Substance-induced psychotic disorder US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Substance-induced psychotic disorder. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Substance-induced psychotic disorder US Medical PG Question 1: An 18-year-old man is brought to the emergency department after his mother found him locked in his room stammering about a government conspiracy to brainwash him in subterranean tunnels. His mother says that he has never done this before, but 6 months ago he stopped going to classes and was subsequently suspended from college. She reports that he has become increasingly taciturn over the course of the past month. He drinks one to two beers daily and has smoked one pack of cigarettes daily for 3 years. He occasionally smokes marijuana. His father was diagnosed with schizophrenia at the age of 25 years. The patient has had no friends or social contacts other than his mother since he was suspended. He appears unkempt and aloof. On mental status examination, he is disorganized and shows poverty of speech. He says his mood is "good." He does not hear voices and has no visual or tactile hallucinations. Toxicology screening is negative. Which of the following is an unfavorable prognostic factor for this patient's condition?
- A. Poor premorbid functioning (Correct Answer)
- B. Late onset of illness
- C. Presence of mood symptoms
- D. Good insight into illness
- E. Strong family support
Substance-induced psychotic disorder Explanation: ***Poor premorbid functioning***
- **Poor premorbid functioning** is a well-established **unfavorable prognostic factor** in schizophrenia, associated with worse long-term outcomes and functional recovery.
- This patient demonstrates poor premorbid functioning: he declined from being a college student to being suspended, became increasingly isolated with no friends or social contacts, and presents as unkempt and aloof.
- The insidious deterioration over 6 months with prominent negative symptoms (taciturnity, poverty of speech, social withdrawal) further suggests poor premorbid adjustment.
*Late onset of illness*
- **Late onset** (after age 25-30) is associated with a **better prognosis** because brain development is more complete and there is typically better premorbid functioning.
- This is a **favorable**, not unfavorable, prognostic factor.
*Presence of mood symptoms*
- The presence of **prominent mood symptoms** (depression, mania) in psychotic disorders is associated with a **better prognosis** than pure schizophrenia.
- Schizoaffective disorder generally has better outcomes than schizophrenia.
- This is a **favorable** prognostic factor.
*Good insight into illness*
- **Good insight** is a highly **favorable prognostic factor** as it increases treatment adherence and engagement in recovery.
- This patient lacks insight, demonstrating disorganized thought and delusions without awareness of illness.
*Strong family support*
- **Strong family support** is a crucial **favorable prognostic factor**, improving treatment adherence, recovery, and social reintegration.
- While the mother is involved, the patient's complete social isolation (no friends or contacts besides mother) suggests limited overall support network.
Substance-induced psychotic disorder US Medical PG Question 2: 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
Substance-induced psychotic disorder 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.
Substance-induced psychotic disorder US Medical PG Question 3: A 34-year-old man presents to the behavioral health clinic for an evaluation after seeing animal-shaped clouds in the form of dogs, cats, and monkeys. The patient says that these symptoms have been present for more than 2 weeks. Past medical history is significant for simple partial seizures for which he takes valproate, but he has not had his medication adjusted in several years. His vital signs include: blood pressure of 124/76 mm Hg, heart rate of 98/min, respiratory rate of 12/min, and temperature of 37.1°C (98.8°F). On physical examination, the patient is alert and oriented to person, time, and place. Affect is not constricted or flat. Speech is of rapid rate and high volume. Pupils are equal and reactive bilaterally. The results of a urine drug screen are as follows:
Alcohol positive
Amphetamine negative
Benzodiazepine negative
Cocaine positive
GHB negative
Ketamine negative
LSD negative
Marijuana negative
Opioids negative
PCP negative
Which of the following is the most likely diagnosis in this patient?
- A. Delusion
- B. Alcohol withdrawal
- C. Visual hallucination
- D. Cocaine intoxication
- E. Illusion (Correct Answer)
Substance-induced psychotic disorder Explanation: ***Illusion***
- The patient is seeing **animal shapes in the clouds**, which is a misinterpretation of a real external stimulus. This is the definition of an **illusion**.
