Pica and Rumination Disorder — MCQs
A young lady presents with a history of repeated episodes of overeating followed by purging using laxatives. She is probably suffering from -
Diagnostic criteria for Bulimia nervosa are all EXCEPT
A young girl presents with a history of multiple episodes of loss of consciousness lasting for 20 minutes. These episodes occur only in front of family members and only during the daytime. There is no history of tongue biting or incontinence, and EEG and MRI studies are normal. What is the most appropriate management?
A 16-year-old girl has intense cravings for food and consumes large amounts of it, followed by purging behaviors. What is the most likely diagnosis?
History of dislike for sweet food items is typically present in:
Pagophagia involves eating
A four year old boy Tinu has normal developmental milestones except delayed speech. He is interested to watch spinning objects like fan and the washing machine. His parents struggle to get him interested in other children at home. People often comment that he is disinterested and self centred. What will be your thought regarding his diagnosis?
Type of schizophrenia with intellectual disability:
Which of the following is FALSE regarding Anorexia Nervosa:
Which of the following is NOT true about anorexia nervosa?
Pica and Rumination Disorder Indian Medical PG Practice Questions and MCQs
Question 1: A young lady presents with a history of repeated episodes of overeating followed by purging using laxatives. She is probably suffering from -
- A. Binge eating disorder
- B. Schizophrenia
- C. Anorexia nervosa
- D. Bulimia nervosa (Correct Answer)
Explanation: ***Bulimia nervosa*** - This condition is characterized by recurrent episodes of **binge eating** followed by inappropriate compensatory behaviors like **purging (e.g., laxative use)**, self-induced vomiting, excessive exercise, or fasting. - The patient's presentation of repeated overeating followed by purging with laxatives directly aligns with the diagnostic criteria for **bulimia nervosa**. *Binge eating disorder* - While it involves recurrent episodes of **binge eating**, it **does not include** the regular use of inappropriate compensatory behaviors such as purging. - Individuals with binge eating disorder typically experience significant distress about their binging but do not attempt to undo the caloric intake. *Schizophrenia* - This is a severe mental disorder characterized by **distortions in thinking, perception, emotions, language, sense of self, and behavior**, such as hallucinations and delusions. - It is a **psychotic disorder** and does not involve specific eating patterns or purging behaviors. *Anorexia nervosa* - This eating disorder is characterized by a persistent restriction of energy intake leading to a **significantly low body weight**, an intense **fear of gaining weight**, and a distorted body image. - Although some individuals with anorexia nervosa may engage in binge-purging type behavior, the primary defining feature is **significantly low body weight**, which is not mentioned in the patient's presentation.
Question 2: Diagnostic criteria for Bulimia nervosa are all EXCEPT
- A. Lack of control over eating behaviour
- B. Self induced vomiting
- C. Presence of other psychiatric disorders (Correct Answer)
- D. Binge eating
Explanation: ***Presence of other psychiatric disorders*** - While psychiatric comorbidities like depression, anxiety, and substance abuse are **extremely common** in individuals with bulimia nervosa, they are **not a diagnostic criterion** for the disorder. - The DSM-5 diagnosis of bulimia nervosa focuses specifically on **eating behaviors** (binge eating), **compensatory mechanisms** (purging/non-purging), and the impact on self-evaluation, not on the presence of co-occurring mental health conditions. - This is the correct answer as it is **NOT** a diagnostic criterion. *Lack of control over eating behaviour* - This is a **core diagnostic criterion** of bulimia nervosa. - Individuals must experience a sense of **lack of control** over eating during binge episodes (feeling unable to stop eating or control what or how much they are eating). - This feeling of loss of control during binges is essential for diagnosis. *Self induced vomiting* - This is a **diagnostic criterion** as one of the inappropriate compensatory behaviors used to prevent weight gain after binge eating. - Other compensatory behaviors include misuse of laxatives, diuretics, enemas, fasting, or excessive exercise. - At least one type of compensatory behavior must occur regularly (average of once weekly for 3 months). *Binge eating* - This is a **fundamental diagnostic criterion** involving eating an amount of food that is definitely larger than what most people would eat in a similar period under similar circumstances. - Must occur in a discrete time period (e.g., within any 2-hour period) with a sense of lack of control. - Binge episodes must occur, on average, at least once a week for 3 months for diagnosis.
