A 33-year-old woman is brought to the physician by her husband because of persistent sadness for the past 2 months. During this period, she also has had difficulty sleeping and an increased appetite. She had similar episodes that occurred 2 years ago and 9 months ago that each lasted for 4 months. Between these episodes, she reported feeling very energetic and rested after 3 hours of sleep. She often went for long periods of time without eating. She works as a stock market trader and received a promotion 5 months ago. She regularly attends yoga classes on the weekends with her friends. On mental status examination, she has a blunted affect. She denies suicidal thoughts and illicit drug use. Which of the following is the most likely diagnosis?
Q2
A 24-year-old woman is brought to the hospital by her mother because she has "not been herself" for the past 3 months. The patient says she hears voices in her head. The mother said that when she is talking to her daughter she can’t seem to make out what she is saying; it is as if her thoughts are disorganized. When talking with the patient, you notice a lack of energy and an apathetic affect. Which of the following is the most likely diagnosis for this patient?
Q3
A 28-year-old woman presents with continuous feelings of sadness and rejection. She says that over the past couple of weeks, she has been unable to concentrate on her job and has missed several days of work. She also has no interest in any activity and typically rejects invitations to go out with friends. She has no interest in food or playing with her dog. Her husband is concerned about this change in behavior. A few months ago, she was very outgoing and made many plans with her friends. She remembers being easily distracted and also had several ‘brilliant ideas’ on what she should be doing with her life. She did not sleep much during that week, but now all she wants to do is lie in bed all day. She denies any suicidal or homicidal ideations. She has no past medical history and has never been hospitalized. Laboratory tests were normal. Which of the following is the most likely diagnosis in this patient?
Q4
A 55-year-old man presents to his primary care physician with complaints of fluctuating mood for the past 2 years. He feels great and full of energy for some months when he is very creative with tons of ideas just racing through his mind. He is noted to be very talkative and distracted by his different ideas. During these times, he is very productive and able to accomplish much at work and home. However, these periods are frequently followed by a prolonged depressed mood. During this time, he has low energy, poor concentration, and low self-esteem. The accompanying feeling of hopelessness from these cycling “ups” and “downs” have him eating and sleeping more during the “downs.” He does not remember a period within the last 2 years where he felt “normal.” What is the most likely diagnosis?
Q5
A 29-year-old man comes to the physician with his wife because she has noticed a change in his behavior over the past 2 weeks. His wife reports that he is very distracted and irritable. His colleagues have voiced concerns that he has not been turning up for work regularly and behaves erratically when he does. Previously, her husband had been a reliable and reasonable person. The patient says that he feels “fantastic”; he only needs 4 hours of sleep each night and wakes up cheerful and full of energy each morning. He thinks that his wife is overreacting. The patient has been healthy except for a major depressive episode 5 years ago that was treated with paroxetine. He currently takes no medications. His pulse is 98/min, respirations are 12/min, and blood pressure is 128/62 mm Hg. Mental status examination shows frenzied speech and a flight of ideas. Which of the following is the strongest predisposing factor for this patient's condition?
Q6
A 38-year-old woman comes to the physician for a follow-up visit. She has a 2-year history of depressed mood and fatigue accompanied by early morning awakening. One week ago, she started feeling a decrease in her need for sleep and now feels rested after about 5 hours of sleep per night. She had two similar episodes that occurred 6 months ago and a year ago, respectively. She reports increased energy and libido. She has a 4-kg (8.8-lb) weight loss over the past month. She does not feel the need to eat and says she derives her energy ""from the universe"". She enjoys her work as a librarian. She started taking fluoxetine 3 months ago. On mental exam, she is alert and oriented to time and place; she is irritable. She does not have auditory or visual hallucinations. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?
Q7
A 26-year-old female college student is brought back into the university clinic for acting uncharacteristically. The patient presented to the same clinic 6 weeks ago with complaints of depressed mood, insomnia, and weightloss. She had been feeling guilty for wasting her parent’s money by doing so poorly at the university. She felt drained for at least 2 weeks before presenting to the clinic for the first time. She was placed on an antidepressant and was improving but now presents with elevated mood. She is more talkative with a flight of ideas and is easily distractible. Which of the following statements is most likely true regarding this patient’s condition?
