Anxiety disorder differential diagnosis — MCQs

10 questions

A 30-year-old woman comes to the physician because of difficulty sleeping. She is afraid of falling asleep and gets up earlier than desired. Four months ago, she was the driver in a car accident that resulted in the death of her unborn child. She has vivid nightmares of the event and reports that she frequently re-experiences the accident. She blames herself for the death of her child, has stopped working as an accountant, avoids driving in cars, and has withdrawn from her parents and close friends. Which of the following is the most likely diagnosis?

A 45-year-old woman presents to her primary care physician with complaints of muscle pains, poor sleep, and daytime fatigue. When asked about stressors she states that she "panics" about her job, marriage, children, and finances. When asked to clarify what the "panics" entail, she states that it involves severe worrying. She has had these symptoms since she last saw you one year ago. What is the most likely diagnosis?

A mental health volunteer is interviewing locals as part of a community outreach program. A 46-year-old man discloses that he has felt sad for as long as he can remember. He feels as though his life is cursed and if something terrible can happen to him, it usually will. He has difficulty making decisions and feels hopeless. He also feels that he has had worsening suicidal ideations, guilt from past problems, decreased energy, and poor concentration over the past 2 weeks. He is otherwise getting enough sleep and able to hold a job. Which of the following statement best describes this patient's condition?

A 35-year-old woman presents with increased anxiety and a reeling sensation. Her complaint started 30 minutes ago with increased sweating and palpitations and is gradually worsening. On examination, the blood pressure was found to be 194/114 mm Hg. She had normal blood pressure at the local pharmacy 5 days ago. She currently works as an event manager and her job involves a lot of stress. The family history is significant for thyroid carcinoma in her father. Which of the following is most likely in this person?

A previously healthy 25-year-old woman comes to the physician because of a 1-month history of palpitations that occur on minimal exertion and sometimes at rest. She has no chest discomfort or shortness of breath. She feels nervous and irritable most of the time and attributes these feelings to her boyfriend leaving her 2 months ago. Since then she has started exercising more frequently and taking an herbal weight-loss pill, since which she has lost 6.8 kg (15 lb) of weight. She finds it hard to fall asleep and awakens 1 hour before the alarm goes off each morning. She has been drinking 2 to 3 cups of coffee daily for the past 7 years and has smoked one pack of cigarettes daily for the past 3 years. Her temperature is 37.4°C (99.4°F), pulse is 110/min, respirations are 18/min, and blood pressure is 150/70 mm Hg. Examination shows moist palms. Neurologic examination shows a fine resting tremor of the hands. Deep tendon reflexes are 3+ with a shortened relaxation phase. Which of the following is the most likely cause of this patient's symptoms?

A 33-year-old woman presents with lethargy and neck pain. She says that, for the past 6 months, she has been feeling tired all the time and has noticed a lot of muscle tension around the base of her neck. She also says she finds herself constantly worrying about everything, such as if her registered mail would reach family and friends in time for the holidays or if the children got their nightly bath while she was away over the weekend. She says that this worrying has prevented her from sleeping at night and has made her more irritable and edgy with her family and friends. Which of the following is the best course of treatment for this patient?

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 35-year-old woman presents to clinic in emotional distress. She states she has been unhappy for the past couple of months and is having problems with her sleep and appetite. Additionally, she reports significant anxiety regarding thoughts of dirtiness around the house. She states that she cleans all of the doorknobs 5-10 times per day and that, despite her actions, the stress related to cleaning is becoming worse. What is this patient's diagnosis?

An 8-year-old girl is brought to the physician by her parents because of difficulty sleeping. One to two times per week for the past 2 months, she has woken up frightened in the middle of the night, yelling and crying. She has not seemed confused after waking up, and she is consolable and able to fall back asleep in her parents' bed. The following day, she seems more tired than usual at school. She recalls that she had a bad dream and looks for ways to delay bedtime in the evenings. She has met all her developmental milestones to date. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?

