Narcissistic personality disorder US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Narcissistic personality disorder. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Narcissistic personality disorder US Medical PG Question 1: The prison doctor sees a 25-year-old man for some minor injuries sustained during a recent lunchroom brawl. The patient has a long history of getting into trouble. During his interview, he seems very charming and carefully deflects all responsibility to others and gets irritable and hostile once probed on the issues. He is married and has 2 young children for whom he does not pay child support. Which of the following details is most critical for diagnosing this patient’s condition?
- A. Criminal record
- B. History of substance abuse
- C. Family history
- D. Evidence of lack of remorse
- E. Childhood history (Correct Answer)
Narcissistic personality disorder Explanation: ***Childhood history***
- A diagnosis of **Antisocial Personality Disorder (ASPD)** requires evidence of **conduct disorder** symptoms beginning before age 15. The childhood history provides insight into the chronicity and developmental pattern of pervasive disregard and violation of the rights of others.
- The patient's current presentation of deceitfulness, impulsivity, irritability, and irresponsibility, along with a "long history of getting into trouble," aligns with ASPD criteria, which must be contextualized by their early onset of behavioral problems.
*Criminal record*
- While a criminal record often accompanies ASPD, it is a consequence of the disorder rather than a diagnostic criterion in itself. Many individuals with ASPD engage in criminal behavior, but the diagnosis focuses on a broader pattern of *disregard for the rights of others*, not just legal infractions.
- While it supports the pattern of antisocial behavior, it doesn't provide the crucial developmental information (onset before age 15) required for diagnosis.
*History of substance abuse*
- **Substance abuse** is highly comorbid with ASPD, often used as a coping mechanism or as a direct consequence of impulsive and risky behaviors. However, it is not a direct criterion for ASPD itself.
- While relevant to the patient's overall clinical picture and management, it does not directly contribute to the diagnostic criteria for ASPD.
*Family history*
- A family history of mental health disorders, including personality disorders, can increase the risk of developing ASPD, indicating a genetic predisposition. However, it is not a diagnostic criterion.
- While useful for understanding risk factors, family history does not provide specific information about the patient's individual behavioral patterns or the onset of symptoms crucial for diagnosis.
*Evidence of lack of remorse*
- **Lack of remorse** is an important diagnostic criterion for ASPD, demonstrating a profound deficit in empathy and moral reasoning. It's evident in the patient's deflection of responsibility.
- While a critical symptom, it's one of several criteria. Without evidence of a conduct disorder in childhood, even significant interpersonal impairment and lack of remorse in adulthood may not lead to an ASPD diagnosis.
Narcissistic personality disorder US Medical PG Question 2: A 29-year-old woman is hospitalized due to depression and suicidal ideation. She has a 5-year history of chaotic relationships that last only a few short weeks or months. Each relationship has left her feeling abandoned, empty, and extremely upset. During these periods, the patient confesses to shopping and making big purchases on impulse. She says she gets bored easily and moves on to the next adventure. The patient denies any changes in appetite, energy level, or concentration. On examination, multiple linear lacerations of varying phases of healing were noted on her forearms and trunk. Following consultation, she praises physicians to be ‘the best people on the planet’, but when the nurse came in to take her blood, she furiously stated that ‘all nurses are incompetent and cruel’. Which of the following is the most likely diagnosis?
- A. Borderline personality disorder (Correct Answer)
- B. Histrionic personality disorder
- C. Major depressive disorder (MDD)
- D. Bipolar I disorder
- E. Factitious disorder
Narcissistic personality disorder Explanation: ***Borderline personality disorder***
- This condition is characterized by a pervasive pattern of **instability in interpersonal relationships**, **self-image**, and **affects**, along with marked impulsivity, as evidenced by chaotic relationships, feelings of abandonment, and impulsive shopping.
- The patient's rapid shift from idealizing physicians to devaluing nurses (the "best people" to "incompetent and cruel") is characteristic of **splitting**, a common defense mechanism in borderline personality disorder, and the self-inflicted lacerations indicate **self-harm**, another hallmark feature.
*Histrionic personality disorder*
- Characterized by **excessive emotionality** and **attention-seeking behavior**, often through dramatic and sexually provocative means.
- While there may be some superficial overlap in relationship instability, the primary symptoms of splitting, impulsivity (shopping), and self-harm are less prominent here than in borderline personality disorder.
