of posttraumatic stress disorder (PTSD), which is relatively common in patients who have combat exposure. In addition to having witnessed a traumatic event, patients also complain of flashbacks, nightmares, persistent avoidance of stimuli associated with the trauma, and symptoms of increased arousal.
Acute stress disorder (Choice A) is similar to PTSD; however, symptoms are resolved within 4 weeks of the associated event.
In generalized anxiety disorder (Choice B), there is excessive worry about a number of things and there often are somatic manifestations of the anxiety, such as irritability and restlessness. Nightmares, flashbacks, and an identifiable traumatic event are not prominent features.
Schizoid personality disorder (Choice D) is characterized by a pervasive detachment from social relationships. There often is an indifference on the patient’s part with regard to establishing relationships with others. The patient described above is obviously distressed that he can no longer seem to form a connection with others.
Patients with sleep terrors (Choice E) often do not report nightmares. They have the sensation of fear and autonomic hyperactivity on sudden awakening, and there is unresponsiveness to efforts of others to comfort them during the episode.
A 20-year-old woman with bipolar disorder, who is currently in a manic state, responds to many emergency department interview questions with flight of ideas. The patient is asked how she got to the hospital. Which of the following statements by the patient is the best example of this form of thought disturbance?
(A) “I drove here myself.”
(B) “I was reading a great book at home and, after I finished it, I drove here myself.”
(C) “I really like history books and I was reading one at home today while eating tuna fish.”
(D) “I started driving but was thinking about my history. History books are great. I once wrote a paper on Alexander the Great. I do well in college.”
(E) “The spy in the book I was reading is real, and he was watching me through the pages. He knew who I was.”
Respuesta: D
The correct answer is D. Flight of ideas is non-goal directed speech that reflects a rapid jumping of thoughts through a series of weakly related ideas. “I started driving but was thinking about my history. History books are great. I once wrote a paper on Alexander the Great. I do well in college,” demonstrates this process. The sentences are abruptly and tenuously connected. The “great” in “history books” is the topic for the reference to “Alexander the Great,” which was the subject of a paper. The paper was likely an assignment written in college, which led to the reference to “do(ing) well in college.” The patient did not answer the question she was asked.
“I drove here myself” (Choice A) is a goal-directed, linear statement.
“I was reading a great book at home and, after I finished it, I drove here myself” (Choice B) is an example of circumstantiality. The answer is overly detailed, but the question is ultimately answered. The mention of the book is vaguely related to the patient’s driving herself to the emergency department.
“I really like history books and I was reading one at home today while eating tuna fish” (Choice C) is an example of tangentiality. The question is not answered; however, proper words and grammar are used, and ideas flow from a train of thought.
“The spy in the book I was reading is real, and he was watching me through the pages. He knew who I was” (Choice E) is an example of looseness of association. There is a disintegration of a meaningful connection of ideas. In addition, this statement describes paranoia and a delusion of reference and likely also of persecution.
A 45-year-old man is admitted to the ICU for traumarelated injuries sustained in a car accident. Thirty-six hours after admission he becomes agitated. He is pulling at his IV access lines and is disoriented to place and time. His blood pressure is 190/110 mm Hg, and his pulse is 114/min. A reliable history from the patient’s son reveals that the patient is alcohol dependent. Which of the following is the most appropriate next step in management?
(A) Haloperidol
(B) Lithium
(C) Lorazepam
(D) Propranolol
(E) No medication
Respuesta: C
The correct answer is C. This patient is likely beginning to exhibit alcohol withdrawal. Even without full-blown delirium tremens (DTs), alcohol withdrawal can be serious and should be treated. Tremulousness usually develops 6-8 hours after the cessation of drinking. Perceptual symptoms often begin after 8-12 hours, seizures in 12-24 hours, and DTs after 72 hours.
Benzodiazepines are the primary medications for the control of alcohol withdrawal symptoms. Benzodiazepines, such as lorazepam, help with anxiety, shakiness, tachycardia, hypertension, diaphoresis, seizure activity, and delirium. In this situation, lorazepam has advantages over other benzodiazepines in that it can be administered in PO, IM, and IV forms and is not hepatotoxic.