Q10

A 26-year-old woman presents to the office complaining of bloating and consistent fatigue. Past medical notes on her record show that she has seen several doctors at the clinic in the past year for the same concerns. During the discussion, she admits that coming to the doctor intensifies her anxiety and she does not enjoy it. However, she came because she fears that she has colon cancer and says, “There’s gotta be something wrong with me, I can feel it.” Past medical history is significant for obsessive-compulsive disorder (OCD). She sees a therapist a few times a month. Her grandfather died of colon cancer at 75. Today, her blood pressure is 120/80 mm Hg, heart rate is 90/min, respiratory rate is 18/min, and temperature is 37.0°C (98.6°F). Physical examination reveals a well-nourished, well-developed woman who appears anxious and tired. Her heart has a regular rhythm and her lungs are clear to auscultation bilaterally. Her abdomen is soft, non-tender, and non-distended. No masses are palpated, and a digital rectal examination is unremarkable. Laboratory results are as follows: Serum chemistry Hemoglobin 13 g/dL Hematocrit 38% MCV 90 fl TSH 4.1 μU/mL Fecal occult blood test negative Which of the following is the most likely diagnosis?

Anxiety disorder differential diagnosis US Medical PG Practice Questions and MCQs

Question 1: A 30-year-old woman comes to the physician because of difficulty sleeping. She is afraid of falling asleep and gets up earlier than desired. Four months ago, she was the driver in a car accident that resulted in the death of her unborn child. She has vivid nightmares of the event and reports that she frequently re-experiences the accident. She blames herself for the death of her child, has stopped working as an accountant, avoids driving in cars, and has withdrawn from her parents and close friends. Which of the following is the most likely diagnosis?

A. Acute stress disorder
B. Normal grief
C. Major depressive disorder
D. Adjustment disorder
E. Post-traumatic stress disorder (Correct Answer)

Explanation: ***Post-traumatic stress disorder*** - The patient's symptoms, including **re-experiencing the trauma** (nightmares, flashbacks), avoidance behaviors (avoiding driving, withdrawing from social interactions), and negative alterations in cognition and mood (difficulty sleeping, self-blame), persisting for **four months** after a traumatic event, are characteristic of PTSD. - The severity and chronicity of these symptoms, significantly impacting her daily functioning, align with the diagnostic criteria for PTSD. *Acute stress disorder* - This diagnosis also involves exposure to a traumatic event and similar symptoms (intrusive thoughts, negative mood, avoidance) but is diagnosed only when symptoms last for a minimum of **3 days and a maximum of 1 month** after the trauma. - Since the patient's symptoms have persisted for **four months**, acute stress disorder is ruled out. *Normal grief* - While grief is a natural response to loss, the patient's symptoms extend beyond typical grief, involving specific **trauma-related re-experiencing** and **avoidance behaviors** that are not primarily focused on the deceased, but rather on the traumatic event itself. - Normal grief typically does not involve the severe, persistent avoidance and intrusive symptoms of a traumatic nature seen here. *Major depressive disorder* - Although the patient exhibits symptoms that could overlap with depression (difficulty sleeping, withdrawal, loss of interest), the primary driver of her symptoms is the **traumatic event** and its associated re-experiencing and avoidance. - A diagnosis of MDD would be considered if the depressive symptoms are paramount and not better explained by the trauma response, but in this case, the **trauma-specific symptoms** are central. *Adjustment disorder* - This disorder is characterized by the development of emotional or behavioral symptoms in response to an identifiable stressor, occurring within **3 months of the stressor**. - While a traumatic event could be a stressor, adjustment disorder is diagnosed when the symptoms **do not meet the criteria for another specific mental disorder**, like PTSD, and are generally less severe and pervasive than what is described in this patient.