Q8
A 25-year-old woman is brought to a psychiatrist's office by her husband who states that he is worried about her recent behavior, as it has become more violent. The patient's husband states that his family drove across the country to visit them and that his wife 'threatened his parents with a knife' at dinner last night. Police had to be called to calm her down. He states that she has been acting 'really crazy' for the last 9 months, and the initial behavior that caused him alarm was her admission that his deceased sister was talking to her through a decorative piece of ceramic art in the living room. Initially, he thought she was joking, but soon realized her complaints of 'hearing ghosts' talking to her throughout the house were persisting and 'getting worse'. Over the past 9 months, she has experienced multiple periods of profound sadness, with persistent insomnia and an unintentional weight loss of 12 pounds over several months. She has been complaining of feeling 'worthless' and has had markedly diminished interest in activities for much of this time period. Her general hygiene has also suffered from her recent lack of motivation and she insists that the 'ghosts' are asking her to kill as many people as she can so they won't be alone in the house. Her husband is extremely concerned that she may harm herself or someone else. He states that she currently does not take any medications or illicit drugs as far as he knows. She does not smoke or drink alcohol. The patient herself does not make eye contact or want to speak to the psychiatrist, allowing her husband to speak on her behalf. Which of the following is the most likely diagnosis in this patient?
Q9
An 8-year-old girl is brought to the physician by her parents because they are concerned with her behavior. She has temper outbursts six or seven times per week, which last anywhere between 5 minutes to half an hour or until she becomes tired. According to her father, she screams at others and throws things in anger “when things don't go her way.” He says these outbursts started when she was 6 and a half years old and even between the outbursts, she is constantly irritable. She had been suspended from school three times in the past year for physical aggression, but her grades have remained unaffected. She appears agitated and restless. Physical examination shows no abnormalities. During the mental status examination, she is uncooperative and refuses to answer questions. What is the most likely diagnosis in this child?
Q10
A 28-year-old woman is brought to the emergency department by her friends. She is naked except for a blanket and speaking rapidly and incoherently. Her friends say that she was found watering her garden naked and refused to put on any clothes when they tried to make her do so, saying that she has accepted how beautiful she is inside and out. Her friends say she has also purchased a new car she can not afford. They are concerned about her, as they have never seen her behave this way before. For the past week, she has not shown up at work and has been acting ‘strangely’. They say she was extremely excited and has been calling them at odd hours of the night to tell them about her future plans. Which of the following drug mechanisms will help with the long-term management this patient’s symptoms?
Hypomanic episode criteria and features US Medical PG Practice Questions and MCQs
Question 1: A 33-year-old woman is brought to the physician by her husband because of persistent sadness for the past 2 months. During this period, she also has had difficulty sleeping and an increased appetite. She had similar episodes that occurred 2 years ago and 9 months ago that each lasted for 4 months. Between these episodes, she reported feeling very energetic and rested after 3 hours of sleep. She often went for long periods of time without eating. She works as a stock market trader and received a promotion 5 months ago. She regularly attends yoga classes on the weekends with her friends. On mental status examination, she has a blunted affect. She denies suicidal thoughts and illicit drug use. Which of the following is the most likely diagnosis?
A. Major depressive disorder with seasonal pattern
B. Persistent depressive disorder
C. Bipolar II disorder (Correct Answer)
D. Major depressive disorder with atypical features
E. Cyclothymic disorder
Explanation: ***Bipolar II disorder***
- The patient exhibits recurrent episodes of **major depression** (sadness, sleep difficulties, increased appetite) interspersed with periods of **hypomania** (energetic, reduced need for sleep, long periods without eating, successful work performance with promotion)
- This pattern is characteristic of **Bipolar II disorder**: major depressive episodes plus at least one hypomanic episode
- No evidence of **frank mania** (e.g., psychosis, severe impairment requiring hospitalization) is present, which distinguishes this from Bipolar I disorder
*Major depressive disorder with seasonal pattern*
- While the patient presents with depressive symptoms, the episodes of **hypomania** (increased energy, decreased need for sleep) rule out unipolar depression
- The history of episodes at various times (2 years ago, 9 months ago, current) does not fit a **seasonal pattern**
- The **hypomanic phases** between depressive episodes are inconsistent with any form of major depressive disorder
*Persistent depressive disorder*
- This condition involves **chronic depressive symptoms** lasting at least 2 years, but typically less severe than major depressive episodes
- The presence of distinct, severe **major depressive episodes** and recurrent **hypomanic periods** contradicts this diagnosis
- Persistent depressive disorder does not include hypomania or mood elevation
*Major depressive disorder with atypical features*
- Atypical features include **increased appetite**, **hypersomnia**, leaden paralysis, interpersonal rejection sensitivity, and mood reactivity
- While increased appetite is present during depressive phases, the alternating periods of **hypomania** exclude this from being major depressive disorder
- Any form of major depressive disorder is ruled out by the presence of hypomanic episodes
*Cyclothymic disorder*
- Cyclothymic disorder involves numerous periods of **hypomanic symptoms** and **depressive symptoms** for at least 2 years, but symptoms do not meet full criteria for major depressive or hypomanic episodes
- This patient explicitly experiences **major depressive episodes** (persistent sadness, neurovegetative symptoms lasting 4 months), which exceed the threshold for cyclothymia
- The severity and duration of depressive episodes make Bipolar II disorder the correct diagnosis
Question 2: A 24-year-old woman is brought to the hospital by her mother because she has "not been herself" for the past 3 months. The patient says she hears voices in her head. The mother said that when she is talking to her daughter she can’t seem to make out what she is saying; it is as if her thoughts are disorganized. When talking with the patient, you notice a lack of energy and an apathetic affect. Which of the following is the most likely diagnosis for this patient?
