Course and prognosis US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Course and prognosis. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Course and prognosis US Medical PG Question 1: A 35-year-old woman is brought to the inpatient psychiatric unit by the police after she was found violating the conditions of her restraining order by parking on the side street of her "lover’s" home every night for the past week. Her "lover", a famous hometown celebrity, has adamantly denied any relationship with the patient over the past 6 months. The patient insists that ever since he signed a copy of his album at a local signing, she knew they were in love. Despite him having his own wife and children, the patient insists that he is in love with her and goes to his house to meet in secret. Physical examination of the patient is unremarkable. Urine toxicology is negative. Which of the following statements best describes this patient’s condition?
- A. The patient will have concurrent psychotic disorders.
- B. The disorder must meet 2 out of the 5 core criteria.
- C. Symptoms must be present for at least 4 weeks. (Correct Answer)
- D. This disorder has a high prevalence rate.
- E. Patients may have a contributing medical condition.
Course and prognosis Explanation: ***Symptoms must be present for at least 4 weeks.***
- This patient presents with symptoms highly suggestive of **delusional disorder, erotomanic type**, where the primary delusion is that another person, usually of higher status, is in love with them. For a diagnosis of delusional disorder, the DSM-5 criteria state that the presence of one or more delusions must persist for **at least 1 month**.
- The patient's unwavering belief in a secret relationship with a celebrity, despite clear evidence to the contrary and the celebrity's denial, aligns with the characteristics of a **fixed, nonbizarre delusion**, which is the hallmark of delusional disorder.
*The patient will have concurrent psychotic disorders.*
- In **delusional disorder**, by definition, the patient typically does **not experience other psychotic symptoms** like prominent hallucinations, disorganized speech, or grossly disorganized/catatonic behavior.
- If other psychotic symptoms are prominent, the diagnosis would likely shift to **schizophrenia** or **schizoaffective disorder**, not delusional disorder.
*The disorder must meet 2 out of the 5 core criteria.*
- This statement refers to the diagnostic criteria for **schizophrenia**, which requires two or more of the five core symptoms (delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behavior, negative symptoms).
- Delusional disorder is characterized primarily by the presence of **nonbizarre delusions** without meeting the full criteria for schizophrenia.
*This disorder has a high prevalence rate.*
- **Delusional disorder** is relatively **uncommon**, with an estimated lifetime prevalence of about 0.2%.
- It is one of the **less common psychotic disorders**, especially when compared to schizophrenia or mood disorders with psychotic features.
*Patients may have a contributing medical condition.*
- While medical conditions can sometimes cause psychotic symptoms (e.g., **substance-induced psychosis** or psychosis due to another medical condition), this is typically excluded in the diagnosis of **primary delusional disorder**.
- The patient's urine toxicology is negative, and her physical examination is unremarkable, suggesting that her symptoms are not due to a medical condition or substance use.
Course and prognosis US Medical PG Question 2: A 26-year-old woman thinks poorly of herself and is extremely sensitive to criticism. She is socially inhibited and has never had a romantic relationship, although she desires one. Which of the following is the most likely diagnosis?
- A. Schizoid personality disorder
- B. Paranoid personality disorder
- C. Depression
- D. Dysthymia
- E. Avoidant personality disorder (Correct Answer)
Course and prognosis Explanation: ***Avoidant personality disorder***
- Characterized by **social inhibition**, feelings of **inadequacy**, and **hypersensitivity to negative evaluation**, leading to avoidance of social interactions despite a desire for connection.
- The patient's self-perception, sensitivity to criticism, and absence of romantic relationships are classic signs.
*Schizoid personality disorder*
- Individuals with schizoid personality disorder exhibit a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression.
- Unlike avoidant personality disorder, they typically **do not desire social connection** and are indifferent to criticism or praise.
*Paranoid personality disorder*
- Marked by pervasive **distrust and suspiciousness of others**, interpreting their motives as malevolent.
- This patient's symptoms are more focused on self-perception and social anxiety rather than paranoid ideation.
*Depression*
- Depression involves a sustained period of **low mood**, loss of interest or pleasure, and other vegetative symptoms, which are not explicitly described as the primary, long-standing issue here.
