A 24-year-old male graduate student comes to the physician for a two-month history of repeated thoughts and anxiety that he is going to be harmed by someone on the street. The anxiety worsened after witnessing a pedestrian getting hit by a car two weeks ago. He says, “That was a warning sign.” On his way to school, he now often leaves an hour earlier to take a detour and hide from people that he thinks might hurt him. He is burdened by his coursework and fears that his professors are meaning to fail him. He says his friends are concerned about him but that they do not understand because they were not present at the accident. The patient has no known history of psychiatric illness. On mental status exam, he is alert and oriented, and shows full range of affect. Thought processes and speech are organized. His memory and attention are within normal limits. He denies auditory, visual, or tactile hallucinations. Urine toxicology screening is negative. Which of the following is the most likely diagnosis in this patient?
Q12
A 46-year-old homeless man was found wandering aimlessly in the supermarket. On examination, he is confused and said that the President appointed men to kill him because he is disclosing state secrets to extraterrestrial organisms. The man also has horizontal nystagmus and an ataxic gait. What is the most likely cause of the clinical presentation?
Q13
A 38-year-old woman comes to the physician for a 6-week history of sleeping difficulties because she thinks that someone is watching her through security cameras. Her anxiety started 6 weeks ago when a security camera was installed outside her house by the police. Ever since, she has felt that she is being monitored by security cameras throughout the city. She avoids going outside whenever possible and refuses to take the subway. Whenever she needs to leave the house she wears large hats or hooded sweaters so that she cannot be recognized by the cameras. As soon as she arrives at her office or at home she feels safer. She was recently promoted to the team manager of a small advertising agency. She takes no medications. On mental status examination, she is alert, oriented, and shows normal range of affect. Urine toxicology screening is negative. The patient's symptoms are best described as which of the following?
Q14
A 22-year-old man is brought to the emergency department by his father because he is having bizarre thoughts. The patient says that he is being haunted by aliens from outer space. The father is worried as his son has had these symptoms for the past 7 months and lately, it seems to be getting worse. He has become more self-obsessed and does not seem to have any interest in his favorite activities. He has no plans to harm himself or others but spends a lot of time and energy building ‘defenses’ in and around his room as he is absolutely sure that aliens will come to get him soon. His blood pressure is 121/79 mm Hg, pulse 86/min, respiratory rate 15/min, temperature 36.8°C (98.2°F). Which of the following is correct regarding the patient’s symptoms?
Q15
A 33-year-old man is brought to the emergency department by his mother because of erratic behavior over the past 6 months. He spends most of his time alone in his room because he believes he is being followed by the Secret Service. He was fired from his job 3 months ago after threatening a colleague. He appears suspicious of his surroundings and asks the doctor questions about “the security of the hospital.” The patient exhibits a flat affect. During physical examination, he tells the doctor that he has a gun at home and plans to shoot his neighbor, whom he thinks is working for the Secret Service. Which of the following is the most appropriate action by the doctor?
Delusional disorder US Medical PG Practice Questions and MCQs
Question 11: A 24-year-old male graduate student comes to the physician for a two-month history of repeated thoughts and anxiety that he is going to be harmed by someone on the street. The anxiety worsened after witnessing a pedestrian getting hit by a car two weeks ago. He says, “That was a warning sign.” On his way to school, he now often leaves an hour earlier to take a detour and hide from people that he thinks might hurt him. He is burdened by his coursework and fears that his professors are meaning to fail him. He says his friends are concerned about him but that they do not understand because they were not present at the accident. The patient has no known history of psychiatric illness. On mental status exam, he is alert and oriented, and shows full range of affect. Thought processes and speech are organized. His memory and attention are within normal limits. He denies auditory, visual, or tactile hallucinations. Urine toxicology screening is negative. Which of the following is the most likely diagnosis in this patient?