Question 3: A young girl presents with a history of multiple episodes of loss of consciousness lasting for 20 minutes. These episodes occur only in front of family members and only during the daytime. There is no history of tongue biting or incontinence, and EEG and MRI studies are normal. What is the most appropriate management?
- A. Treat with aversive therapy
- B. Insight-oriented psychotherapy (Correct Answer)
- C. Valproate
- D. Ketogenic diet
Explanation: ***Insight-oriented psychotherapy*** - The presentation strongly suggests **non-epileptic seizures (NES)**, also known as **psychogenic non-epileptic seizures (PNES)**, which are usually of psychological origin. - **Insight-oriented psychotherapy** is the most appropriate management, aiming to address underlying psychological conflicts or stress that manifest as these episodes. *Treat with aversive therapy* - **Aversive therapy** is typically used for behavioral modification in conditions like substance abuse or paraphilias, where a negative stimulus is paired with an undesirable behavior. - It is not indicated for **psychogenic non-epileptic seizures**, where the underlying cause is psychological distress rather than a learned undesirable behavior. *Valproate* - **Valproate** is an **antiepileptic drug** used to treat various types of seizures, including generalized tonic-clonic and absence seizures. - Since EEG and MRI are normal, and the clinical features (no tongue biting/incontinence, specific timing/audience) rule out epilepsy, antiepileptic medication like Valproate is **inappropriate**. *Ketogenic diet* - The **ketogenic diet** is a high-fat, low-carbohydrate diet used as a medical treatment for **drug-resistant epilepsy**, particularly in children. - Given that the episodes are **non-epileptic** and investigations are normal, a ketogenic diet would be ineffective and unnecessary.
Question 4: A 16-year-old girl has intense cravings for food and consumes large amounts of it, followed by purging behaviors. What is the most likely diagnosis?
- A. Anorexia nervosa
- B. Bulimia nervosa (Correct Answer)
- C. Major depressive disorder
- D. Binge eating disorder
Explanation: ***Bulimia nervosa*** - **Bulimia nervosa** is characterized by recurrent episodes of **binge eating** (consuming large amounts of food with a sense of lack of control), followed by inappropriate **compensatory behaviors** such as self-induced vomiting, laxative abuse, or excessive exercise. - The patient's presentation of "intense cravings for food," consuming "large amounts," and "purging behaviors" directly aligns with DSM-5 diagnostic criteria for bulimia nervosa. - Peak onset is typically in **adolescence and early adulthood**, and it is more common in females. *Anorexia nervosa* - **Anorexia nervosa** is primarily characterized by **restriction of energy intake** leading to significantly low body weight, intense fear of gaining weight, and disturbance in body image. - While the binge-eating/purging subtype of anorexia exists, the defining feature is **persistent restriction** and significantly **low body weight**, which is not mentioned in this clinical scenario. *Major depressive disorder* - **Depression** is a mood disorder with persistent sadness, anhedonia, and neurovegetative symptoms. - While depression commonly co-occurs with eating disorders and may cause appetite changes, the specific cyclical pattern of **binge eating followed by compensatory purging** is not a characteristic feature of depression itself. *Binge eating disorder* - **Binge eating disorder** involves recurrent episodes of consuming large amounts of food with a sense of lack of control, accompanied by marked distress. - The key distinguishing feature is the **absence of regular compensatory behaviors** (purging, excessive exercise, fasting) that are present in bulimia nervosa.