- While feelings of worthlessness can occur in depression, the chronic, pervasive social inhibition and desire for relationships point away from a primary depressive episode as the sole diagnosis.
*Dysthymia*
- Dysthymia, or persistent depressive disorder, is characterized by a chronically depressed mood for at least two years, but it usually includes more pervasive depressive symptoms like low energy and anhedonia.
- While it can involve poor self-esteem, it doesn't fully explain the specific pattern of social avoidance and hypersensitivity to criticism, especially the patient's desire for social connection, which is often dampened in dysthymia.
Course and prognosis US Medical PG Question 3: A 20-year-old male is involuntarily admitted to the county psychiatric unit for psychotic behavior over the past three months. The patient's mother explained to the psychiatrist that her son had withdrawn from family and friends, appeared to have no emotions, and had delusions that he was working for the CIA. When he spoke, his sentences did not always seem to have any connection with each other. The mother finally decided to admit her son after he began stating that he "revealed too much information to her and was going to be eliminated by the CIA." Which of the following diagnoses best fits this patient's presentation?
- A. Schizophrenia
- B. Brief psychotic disorder
- C. Schizophreniform disorder (Correct Answer)
- D. Schizoid personality disorder
- E. Schizotypal personality disorder
Course and prognosis Explanation: ***Schizophreniform disorder***
- The patient exhibits classic symptoms of **psychosis**, including delusions, disorganized speech, flat affect, and social withdrawal, which are characteristic of schizophrenia spectrum disorders.
- The duration of symptoms (3 months) fits the criteria for **schizophreniform disorder**, which is when psychotic symptoms last between 1 month and 6 months.
*Schizophrenia*
- Schizophrenia requires symptoms to be present for at least **6 months**, including at least 1 month of active-phase symptoms.
- While this patient's symptoms are consistent with psychotic disorder, the **duration criteria** for schizophrenia have not yet been met.
*Brief psychotic disorder*
- Brief psychotic disorder is characterized by symptoms lasting from **1 day to 1 month**, with eventual full return to premorbid functioning.
- The patient's symptoms have persisted for **3 months**, exceeding the maximum duration for brief psychotic disorder.
*Schizoid personality disorder*
- This disorder is characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression.
- While the patient exhibits social withdrawal, the presence of **delusions, disorganized speech, and flat affect** indicates a psychotic disorder, not merely a personality disorder.
*Schizotypal personality disorder*
- Schizotypal personality disorder involves pervasive social and interpersonal deficits with **cognitive or perceptual distortions** and eccentric behaviors.
- While it can involve odd beliefs, it does not typically include the prominent, fixed, and systematized **delusions and disorganized speech** seen in this patient's presentation.
Course and prognosis US Medical PG Question 4: A 21-year-old woman is brought by her mother to a psychiatrist due to concerns about her behavior. The patient’s mother tells the psychiatrist that she believes that a famous Hollywood celebrity actor loves her and will marry her. When the patient is asked about this, she says that she attended a function at which this actor was the guest of honor six months back, and he waved his hand at her by which she understood that he loves her. However, when she tries to contact him over the phone, he does not respond, which she says is probably because he is too busy with his career at present. When asked why the successful actor would marry her, she says, “Celebrities often prefer to marry ordinary people and that is why he expressed his interest in me that day”. The patient is otherwise healthy with no known medical condition. She denies any mood disturbances, hallucinations, or anxiety. She is currently working as an assistant manager at a private advertising firm and has a normal socio-occupational life. Which of the following is the most likely diagnosis in this patient?
- A. Schizotypal personality disorder
- B. Schizophreniform disorder
- C. Delusional disorder (Correct Answer)
- D. Schizoid personality disorder
- E. Schizophrenia
Course and prognosis Explanation: ***Delusional disorder***
- The patient exhibits a **non-bizarre delusion** (erotomanic type) that a famous actor is in love with her, which is a key characteristic of delusional disorder.
- She maintains a relatively **normal socio-occupational life** and **lacks other psychotic symptoms** (hallucinations, mood disturbances), which differentiates it from other psychotic disorders.
*Schizotypal personality disorder*
- Characterized by pervasive patterns of **social and interpersonal deficits**, cognitive or perceptual distortions, and eccentricities of behavior.