A. Avoidant personality disorder
B. Schizotypal personality disorder
C. Delusional disorder (Correct Answer)
D. Generalized anxiety disorder
E. Acute stress disorder
Explanation: ***Delusional disorder***
- This patient presents with **persistent non-bizarre delusions** (fear of harm, professors failing him) that have lasted for two months. His functioning is largely intact outside of the delusions, and there are no prominent hallucinations or disorganized thought. The anxiety and behavioral changes (detouring, hiding) are consequences of his delusions.
- The patient's belief that his friends *do not understand* because they were not present at the accident suggests he is trying to rationalize his beliefs and behaviors within his delusional system, which is characteristic of delusional disorder where insight into the delusion is typically absent.
*Avoidant personality disorder*
- Characterized by **social inhibition**, feelings of inadequacy, and **hypersensitivity to negative evaluation**.
- While there is some social withdrawal (hiding from people), his primary motivation is a fear of harm based on fixed beliefs, not a fear of social rejection or embarrassment.
*Schizotypal personality disorder*
- Involves a pervasive pattern of **social and interpersonal deficits** marked by acute discomfort with, and reduced capacity for, close relationships, as well as by **cognitive or perceptual distortions** and eccentricities of behavior.
- This patient does not exhibit the characteristic odd beliefs, magical thinking, unusual perceptual experiences, or eccentric behavior typically seen in schizotypal personality disorder. His thought process is organized, and he denies hallucinations.
*Generalized anxiety disorder*
- Defined by **excessive and uncontrollable worry** about multiple events or activities, often accompanied by physical symptoms like restlessness, fatigue, and muscle tension.
- While the patient experiences anxiety, it is primarily driven by specific, fixed beliefs (delusions) rather than generalized, free-floating worry.
*Acute stress disorder*
- Occurs within **one month of exposure to a traumatic event** and involves dissociative symptoms, intrusion symptoms, negative mood, avoidance symptoms, and arousal symptoms.
- Although he witnessed a traumatic event, the primary features are persistent, non-bizarre delusions rather than a constellation of acute stress symptoms and dissociation. The timeline also extends beyond the typical 1-month duration for acute stress disorder.
Question 12: A 46-year-old homeless man was found wandering aimlessly in the supermarket. On examination, he is confused and said that the President appointed men to kill him because he is disclosing state secrets to extraterrestrial organisms. The man also has horizontal nystagmus and an ataxic gait. What is the most likely cause of the clinical presentation?
A. Neurofibrillary tangles
B. Atrophy of globus pallidus
C. Necrosis of mammillary bodies (Correct Answer)
D. Hypothyroidism
E. Trinucleotide repeat disorder
Explanation: ***Necrosis of mammillary bodies***
- The patient's presentation with confusion, delusions (President appointing men to kill him), horizontal nystagmus, and ataxic gait is highly suggestive of **Wernicke-Korsakoff syndrome**, which is primarily caused by **thiamine (B1) deficiency**.
- **Necrosis of the mammillary bodies** is a classic neuropathological hallmark of Wernicke-Korsakoff syndrome, due to their high metabolic rate and vulnerability to thiamine deficiency.
*Neurofibrillary tangles*
- **Neurofibrillary tangles**, composed of hyperphosphorylated tau protein, are characteristic of **Alzheimer's disease** and other tauopathies.
- While Alzheimer's can cause confusion and disorientation, it typically does not present with acute nystagmus and ataxia in this manner, and delusions are usually less bizarre.
*Atrophy of globus pallidus*
- **Atrophy of the globus pallidus** can be seen in various neurodegenerative disorders, including some forms of **Huntington's disease** or mitochondrial disorders.
- However, it is not a primary or characteristic finding for Wernicke-Korsakoff syndrome or the specific acute constellation of symptoms presented.
*Hypothyroidism*
- **Hypothyroidism** can cause confusion, cognitive slowing, and sometimes ataxia (due to cerebellar dysfunction).
- However, it typically does not cause acute horizontal nystagmus or the distinct, florid psychotic delusions described.