A. Major depressive disorder
B. Schizophrenia
C. Brief psychotic disorder
D. Schizotypal disorder
E. Schizophreniform disorder (Correct Answer)
Explanation: ***Schizophreniform disorder***
- The patient exhibits core **psychotic symptoms** (hearing voices, disorganized thoughts) for a duration of **3 months**, which is characteristic of schizophreniform disorder (symptoms lasting **1 to 6 months**).
- Her **lack of energy** and **apathetic affect** align with the negative symptoms commonly seen in psychotic disorders.
*Major depressive disorder*
- While **lack of energy** and **apathetic affect** can be present, the prominent **hallucinations** (hearing voices) and **disorganized thoughts** are not primary features of major depressive disorder.
- A diagnosis of depression alone would not fully account for her psychotic symptoms.
*Schizophrenia*
- Schizophrenia requires symptoms to be present for **at least 6 months**, including at least one month of **active phase symptoms**. This patient's symptoms have only been present for 3 months.
- While the symptoms are consistent with schizophrenia, the **duration criterion** has not yet been met.
*Brief psychotic disorder*
- Brief psychotic disorder is characterized by psychotic symptoms lasting **less than 1 month**. This patient's symptoms have been ongoing for 3 months.
- The chronicity of symptoms makes this diagnosis unlikely.
*Schizotypal disorder*
- Schizotypal disorder is a **personality disorder** characterized by peculiar thoughts and behaviors, but typically **without overt psychotic episodes** or pronounced disorganized speech/hallucinations as described.
- While there may be odd beliefs or ideas of reference, the clear **auditory hallucinations** and **thought disorder** in this case point to a more severe psychotic condition.
Question 3: A 28-year-old woman presents with continuous feelings of sadness and rejection. She says that over the past couple of weeks, she has been unable to concentrate on her job and has missed several days of work. She also has no interest in any activity and typically rejects invitations to go out with friends. She has no interest in food or playing with her dog. Her husband is concerned about this change in behavior. A few months ago, she was very outgoing and made many plans with her friends. She remembers being easily distracted and also had several ‘brilliant ideas’ on what she should be doing with her life. She did not sleep much during that week, but now all she wants to do is lie in bed all day. She denies any suicidal or homicidal ideations. She has no past medical history and has never been hospitalized. Laboratory tests were normal. Which of the following is the most likely diagnosis in this patient?
A. Major depressive disorder
B. Dysthymia
C. Bipolar disorder, type II (Correct Answer)
D. Schizoaffective disorder
E. Bipolar disorder, type I
Explanation: ***Bipolar disorder, type II***
− This patient's current symptoms of profound **sadness, anhedonia, low energy, and social withdrawal** are indicative of a major depressive episode.
− The history of prior periods of **decreased need for sleep, brilliant ideas, and being easily distracted** suggests a hypomanic episode, a hallmark of bipolar disorder type II.
*Major depressive disorder*
− While the patient is currently experiencing a **major depressive episode**, the history of previous hypomanic symptoms rules out a diagnosis of unipolar major depressive disorder.
− **Major depressive disorder** does not include a history of manic or hypomanic episodes.
*Dysthymia*
− **Dysthymia** (persistent depressive disorder) is characterized by chronic, milder depressive symptoms lasting at least two years.