Haloperidol (Choice A) will help with some perceptual disturbances of alcohol withdrawal and may cause a calming effect on agitated behavior, but it will not address the sympathetic hyperactivity, seizures, or alcohol-withdrawal delirium.
Lithium (Choice B) is an antimanic agent used in bipolar disorders and will not treat alcohol withdrawal symptoms.
Propranolol (Choice D) helps block the symptoms of sympathetic hyperactivity; it is not an effective drug for seizures or delirium.
No medication (Choice E) is incorrect because alcohol withdrawal, especially DTs, is a medical emergency that can result in significant morbidity and mortality. Even with treatment, DTs have a mortality rate of approximately 15%. Although this patient is not described as having DTs, treatment with lorazepam will help prevent them from occurring.
A 29-year-old woman consistently meets “the man of her dreams” only to have the relationships fail after a month or two. She views herself as unworthy of being loved and often hurts herself after these relationships fail. She feels depressed if she has no weekend plans and has difficulty controlling both her anger and sadness if she knows she will be alone. When frustrated, she often acts out, impulsively drinking alcohol and having sex with men whom she does not know well, only to find herself feeling empty afterward. Further, she is unhappy in her job and thinks that she could “do better.” Which of the following is the most characteristic defense mechanism used by people who have this personality disorder?
(A) Displacement
(B) Idealization
(C) Intellectualization
(D) Reaction formation
(E) Splitting
Respuesta: E
The correct answer is E. This patient meets the DSM-IV criteria for borderline personality disorder. She has a pervasive pattern of unstable interpersonal relationships, poor self-image, and lack of control of her affect. Her behavior is marked by impulsivity. She feels sad during weekends when she is alone and imagines herself as being abandoned. Her unstable relationships are characterized by alternating between extremes of idealization (“the man of her dreams”) and devaluation.
She appears to have a very poor sense of self, with an inability to find a suitable partner and job. She is impulsive in substance abuse and sexual activity, both of which are potentially self-damaging, and she shows lability of affect because of a marked reactivity of mood. The question did not indicate whether this person is suicidal, although she quite possibly would be; some of the described behaviors of hurting herself may include suicide gestures. One of the most characteristic defense mechanisms associated with borderline personality disorder is splitting, which means that the person psychologically separates positive attributes into one individual and negative attributes into another. Splitting occurs because the person is not able to tolerate her ambivalent feelings toward another individual. Usually, the person is unconscious of her ambivalence toward another and does not realize the extremes of her reaction.
Displacement (Choice A) occurs when the feelings associated with a psychologically unacceptable object, idea, or situation are transferred to another object, idea, or situation. The latter one is often symbolically related to the former. For instance, a woman who is raped by her husband may become angry at the prosecutor who is handling the case because he was 10 minutes late for a meeting.
Idealization (Choice B) occurs when a person unrealistically attributes strictly positive characteristics to another person or situation. In the above example, the person with borderline personality disorder repeatedly believed that she had met the “man of her dreams”; however, this idealization was only short-lived and was quickly replaced with devaluation.
Intellectualization (Choice C) is the transformation of emotionally disturbing events into cognitive challenges that do not recognize the emotional stress. For example, a person who has been rejected for a job she wanted very much says that this is simply a problem of getting her resume into a better format.
Reaction formation (Choice D) occurs when an unacceptable feeling or thought is transformed into its opposite. This often occurs when hate is transformed into love or fear is transformed into empowerment. For instance, a battered woman who has managed to leave her abusive home situation may become involved in work with her local battered women’s shelter.
A 51-year-old Vietnam veteran who has been treated for several months with antidepressants for posttraumatic stress disorder (PTSD) recently began taking a new sleep medication for insomnia. After several days, he calls his doctor complaining of a prolonged and painful erection. The doctor instructs him to stop the medication and immediately come into the emergency department. Which of the following medications is most likely causing this condition?