Question 2: A 45-year-old woman presents to her primary care physician with complaints of muscle pains, poor sleep, and daytime fatigue. When asked about stressors she states that she "panics" about her job, marriage, children, and finances. When asked to clarify what the "panics" entail, she states that it involves severe worrying. She has had these symptoms since she last saw you one year ago. What is the most likely diagnosis?

A. Generalized anxiety disorder (Correct Answer)
B. Social phobia
C. Adjustment disorder
D. Obsessive-compulsive disorder
E. Panic disorder

Explanation: ***Generalized anxiety disorder*** - This patient presents with **chronic, excessive, and uncontrollable worry** about multiple life circumstances (job, marriage, children, finances), fulfilling the core diagnostic criterion for GAD. - The associated symptoms of **muscle pains**, **poor sleep**, and **daytime fatigue** are common physical manifestations of GAD, and the duration of symptoms for over a year supports the diagnosis. *Social phobia* - **Social phobia**, or social anxiety disorder, involves intense fear and anxiety in **social situations** where one might be scrutinized or judged. - The patient's reported worries are broad and not limited to social interactions, making social phobia less likely. *Adjustment disorder* - **Adjustment disorder** is characterized by emotional or behavioral symptoms developing within **three months of an identifiable stressor**, not diffuse chronic worry. - The symptoms in adjustment disorder typically resolve within **six months** after the stressor or its consequences have ended, whereas this patient's symptoms are chronic and pervasive. *Obsessive-compulsive disorder* - **Obsessive-compulsive disorder (OCD)** involves recurrent, intrusive **obsessions** (thoughts, urges, images) and/or **compulsions** (repetitive behaviors or mental acts) performed to reduce anxiety. - While the patient experiences severe worrying, there's no mention of specific obsessions or compulsive behaviors aimed at neutralizing those anxieties. *Panic disorder* - **Panic disorder** is characterized by recurrent, unexpected **panic attacks**—sudden surges of intense fear or discomfort accompanied by physical and cognitive symptoms. - While the patient uses the term "panics," she clarifies it involves "severe worrying," not discrete, intense, and short-lived panic attacks.

Question 3: A mental health volunteer is interviewing locals as part of a community outreach program. A 46-year-old man discloses that he has felt sad for as long as he can remember. He feels as though his life is cursed and if something terrible can happen to him, it usually will. He has difficulty making decisions and feels hopeless. He also feels that he has had worsening suicidal ideations, guilt from past problems, decreased energy, and poor concentration over the past 2 weeks. He is otherwise getting enough sleep and able to hold a job. Which of the following statement best describes this patient's condition?

A. The patient may have symptoms of mania or psychosis.
B. The patient is likely to show anhedonia.
C. The patient likely has paranoid personality disorder.
D. The patient has double depression. (Correct Answer)
E. The patient should be started on an SSRI.

Explanation: ***The patient has double depression.*** - The patient describes **chronic low-grade depressive symptoms** ("felt sad for as long as he can remember," "life is cursed," "difficulty making decisions," "hopeless") consistent with **persistent depressive disorder (dysthymia)**, which requires at least 2 years of symptoms. - The recent worsening of symptoms over the past two weeks, including "worsening suicidal ideations, guilt from past problems, decreased energy, and poor concentration," indicates an additional **major depressive episode (MDE) superimposed on dysthymia**, a condition known as **double depression**. - This patient currently meets criteria for both conditions simultaneously, not just at risk for developing them. *The patient may have symptoms of mania or psychosis.* - There are no symptoms mentioned that suggest **mania**, such as elevated mood, increased energy, decreased need for sleep, grandiosity, or racing thoughts. - While suicidal ideation is present, there is no evidence of **psychotic features** like hallucinations or delusions. *The patient is likely to show anhedonia.* - **Anhedonia** (inability to feel pleasure) is a common symptom of depression and may well be present in this patient. - However, the patient's presentation specifically highlights the pattern of **chronic dysthymia with a superimposed major depressive episode**, making **double depression** a more precise, comprehensive, and diagnostically specific description of his current condition. - While anhedonia might be present, it is a symptom rather than a diagnostic formulation. *The patient likely has paranoid personality disorder.* - **Paranoid personality disorder** is characterized by pervasive distrust and suspicion of others, interpreting their motives as malevolent, without sufficient basis. - The patient's feelings of being "cursed" and that "something terrible can happen" reflect **depressive pessimism and negative cognitive distortions**, not paranoid ideation about others' intentions. - This is consistent with the hopelessness seen in depression. *The patient should be started on an SSRI.* - While an **SSRI (selective serotonin reuptake inhibitor)** combined with psychotherapy would likely be appropriate treatment for double depression, making a specific treatment recommendation is premature without comprehensive clinical assessment. - The question asks for the **best statement describing the patient's condition** (diagnosis), not for treatment recommendations.