*Major depressive disorder (MDD)*
- While the patient exhibits **depression and suicidal ideation**, MDD typically involves core symptoms like persistent sadness, anhedonia, and changes in appetite, sleep, and energy, which the patient denies ("denies any changes in appetite, energy level, or concentration").
- The long-standing pattern of chaotic relationships, impulsivity, and splitting points away from MDD as the primary diagnosis, suggesting a more pervasive personality difficulty.
*Bipolar I disorder*
- This disorder is characterized by distinct periods of **mania or hypomania** alternating with depressive episodes.
- While impulsivity can be seen in hypomanic/manic states, the patient's symptoms are described as persistent emotional instability and chaotic relationships present for five years, rather than episodic changes in mood and energy, and she denies changes in appetite or energy.
*Factitious disorder*
- Involves **falsification of physical or psychological signs or symptoms**, or induction of injury or disease, associated with identified deception, to assume the sick role.
- Although the patient has self-inflicted lacerations, this behavior is more consistent with **self-harm** seen in borderline personality disorder as a coping mechanism for emotional distress, rather than a deliberate attempt to deceive medical professionals for secondary gain.
Narcissistic personality disorder US Medical PG Question 3: A 60-year-old man is brought to the emergency department after a fall. He has been seen by the triage nurse but has not been evaluated by a physician. He is heard yelling down the hallway, requesting to speak to “whoever is in charge.” He refuses to talk to the emergency resident and insists on talking to the attending physician despite being informed that the attending is currently resuscitating a patient who was in a car accident. He says that he deserves better treatment because he has made numerous contributions to the field of medicine. When asked about his work, he mentions that he was a medical device salesman. He is accompanied by his wife, who appears embarrassed. She claims that her husband frequently makes a scene and apologizes for her husband's behavior. On mental status examination, the patient is oriented to person, place, and time. He appears agitated and speaks in short, pressured sentences. There is no disorder of thought process or content. Which of the following is the most likely diagnosis?
- A. Acute stress disorder
- B. Bipolar disorder
- C. Histrionic personality disorder
- D. Narcissistic personality disorder (Correct Answer)
- E. Obsessive compulsive personality disorder
Narcissistic personality disorder Explanation: ***Narcissistic personality disorder***
- The patient's exaggerated sense of importance, belief that he deserves special treatment, and grandiosity (claiming to have made "numerous contributions to the field of medicine" despite being a medical device salesman) are classic signs of **narcissistic personality disorder**.
- His refusal to speak to a resident and insistence on seeing an attending, along with his agitated, pressured speech without formal thought disorder, further support this diagnosis, illustrating his need for **admiration** and disdain for perceived inferiors.
*Acute stress disorder*
- This disorder typically develops **immediately after a traumatic event** and involves symptoms like dissociation, intrusive memories, and hyperarousal.
- The patient's presentation of grandiosity and sense of entitlement is not characteristic of acute stress disorder, and his symptoms are not directly linked to the fall as a recent trauma.
*Bipolar disorder*
- While the patient exhibits agitation and pressured speech (which can be seen in mania), the **chronic, stable pattern** of behavior described by his wife points away from bipolar disorder, which involves **episodic mood disturbances** with distinct periods of mania/hypomania and depression.
- There is no mention of other DSM-5 manic criteria such as decreased need for sleep, flight of ideas, increased goal-directed activity, or risky behavior, and the grandiosity appears to be a **pervasive personality trait** rather than an episodic mood state.
*Histrionic personality disorder*
- Individuals with **histrionic personality disorder** seek attention, but they tend to do so through dramatic, theatrical, and often sexually provocative behavior with excessive emotionality.
- While this patient is seeking attention, his behavior is more driven by a sense of superiority and entitlement rather than a desire to be the center of attention through emotional display.
*Obsessive compulsive personality disorder*
- **Obsessive-compulsive personality disorder** is characterized by a preoccupation with orderliness, perfectionism, and control, often at the expense of flexibility and efficiency.
- The patient's behavior is impulsive, arrogant, and attention-demanding, which is inconsistent with the traits of rigidity and meticulousness seen in OCPD.
Narcissistic personality disorder US Medical PG Question 4: 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)
Narcissistic personality disorder 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.
Narcissistic personality disorder US Medical PG Question 5: A 23-year-old woman is brought to the emergency room by her mother after she is found to have cut both of her wrists with razor blades. The patient admits to a history of self-mutilation and attributed this incident to a recent breakup with a man she had been seeing for the previous 2 weeks. On morning rounds, the patient reports that the nurses are incompetent but the doctors are some of the best in the world. The patient's vitals are stable and her wrist lacerations are very superficial requiring only simple dressings without sutures. The patient is discharged a few days later and she feels well. Which of the following is the most appropriate initial treatment for this patient?