- Unlike hallucinations, illusions involve a distorted perception of an existing object, rather than perceiving something that is not present.
*Delusion*
- A **delusion** is a **fixed, false belief** that is not amenable to change in light of conflicting evidence, and it is not what is being described here.
- The patient is experiencing a perceptual distortion, not a false belief system.
*Alcohol withdrawal*
- While the patient tests positive for alcohol, the symptoms described are **perceptual distortions** (misinterpretation of clouds), not typical signs of alcohol withdrawal which include tremors, seizures, and delirium tremens.
- The timeline of "more than 2 weeks" also makes acute alcohol withdrawal less likely, as withdrawal symptoms typically peak within days.
*Visual hallucination*
- A **hallucination** is a perception in the absence of an external stimulus; the patient would be seeing animals when no clouds (or other visual stimuli) are present.
- The patient is seeing animal shapes *in the clouds*, indicating an existing external stimulus that is being misinterpreted.
*Cocaine intoxication*
- While cocaine intoxication can cause psychiatric symptoms like paranoia and hallucinations, the specific description of **seeing animal shapes in clouds** (misinterpretation of a real stimulus) points more directly to an illusion rather than a primary effect of cocaine use.
- The patient's presentation does not include other common symptoms of acute cocaine intoxication like severe agitation, dilated pupils, or hyperthermia beyond a rapid heart rate.
Substance-induced psychotic disorder US Medical PG Question 4: A 21-year-old man presents to the emergency room requesting surgery to remove "microchips," which he believes were implanted in his brain by "Russian spies" 6 months ago to control his thoughts. He also reports hearing the "spies" talk to each other through embedded "microspeakers." You notice that his hair appears unwashed and some of his clothes are on backward. Urine toxicology is negative for illicit drugs. Which of the following additional findings are you most likely to see in this patient during the course of his illness?
- A. Anhedonia, guilty rumination, and insomnia
- B. Grandiose delusions, racing thoughts, and pressured speech
- C. Asociality, flat affect, and alogia (Correct Answer)
- D. Amnesia, multiple personality states, and de-realization
- E. Intrusive thoughts, ritualized behaviors, and anxious mood
Substance-induced psychotic disorder Explanation: ***Asociality, flat affect, and alogia***
- This patient exhibits **delusions (persecutory, control)** and **auditory hallucinations**, classic positive symptoms of **schizophrenia**. The question asks about findings "during the course of his illness," which points to the **typical progression of schizophrenia**: patients initially present with **positive symptoms** (as seen in this case) and **over time develop negative symptoms** such as **asociality** (lack of motivation to engage in social interaction), **flat affect** (reduced emotional expression), and **alogia** (poverty of speech).
- The disorganized appearance (unwashed hair, clothes on backward) already demonstrates **disorganized behavior**, part of the schizophrenia spectrum. Negative symptoms typically emerge or worsen as the illness progresses, representing the most likely additional findings.
*Anhedonia, guilty rumination, and insomnia*
- While **anhedonia** and **insomnia** can be seen in schizophrenia, their presence alongside prominent **guilty rumination** would more strongly suggest a **depressive disorder with psychotic features**, rather than primary schizophrenia, especially with the patient's specific, classic psychotic symptoms.
- The primary symptoms described (delusions of control, auditory hallucinations) are more characteristic of primary psychotic disorders, and guilty rumination is not a typical feature of schizophrenia progression.
*Grandiose delusions, racing thoughts, and pressured speech*
- These symptoms are hallmark features of **mania** or a **manic episode with psychotic features**. While psychotic features can occur in bipolar disorder with mania, the patient's specific delusions of being controlled by spies and hearing voices discussing him are more typical of schizophrenia.
- The absence of information about elevated mood, increased energy, or decreased need for sleep also makes mania less likely compared to schizophrenia.