Question 5: History of dislike for sweet food items is typically present in:
- A. Glycogen storage disease
- B. Diabetes mellitus
- C. Galactosemia
- D. Hereditary fructose intolerance (Correct Answer)
Explanation: ***Hereditary fructose intolerance*** - Patients with hereditary fructose intolerance develop severe symptoms like **nausea, vomiting, abdominal pain, and hypoglycemia** after ingesting fructose, leading to an aversive response and **dislike for sweet food items**. - This aversion is a protective mechanism, as avoiding fructose-containing foods (including many sweets) prevents the accumulation of toxic metabolites due to a deficiency in **hepatic aldolase B**. *Glycogen storage disease* - While glycogen storage diseases can cause hypoglycemia, they typically do not lead to a specific **aversion to sweet foods**. - The primary defect is in **glycogen synthesis or breakdown**, leading to symptoms like hepatomegaly, muscle weakness, and exercise intolerance. *Diabetes mellitus* - Patients with diabetes mellitus often have a **craving for sweet foods** due to uncontrolled blood glucose levels and insulin resistance, rather than a dislike. - The condition is characterized by **hyperglycemia** and may involve polydipsia, polyuria, and polyphagia. *Galactosemia* - Galactosemia involves an inability to metabolize galactose, leading to symptoms such as **vomiting, lethargy, and jaundice** upon milk ingestion [1]. - While patients will avoid milk, their aversion is not generally to all sweet foods, as sweet foods do not always contain galactose [1].
Question 6: Pagophagia involves eating
- A. Sand
- B. Ice (Correct Answer)
- C. Salt
- D. Clay
Explanation: ***Ice*** - **Pagophagia** is a specific form of **pica**, characterized by a compulsive desire to consume **ice**, ice chips, or iced drinks. - It is often associated with **iron-deficiency anemia**, though the exact mechanism for this craving is unclear. *Sand* - The compulsive consumption of **sand** is known as **geophagy**, which is another form of pica. - This behavior is distinct from pagophagia and is not specifically linked to ice consumption. *Salt* - An excessive craving for **salt**, while sometimes indicative of an underlying condition (e.g., adrenal insufficiency), is not referred to as pagophagia. - **Pagophagia** specifically refers to the consumption of ice. *Clay* - The ingestion of **clay** is a specific type of **geophagy**, similar to eating sand. - It is a different form of pica and does not describe the selective craving for and consumption of ice.
Question 7: A four year old boy Tinu has normal developmental milestones except delayed speech. He is interested to watch spinning objects like fan and the washing machine. His parents struggle to get him interested in other children at home. People often comment that he is disinterested and self centred. What will be your thought regarding his diagnosis?
- A. Specific learning disability
- B. Intellectual disability
- C. Sibling Rivalry
- D. Autism Spectrum Disorder (Correct Answer)
Explanation: ***Autism Spectrum Disorder*** - The child's delayed speech, **restricted interests** (spinning objects), lack of social engagement, and difficulty interacting with other children are classic symptoms of **Autism Spectrum Disorder (ASD)**. - Normal developmental milestones in other areas, such as motor skills, differentiate ASD from global developmental delays. - The **triad of impairments** includes social communication deficits, restricted interests, and repetitive behaviors, all evident in this case. *Specific learning disability* - This diagnosis typically presents with difficulties in specific academic areas like reading, writing, or math in a child with otherwise average intelligence. - It is generally diagnosed after school entry (age 6-7 years) when academic demands increase. - It doesn't explain the **social communication deficits** and **restricted, repetitive behaviors** seen in this case. *Intellectual disability* - This condition involves significant limitations in both intellectual functioning and adaptive behavior, with onset during the developmental period. - While delayed speech can be a feature, the child's otherwise **normal developmental milestones** in motor and other domains argue against a global intellectual deficit. - The **restricted interests** and social deficits are more characteristic of ASD than intellectual disability alone. *Sibling Rivalry* - This refers to competition or animosity between siblings, often manifesting as behavioral problems or attention-seeking from parents. - It is a normal developmental phenomenon, not a psychiatric disorder. - It does not account for the core symptoms described, such as **delayed speech**, **restricted interests** (fascination with spinning objects), or a pervasive disinterest in social interaction.