- A. Amitriptyline
- B. Fluoxetine
- C. Dialectical behavior therapy (Correct Answer)
- D. Cognitive behavioral therapy
- E. Lithium
Narcissistic personality disorder Explanation: ***Dialectical behavior therapy***
- The patient's presentation with **recurrent self-harm**, **mood instability** following a brief relationship, and **splitting** ("nurses are incompetent but doctors are the best") are classic features of **borderline personality disorder (BPD)**.
- **Dialectical behavior therapy (DBT)** is the gold-standard and most effective initial treatment for BPD, specifically targeting **emotional dysregulation**, self-harm, and suicidal behaviors.
*Amitriptyline*
- **Amitriptyline** is a **tricyclic antidepressant (TCA)**, primarily used for depression and chronic pain.
- While antidepressants might be used *adjunctively* for comorbid mood symptoms in BPD, they are not the primary or most appropriate *initial* treatment for the core features of BPD itself, and TCAs have a high overdose risk.
*Fluoxetine*
- **Fluoxetine** is a **selective serotonin reuptake inhibitor (SSRI)**, commonly used for depression, anxiety disorders, and some eating disorders.
- Similar to other antidepressants, SSRIs may treat comorbid depressive or anxiety symptoms in BPD but do not address the fundamental **personality organization issues** or behavioral patterns like self-harm and splitting characteristic of BPD.
*Cognitive behavioral therapy*
- **Cognitive behavioral therapy (CBT)** is effective for a wide range of mental health conditions, including depression and anxiety, by focusing on changing negative thought patterns and behaviors.
- While elements of CBT are incorporated into DBT, **DBT is specifically adapted and more effective for BPD** due to its emphasis on **emotion regulation**, distress tolerance, and interpersonal effectiveness skills, which are crucial for this patient's presentation.
*Lithium*
- **Lithium** is a mood stabilizer primarily used to treat **bipolar disorder**.
- Although there can be some overlap in symptoms (e.g., mood swings), the patient's presentation is more indicative of BPD due to the **recurrent self-harm, interpersonal instability**, and **splitting**, rather than the distinct mood episodes seen in bipolar disorder.
Narcissistic personality disorder US Medical PG Question 6: A 27-year-old man presents to his primary care physician for exposure to toxic materials. The patient states that when he left for work this morning he was certain that he had closed the door to his pantry. However, upon returning home, he saw that the door to his pantry was wide open. The patient is certain that his neighbors have been tampering with his food and potentially poisoned him. He further states that he has known, ever since they have moved in, that they have been trying to break into his house and steal his things. He has tried multiple times to get them evicted from the building to no avail. It is for this reason that he is certain that they are trying to get their revenge upon him. The physician performs a physical exam and tells the patient that he thinks there is nothing to be concerned about, but that he should call him or come into the office if he experiences any symptoms. The patient is outraged at this news and requests a competent doctor who is not colluding with his enemies. He storms out of the office angrily, stating that he deserves the best in medical care, not this. Which of the following is the most likely personality disorder that this patient is suffering from?
- A. Intermittent explosive disorder
- B. Paranoid personality disorder (Correct Answer)
- C. Schizoid personality disorder
- D. Narcissistic personality disorder
- E. Borderline personality disorder
Narcissistic personality disorder Explanation: ***Paranoid personality disorder***
- This patient exhibits a pervasive distrust and **suspiciousness of others**, interpreting their motives as malevolent.
- His belief that his neighbors are tampering with his food, trying to break into his house, and that the doctor is colluding with them demonstrates **unwarranted suspicion and paranoid ideation**.
- **Note:** The intensity and fixed nature of these beliefs suggest they may cross into delusional territory, which would indicate **delusional disorder (persecutory type)** rather than a personality disorder. However, among the personality disorder options listed, paranoid personality disorder best fits the presentation of pervasive distrust and suspiciousness.
*Intermittent explosive disorder*
- This disorder is characterized by recurrent **behavioral outbursts** representing a failure to control aggressive impulses.
- While the patient exhibited anger, his primary issue is **pervasive paranoia** rather than episodic impulsive aggression.
*Schizoid personality disorder*
- Individuals with schizoid personality disorder typically display a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression.
- This patient is actively engaged, albeit negatively, with others and expresses strong emotions, which differs from the emotional aloofness of schizoid personality disorder.