*Amnesia, multiple personality states, and de-realization*
- These symptoms are characteristic of **dissociative disorders**. **Amnesia** and **multiple personality states** (now known as identity alteration in dissociative identity disorder) involve disturbances in memory and identity.
- **De-realization** involves feelings of unreality regarding one's surroundings. None of these align with the patient's primary presentation of well-formed delusions and hallucinations characteristic of a psychotic disorder.
*Intrusive thoughts, ritualized behaviors, and anxious mood*
- These are core features of **obsessive-compulsive disorder (OCD)**. The patient's symptoms are clearly defined as delusions (fixed false beliefs) and hallucinations (perceptions without external stimuli), which are distinct from the ego-dystonic intrusive thoughts and ritualistic compulsions of OCD.
- While anxiety may be present in psychotic disorders, the primary presentation here is not dominated by OCD-like symptoms, and these would not be expected to develop as part of schizophrenia's natural course.
Substance-induced psychotic disorder US Medical PG Question 5: A 57-year-old man is brought to the emergency department by the police after he was found running around a local park naked and screaming late at night. During intake, the patient talks non-stop about the government spying on him and his family, but provides little useful information besides his name and date of birth. Occasionally he refers to himself in the third person. He refuses to eat anything and will only drink clear fluids because he is afraid of being poisoned. A medical records search reveals that the patient has been treated for psychotic behavior and occasional bouts of severe depression for several years. Today, his heart rate is 90/min, respiratory rate is 19/min, blood pressure is 135/85 mm Hg, and temperature is 37.0°C (98.6°F). On physical exam, he appears gaunt and anxious. His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally. CMP, CBC, and TSH are normal. A urine toxicology test is negative. What is the most likely diagnosis?
- A. Schizophrenia
- B. Major depressive disorder
- C. Schizoaffective disorder (Correct Answer)
- D. Brief psychotic disorder
- E. Bipolar 1 disorder
Substance-induced psychotic disorder Explanation: ***Schizoaffective disorder***
- The patient exhibits features of both a **mood disorder** (severe depression) and a **psychotic disorder** (delusions, disorganized behavior, referring to himself in the third person), which are key characteristics of schizoaffective disorder.
- The history of **psychotic behavior** and **severe depression** over several years, with current presentation involving both prominent mood symptoms (agitation, gaunt appearance suggesting poor self-care due to mood) and psychotic features (paranoia, disorganized speech), supports this diagnosis over other psychotic or mood disorders.
*Schizophrenia*
- While the patient exhibits **psychotic symptoms** (delusions, disorganization), the history of "occasional bouts of severe depression" suggests a more prominent and recurring mood component than typically seen in schizophrenia.
- In schizophrenia, mood symptoms are often confined to brief periods relative to the duration of the psychotic illness or are not a prominent and defining feature.
*Major depressive disorder*
- This diagnosis is incorrect because the patient displays clear and pervasive **psychotic symptoms** such as paranoia, disorganized speech, and bizarre behavior (running naked, screaming), which are beyond what is typically seen in major depressive disorder with psychotic features (where psychosis is congruent with the depressive theme).
- The historical pattern of **psychotic behavior** occurring separately from or alongside depressive episodes points away from a primary diagnosis of major depressive disorder.
*Brief psychotic disorder*
- This diagnosis is characterized by psychotic symptoms lasting **less than one month**, with an eventual full return to premorbid functioning.
- The patient's history of **several years** of psychotic behavior and severe depression rules out this acute and time-limited condition.
*Bipolar 1 disorder*
- While bipolar 1 disorder can feature **psychotic symptoms** during manic or depressive episodes, the presentation here emphasizes persistent psychotic features (delusions of being spied on, fear of poisoning) that are not always directly tied to mood episodes or are more enduring than typical for bipolar disorder.
- The long-standing history of both **psychotic and depressive episodes** suggests a more integrated condition of mood and psychosis rather than distinct episodes as seen in bipolar 1 disorder.