− The current episode is severe and marked by a clear change from a previous elevated mood state, which is inconsistent with dysthymia.
*Schizoaffective disorder*
− **Schizoaffective disorder** involves episodes of mood disturbance alongside symptoms of schizophrenia (e.g., hallucinations, delusions) that occur at least two weeks without prominent mood symptoms.
− This patient's symptoms are primarily mood-related and do not include psychotic features characteristic of schizophrenia.
*Bipolar disorder, type I*
− **Bipolar disorder type I** is characterized by the occurrence of at least one manic episode, which involves more severe symptoms, significant impairment, and often psychosis.
− The patient's previous "brilliant ideas" and decreased need for sleep describe a **hypomanic episode** rather than a full manic episode and are not associated with marked functional impairment or psychotic features.
Question 4: A 55-year-old man presents to his primary care physician with complaints of fluctuating mood for the past 2 years. He feels great and full of energy for some months when he is very creative with tons of ideas just racing through his mind. He is noted to be very talkative and distracted by his different ideas. During these times, he is very productive and able to accomplish much at work and home. However, these periods are frequently followed by a prolonged depressed mood. During this time, he has low energy, poor concentration, and low self-esteem. The accompanying feeling of hopelessness from these cycling “ups” and “downs” have him eating and sleeping more during the “downs.” He does not remember a period within the last 2 years where he felt “normal.” What is the most likely diagnosis?
A. Dysthymic disorder
B. Bipolar II disorder
C. Persistent depressive disorder
D. Bipolar I disorder
E. Cyclothymic disorder (Correct Answer)
Explanation: ***Cyclothymic disorder***
- The patient experiences chronic **fluctuating moods**, with numerous periods of **hypomanic symptoms** (elevated energy, racing thoughts, increased productivity) and numerous periods of **depressive symptoms** (low energy, poor concentration, hopelessness) over at least 2 years.
- The symptoms are not severe enough to meet full criteria for a **manic episode**, **hypomanic episode**, or **major depressive episode**, and there has been no period longer than 2 months without symptoms.
*Dysthymic disorder*
- This is the **DSM-IV term** for what is now called **persistent depressive disorder** in DSM-5, involving a **chronic depressed mood** that lasts for at least 2 years.
- It does not include periods of significant elevated mood or hypomania.
- The patient's presentation includes distinct periods of **elevated mood and energy**, which are not characteristic of dysthymic disorder.
*Bipolar II disorder*
- Bipolar II disorder requires at least one **major depressive episode** and at least one **hypomanic episode**.
- While the patient exhibits hypomanic and depressive symptoms, the periods of depression do not meet the full criteria for a **major depressive episode** (e.g., duration, number of symptoms) and the hypomanic symptoms are subsyndromal.
*Persistent depressive disorder*
- This is the **DSM-5 term** for chronic low-grade depression (formerly called dysthymic disorder), characterized by depressed mood for at least 2 years without manic or hypomanic symptoms.
- The patient's history of elevated mood and energy precludes this diagnosis.
*Bipolar I disorder*
- Bipolar I disorder requires at least one **manic episode**, which is characterized by a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and causing significant impairment.
- The patient's "ups" are described as productive and not causing significant impairment or involving psychotic features, indicating **hypomanic symptoms** rather than full mania.
Question 5: A 29-year-old man comes to the physician with his wife because she has noticed a change in his behavior over the past 2 weeks. His wife reports that he is very distracted and irritable. His colleagues have voiced concerns that he has not been turning up for work regularly and behaves erratically when he does. Previously, her husband had been a reliable and reasonable person. The patient says that he feels “fantastic”; he only needs 4 hours of sleep each night and wakes up cheerful and full of energy each morning. He thinks that his wife is overreacting. The patient has been healthy except for a major depressive episode 5 years ago that was treated with paroxetine. He currently takes no medications. His pulse is 98/min, respirations are 12/min, and blood pressure is 128/62 mm Hg. Mental status examination shows frenzied speech and a flight of ideas. Which of the following is the strongest predisposing factor for this patient's condition?
A. Advanced paternal age
B. Genetic predisposition (Correct Answer)
C. Higher socioeconomic class
D. Maternal obstetric complications
E. Being married
Explanation: ***Genetic predisposition***
- A strong **genetic predisposition** is a primary predisposing factor for bipolar disorder, as evidenced by a significantly higher concordance rate in monozygotic twins compared to dizygotic twins or the general population.