(A) Chlordiazepoxide
(B) Hydroxyzine
(C) Mirtazapine
(D) Trazodone
(E) Zolpidem
Respuesta: D
The correct answer is D. Priapism is persistent penile erection accompanied by severe pain. It can occur with antidepressants or antipsychotics, but it is most frequently seen with trazodone use (1 in 1000 men). It is a medical emergency that requires evaluation by a urologist.
Chlordiazepoxide (Choice A) belongs to the group of long-acting benzodiazepines and is usually used for detoxification from sedative hypnotics because of its long half-life. It is not used for the treatment of insomnia. Side effects include sedation, amnesia, psychomotor retardation, decreased respiratory response to carbon dioxide, and a potential withdrawal syndrome.
Hydroxyzine (Choice B) is a piperazine derivative that exerts antihistaminic, anticholinergic, mild sedative, and bronchodilator effects. It is used as premedication in anesthesia and in the management of pruritic syndromes. It exerts a mild antianxiety effect. It is not used as a hypnotic. Its side effects include drowsiness and dry mouth.
Mirtazapine (Choice C) is a novel antidepressant. It has sedative properties related to its antihistaminic activity; in lower doses, it can be used for treatment of insomnia. It is mainly indicated for the treatment of depression. Side effects include dizziness, weight gain, and increases in serum lipids and transaminases.
Zolpidem (Choice E) is a nonbenzodiazepine hypnotic used for short-term treatment of insomnia. Its most common side effects include headache, dizziness, drowsiness, gastrointestinal symptoms, generalized pain, and myalgias.
A 32-year-old man has chronic paranoid schizophrenia and a history of mild tardive dyskinesia. His psychiatrist recently switched his medication to olanzapine taken at bedtime. The patient smokes approximately a pack of cigarettes daily, weighs 70 kg (154 lb) at a height of 5 feet 10 inches (178 cm), and does not drink alcohol. Which of the following would be the most common adverse side effect of olanzapine in this patient?
(A) Gastrointestinal complications
(B) Orthostatic hypotension
(C) Sedation
(D) Tardive dyskinesia
(E) Weight gain
Respuesta: C
The correct answer is C. Approximately 30% of patients taking the usual maintenance dose of olanzapine experience sedation, making it the most common side effect of the choices listed. The reason that the medication is given at bedtime is to reduce adverse effects of sedation as much as possible. Other much less common side effects of olanzapine include prolactinemia, dizziness, and akathisia.
Gastrointestinal complications (choice A), particularly constipation, are known to be associated with olanzapine use, but are not as common as sedation.
Orthostatic hypotension (choice B) is also a complication of olanzapine use. Patients who take olanzapine should be cautious when rising in the morning or nighttime hours, or when rising from a sitting position, so that they do not lose consciousness or become unsteady. However, orthostatic hypotension is less common than sedation with olanzapine.
Tardive dyskinesia (choice D), a syndrome of abnormal involuntary movements associated with neuroleptic use, has not yet been reported in patients taking olanzapine.
Weight gain (choice E) is a recognized complication of olanzapine use but is not as common as sedation.
A 34-year-old man has had a significantly increased appetite, gained 10 lb, and required increased sleep over the past several months. He has felt severely fatigued during the same time period and describes a heavy feeling in his arms and legs. His brother, a psychiatrist, visits him, notes the complaints, and feels that the sensation he described in his arms and legs is pathognomonic for “leaden paralysis.” This is a characteristic feature of which of the following diagnoses?