- While there might be odd beliefs, they don't typically reach the **convictional intensity of a delusion** and are accompanied by social isolation and discomfort.
*Schizophreniform disorder*
- Involves symptoms similar to schizophrenia (hallucinations, delusions, disorganized speech/behavior, negative symptoms) but with a **duration between 1 and 6 months**.
- The patient here only presents with a delusion, **lacks other prominent psychotic symptoms**, and her functionality is preserved, making this unlikely.
*Schizoid personality disorder*
- Defined by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression in interpersonal settings.
- This patient maintains a **normal socio-occupational life** and her primary issue is a specific delusion, not social withdrawal or emotional flatness.
*Schizophrenia*
- Requires two or more characteristic symptoms (delusions, hallucinations, disorganized speech, disorganized behavior, negative symptoms) for at least **6 months**, with significant impact on functioning.
- This patient's symptoms are limited to a **non-bizarre delusion**, and her **socio-occupational functioning is intact**, ruling out schizophrenia.
Course and prognosis US Medical PG Question 5: A 24-year-old woman is brought to the hospital by her mother because she has "not been herself" for the past 3 months. The patient says she hears voices in her head. The mother said that when she is talking to her daughter she can’t seem to make out what she is saying; it is as if her thoughts are disorganized. When talking with the patient, you notice a lack of energy and an apathetic affect. Which of the following is the most likely diagnosis for this patient?
- A. Major depressive disorder
- B. Schizophrenia
- C. Brief psychotic disorder
- D. Schizotypal disorder
- E. Schizophreniform disorder (Correct Answer)
Course and prognosis Explanation: ***Schizophreniform disorder***
- The patient exhibits core **psychotic symptoms** (hearing voices, disorganized thoughts) for a duration of **3 months**, which is characteristic of schizophreniform disorder (symptoms lasting **1 to 6 months**).
- Her **lack of energy** and **apathetic affect** align with the negative symptoms commonly seen in psychotic disorders.
*Major depressive disorder*
- While **lack of energy** and **apathetic affect** can be present, the prominent **hallucinations** (hearing voices) and **disorganized thoughts** are not primary features of major depressive disorder.
- A diagnosis of depression alone would not fully account for her psychotic symptoms.
*Schizophrenia*
- Schizophrenia requires symptoms to be present for **at least 6 months**, including at least one month of **active phase symptoms**. This patient's symptoms have only been present for 3 months.
- While the symptoms are consistent with schizophrenia, the **duration criterion** has not yet been met.
*Brief psychotic disorder*
- Brief psychotic disorder is characterized by psychotic symptoms lasting **less than 1 month**. This patient's symptoms have been ongoing for 3 months.
- The chronicity of symptoms makes this diagnosis unlikely.
*Schizotypal disorder*
- Schizotypal disorder is a **personality disorder** characterized by peculiar thoughts and behaviors, but typically **without overt psychotic episodes** or pronounced disorganized speech/hallucinations as described.
- While there may be odd beliefs or ideas of reference, the clear **auditory hallucinations** and **thought disorder** in this case point to a more severe psychotic condition.
Course and prognosis US Medical PG Question 6: A 16-year-old boy is brought in to a psychiatrist's office by his mother for increasingly concerning erratic behavior. Her son has recently entered a new relationship, and he constantly voices beliefs that his girlfriend is cheating on him. He ended his last relationship after voicing the same beliefs about his last partner. During the visit, the patient reports that these beliefs are justified, since everyone at school is “out to get him.” He says that even his teachers are against him, based on their criticism of his schoolwork. His mother adds that her son has always held grudges against people and has always taken comments very personally. The patient has no psychiatric history and is in otherwise good health. What condition is this patient genetically predisposed for?
- A. Antisocial personality disorder
- B. Major depressive disorder
- C. Narcolepsy
- D. Substance use disorder
- E. Schizophrenia (Correct Answer)
Course and prognosis Explanation: ***Schizophrenia***
- The patient's symptoms of **pervasive distrust**, **suspiciousness**, beliefs that others are "out to get him," and taking comments personally are characteristic of **paranoid personality disorder**.
- **Paranoid personality disorder (PPD)** is considered part of the **schizotypal spectrum** or **cluster A personality disorders**, and individuals with PPD have a higher genetic predisposition to develop **schizophrenia** and other psychotic disorders.