Question 4: A 35-year-old woman presents with increased anxiety and a reeling sensation. Her complaint started 30 minutes ago with increased sweating and palpitations and is gradually worsening. On examination, the blood pressure was found to be 194/114 mm Hg. She had normal blood pressure at the local pharmacy 5 days ago. She currently works as an event manager and her job involves a lot of stress. The family history is significant for thyroid carcinoma in her father. Which of the following is most likely in this person?

A. Increased urine metanephrines (Correct Answer)
B. Decreased C-peptide
C. Decreased hemoglobin
D. Decreased TSH levels
E. Increased serum serotonin

Explanation: ***Increased urine metanephrines*** - The patient's symptoms (anxiety, reeling sensation, sweating, palpitations, and paroxysmal hypertension) are highly suggestive of a **pheochromocytoma**, which is a tumor of the adrenal medulla that secretes catecholamines. - **Metanephrines** (metabolism products of catecholamines) are often elevated in urine and plasma samples from patients with pheochromocytoma, making this the most likely finding. *Decreased C-peptide* - **Decreased C-peptide** levels are indicative of reduced endogenous insulin production, typically seen in type 1 diabetes, which does not align with the patient's acute presentation of paroxysmal hypertension and anxiety. - Her symptoms are not consistent with **hypoglycemia** or **diabetes mellitus**. *Decreased hemoglobin* - **Decreased hemoglobin** indicates anemia, which would present with fatigue, pallor, and shortness of breath, not the acute hypertensive crisis and anxiety described. - There is no clinical information in the vignette to suggest **blood loss** or **red blood cell destruction**. *Decreased TSH levels* - **Decreased TSH levels** would suggest hyperthyroidism, which can cause anxiety and palpitations, but the sudden onset and extreme hypertension (194/114 mm Hg) are more characteristic of a **catecholamine surge** than typical hyperthyroidism. - While there is a family history of **thyroid carcinoma**, the acute presentation points away from purely thyroid-related issues as the primary cause. *Increased serum serotonin* - **Increased serum serotonin** is associated with carcinoid syndrome, which typically presents with flushing, diarrhea, bronchospasm, and valvular heart disease, not the predominant features of anxiety, palpitations, and paroxysmal hypertension seen in this patient. - The symptoms are more consistent with an acute release of **catecholamines**, not serotonin.

Question 5: A previously healthy 25-year-old woman comes to the physician because of a 1-month history of palpitations that occur on minimal exertion and sometimes at rest. She has no chest discomfort or shortness of breath. She feels nervous and irritable most of the time and attributes these feelings to her boyfriend leaving her 2 months ago. Since then she has started exercising more frequently and taking an herbal weight-loss pill, since which she has lost 6.8 kg (15 lb) of weight. She finds it hard to fall asleep and awakens 1 hour before the alarm goes off each morning. She has been drinking 2 to 3 cups of coffee daily for the past 7 years and has smoked one pack of cigarettes daily for the past 3 years. Her temperature is 37.4°C (99.4°F), pulse is 110/min, respirations are 18/min, and blood pressure is 150/70 mm Hg. Examination shows moist palms. Neurologic examination shows a fine resting tremor of the hands. Deep tendon reflexes are 3+ with a shortened relaxation phase. Which of the following is the most likely cause of this patient's symptoms?