(A) Conversion disorder
(B) Major depression with atypical features
(C) Schizophrenia, catatonic type
(D) Schizotypal personality disorder
(E) Somatoform disorder
Respuesta: B
The correct answer is B. Major depression with atypical features is characterized by mood reactivity, in which the patient’s mood brightens in response to actual or potentially positive events, and two or more of the following features: leaden paralysis, significant weight gain or increase in appetite, hypersomnia, or a long-standing pattern of interpersonal rejection sensitivity that results in significant social or occupational impairment. This type of depression differs from other types in that its characteristic psychomotor disturbances are opposite those of others. In other depressions, there is a lack of reactivity to usually pleasurable stimuli. Affected patients do not feel much better, even temporarily, when something good happens. Likewise, in other types of depression, there is usually anorexia and weight loss, and early morning awakening commonly marks the sleep pattern. Further, there typically are no complaints of either a heavy feeling in one’s arms or legs or a sensitivity-based concern of rejection. Atypical depression responds especially well to MAOIs.
Conversion disorder (choice A) is a disturbance of bodily functioning that does not conform to the current concepts of the anatomy and physiology of the central or peripheral nervous systems. It is characterized by one or more symptoms affecting voluntary motor or sensory function that suggest a neurologic or medical condition but cannot be explained by one. It typically occurs in a setting of stress and tends to transform the psychic energy of the turmoil of acute conflict into a personally meaningful metaphor of bodily dysfunction. The symptom is not intentionally produced, as in a factitious disorder or malingering.
Schizophrenia, catatonic type (choice C), is marked by at least two of the following features: immobility suggestive of either catalepsy or stupor, excessive and apparently purposeless motor activity, extreme negativism, peculiar voluntary movement such as posturing, stereotypy, mannerisms, grimacing, echolalia, or echopraxia. There are no common somatic complaints, and leaden paralysis is not typical of this disorder.
Schizotypal personality disorder (choice D) is in the cluster A category of personality disorders. It is marked by a pervasive pattern of social and interpersonal deficits characterized by acute discomfort with, and reduced capacity for, close relationships. There also are cognitive or perceptual distortions and eccentricities of behavior that begin by early adulthood. Furthermore, there must be five of the following features: ideas of reference, odd beliefs that influence behavior, unusual perceptual experiences, odd thinking and speech, suspiciousness, inappropriate affect, eccentric behavior, and lack of close friends. As in schizophrenia, there are no common somatic complaints, and leaden paralysis is not typical of this disorder.
Somatoform disorder (choice E) is not a disorder in and of itself. There are five specific somatoform disorders: somatization disorder, conversion disorder, pain disorder, hypochondriasis, and body dysmorphic disorder.
Available clinical evidence indicates that individuals who are homozygous for the Apo E4 gene are at increased risk of developing Alzheimer disease. However, laboratory testing aimed at the identification of Apo E4 carriers does not appear adequate as a screening test for early detection of this risk factor. Which of the following is the most commonly suggested reason for not using Apo E allele determination as a screening test?
(A) The disease does not have a preclinical (asymptomatic) stage
(B) The disease is not preventable or treatable
(C) The disease is not sufficiently prevalent
(D) The disease is not sufficiently serious
(E) The test is not sufficiently accurate
(F) The test is not sufficiently sensitive
Respuesta: B
The correct answer is B. There are three allelic forms of this gene, e2, e3, and e4. Clinical studies have shown that the allele e4 of apolipoprotein E (Apo E) increases the risk for late-onset Alzheimer disease (AD), especially in homozygous individuals. However, its use as a screening tool to identify individuals who have an increased risk of developing AD is highly controversial, mainly because there are no known effective methods to prevent AD or cure it once it manifests. The clinical usefulness of a screening test for early detection of diseases or predisposing factors is based on a number of criteria, including the following: the disease must be sufficiently serious, prevalent, treatable, or preventable, and the test should be sufficiently accurate (i.e., sensitive and specific). Furthermore, a presymptomatic stage should precede the onset of the disease to allow preclinical or early detection.
AD has a long preclinical stage (compare with choice A) before its earliest manifestations.
The prevalence of AD is very high (compare with choice C). Approximately 6% of persons older than 65 have varying degrees of AD.
AD is a severe form of dementing disorder and ultimately leads to death within an average of 7-10 years following clinical onset (compare with choice D).
Testing for Apo E phenotype is both sensitive (compare with choice F) and specific (compare with choice E).