*Antisocial personality disorder*
- This disorder is characterized by **disregard for and violation of the rights of others**, impulsivity, and lack of remorse, which are not the primary features described here.
- While individuals with this disorder may exhibit manipulative behavior, their core issue is not paranoid ideation but rather a pattern of social irresponsibility and law-breaking.
*Major depressive disorder*
- This condition is characterized by **persistent sadness**, loss of interest or pleasure, and other vegetative symptoms, which are not present in this patient's presentation.
- The patient's primary symptoms revolve around **paranoia and suspiciousness**, not mood disturbances.
*Narcolepsy*
- Narcolepsy is a **neurological condition** characterized by overwhelming daytime sleepiness and sudden attacks of sleep.
- This diagnosis is entirely unrelated to the patient's psychological symptoms of paranoia and distrust.
*Substance use disorder*
- While substance use can sometimes induce paranoid thinking, the patient's long-standing history of **grudges** and taking comments personally, even prior to potential substance exposure (implied by no psychiatric history mentioned for substance abuse), suggests a more ingrained personality trait rather than solely substance-induced paranoia.
- There is **no information provided about substance use**, making this a less likely primary condition or genetic predisposition.
Course and prognosis US Medical PG Question 7: A previously healthy 56-year-old woman comes to the family physician for a 1-month history of sleep disturbance and sadness. The symptoms have been occurring since her husband died in a car accident. Before eventually falling asleep, she stays awake for multiple hours and has crying spells. Several times she has been woken up by the sound of her husband calling her name. She has lost 3 kg (6.6 lb) over the past month. She has 3 children with whom she still keeps regular contact and regularly attends church services with her friends. She expresses feeling a great feeling of loss over the death of her husband. She has no suicidal ideation. She is alert and oriented. Neurological exam shows no abnormalities. Which of the following is the most likely diagnosis for this patient's symptoms?
- A. Adjustment disorder with depressed mood
- B. Acute stress disorder
- C. Major depressive disorder
- D. Normal bereavement (Correct Answer)
- E. Schizoaffective disorder
Course and prognosis Explanation: ***Normal bereavement***
- The patient's symptoms (sleep disturbance, sadness, weight loss, crying spells, auditory hallucinations of a loved one) are all **common and expected responses to the death of a loved one** within a short timeframe (1 month).
- Her continued social engagement and lack of suicidal ideation suggest that her grief, while intense, is within the range of **normal bereavement**, especially given the recent and traumatic loss.
*Adjustment disorder with depressed mood*
- This diagnosis is considered when symptoms in response to a stressor are **clinically significant** but do not meet criteria for a major depressive episode and cause significant impairment.
- However, in this case, the symptoms are directly related to the death of her husband, making **bereavement a more specific and appropriate diagnosis** if the symptoms are within normal grief.
*Acute stress disorder*
- This disorder typically involves exposure to actual or threatened **death, serious injury, or sexual violence**, followed by intrusive symptoms, negative mood, dissociation, avoidance, and arousal symptoms, and lasts from 3 days to 1 month.
- While there is a significant stressor (husband's death), her symptoms are more indicative of **grief and loss** rather than the specific dissociative, avoidance, and arousal symptom clusters required for acute stress disorder.
*Major depressive disorder*
- While some symptoms overlap (depressed mood, sleep disturbance, weight loss), several factors argue against MDD, such as the direct and recent link to a **major loss**, her **intact social functioning**, and the **absence of suicidal ideation** or pervasive anhedonia beyond grief.
- The **auditory hallucinations of her husband's voice** are also common in normal bereavement, especially shortly after a loss, and do not necessarily indicate a psychotic disorder or MDD with psychotic features in this context.
*Schizoaffective disorder*
- This diagnosis requires a **period of illness during which a major mood episode is present concurrently with Criterion A of schizophrenia** (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms) and delusions or hallucinations for 2 or more weeks in the absence of a major mood episode.
- The patient's isolated auditory hallucination, occurring in the context of profound grief, does not meet the extensive criteria for schizophrenia or schizoaffective disorder, and there are **no other psychotic symptoms** or a history of such.