- The patient's presentation with **manic symptoms** (decreased need for sleep, euphoria, irritability, frenzied speech, flight of ideas, erratic behavior) following a history of a **major depressive episode** is highly suggestive of **bipolar I disorder**.
*Advanced paternal age*
- While advanced paternal age has been associated with an increased risk of some neurodevelopmental disorders like **schizophrenia** and **autism spectrum disorder**, its link to bipolar disorder is less robust and not considered the strongest predisposing factor.
- The primary risk factor for bipolar disorder involves heritability rather than specific parental age.
*Higher socioeconomic class*
- There is **no consistent evidence** to suggest that higher socioeconomic class is a predisposing factor for bipolar disorder.
- Bipolar disorder affects individuals across all socioeconomic levels.
*Maternal obstetric complications*
- Maternal obstetric complications, such as **prenatal infections** or **hypoxia**, have been implicated in the development of certain psychiatric disorders, particularly **schizophrenia**.
- However, for bipolar disorder, genetic factors play a far more significant and direct role than obstetric complications.
*Being married*
- **Marital status** does not serve as a predisposing factor for the development of bipolar disorder.
- While relationship challenges can be a consequence or stressor for individuals with bipolar disorder, marriage itself is not a cause.
Question 6: A 38-year-old woman comes to the physician for a follow-up visit. She has a 2-year history of depressed mood and fatigue accompanied by early morning awakening. One week ago, she started feeling a decrease in her need for sleep and now feels rested after about 5 hours of sleep per night. She had two similar episodes that occurred 6 months ago and a year ago, respectively. She reports increased energy and libido. She has a 4-kg (8.8-lb) weight loss over the past month. She does not feel the need to eat and says she derives her energy ""from the universe"". She enjoys her work as a librarian. She started taking fluoxetine 3 months ago. On mental exam, she is alert and oriented to time and place; she is irritable. She does not have auditory or visual hallucinations. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?
A. Delusional disorder
B. Cyclothymic disorder
C. Schizoaffective disorder
D. Bipolar II disorder (Correct Answer)
E. Medication-induced bipolar disorder
Explanation: ***Bipolar II disorder***
- The patient meets criteria for **Bipolar II disorder**: at least one **hypomanic episode** (current presentation) and at least one **major depressive episode** (2-year history with recurrent episodes).
- Current hypomanic features include: **decreased need for sleep** (feels rested after 5 hours), **increased energy and libido**, **significant weight loss** (4 kg in one month), **irritability**, and grandiose thinking ("derives energy from the universe").
- She has had **recurrent depressive episodes** over 2 years (episodes 1 year ago and 6 months ago), fulfilling the major depressive episode requirement.
- While the hypomania emerged after starting **fluoxetine**, antidepressants commonly **unmask underlying bipolar disorder** rather than cause a separate medication-induced condition. The diagnosis remains **Bipolar II disorder** per DSM-5-TR when there is evidence of an underlying mood disorder pattern.
*Medication-induced bipolar disorder*
- Substance/medication-induced bipolar disorder requires that symptoms occur **exclusively during substance use** without evidence of an independent bipolar disorder.
- This patient's **recurrent pattern** of mood episodes (multiple depressive episodes over 2 years) suggests an **underlying bipolar disorder** that was unmasked by antidepressant treatment, not a purely medication-induced condition.
- The temporal relationship with fluoxetine is significant but represents **antidepressant-induced switching** in bipolar disorder, not a separate diagnostic entity.
*Delusional disorder*
- Requires **non-bizarre delusions** persisting for at least one month as the predominant feature, without prominent mood symptoms.
- This patient's primary presentation is a **mood episode** (hypomania) with the "universe" comment being part of her elevated/expansive mood rather than a fixed, systematized delusion.
- Functioning remains relatively intact (still enjoys her work).
*Cyclothymic disorder*
- Involves numerous periods of **hypomanic and depressive symptoms** for at least 2 years, but symptoms never meet full criteria for hypomanic or major depressive episodes.
- This patient has **full hypomanic and major depressive episodes**, making Bipolar II disorder the more appropriate diagnosis.
- The severity of her current symptoms (significant sleep reduction, 4-kg weight loss, marked functional changes) exceeds cyclothymic disorder.
*Schizoaffective disorder*
- Requires a **major mood episode** concurrent with **criterion A symptoms of schizophrenia** (delusions, hallucinations) for at least 2 weeks, plus psychotic symptoms without mood symptoms for at least 2 weeks.