*Narcissistic personality disorder*
- This disorder is characterized by a pervasive pattern of **grandiosity**, a need for admiration, and a lack of empathy; symptoms include sense of entitlement and arrogance.
- While the patient states he \"deserves the best in medical care,\" his primary features are **suspicion and distrust**, not grandiosity or a focus on self-importance.
*Borderline personality disorder*
- This disorder is marked by a pervasive pattern of **instability in interpersonal relationships**, self-image, affects, and impulsivity.
- The patient's presentation lacks the impulsivity, self-harm behaviors, or frantic efforts to avoid abandonment seen in **borderline personality disorder**.
Narcissistic personality disorder US Medical PG Question 7: A 12-year-old boy is brought in by his parents as they are concerned about his behavior. He is constantly arguing with his parents and blatantly defying their every request. In school, he is known for being intentionally tardy and for defying his teachers. Upon further questioning of the patient you learn about some of his recent behaviors such as beginning smoking to bother his parents. You also notice that he is disrespectful towards you. You then learn that he has also gotten into weekly fights with his peers at school with no apparent cause. In addition, last week he was seen hitting one of the local neighborhood cats with a baseball bat trying to kill it. The patient lives at home with his two parents in a pre-World War II house that was recently renovated. Physical exam is unremarkable.
Laboratory values are as follows:
Na: 140 mmol/L
K: 4.5 mmol/L
Cl: 100 mmol/L
Glucose: 80 mg/dL
Ca: 10 mmol/L
Mg: 3 mEq/L
Cr: 0.8 mg/dL
BUN: 10 mg/dL
Serum lead: < .01 µg/dL
Hb: 15 g/dL
Hct: 45%
MCV: 95
Urine toxicology: negative
As the patient leaves the office you notice him stealing all of the candy from the office candy bowl. The patient seems unconcerned about his behavior overall. Which of the following statements is most likely to be true in this patient?
- A. This patient will likely function normally despite continuing to defy authority figures
- B. Environmental exposures are likely causing this patient's behavior
- C. The patient's symptoms could progress to antisocial personality disorder (Correct Answer)
- D. This patient is suffering from antisocial personality disorder and will likely be incarcerated in adulthood
- E. Strong D2 antagonists are first-line pharmacotherapy
Narcissistic personality disorder Explanation: ***The patient's symptoms could progress to antisocial personality disorder***
- The patient's pattern of **aggression towards people and animals**, **deceitfulness or theft**, and **serious violations of rules** (e.g., truancy, defying authority) are all diagnostic criteria for **conduct disorder**.
- If conduct disorder symptoms persist into adulthood (age 18 or older), it can lead to a diagnosis of **antisocial personality disorder (ASPD)**, as ASPD requires evidence of conduct disorder before age 15.
*This patient will likely function normally despite continuing to defy authority figures*
- The described behaviors go beyond simple defiance; they include **aggression, severe rule violations, and lack of remorse**. These are significant indicators of a **conduct disorder**, which is associated with poor long-term outcomes and functional impairment, not normal functioning.
- Undiagnosed and untreated conduct disorder can lead to **academic difficulties, substance abuse, legal problems, and inability to maintain relationships**, making normal functioning unlikely.
*Environmental exposures are likely causing this patient's behavior*
- While environmental factors can contribute, the **severity and widespread nature** of the behaviors (at home, school, with peers, and animals), coupled with the **lack of remorse and intentional malice**, point more strongly to an underlying psychiatric diagnosis like conduct disorder rather than solely environmental causes.
- The provided lab results rule out common environmental toxins like **lead poisoning**, and the recent house renovation doesn't provide direct evidence of a toxic exposure causing these specific behavioral manifestations.
*This patient is suffering from antisocial personality disorder and will likely be incarcerated in adulthood*
- **Antisocial personality disorder (ASPD)** cannot be diagnosed before age 18. This patient is 12 years old, making ASPD an incorrect diagnosis at this stage, although his current behaviors are consistent with **conduct disorder**, which is a precursor.
- While there is an increased risk of incarceration for individuals with ASPD, stating it as a **definitive outcome** or that he "will likely be incarcerated" is deterministic and not universally true, as interventions can impact outcomes.
*Strong D2 antagonists are first-line pharmacotherapy*
- **First-line treatment for conduct disorder** typically involves **psychosocial interventions**, such as parent management training, cognitive behavioral therapy, and multisystemic therapy.