Question 8: Type of schizophrenia with intellectual disability:
- A. Catatonic schizophrenia
- B. Pfropf schizophrenia (Correct Answer)
- C. Paranoid schizophrenia
- D. Hebephrenic schizophrenia
Explanation: ***Pfropf schizophrenia*** - **Pfropf schizophrenia** is a historical term specifically used to describe a form of schizophrenia that develops in individuals with **pre-existing intellectual disability** (formerly termed mental retardation). - The term "Pfropf" is derived from German, meaning "grafted" or "engrafted," referring to schizophrenia being "grafted onto" pre-existing intellectual disability. - This term distinguishes it from other types of schizophrenia where intellectual disability is not a primary defining characteristic. - While this classification is largely historical (modern DSM-5 has removed schizophrenia subtypes), it remains relevant for older examination questions. *Catatonic schizophrenia* - Characterized primarily by prominent **psychomotor disturbances**, which can include stupor, catalepsy, waxy flexibility, mutism, and negativism. - While intellectual disability might coexist, it is not a defining feature of the catatonic subtype itself. *Paranoid schizophrenia* - Marked by the prominence of **delusions**, typically persecutory or grandiose, and **auditory hallucinations**. - Intellectual disability is not a core diagnostic criterion or a defining characteristic of this subtype. *Hebephrenic schizophrenia* - Also known as **disorganized schizophrenia**, this type is characterized by marked **disorganization of thought processes**, flat or inappropriate affect, and bizarre behavior. - While it often presents early and can lead to significant functional impairment, intellectual disability is not a defining feature; rather, the primary disturbance is in thought and emotion.
Question 9: Which of the following is FALSE regarding Anorexia Nervosa:
- A. Decreased appetite (Correct Answer)
- B. Body image distortion
- C. Vigor exceeding physical ill being
- D. Weight loss
Explanation: ***Decreased appetite*** - Patients with anorexia nervosa typically experience **increased hunger** and **preoccupation with food**, despite efforts to restrict intake, rather than a decreased appetite. - The sensation of hunger often intensifies due to severe caloric restriction, making the statement "decreased appetite" false. *Body image distortion* - This is a core diagnostic criterion of anorexia nervosa, where individuals perceive themselves as **overweight** even when they are severely underweight. - The distorted body image drives their relentless pursuit of thinness and fear of weight gain. *Vigor exceeding physical ill being* - Patients with anorexia nervosa often display surprising **energy and hyperactivity** despite severe physical debilitation and malnutrition. - This "vigor" can be a mechanism to burn calories, suppress hunger, or avoid rest, exceeding what would be expected given their poor health status. *Weight loss* - **Significant weight loss** or failure to gain weight during growth is a defining characteristic of anorexia nervosa. - This weight loss is intentionally achieved through severe dietary restriction, excessive exercise, or purging behaviors.
Question 10: Which of the following is NOT true about anorexia nervosa?
- A. Leukopenia
- B. Amenorrhea
- C. Self-induced vomiting (Correct Answer)
- D. More common in adult females
Explanation: **Explanation:** The core psychopathology of **Anorexia Nervosa (AN)** is a distorted body image and an intense fear of gaining weight, leading to restricted energy intake and significantly low body weight. **Why "Self-induced vomiting" is the correct answer:** While self-induced vomiting *can* occur in the "Binge-eating/Purging type" of Anorexia, it is **not a mandatory diagnostic feature** or a universal finding. In contrast, self-induced vomiting is a hallmark and often defining compensatory behavior of **Bulimia Nervosa**. In Anorexia, the primary mechanism of weight loss is typically severe caloric restriction and excessive exercise. **Analysis of other options:** * **Leukopenia (A):** This is a common hematological complication of starvation in AN due to bone marrow hypoplasia (gelatinous transformation of marrow). * **Amenorrhea (B):** Though no longer a strict DSM-5 diagnostic criterion, it remains a classic clinical feature caused by hypogonadotropic hypogonadism (low FSH/LH due to hypothalamic dysfunction). * **More common in adult females (D):** AN has a significant female-to-male preponderance (roughly 10:1), typically peaking in adolescence and young adulthood. **NEET-PG High-Yield Pearls:** 1. **Most common cause of death:** Suicide (psychiatric) or Cardiac Arrhythmias (medical, often due to hypokalemia). 2. **Refeeding Syndrome:** Characterized by **Hypophosphatemia** (hallmark), hypokalemia, and hypomagnesemia when food is reintroduced too rapidly. 3. **Physical signs:** Lanugo hair, bradycardia, hypotension, and "Russell’s sign" (calluses on knuckles if purging is present). 4. **Treatment:** Nutritional rehabilitation is the priority. Family-Based Therapy (FBT) is the gold standard for adolescents.
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