- This patient has **no hallucinations** and no clear psychotic symptoms independent of her mood state.
- Her elevated mood fully accounts for her presentation.
Question 7: A 26-year-old female college student is brought back into the university clinic for acting uncharacteristically. The patient presented to the same clinic 6 weeks ago with complaints of depressed mood, insomnia, and weightloss. She had been feeling guilty for wasting her parent’s money by doing so poorly at the university. She felt drained for at least 2 weeks before presenting to the clinic for the first time. She was placed on an antidepressant and was improving but now presents with elevated mood. She is more talkative with a flight of ideas and is easily distractible. Which of the following statements is most likely true regarding this patient’s condition?
A. The patient may have psychotic features.
B. Her diagnosis of unipolar depression is incorrect. (Correct Answer)
C. The patient may have a history of mania.
D. Antidepressants are inappropriate.
E. Her new symptoms need to last at least 7 days.
Explanation: ***Correct: Her diagnosis of unipolar depression is incorrect.***
The patient initially presented with symptoms consistent with a **depressive episode**, but the subsequent emergence of **elevated mood, increased talkativeness, flight of ideas, and distractibility after antidepressant use** strongly suggests a shift to a **manic or hypomanic episode**. This antidepressant-induced mood switch is a hallmark feature revealing **bipolar disorder** that was initially misdiagnosed as unipolar depression. This statement most directly addresses **what is true about this patient's condition** - that the fundamental diagnosis is incorrect. Once we establish the correct diagnosis of bipolar disorder, all treatment and management decisions follow from this.
*Incorrect: The patient may have psychotic features.*
While patients with severe **mania** can develop **psychotic features** (e.g., delusions, hallucinations), the provided symptoms (elevated mood, increased talkativeness, flight of ideas, distractibility) do not describe psychotic symptoms. There is no information suggesting the presence of **delusions or hallucinations**, which are necessary to diagnose psychotic features. The word "may" makes this theoretically possible but not supported by the clinical presentation described.
*Incorrect: The patient may have a history of mania.*
While patients with bipolar disorder often have previous undiagnosed episodes, this statement is speculative about her **past history** rather than addressing what is most directly evident from the **current presentation**. The vignette focuses on the antidepressant-induced mood switch, which immediately reveals that the current diagnosis of unipolar depression is incorrect. Whether or not she had previous manic episodes is less relevant than recognizing the misdiagnosis now.
*Incorrect: Antidepressants are inappropriate.*
This statement is clinically **true in principle** - antidepressants as monotherapy are generally inappropriate for bipolar disorder due to the risk of inducing mania or hypomania. However, this option addresses **treatment implications** rather than directly stating what is true about **the patient's condition itself**. The more fundamental and direct truth is that **her diagnosis is wrong** (bipolar, not unipolar depression). Once the correct diagnosis is established, then the inappropriateness of antidepressant monotherapy follows. Additionally, at the time of initial presentation with pure depressive symptoms, the antidepressant prescription was reasonable based on the information available - the inappropriateness only became clear retrospectively after the mood switch occurred.
*Incorrect: Her new symptoms need to last at least 7 days.*
For a diagnosis of **mania**, symptoms must last at least **one week** (or any duration if hospitalization is required). However, for **hypomania**, symptoms need to last only **4 consecutive days**. The vignette does not specify whether this is mania or hypomania, nor does it clearly state the duration of the current symptoms beyond "now presents." Therefore, we cannot definitively say a 7-day duration is required - it could be hypomania requiring only 4 days. This statement is not necessarily true.
Question 8: A 25-year-old woman is brought to a psychiatrist's office by her husband who states that he is worried about her recent behavior, as it has become more violent. The patient's husband states that his family drove across the country to visit them and that his wife 'threatened his parents with a knife' at dinner last night. Police had to be called to calm her down. He states that she has been acting 'really crazy' for the last 9 months, and the initial behavior that caused him alarm was her admission that his deceased sister was talking to her through a decorative piece of ceramic art in the living room. Initially, he thought she was joking, but soon realized her complaints of 'hearing ghosts' talking to her throughout the house were persisting and 'getting worse'. Over the past 9 months, she has experienced multiple periods of profound sadness, with persistent insomnia and an unintentional weight loss of 12 pounds over several months. She has been complaining of feeling 'worthless' and has had markedly diminished interest in activities for much of this time period. Her general hygiene has also suffered from her recent lack of motivation and she insists that the 'ghosts' are asking her to kill as many people as she can so they won't be alone in the house. Her husband is extremely concerned that she may harm herself or someone else. He states that she currently does not take any medications or illicit drugs as far as he knows. She does not smoke or drink alcohol. The patient herself does not make eye contact or want to speak to the psychiatrist, allowing her husband to speak on her behalf. Which of the following is the most likely diagnosis in this patient?