A. Exogenous hyperthyroidism (Correct Answer)
B. Pheochromocytoma
C. Hashimoto thyroiditis
D. Coffee consumption
E. Generalized anxiety disorder

Explanation: ***Exogenous hyperthyroidism*** - The patient's symptoms including **palpitations, weight loss, nervousness, irritability, insomnia**, and physical findings like **tachycardia, moist palms, fine tremor**, and **hyperreflexia with shortened relaxation phase** are highly indicative of **hyperthyroidism**. - The use of an **herbal weight-loss pill** strongly suggests the possibility of exogenous thyroid hormone intake or other thyroid-stimulating substances within the pill, leading to **exogenous hyperthyroidism**. *Pheochromocytoma* - While **palpitations** and **hypertension** can occur, **pheochromocytoma** is typically characterized by paroxysmal episodes of severe headaches, sweating, and anxiety. - The chronic nature of the patient's symptoms, along with significant **weight loss** and **hyperreflexia**, are less typical for **pheochromocytoma**. *Hashimoto thyroiditis* - **Hashimoto thyroiditis** typically causes **hypothyroidism**, characterized by symptoms like weight gain, fatigue, cold intolerance, and bradycardia. - While it can sometimes have a transient hyperthyroid phase (hashitoxicosis), the overall clinical picture here is more consistent with sustained **hyperthyroidism**, especially given the suspected external factor. *Coffee consumption* - Although **caffeine** can cause palpitations, nervousness, and insomnia, the severity and breadth of this patient's symptoms, including significant **weight loss, hyperreflexia**, and **moist palms**, extend far beyond what would typically be attributed solely to coffee intake, especially given her chronic coffee use. - The new onset and progression of these symptoms, coinciding with the herbal pill, points to a stronger underlying cause. *Generalized anxiety disorder* - **Generalized anxiety disorder (GAD)** can explain nervousness, irritability, and insomnia, but it does not typically cause **significant weight loss** or objective physical findings such as **tachycardia, moist palms, fine tremor, and hyperreflexia**. - These physical signs are hallmarks of a physiological rather than purely psychological condition.

Question 6: A 33-year-old woman presents with lethargy and neck pain. She says that, for the past 6 months, she has been feeling tired all the time and has noticed a lot of muscle tension around the base of her neck. She also says she finds herself constantly worrying about everything, such as if her registered mail would reach family and friends in time for the holidays or if the children got their nightly bath while she was away over the weekend. She says that this worrying has prevented her from sleeping at night and has made her more irritable and edgy with her family and friends. Which of the following is the best course of treatment for this patient?

A. Support groups
B. A vacation
C. Diazepam
D. Family therapy
E. Buspirone (Correct Answer)

Explanation: ***Buspirone*** - **Buspirone** is a non-benzodiazepine anxiolytic agent. It is often preferred for long-term management of **generalized anxiety disorder (GAD)** due to its favorable side effect profile and lack of dependence potential, addressing the patient's chronic symptoms effectively. - Unlike benzodiazepines, buspirone does not cause sedation or withdrawal symptoms, making it suitable for a patient experiencing prolonged anxiety, sleep disturbances, and irritability. *Support groups* - While **support groups** can provide emotional support and coping strategies, they are typically used as an adjunct to pharmacotherapy or psychotherapy, not as a primary standalone treatment for moderate to severe GAD. - This patient's symptoms (lethargy, significant muscle tension, chronic worrying, sleep disturbance) suggest a need for a more direct pharmacological intervention to alleviate her symptoms. *A vacation* - A vacation might offer temporary relief from stress but will not address the underlying physiological and psychological components of her **generalized anxiety disorder**. - Her chronic and pervasive worrying, along with physical symptoms, indicates a need for sustained medical management. *Diazepam* - **Diazepam** is a benzodiazepine that provides rapid, short-term relief from anxiety, but it is generally not recommended for long-term management due to the risks of **dependence, tolerance, and withdrawal symptoms**, especially in a patient with chronic symptoms. - Given the patient's 6-month history of symptoms, a medication with a better long-term safety profile is preferred. *Family therapy* - **Family therapy** could be beneficial if family dynamics are a significant contributor to her stress or if her symptoms are impacting family relationships negatively. However, it does not directly address the primary diagnosis of generalized anxiety disorder with its constellation of chronic symptoms. - While it may provide some support, it is not the initial best course of treatment for the patient's core anxiety symptoms.