A teacher calls the parents of an 8-year-old boy to discuss his poor adjustment to the second grade. He has difficulty sitting still for group activities and needs constant reminders from the teacher not to hit his classmates. He has problems listening in class and does not complete assignments without several reminders. These multiple reminders and behavioral reprimands do not seem to be leading to any improvement. His parents have also been noticing similar problems at home. The boy is sent to a child psychiatrist, who notes increased psychomotor activity with restlessness during the evaluation. The testing revealed no learning disability, and the boy was diagnosed with attention-deficit hyperactivity disorder. This boy is at a higher risk than the normal population to have which of the following comorbid disorders?
(A) Asperger disorder
(B) Autistic disorder
(C) Anxiety disorder
(D) Oppositional defiant disorder
(E) Schizophrenia, undifferentiated type
Respuesta: D
The correct answer is D. The most common comorbid disorders found in both clinical and epidemiologic samples of children with attention-deficit hyperactivity disorder (ADHD) are oppositional defiant disorder (ODD) and conduct disorder (CD). Typically these children display argumentative behavior and attitudes, temper tantrums, defiance of authority and rules, and aggressive, antisocial behavior in addition to the symptoms of ADHD. The rate of concurrent ADHD and ODD is 35%; the combination of concurrent ODD or CD and ADHD is 50 to 60%. Interestingly, school-aged children with ODD or CD almost invariably meet criteria for ADHD; yet, it is more common for adolescents with ODD or CD to not have a concurrent diagnosis of ADHD. Other influences that seem to correlate ODD and CD with ADHD include greater symptom severity, reading disorder, lower socioeconomic status, and parental alcoholism. Short-acting psychostimulants are the first- line treatment for the pharmacotherapy of ADHD, mostly because of their ability to improve both behavioral and cognitive problems in 70 to 80% of affected children. However, behavioral improvements do not always lead to complete remission of symptoms. There often is significant residual ADHD symptomatology, as well as peer and academic problems, even after treatment.
Asperger disorder (choice A) is a pervasive developmental disorder characterized by qualitative impairment in social interaction, restricted and repetitive stereotyped patterns of behavior, and no clinically significant language or cognitive delay. Persons with this disorder do not have difficulty in the development of age- appropriate self-help skills or adaptive behavior that children with ADHD often have. Rather, children with Asperger disorder often do not play with others and are seen more as aloof, introverted, and bizarre in comparison to the disruptive and extroverted behavior of children with ADHD.
Autistic disorder (choice B), like Asperger disorder, is a pervasive developmental disorder. It causes impairment in social interaction, often with the use of multiple nonverbal behaviors, failure to develop peer relationships, and lack of social or emotional reciprocity. There is a problem in communication, often with delay or total lack in the development of spoken language and stereotyped behavior that may encompass an inflexible adherence to a preoccupation with a specific, nonfunctional routine. Autistic persons often have low IQs and cannot tolerate standard classroom environments. They do not present similarly to children with ADHD.
Anxiety disorder (choice C) is incorrect. Nonetheless, significant comorbidity exists with ADHD and anxiety disorders. The average comorbidity is 25%. With the early onset of ADHD, most diagnoses of anxiety disorders are made after the emergence of ADHD. This suggests that some instances of ADHD-anxiety disorder comorbidity are possibly secondary to the experience of enduring the chronic disorder of ADHD itself. Some differences in patterns of performance on cognitive tasks and reduced cognitive improvement with stimulants distinguish children with ADHD plus anxiety and those without anxiety.
Schizophrenia, undifferentiated type (choice E) is incorrect. There is no known correlation between ADHD and schizophrenia of any type.
A 22-year-old female student presents to her physician after collapsing in the cafeteria following loud joking and laughter with her friends. She describes loss of muscle tone after she fell but no loss of consciousness. On further examination, she reveals a 4- month history of increased daytime sleepiness, with several episodes of falling asleep during her classes. She believed that the episodes were related to poor sleep because of vivid dreams she had on falling asleep. Which of the following is the most likely diagnosis?