A. Schizophreniform disorder
B. Schizophrenia
C. Delusional disorder
D. Schizoaffective disorder (Correct Answer)
E. Brief psychotic disorder
Explanation: ***Schizoaffective disorder***
- This patient exhibits symptoms of both a **major depressive disorder** (multiple periods of profound **sadness**, persistent **insomnia**, **weight loss** over several months, feelings of **worthlessness**, and markedly **diminished interest in activities**) and a **psychotic disorder** (auditory **hallucinations**, command hallucinations, **delusions**, violent behavior).
- The total symptom duration is **9 months**, with **mood symptoms present for the majority of this period**, meeting the key DSM-5 criterion for schizoaffective disorder.
- The patient also demonstrates **psychotic symptoms (hallucinations) that persist throughout**, including periods when mood symptoms may fluctuate, satisfying the requirement for delusions or hallucinations for ≥2 weeks in the absence of a major mood episode.
- The combination of prominent mood episodes concurrent with schizophrenia-spectrum symptoms, with mood symptoms present for the majority of the illness duration, confirms schizoaffective disorder.
*Schizophreniform disorder*
- This disorder involves symptoms characteristic of **schizophrenia** lasting **between 1 and 6 months**.
- The patient's symptoms have been present for **9 months**, exceeding the maximum duration for schizophreniform disorder.
*Schizophrenia*
- Schizophrenia requires persistent psychotic symptoms lasting **at least 6 months**, with at least one month of active-phase symptoms.
- While this patient has psychotic symptoms for 9 months, the **prominent and prolonged depressive symptoms** that are present for the **majority of the illness duration** distinguish this from schizophrenia.
- In schizophrenia, mood symptoms, if present, are **brief relative to the total duration** of the psychotic illness, which is not the case here.
*Delusional disorder*
- Delusional disorder is characterized by **non-bizarre delusions** for at least 1 month, without other prominent psychotic symptoms.
- This patient experiences prominent **auditory hallucinations** ("hearing ghosts," "deceased sister talking to her") and **command hallucinations**, which are not features of delusional disorder.
- The presence of hallucinations rules out this diagnosis.
*Brief psychotic disorder*
- This diagnosis involves sudden onset of psychotic symptoms lasting **more than 1 day but less than 1 month**, with eventual full recovery.
- The patient's symptoms have persisted for **9 months**, far exceeding the duration criterion for brief psychotic disorder.
Question 9: An 8-year-old girl is brought to the physician by her parents because they are concerned with her behavior. She has temper outbursts six or seven times per week, which last anywhere between 5 minutes to half an hour or until she becomes tired. According to her father, she screams at others and throws things in anger “when things don't go her way.” He says these outbursts started when she was 6 and a half years old and even between the outbursts, she is constantly irritable. She had been suspended from school three times in the past year for physical aggression, but her grades have remained unaffected. She appears agitated and restless. Physical examination shows no abnormalities. During the mental status examination, she is uncooperative and refuses to answer questions. What is the most likely diagnosis in this child?
A. Pediatric bipolar disorder
B. Conduct disorder
C. Intermittent explosive disorder
D. Oppositional defiant disorder
E. Disruptive mood dysregulation disorder (Correct Answer)
Explanation: ***Disruptive mood dysregulation disorder***
- This diagnosis is characterized by **frequent, severe temper outbursts** that are out of proportion to the situation, along with persistent **irritable or angry mood** between outbursts, lasting for at least 12 months. The girl's symptoms, including frequent outbursts starting before age 10 and chronic irritability, fit these criteria.
- The onset of symptoms occurred at 6.5 years of age, and the child is currently 8-years-old, which falls within the diagnostic age range (onset before age 10, diagnosis between 6 and 18 years).
*Pediatric bipolar disorder*
- This typically involves distinct periods of **elevated or expansive mood** and increased energy (mania or hypomania) that last for at least several days, which are not described in this case.