Course and prognosis US Medical PG Question 8: A 36-year-old woman comes to the physician because of an 8-month history of occasional tremor. The tremor is accompanied by sudden restlessness and nausea, which disrupts her daily work as a professional violinist. The symptoms worsen shortly before upcoming concerts but also appear when she goes for a walk in the city. She is concerned that she might have a neurological illness and have to give up her career. The patient experiences difficulty falling asleep because she cannot stop worrying that a burglar might break into her house. Her appetite is good. She drinks one glass of wine before performances "to calm her nerves" and otherwise drinks 2–3 glasses of wine per week. The patient takes daily multivitamins as prescribed. She appears nervous. Her temperature is 36.8°C (98.2°F), pulse is 92/min, and blood pressure is 135/80 mm Hg. Mental status examination shows a full range of affect. On examination, a fine tremor on both hands is noted. She exhibits muscle tension. The remainder of the neurological exam shows no abnormalities. Which of the following is the most likely explanation for this patient's symptoms?
- A. Atypical depressive disorder
- B. Adjustment disorder
- C. Generalized anxiety disorder (Correct Answer)
- D. Panic disorder
- E. Essential tremor
Course and prognosis Explanation: ***Generalized anxiety disorder***
- The patient exhibits persistent and excessive worry about various life circumstances (performance, burglaries, general anxiety), accompanied by physical symptoms like **restlessness**, muscle tension, and sleep disturbances, which are hallmark features of **Generalized Anxiety Disorder (GAD)**.
- The symptoms have been present for **8 months**, exceed the diagnostic duration for GAD (at least 6 months), and are not clearly tied to a specific stressor or episodic panic attacks.
*Atypical depressive disorder*
- Atypical depression is characterized by mood reactivity, increased appetite/weight gain, hypersomnia, leaden paralysis, and interpersonal rejection sensitivity.
- This patient reports difficulty sleeping (*insomnia*) and primarily presents with anxiety symptoms, not depressive mood.
*Adjustment disorder*
- **Adjustment disorder** involves emotional or behavioral symptoms in response to an identifiable stressor, occurring within 3 months of the stressor's onset, and usually resolving within 6 months after the stressor or its consequences have ceased.
- The patient's symptoms are chronic (8 months), excessive, and not solely linked to *one* identifiable recent stressor, but rather a pervasive pattern of worry.
*Panic disorder*
- **Panic disorder** is characterized by recurrent unexpected **panic attacks** with sudden onset of intense fear and physical symptoms (e.g., palpitations, dyspnea, dizziness).
- While she experiences sudden restlessness and nausea related to performances, these are specific triggers and not unexpected, unprovoked panic attacks. The primary pattern is persistent worry, not recurrent panic attacks.
*Essential tremor*
- **Essential tremor** is a neurological condition causing an *action tremor*, often visible when performing daily tasks, and typically improves with alcohol.
- While she has a tremor that improves with alcohol, the presence of marked and pervasive psychological symptoms like severe worrying, restlessness, and insomnia point to an underlying anxiety disorder, not solely an isolated neurological tremor.
Course and prognosis US Medical PG Question 9: A previously healthy 36-year-old man is brought to the physician by a friend because of fatigue and a depressed mood for the past few weeks. During this time, he has not been going to work and did not show up to meet his friends for two bowling nights. The friend is concerned that he may lose his job. He spends most of his time alone at home watching television on the couch. He has been waking up often at night and sometimes takes 20 minutes to go back to sleep. He has also been drinking half a pint of whiskey per day for 1 week. His wife left him 4 weeks ago and moved out of their house. His vital signs are within normal limits. On mental status examination, he is oriented to person, place and time. He displays a flattened affect and says that he “doesn't know how he can live without his wife.” He denies suicidal ideation. Which of the following is the next appropriate step in management?
- A. Prescribe a short course of alprazolam
- B. Hospitalize the patient
- C. Initiate cognitive behavioral therapy (Correct Answer)
- D. Initiate disulfiram therapy
- E. Prescribe a short course of duloxetine
Course and prognosis Explanation: ***Initiate cognitive behavioral therapy***
- The patient exhibits features of **adjustment disorder with depressed mood**, characterized by significant distress or impairment in functioning in response to an identifiable stressor (wife leaving).