Question 7: 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

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.

Question 8: A 35-year-old woman presents to clinic in emotional distress. She states she has been unhappy for the past couple of months and is having problems with her sleep and appetite. Additionally, she reports significant anxiety regarding thoughts of dirtiness around the house. She states that she cleans all of the doorknobs 5-10 times per day and that, despite her actions, the stress related to cleaning is becoming worse. What is this patient's diagnosis?

A. Panic Disorder (PD)
B. Generalized anxiety disorder (GAD)
C. Obsessive compulsive personality disorder (OCPD)
D. Obsessive compulsive disorder (OCD) (Correct Answer)
E. Tic disorder

Explanation: ***Obsessive compulsive disorder (OCD)*** - The patient's **recurrent distressing thoughts** about dirtiness (obsessions) and **repetitive cleaning behaviors** (compulsions) designed to reduce anxiety are hallmark symptoms of OCD. - The significant **emotional distress**, impact on daily life, and worsening stress despite the compulsions further support this diagnosis. *Panic Disorder (PD)* - Characterized by **recurrent, unexpected panic attacks** and persistent worry about additional attacks or their consequences. - While anxiety is present, the patient's primary distress is driven by specific obsessions and compulsions, not sudden episodes of intense fear. *Generalized anxiety disorder (GAD)* - Involves **excessive, uncontrollable worry** about a variety of events or activities for at least 6 months. - The anxiety symptoms are general, not focused on specific obsessions leading to compulsive behaviors as seen in this case. *Obsessive compulsive personality disorder (OCPD)* - Marked by pervasive patterns of **perfectionism, orderliness, and control** at the expense of flexibility and efficiency. - While there may be a preoccupation with rules, OCPD does not typically involve intrusive, ego-dystonic obsessions or ritualistic compulsions like repetitive cleaning to reduce anxiety. *Tic disorder* - Characterized by **sudden, rapid, recurrent, non-rhythmic motor movements or vocalizations**. - Tics are distinct from the complex, goal-directed, and anxiety-driven compulsive behaviors described by the patient.

Question 9: An 8-year-old girl is brought to the physician by her parents because of difficulty sleeping. One to two times per week for the past 2 months, she has woken up frightened in the middle of the night, yelling and crying. She has not seemed confused after waking up, and she is consolable and able to fall back asleep in her parents' bed. The following day, she seems more tired than usual at school. She recalls that she had a bad dream and looks for ways to delay bedtime in the evenings. She has met all her developmental milestones to date. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?

A. Normal development
B. Sleep terror disorder
C. Nightmare disorder (Correct Answer)
D. Post-traumatic stress disorder
E. Separation anxiety disorder