(A) Catalepsy
(B) Kleine-Levin syndrome
(C) Narcolepsy
(D) Periodic paralysis
(E) Primary hypersomnia
Respuesta: C
The correct answer is C. Narcolepsy is diagnosed by irresistible attacks of refreshing sleep that occur during the day over at least 3 months. It is characterized by the presence of cataplexy (brief episodes of sudden loss of muscle tone throughout the body mostly in association with intense emotion) or recurrent intrusions of REM sleep in transition between sleep and wakefulness, as manifested by hypnagogic or hypnopompic hallucinations. Narcolepsy occurs most frequently before the age of 30. Sleep paralysis, characterized by the inability to move in the presence of preserved consciousness, is another typical symptom on waking up.
Catalepsy (choice A) is a term for motoric immobility maintained voluntarily and is most commonly seen as a part of schizophrenic symptomatology.
Kleine-Levin syndrome (choice B) is a rare, self-limiting condition consisting of recurrent episodes of prolonged sleep lasting one to several weeks. It begins in childhood, and the wakeful periods are marked by social withdrawal, irritability, confusion, and frank psychotic symptoms, such as delusions or hallucinations.
Periodic paralysis (choice D) is a group of hereditary muscle disorders inherited in autosomal-dominant fashion; it develops in early childhood and adolescence. Attacks occur at rest following heavy exercise or meals rich in carbohydrates. During the attacks, patients are unable to move their limbs. Serum levels of potassium can be below, at, or above normal limits, depending on the type of disorder. Treatment is directed at controlling serum potassium and preventing attacks.
Primary hypersomnia (choice E) is a syndrome of excessive sleepiness for at least 1 month, as evidenced by prolonged sleep or daytime sleep episodes. It causes clinically significant impairment in social functioning. It does not occur secondary to the effects of substance abuse or a general medical condition and does not happen during the course of another sleep disorder.
A 27-year-old woman, after undergoing elective cosmetic breast augmentation surgery, presents to her surgeon dissatisfied with the results and requesting more surgery, even though she has received compliments from both her friends and her boyfriend concerning her new appearance. She has had no medical complications from the procedure. The patient, who weighs about 110 pounds, tells her surgeon that she has been preoccupied with her breast size since she was a teenager and that she has had difficulties in relationships with previous boyfriends because she felt that they viewed her as inadequately feminine. She describes that she has also had difficulties dating in the past because of the excessive amount of time she spends working out at the gym and jogging to maintain her figure. Which of the following would be the most appropriate diagnosis in this patient?
(A) Adjustment disorder with disturbance of emotion
(B) Body dysmorphic disorder
(C) Borderline personality disorder
(D) Hypochondriasis
(E) Somatoform disorder, not otherwise specified
Respuesta: B
The correct answer is B. Body dysmorphic disorder involves a preoccupation with an imagined defect in appearance, which causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The preoccupation is not better accounted for by another mental disorder, such as the dissatisfaction with body shape and size found in anorexia nervosa. The fact that this patient has had social difficulties because of her perception of her body shape points to body dysmorphic disorder as the most appropriate diagnosis.
Adjustment disorder with disturbance of emotion (Choice A) requires both a recent stressor and some symptoms of depression, which this patient does not report.
The patient does not have evidence of borderline personality disorder (Choice C), as she does not have an unstable self-image or sense of self, and she does not have any recurrent suicidal behavior or gestures required for this diagnosis.
Hypochondriasis (Choice D) requires a preoccupation with fears of having a serious disease based on the person’s misinterpretation of bodily symptoms. The belief is not restricted to a circumscribed concern about appearance (as in body dysmorphic disorder).
Somatoform disorder, not otherwise specified (Choice E), includes false beliefs (for example, that one is pregnant when actually not) or disorders that involve unexplained physical complaints (such as fatigue or body weakness) of less than 6 months’ duration that are not due to another mental disorder.