Substance-induced psychotic disorder US Medical PG Question 6: A 48-year-old man is brought to the emergency department after he was found in a stuporous state with a small cut on his forehead on a cold night in front of his apartment. Non-contrast head CT is normal, and he is monitored in the emergency department. Twelve hours later, he yells for help because he hears the wallpaper threatening his family. He also has a headache. The patient started drinking regularly 10 years ago and consumed a pint of vodka prior to admission. He occasionally smokes marijuana and uses cocaine. His vital signs are within normal limits. On mental status examination, the patient is alert and oriented. He appears markedly distressed and is diaphoretic. A fine digital tremor on his right hand is noted. The remainder of the neurological exam shows no abnormalities. Urine toxicologic screening is pending. Which of the following is the most likely diagnosis?
- A. Delirium tremens
- B. Alcoholic hallucinosis (Correct Answer)
- C. Cocaine intoxication
- D. Brief psychotic disorder
- E. Phencyclidine intoxication
Substance-induced psychotic disorder Explanation: ***Alcoholic hallucinosis***
- The patient's history of **heavy alcohol use**, followed by the development of **hallucinations** (hearing wallpaper threatening his family) within 12-48 hours of reduced or cessation of alcohol intake, is classic for alcoholic hallucinosis.
- Unlike delirium tremens, **alcoholic hallucinosis** primarily involves prominent **auditory and visual hallucinations** without significant disorientation or vital sign instability.
*Delirium tremens*
- Delirium tremens typically presents later, usually **48-96 hours after alcohol cessation**, and is characterized by a more severe clinical picture including **global disorientation**, marked autonomic instability (fever, tachycardia, hypertension), and severe agitation.
- While the patient is agitated and diaphoretic, the absence of significant disorientation, fever, or tachycardia makes delirium tremens less likely at this early stage.
*Cocaine intoxication*
- Cocaine intoxication would typically present with symptoms such as **tachycardia**, **hypertension**, **pupillary dilation**, **psychomotor agitation**, and potentially paranoia or hallucinations, but these would occur **acutely after cocaine use**, rather than 12 hours after being found in a stuporous state.
- The patient's vital signs are noted to be normal, which argues against acute cocaine intoxication as the primary cause of his current symptoms.
*Brief psychotic disorder*
- Brief psychotic disorder is characterized by the sudden onset of psychotic symptoms (delusions, hallucinations, disorganized speech or behavior) lasting more than one day but less than one month, followed by full return to premorbid functioning.
- While the patient exhibits hallucinations, the strong temporal link to **alcohol use and withdrawal** makes a substance-induced psychotic disorder, such as alcoholic hallucinosis, a more specific and likely diagnosis.
*Phencyclidine intoxication*
- PCP intoxication is associated with symptoms such as **nystagmus**, **ataxia**, **hypertension**, **tachycardia**, **violence**, and *dissociative symptoms*, along with hallucinations and delusions.
- The patient does not exhibit the characteristic nystagmus, ataxia, or typical behavioral aggression associated with PCP intoxication.
Substance-induced psychotic disorder US Medical PG Question 7: A 23-year-old male presents to the emergency department. He was brought in by police for shouting on a subway. The patient claims that little people were trying to kill him, and he was acting within his rights to defend himself. The patient has a past medical history of marijuana and IV drug use as well as multiple suicide attempts. He is currently homeless. While in the ED, the patient is combative and refuses a physical exam. He is given IM haloperidol and diphenhydramine. The patient is transferred to the inpatient psychiatric unit and is continued on haloperidol throughout the next week. Though he is no longer aggressive, he is seen making "armor" out of paper plates and plastic silverware to defend himself. The patient is switched onto risperidone. The following week the patient is still seen gathering utensils, and muttering about people trying to harm him. The patient's risperidone is discontinued. Which of the following is the best next step in management?
- A. Olanzapine
- B. Thioridazine
- C. Clozapine (Correct Answer)
- D. Chlorpromazine
- E. Fluphenazine
Substance-induced psychotic disorder Explanation: ***Clozapine***
- This patient has demonstrated **treatment-resistant schizophrenia**, evidenced by persistent positive symptoms despite trials of haloperidol and risperidone, necessitating a trial of clozapine.