Explanation: ***Nightmare disorder*** - The key features supporting **nightmare disorder** are vivid, frightening dreams that lead to waking up, the ability to recall the dream content, being easily consolable, and attempts to avoid bedtime. - Sleep disturbances, daytime fatigue, and negative emotional responses centered around sleep are characteristic of this disorder. *Normal development* - While occasional bad dreams are part of normal development, a frequency of one to two times per week over 2 months, leading to daytime tiredness and bedtime avoidance, suggests a **clinical disorder** exceeding typical developmental experiences. - The distress caused and impact on daily functioning (tiredness at school) differentiate it from normal, transient nightmares. *Sleep terror disorder* - **Sleep terrors** typically involve abrupt awakening with intense fear, screaming, and autonomic arousal, but the individual is usually disoriented, inconsolable, and has no recall of the event upon waking or the next day. - In this case, the child is consolable and *recalls* having a bad dream, distinguishing it from sleep terrors. *Post-traumatic stress disorder* - **PTSD** requires exposure to a traumatic event, which is not mentioned in the vignette. - While nightmares can be a symptom of PTSD, they are usually accompanied by other symptoms like flashbacks, avoidance behavior, negative alterations in cognition/mood, and hypervigilance related to the trauma. *Separation anxiety disorder* - **Separation anxiety disorder** is characterized by excessive fear or anxiety concerning separation from attachment figures. - Although the child sleeps in her parents' bed, the primary issue is frightening dreams and difficulty sleeping, not anxiety specifically related to separation from her parents.

Question 10: A 26-year-old woman presents to the office complaining of bloating and consistent fatigue. Past medical notes on her record show that she has seen several doctors at the clinic in the past year for the same concerns. During the discussion, she admits that coming to the doctor intensifies her anxiety and she does not enjoy it. However, she came because she fears that she has colon cancer and says, “There’s gotta be something wrong with me, I can feel it.” Past medical history is significant for obsessive-compulsive disorder (OCD). She sees a therapist a few times a month. Her grandfather died of colon cancer at 75. Today, her blood pressure is 120/80 mm Hg, heart rate is 90/min, respiratory rate is 18/min, and temperature is 37.0°C (98.6°F). Physical examination reveals a well-nourished, well-developed woman who appears anxious and tired. Her heart has a regular rhythm and her lungs are clear to auscultation bilaterally. Her abdomen is soft, non-tender, and non-distended. No masses are palpated, and a digital rectal examination is unremarkable. Laboratory results are as follows: Serum chemistry Hemoglobin 13 g/dL Hematocrit 38% MCV 90 fl TSH 4.1 μU/mL Fecal occult blood test negative Which of the following is the most likely diagnosis?

A. Malingering
B. Somatic symptom disorder
C. Generalized anxiety disorder
D. Body dysmorphic disorder
E. Illness anxiety disorder (Correct Answer)

Explanation: ***Illness anxiety disorder*** - This patient exhibits **preoccupation with having or acquiring a serious illness**, despite minimal somatic symptoms and negative diagnostic findings. Her fear of colon cancer, despite an unremarkable physical exam and negative fecal occult blood test, is a key indicator. - Her history of seeking care from multiple doctors, admitting anxiety about visits, and stating "There's gotta be something wrong with me, I can feel it," aligns with the **excessive health-related behaviors** (or maladaptive avoidance) and **high anxiety about health** central to illness anxiety disorder. *Somatic symptom disorder* - This disorder is characterized by **one or more somatic symptoms that are distressing or result in significant disruption of daily life**, accompanied by excessive thoughts, feelings, or behaviors related to these symptoms. - In this case, the patient's symptoms (bloating, fatigue) are minimal, and her primary concern is the *fear of having* a serious illness, rather than the distress caused by the physical symptoms themselves. *Generalized anxiety disorder* - This involves **excessive anxiety and worry about a number of events or activities** that is difficult to control and present for at least 6 months. - While the patient experiences anxiety, it is specifically focused on her health, not generalized concerns about various aspects of her life. *Malingering* - This involves the **intentional production of false or grossly exaggerated physical or psychological symptoms**, motivated by external incentives such as avoiding work or obtaining financial compensation. - The patient genuinely believes she has a serious illness and is distressed by this belief, rather than faking symptoms for an external gain. *Body dysmorphic disorder* - This disorder is characterized by **preoccupation with one or more perceived defects or flaws in physical appearance** that are not observable or appear slight to others. - The patient's concerns are about an internal illness (colon cancer), not specific physical appearance flaws.

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