- While **D2 antagonists** (antipsychotics) may be used in severe cases, particularly for **aggression and impulsivity** when other treatments fail or if there are comorbid conditions, they are not considered **first-line pharmacotherapy** for conduct disorder itself.
Narcissistic personality disorder US Medical PG Question 8: A 23-year-old man presents to the emergency department with a chief complaint of being assaulted on the street. The patient claims that he has been followed by the government for quite some time and that he was assaulted by a government agent but was able to escape. He often hears voices telling him to hide. The patient has an unknown past medical history and admits to smoking marijuana frequently. On physical exam, the patient has no signs of trauma. When interviewing the patient, he is seen conversing with an external party that is not apparent to you. The patient states that he is afraid for his life and that agents are currently pursuing him. What is the best initial response to this patient’s statement?
- A. I think you are safe from the agents here.
- B. You have a mental disorder but don’t worry we will help you.
- C. I don’t think any agents are pursuing you.
- D. What medications are you currently taking?
- E. It sounds like you have been going through some tough experiences lately. (Correct Answer)
Narcissistic personality disorder Explanation: ***It sounds like you have been going through some tough experiences lately.***
- This response **acknowledges the patient's distress** and experience without validating or refuting their delusional beliefs.
- It helps establish **rapport** and encourages the patient to share more about their symptoms, which is crucial for assessment in a psychiatric emergency.
*I think you are safe from the agents here.*
- While intended to reassure, directly addressing the delusion can be perceived as dismissive and may **escalate the patient's paranoia** or agitation.
- It does not validate their *feelings* of fear, which are real to them, even if the source is delusional.
*You have a mental disorder but don’t worry we will help you.*
- This statement is **confrontational** and judgmental, labeling the patient immediately with a diagnosis.
- This approach can cause the patient to become defensive, shut down, or feel stigmatized, making further assessment and trust-building very difficult in the **initial interaction**.
*I don’t think any agents are pursuing you.*
- Directly **challenging a patient's delusion** is generally unhelpful in acute settings and can lead to increased agitation.
- It invalidates their subjective reality and can make them feel misunderstood or distrustful of the healthcare provider.
*What medications are you currently taking?*
- While important information, asking about medications is too premature as an *initial response* to a patient expressing severe paranoia and fear.
- This question comes across as dismissive of their current emotional state and **prioritizes medical history over emotional support** and rapport-building.
Narcissistic personality disorder US Medical PG Question 9: A 31-year-old woman comes to the physician because she thinks that her “right wrist is broken.” She says that she has severe pain and that “the bone is sticking out.” She has not had any trauma to the wrist. Her medical records indicate that she was diagnosed with schizophrenia 2 years ago and treated with olanzapine; she has not filled any prescriptions over the past 4 months. Three weeks ago, she stopped going to work because she “did not feel like getting up” in the morning. Vital signs are within normal limits. Physical examination of the right wrist shows no visible injury; there is no warmth, swelling, or erythema. Range of motion is limited by pain. On mental status examination, she has a flat affect. Her speech is pressured and she frequently changes the topic. She has short- and long-term memory deficits. Attention and concentration are poor. There is no evidence of suicidal ideation. Urine toxicology screening is negative. An x-ray of the wrist shows no abnormalities. Which of the following is the most appropriate response to this patient's concerns?
- A. “It seems as though you are having a schizophrenia relapse. If you don't follow my recommendations and take your medications, you will most likely have further and possibly more severe episodes.”
- B. “I cannot see any injury of your wrist and the physical exam as well as the x-ray don't show any injury. I imagine that feeling as if your wrist was broken may be very uncomfortable. Can you tell me more about what it feels like?” (Correct Answer)
- C. I understand your concerns; however, your symptoms seem to be psychological in nature. I would be happy to refer you to a mental health professional.
- D. You are clearly distressed. However, your tests do not suggest a physical problem that can be addressed with medications or surgery. I suggest that we meet and evaluate your symptoms on a regular basis.
- E. I can imagine that you are uncomfortable. That certainly looks painful. Let's take care of this injury first and then we should talk about your problems getting up in the morning.
Narcissistic personality disorder Explanation: ***“I cannot see any injury of your wrist and the physical exam as well as the x-ray don't show any injury. I imagine that feeling as if your wrist was broken may be very uncomfortable. Can you tell me more about what it feels like?”***
- This response **validates the patient's experience of pain and distress** while gently reorienting them to the objective findings (no physical injury).