*Trinucleotide repeat disorder*
- **Trinucleotide repeat disorders** (e.g., Huntington's disease, spinocerebellar ataxias) are genetic conditions that cause various neurological symptoms, including cognitive decline, movement disorders, and psychiatric features.
- These are typically chronic, progressive conditions and do not present acutely with the specific triad of nystagmus, ataxia, and confusion/psychosis seen in thiamine deficiency.
Question 13: A 38-year-old woman comes to the physician for a 6-week history of sleeping difficulties because she thinks that someone is watching her through security cameras. Her anxiety started 6 weeks ago when a security camera was installed outside her house by the police. Ever since, she has felt that she is being monitored by security cameras throughout the city. She avoids going outside whenever possible and refuses to take the subway. Whenever she needs to leave the house she wears large hats or hooded sweaters so that she cannot be recognized by the cameras. As soon as she arrives at her office or at home she feels safer. She was recently promoted to the team manager of a small advertising agency. She takes no medications. On mental status examination, she is alert, oriented, and shows normal range of affect. Urine toxicology screening is negative. The patient's symptoms are best described as which of the following?
A. Hallucinations
B. Delusions (Correct Answer)
C. Agoraphobia
D. Derealization
E. Disorganized thoughts
Explanation: ***Delusions***
- The patient exhibits strong, false beliefs (**fixed beliefs**) that she is being watched through security cameras, despite evidence to the contrary and the unlikelihood of such widespread monitoring.
- These beliefs are **persecutory** in nature, causing significant distress and impacting her daily functioning (e.g., avoiding public places, wearing concealing clothing).
*Hallucinations*
- Hallucinations are **sensory perceptions** in the absence of an external stimulus (e.g., hearing voices, seeing things that aren't there).
- The patient *believes* she is being watched but does not *perceive* visual or auditory confirmation of this monitoring.
*Agoraphobia*
- Agoraphobia is an **anxiety disorder** characterized by intense fear and avoidance of situations or places where escape might be difficult or help unavailable if panic symptoms occur.
- While she avoids going outside, her avoidance stems from a specific belief about being watched, not a general fear of public spaces or panic attacks.
*Derealization*
- Derealization is a dissociative symptom where an individual feels that the **external world is unreal** or distant.
- The patient's perception of reality is altered by her belief, but she does not feel the world itself is unreal; rather, she believes a specific, false scenario is occurring within it.
*Disorganized thoughts*
- Disorganized thoughts manifest as **incoherent speech**, thought blocking, or illogical associations, making it difficult to follow a conversation.
- Her thought process is coherent and goal-directed, even though the content of her thoughts is delusional.
Question 14: A 22-year-old man is brought to the emergency department by his father because he is having bizarre thoughts. The patient says that he is being haunted by aliens from outer space. The father is worried as his son has had these symptoms for the past 7 months and lately, it seems to be getting worse. He has become more self-obsessed and does not seem to have any interest in his favorite activities. He has no plans to harm himself or others but spends a lot of time and energy building ‘defenses’ in and around his room as he is absolutely sure that aliens will come to get him soon. His blood pressure is 121/79 mm Hg, pulse 86/min, respiratory rate 15/min, temperature 36.8°C (98.2°F). Which of the following is correct regarding the patient’s symptoms?
A. It would benefit from psychosurgery.
B. He has a fixed false belief. (Correct Answer)
C. It is best treated with cognitive behavioral therapy alone.
D. It is a negative symptom.
E. It falls under the disorganized thinking domain.
Explanation: ***He has a fixed false belief.***
- The patient's conviction that he is being haunted by aliens, despite evidence to the contrary and the distress it causes, constitutes a **delusion**.
- A delusion is by definition a **fixed, false belief** that is not in keeping with the individual's cultural background.
*It would benefit from psychosurgery.*
- Psychosurgery, such as lobotomy, is an extreme and rarely used intervention for **severe, refractory mental disorders**, typically only after all other treatments have failed and with significant ethical considerations.