- **Clozapine** is an atypical antipsychotic that is uniquely effective for treatment-resistant schizophrenia, especially in patients with a history of **suicidality**.
*Olanzapine*
- While **olanzapine** is an effective atypical antipsychotic, it is generally considered a first-line or second-line agent, and this patient has already failed two antipsychotics (haloperidol and risperidone).
- Its efficacy in **treatment-resistant cases** is not superior to clozapine.
*Thioridazine*
- **Thioridazine** is a first-generation antipsychotic with a high risk of **QT prolongation** and other cardiac side effects, making it a less safe option.
- It is not typically reserved for **treatment-resistant schizophrenia** due to its side effect profile and lack of superior efficacy compared to newer agents.
*Chlorpromazine*
- **Chlorpromazine** is another first-generation antipsychotic that is not indicated for **treatment-resistant schizophrenia** at this stage.
- It carries significant anticholinergic and sedative side effects, similar to thioridazine, and is not significantly more effective than haloperidol for this indication.
*Fluphenazine*
- **Fluphenazine** is a potent first-generation antipsychotic, often available as a **depot injection** for adherence issues.
- However, it is not considered the best next step for **treatment-resistant schizophrenia** after failure of two different classes of antipsychotics.
Substance-induced psychotic disorder US Medical PG Question 8: Five days after undergoing surgical repair of a hip fracture, a 71-year-old man is agitated and confused. Last night, he had to be restrained multiple times after attempting to leave his room. His overnight nurse reported that at times he would be resting, but shortly afterward he would become agitated again for no clear reason. He has hypertension and COPD. He had smoked one pack of cigarettes daily for 50 years but quit 10 years ago. He drinks 1 glass of whiskey per day. His current medications include oxycodone, hydrochlorothiazide, albuterol, and ipratropium. He appears agitated. His temperature is 37°C (98.6°F), pulse is 72/min, and blood pressure is 141/84 mm Hg. Pulmonary examination shows a prolonged expiratory phase but no other abnormalities. Neurologic examination shows inattentiveness and no focal findings. He is oriented to person but not to place or time. During the examination, the patient attempts to leave the room after pulling out his intravenous line and becomes violent. He is unable to be verbally redirected and is placed on soft restraints. Laboratory studies show:
Hemoglobin 14.5 g/dL
Leukocyte count 8,000/mm3
Platelet count 245,000/mm3
Serum
Na+ 142 mEq/L
K+ 3.5 mEq/L
Cl- 101 mEq/L
HCO3- 24 mEq/L
Urea nitrogen 14 mg/dL
Creatinine 1.1 mg/dL
Urine dipstick shows no abnormalities. Which of the following is the most appropriate next step in management?
- A. Obtain CT scan of the head
- B. Obtain urine culture
- C. Administer lorazepam
- D. Administer haloperidol (Correct Answer)
- E. Obtain x-ray of the chest
Substance-induced psychotic disorder Explanation: ***Administer haloperidol***
- The patient is exhibiting acute **delirium**, characterized by **agitation**, **confusion**, inattentiveness, and fluctuating mental status in a post-surgical setting.
- Given his **violent behavior**, inability to be verbally redirected, and **immediate danger to self/others** (pulling IV line, requiring restraints), pharmacological intervention is necessary for acute safety management.
- **Haloperidol** (a typical antipsychotic) has historically been used for severe agitation in delirium when the patient poses imminent danger, though current guidelines emphasize it should be used at the **lowest effective dose for the shortest duration** while underlying causes are addressed.
- Note: Antipsychotics do not treat the underlying delirium but manage dangerous agitation; concurrent evaluation for reversible causes (pain, infection, medications, alcohol withdrawal) remains essential.
*Obtain CT scan of the head*
- While a CT scan may be indicated in delirium workup to rule out **structural lesions** or **intracranial hemorrhage**, there are no focal neurological deficits, head trauma, or signs of increased intracranial pressure here.