- It opens a dialog to explore the **patient's subjective experience** and build trust, which is crucial for addressing underlying psychiatric issues in a patient with schizophrenia.
*“It seems as though you are having a schizophrenia relapse. If you don't follow my recommendations and take your medications, you will most likely have further and possibly more severe episodes.”*
- This statement is **confrontational and judgmental**, potentially alienating the patient and making them less likely to engage in treatment.
- Directly labeling a relapse and warning of future severity without first building rapport can trigger **defensiveness and non-compliance**.
*I understand your concerns; however, your symptoms seem to be psychological in nature. I would be happy to refer you to a mental health professional.*
- While accurate about the psychological nature of symptoms, this response **dismisses the patient's immediate physical complaint** and might make them feel unheard.
- It prematurely jumps to a referral without fully exploring the current presentation or establishing a therapeutic alliance, which can be perceived as the physician "passing the buck."
*I can imagine that you are uncomfortable. That certainly looks painful. Let's take care of this injury first and then we should talk about your problems getting up in the morning.*
- This response **validates a non-existent injury**, reinforcing the patient's delusion and potentially diverting attention from the underlying psychiatric condition.
- Prioritizing a non-existent injury would lead to inappropriate medical interventions and delay necessary psychiatric care.
*You are clearly distressed. However, your tests do not suggest a physical problem that can be addressed with medications or surgery. I suggest that we meet and evaluate your symptoms on a regular basis.*
- While acknowledging distress and the lack of physical pathology, this response is somewhat **vague and lacks a clear plan** for addressing the primary concern of perceived injury.
- "Regular evaluation" without specific intent to explore the psychological component or re-initiate psychiatric treatment may not be sufficient for a patient experiencing a schizophrenia relapse.
Narcissistic personality disorder US Medical PG Question 10: A 7-year-old girl is brought to the physician by her mother because she has been increasingly reluctant to speak at school over the past 4 months. Her teachers complain that she does not answer their questions and it is affecting her academic performance. She was born at 35 weeks' gestation and pregnancy was complicated by preeclampsia. Previous well-child examinations have been normal. Her older brother was diagnosed with a learning disability 4 years ago. She is at 65th percentile for height and weight. Physical examination shows no abnormalities. She follows commands. She avoids answering questions directly and whispers her answers to her mother instead who then mediates between the doctor and her daughter. Which of the following is the most likely diagnosis?
- A. Selective mutism (Correct Answer)
- B. Social anxiety disorder
- C. Rett syndrome
- D. Autism spectrum disorder
- E. Reactive attachment disorder
Narcissistic personality disorder Explanation: ***Selective mutism***
- The child's reluctance to speak in specific social situations (school) despite being able to speak in others (whispering to her mother), and the impact on academic performance, are classic signs of **selective mutism**
- **Selective mutism** typically involves anxiety and a consistent failure to speak in situations where speaking is expected, despite speaking in other situations
- This diagnosis fits the **DSM-5 criteria**: consistent failure to speak in specific social situations for >1 month, interfering with educational achievement
*Social anxiety disorder*
- While social anxiety can be **comorbid** with selective mutism, the hallmark of this presentation is the **specific refusal to speak** in certain settings, rather than generalized anxiety about social interactions
- A child with generalized social anxiety might interact nervously but would likely attempt to speak, which is not described here
*Rett syndrome*
- **Rett syndrome** is a neurodevelopmental disorder almost exclusively affecting girls, characterized by **normal early development followed by regression** of acquired skills, loss of purposeful hand use, and deceleration of head growth
- The presented symptoms of reluctance to speak in specific settings, without other regressive signs or developmental abnormalities, do not fit the diagnosis of Rett syndrome
*Autism spectrum disorder*
- **Autism spectrum disorder** is characterized by persistent deficits in **social communication and social interaction** across multiple contexts, and **restricted, repetitive patterns of behavior**
- This child's ability to speak to her mother and follow commands suggests intact communication skills in some contexts, making autism less likely than selective mutism for the primary presentation
*Reactive attachment disorder*
- **Reactive attachment disorder** typically arises from patterns of **extremely insufficient care** in early childhood, leading to emotionally withdrawn behavior toward caregivers and limited positive affect
- The child's selective non-speaking in school in this scenario, with normal previous well-child examinations and interaction with her mother, is inconsistent with the characteristic features of reactive attachment disorder
More Narcissistic personality disorder US Medical PG questions available in the OnCourse app. Practice MCQs, flashcards, and get detailed explanations.