- While irritability can be a feature of pediatric bipolar disorder, the primary feature here is persistent irritability and temper outbursts without clear episodes of mood elevation.
*Conduct disorder*
- Conduct disorder involves a pervasive pattern of **disregard for the rights of others** and societal norms, including aggression towards people and animals, destruction of property, deceitfulness or theft, and serious rule violations.
- While the girl shows aggression, there is no evidence of the broader pattern of repetitive and persistent rule-breaking or delinquent behaviors characteristic of conduct disorder.
*Intermittent explosive disorder*
- This is characterized by recurrent behavioral outbursts representing a **failure to control aggressive impulses**, often leading to assaultive acts or destruction of property. However, the outbursts are typically episodic, and the mood between episodes is generally normal.
- The key differentiating factor here is the girl's **persistent irritability or angry mood** between outbursts, which is a hallmark of disruptive mood dysregulation disorder, not intermittent explosive disorder.
*Oppositional defiant disorder*
- Oppositional defiant disorder involves a pattern of **angry/irritable mood, argumentative/defiant behavior**, or vindictiveness lasting at least six months.
- While there is overlap, the **severity and frequency of the temper outbursts experienced by this child** go beyond what is typically seen in ODD, making DMDD a more appropriate diagnosis. Temper outbursts in ODD are generally less severe and less chronic than those in DMDD.
Question 10: A 28-year-old woman is brought to the emergency department by her friends. She is naked except for a blanket and speaking rapidly and incoherently. Her friends say that she was found watering her garden naked and refused to put on any clothes when they tried to make her do so, saying that she has accepted how beautiful she is inside and out. Her friends say she has also purchased a new car she can not afford. They are concerned about her, as they have never seen her behave this way before. For the past week, she has not shown up at work and has been acting ‘strangely’. They say she was extremely excited and has been calling them at odd hours of the night to tell them about her future plans. Which of the following drug mechanisms will help with the long-term management this patient’s symptoms?
A. Inhibition of inositol monophosphatase and inositol polyphosphate 1-phosphatase (Correct Answer)
B. Increase the concentration of dopamine and norepinephrine at the synaptic cleft
C. Modulate the activity of gamma-aminobutyric acid receptors
D. Acts as an antagonist at the dopamine, serotonin and adrenergic receptors
E. Inhibit the reuptake of norepinephrine and serotonin from the presynaptic cleft
Explanation: ***Inhibition of inositol monophosphatase and inositol polyphosphate 1-phosphatase***
- The patient's symptoms (euphoria, grandiosity, reduced need for sleep, impulsivity, rapid speech, and unusual behavior) are classic for a **manic episode**, strongly suggesting **bipolar disorder**.
- **Lithium** is a mood stabilizer used for long-term management of bipolar disorder, and its primary molecular action is thought to involve the **inhibition of inositol phosphatases**, thereby depleting inositol and modulating intracellular signaling.
*Increase the concentration of dopamine and norepinephrine at the synaptic cleft*
- This mechanism describes the action of **stimulants** or some **antidepressants** (like TCAs or SNRIs), which could exacerbate manic symptoms in bipolar disorder.
- Increasing dopamine and norepinephrine would likely worsen the current patient's **hyperactivity**, **agitation**, and **psychosis**.
*Inhibit the reuptake norepinephrine and serotonin from the presynaptic cleft*
- This mechanism is characteristic of **antidepressants** (e.g., SSRIs, SNRIs) used to treat depression.
- Administering such drugs during a manic episode can precipitate or worsen **mania** or induce **rapid cycling** in bipolar patients.
*Modulate the activity of Ƴ-aminobutyric acid receptors*
- This describes the action of **benzodiazepines** or some **antiepileptic drugs** (e.g., valproate, lamotrigine).
- While some antiepileptic drugs (like valproate) are used as mood stabilizers, the direct modulation of GABA receptors to **increase GABAergic activity** (as with benzodiazepines) is typically for acute agitation and anxiety, not the primary long-term mood stabilization for bipolar disorder.
*Acts as an antagonist at the dopamine, serotonin, and adrenergic receptors*
- This mechanism generally describes the action of **antipsychotic medications** (e.g., olanzapine, quetiapine, risperidone).
- While antipsychotics are effective for acute mania and some are used in long-term maintenance of bipolar disorder, the question asks for the primary drug mechanism for long-term management which is **Lithium's mechanism of action**, targeting intracellular signaling rather than broad receptor antagonism.
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