- While the patient's symptoms are impairing, **first-line treatments** for psychotic disorders involve antipsychotic medications and psychotherapy, not psychosurgery.
*It is best treated with cognitive behavioral therapy alone.*
- While CBT for psychosis (CBTp) can be a useful **adjunct** in managing delusions and reducing distress, it is **not sufficient as monotherapy** for active, severe psychotic symptoms.
- The primary intervention for profound delusions like those described is **antipsychotic medication**, with CBT added as an adjunctive treatment to help improve functioning and coping.
- CBT alone would be inadequate for someone with such fixed, impairing delusions actively building defenses against perceived threats.
*It is a negative symptom.*
- Negative symptoms of psychosis include features like **anhedonia** (lack of pleasure), **alogia** (poverty of speech), **avolition** (lack of motivation), and affective flattening.
- The patient's bizarre belief in aliens is a **positive symptom** as it represents an *addition* to normal experience, rather than a *reduction* or *absence* of normal functions.
- Note: The patient's decreased interest in activities suggests negative symptoms are also present, but the question asks about "the patient's symptoms" in context of the delusion described.
*It falls under the disorganized thinking domain.*
- Disorganized thinking or speech involves patterns like **loose associations, tangentiality, incoherence**, or word salad, where the logical connections between thoughts are lost.
- While the content of the patient's thoughts is bizarre, the core issue described is the *belief itself* (a delusion, which is a **positive symptom**), rather than disordered *thought processes* or the way he expresses them.
Question 15: A 33-year-old man is brought to the emergency department by his mother because of erratic behavior over the past 6 months. He spends most of his time alone in his room because he believes he is being followed by the Secret Service. He was fired from his job 3 months ago after threatening a colleague. He appears suspicious of his surroundings and asks the doctor questions about “the security of the hospital.” The patient exhibits a flat affect. During physical examination, he tells the doctor that he has a gun at home and plans to shoot his neighbor, whom he thinks is working for the Secret Service. Which of the following is the most appropriate action by the doctor?
A. Request a court order to override the patient's right to confidentiality
B. Discuss the diagnosis and therapy plan with the patient's mother
C. Inform security and law enforcement
D. Administer haloperidol and request a psychiatric consultation
E. Warn the person at risk and inform law enforcement (Correct Answer)
Explanation: ***Warn the person at risk and inform law enforcement***
- This is the most appropriate action due to the **Tarasoff duty**, which mandates that a therapist must warn an identifiable victim if a patient expresses a serious threat of physical violence against them.
- The patient has expressed a clear intent to harm his neighbor, identifying the victim and providing a means (a gun), necessitating intervention to protect the potential victim and involve law enforcement.
*Request a court order to override the patient's right to confidentiality*
- While patient confidentiality is important, the **Tarasoff duty** creates an exception when there is a serious and immediate threat of harm to others, overriding the need for a court order in such urgent situations.
- Delaying action by seeking a court order could compromise the safety of the identified potential victim.
*Discuss the diagnosis and therapy plan with the patient's mother*
- The patient's mother is not the identified victim, and while she may be concerned, discussing the diagnosis and therapy plan with her would still violate the patient's **confidentiality** without proper consent or a specific legal exception related to her safety.
- The primary concern here is the safety of the identified potential victim, not managing the patient's care through his mother at this immediate juncture.
*Inform security and law enforcement*
- While informing security and law enforcement is a necessary step, it is not sufficient on its own according to the **Tarasoff duty**, which also requires directly warning the potential victim.
- The "duty to warn" the intended victim directly is a critical component of preventing harm, in addition to involving official authorities.
*Administer haloperidol and request a psychiatric consultation*
- Administering medication and requesting a psychiatric consultation are important steps for managing the patient's **psychosis** and overall care.
- However, these actions alone do not fulfill the immediate ethical and legal obligation to warn the identified potential victim of the imminent threat.