- **Cognitive behavioral therapy (CBT)** is an effective first-line treatment for adjustment disorders, helping patients develop coping strategies and restructure negative thought patterns.
*Prescribe a short course of alprazolam*
- **Alprazolam**, a benzodiazepine, can provide temporary relief for anxiety but does not address the underlying issues of adjustment disorder and carries risks of **dependence** and withdrawal.
- It would be inappropriate as a sole initial treatment and could exacerbate his **alcohol use**.
*Hospitalize the patient*
- The patient denies **suicidal ideation** and does not present with acute psychosis or severe impairment that would warrant **hospitalization**.
- His orientation and ability to engage in conversation further suggest an outpatient approach is safe and appropriate.
*Initiate disulfiram therapy*
- **Disulfiram** is used for alcohol dependence to deter drinking, but the patient's current alcohol use is a recent development in response to stress, not necessarily full-blown **alcohol dependence** requiring disulfiram.
- Addressing the underlying **adjustment disorder** is the priority, which may in turn reduce his alcohol consumption.
*Prescribe a short course of duloxetine*
- **Duloxetine** is an antidepressant that is not indicated for **adjustment disorder** as a first-line treatment, especially given the short duration and clear precipitating factor.
- **Psychotherapy**, like CBT, is generally the preferred initial intervention for adjustment disorders.
Course and prognosis US Medical PG Question 10: A 43-year-old woman is brought to the physician by her daughter because she has been intermittently crying for 6 hours and does not want to get out of bed. Her symptoms started after she was fired yesterday from her job of 20 years. She says she feels sad and does not understand what she will do with her life now. She uses an over-the-counter inhaler as needed for exercise-induced asthma, and recently started oral isotretinoin for acne. She used to smoke a pack of cigarettes per day, but for the last year she has decreased to 2 cigarettes daily. She appears sad and very upset. Her temperature is 37°C (98.6°F), pulse is 110/min, respirations are 20/min, and blood pressure is 140/80 mm Hg. Physical examination shows no other abnormalities. On mental status examination, she is oriented to person, place, and time. She maintains eye contact and follows instructions. She denies suicidal ideation. Which of the following is the most likely explanation for this finding?
- A. Drug-related depression
- B. Acute stress disorder
- C. Adjustment disorder
- D. Major depressive disorder
- E. Normal stress reaction (Correct Answer)
Course and prognosis Explanation: ***Normal stress reaction***
- The patient's symptoms (crying, sadness, not wanting to get out of bed) are a direct, understandable emotional response to a significant recent stressor (being fired from a 20-year job). This type of reaction is **expected and transient** in response to acute life changes.
- The duration of symptoms is short (6 hours), and there is **no evidence of significant functional impairment** beyond the initial emotional distress, nor does she meet criteria for a mental disorder.
*Drug-related depression*
- While **isotretinoin has been associated with mood changes**, including depression, the acute onset and direct temporal relationship to a significant psychosocial stressor make a drug-related cause less likely as the primary explanation.
- There are no other features pointing to drug-induced etiology, and her symptoms are clearly linked to the job loss.
*Acute stress disorder*
- Acute stress disorder symptoms (e.g., intrusive thoughts, negative mood, dissociation, avoidance, arousal) typically involve exposure to an **actual or threatened traumatic event**, such as death or serious injury, which is not the case here.
- The symptom duration for acute stress disorder is also typically 3 days to 1 month, and the patient's symptoms are of much shorter duration and less severe.
*Adjustment disorder*
- Adjustment disorder involves significant emotional or behavioral symptoms in response to an identifiable stressor, but these symptoms must cause **marked distress in excess of what would be expected** or significant impairment in social or occupational functioning.
- Given the magnitude of the stressor (losing a 20-year job), the patient's reaction is within the range of a normal and expected emotional response, rather than excessive or impairing functionality long-term.
*Major depressive disorder*
- Major depressive disorder requires a cluster of specific symptoms (e.g., anhedonia, sleep disturbance, appetite changes, low energy, feelings of worthlessness) lasting for at least **two weeks**, causing clinically significant distress or impairment.
- The patient's symptoms are acute (6 hours), directly linked to an external event, and do not yet meet the duration or full criteria for a major depressive episode.
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