- His delirium is likely multifactorial (postoperative state, opioid use, possible pain, stress), and CT would not address the immediate safety concern.
- Neuroimaging can be pursued after acute agitation is controlled.
*Obtain urine culture*
- **Urinary tract infections (UTIs)** are common delirium triggers in elderly patients, but the **urine dipstick is unremarkable** (no leukocyte esterase, nitrites, or WBCs), making UTI less likely.
- While a culture could be ordered as part of comprehensive workup, it does not address the immediate violent behavior.
*Obtain x-ray of the chest*
- A chest x-ray would be appropriate if there were signs of **pneumonia** (fever, cough, hypoxia, new lung sounds), but examination shows only a **prolonged expiratory phase** consistent with his known COPD.
- Pneumonia can cause delirium, but without acute respiratory symptoms, this is not the immediate priority over managing dangerous agitation.
*Administer lorazepam*
- **Benzodiazepines** like lorazepam are **contraindicated** in delirium unless the cause is alcohol or benzodiazepine withdrawal, as they can **worsen confusion**, cause paradoxical agitation, and increase fall risk in elderly patients.
- While the patient drinks 1 glass of whiskey daily, this level of consumption makes severe alcohol withdrawal less likely (though should still be assessed), and benzodiazepines carry significant risks of respiratory depression given his COPD.
- Antipsychotics are preferred for non-withdrawal delirium when pharmacological management is necessary.
Substance-induced psychotic disorder US Medical PG Question 9: A 31-year-old man comes to the emergency department because of chest pain for the last 3 hours. He describes the pain as a sharp, substernal chest pain that radiates to the right shoulder; he says “Please help me. I'm having a heart attack.” He has been admitted to the hospital twice over the past week for evaluation of shortness of breath and abdominal pain but left the hospital the following day on both occasions. The patient does not smoke or drink alcohol but is a known user of intravenous heroin. He has been living in a homeless shelter for the past 2 weeks after being evicted from his apartment for failure to pay rent. His temperature is 37.6°C (99.6°F), pulse is 90/min, respirations are 18/min, and blood pressure is 125/85 mm Hg. The patient seems anxious and refuses a physical examination of his chest. His cardiac troponin I concentration is 0.01 ng/mL (N = 0–0.01). An ECG shows a normal sinus rhythm with nonspecific ST-T wave changes. While the physician is planning to discharge the patient, the patient reports numbness in his arm and insists on being admitted to the ward. On the following day, the patient leaves the hospital without informing the physician or the nursing staff. Which of the following is the most likely diagnosis?
- A. Malingering (Correct Answer)
- B. Factitious disorder
- C. Somatic symptom disorder
- D. Conversion disorder
- E. Illness anxiety disorder
Substance-induced psychotic disorder Explanation: ***Malingering***
- The patient exhibits several signs of **malingering**, including the claim of severe symptoms ("Please help me. I'm having a heart attack."), inconsistent presentation (refusing physical exam, insisting on admission after normal findings, then leaving AMA), and a clear external incentive (access to shelter, food, or drugs, as suggested by his homelessness and IV drug use).
- His normal vital signs, **negative troponin**, and nonspecific ECG changes despite dramatized symptoms further support that his complaints are not genuinely medical. Additionally, his repeated hospital visits and abrupt departure suggest a pattern of utilizing healthcare for secondary gain rather than actual illness.
*Factitious disorder*
- In **factitious disorder**, individuals *intentionally produce or feign* symptoms but lack a clear external incentive for their behavior, driven instead by an internal psychological need to assume the sick role or gain attention.
- This patient's history of homelessness and IV drug use suggests a strong **external incentive** (e.g., shelter, food, access to drugs), making malingering a more likely diagnosis.
*Somatic symptom disorder*
- **Somatic symptom disorder** involves genuine distress and preoccupation with physical symptoms, but these symptoms are *not intentionally produced or feigned*. The patient believes they are truly ill.
- This patient's behavior—dramatizing symptoms, refusing examination, and leaving quickly—suggests an **intentional deception** rather than a deeply held conviction of illness without an observable cause.
*Conversion disorder*
- **Conversion disorder** (functional neurological symptom disorder) involves neurological symptoms (e.g., numbness, paralysis, blindness) that are *not intentionally produced* and are incompatible with known neurological pathways, often precipitated by psychological stress.
- While the patient's report of numbness could be superficial, the overall pattern of behavior, including the seeking of admission and rapid departure, points away from an unconscious manifestation of psychological distress towards **conscious deception for gain.**
*Illness anxiety disorder*
- **Illness anxiety disorder** (formerly hypochondriasis) is characterized by a preoccupation with having or acquiring a serious illness, with minimal or no somatic symptoms, and a high level of anxiety about health despite medical reassurance.
- This patient's behavior is inconsistent with a genuine preoccupation with illness; instead, he appears to be **manipulating the system for immediate benefit**, rather than genuinely fearing a specific disease.
Substance-induced psychotic disorder US Medical PG Question 10: A 45-year-old man presents to a psychiatrist by his wife with recent behavioral and emotional changes. The patient’s wife says that her husband’s personality has completely changed over the last year. She also says that he often complains of unpleasant odors when actually there is no discernible odor present. The patient mentions that he is depressed at times while on other occasions, he feels like he is ‘the most powerful man in the world.’ The psychiatrist takes a detailed history from this patient and concludes that he is most likely suffering from a psychotic disorder. However, before prescribing an antipsychotic medication, he recommends that the patient undergoes brain imaging to rule out a brain neoplasm. Based on the presence of which of the following clinical signs or symptoms in this patient is the psychiatrist most likely recommending this imaging test?
- A. Olfactory hallucinations (Correct Answer)
- B. Echolalia
- C. Anhedonia
- D. Delusions of grandeur
- E. Thought broadcasting
Substance-induced psychotic disorder Explanation: ***Olfactory hallucinations***
- The presence of **olfactory hallucinations** ("unpleasant odors when actually there is no discernible odor present") in the context of new-onset psychotic symptoms and personality changes, particularly in a middle-aged adult, raises suspicion for an underlying **structural brain lesion**, such as a **frontal or temporal lobe tumor**.
- Brain neoplasms in these regions can irritate cortical areas, leading to atypical psychotic symptoms and these specific types of hallucinations, making imaging crucial before initiating antipsychotic therapy.
*Echolalia*
- **Echolalia** is the involuntary repetition of words or phrases spoken by another person, often associated with conditions like **autism spectrum disorder**, **Tourette's syndrome**, or severe **psychotic disorders**, particularly **schizophrenia**.
- While it can be a feature of psychiatric illness, it is not a red flag for structural brain pathology in the same manner as new-onset olfactory hallucinations.
*Anhedonia*
- **Anhedonia** is the inability to experience pleasure from activities usually found enjoyable, a prominent symptom of **major depressive disorder** and other mood disorders, as well as some psychotic disorders.
- Although the patient reports feeling "depressed at times," anhedonia is a common psychiatric symptom and does not specifically point to a need for urgent brain imaging in the absence of other alarming features.
*Delusions of grandeur*
- **Delusions of grandeur** are false beliefs that one is much greater or more powerful than they truly are, as described by the patient feeling like "the most powerful man in the world." This symptom is characteristic of **bipolar disorder (manic episodes)** or some **psychotic disorders**.
- While present in this patient, grandiose delusions are part of the core symptomatology of many psychiatric conditions and, by themselves, do not typically necessitate brain imaging to rule out a tumor.
*Thought broadcasting*
- **Thought broadcasting** is the belief that one's thoughts are being transmitted into the minds of others, a classic **first-rank symptom of schizophrenia**.
- This symptom is indicative of a severe thought disorder within the spectrum of psychotic illnesses but does not specifically raise the suspicion of an underlying brain lesion requiring neuroimaging.
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