A 35-year-old woman is brought to the inpatient psychiatric unit by the police after she was found violating the conditions of her restraining order by parking on the side street of her "lover’s" home every night for the past week. Her "lover", a famous hometown celebrity, has adamantly denied any relationship with the patient over the past 6 months. The patient insists that ever since he signed a copy of his album at a local signing, she knew they were in love. Despite him having his own wife and children, the patient insists that he is in love with her and goes to his house to meet in secret. Physical examination of the patient is unremarkable. Urine toxicology is negative. Which of the following statements best describes this patient’s condition?
Q2
A 26-year-old man is brought to the emergency department by his wife because of bizarre and agitated behavior for the last 6 weeks. He thinks that the NSA is spying on him and controlling his mind. His wife reports that the patient has become withdrawn and at times depressed for the past 3 months. He lost his job because he stopped going to work 4 weeks ago. Since then, he has been working on an invention that will block people from being able to control his mind. Physical and neurologic examinations show no abnormalities. On mental status examination, he is confused and suspicious with marked psychomotor agitation. His speech is disorganized and his affect is labile. Which of the following is the most likely diagnosis?
Q3
A 24-year-old man is brought to your emergency department under arrest by the local police. The patient was found naked at a busy intersection jumping up and down on top of a car. Interviewing the patient, you discover that he has not slept in 2 days because he does not feel tired. He reports hearing voices. The patient was previously hospitalized 1 year ago with auditory hallucinations, paranoia, and a normal mood. What is the most likely diagnosis?
Q4
A 23-year-old man is brought to the emergency department by his girlfriend because of acute agitation and bizarre behavior. The girlfriend reports that, over the past 3 months, the patient has become withdrawn and stopped pursuing hobbies that he used to enjoy. One month ago, he lost his job because he stopped going to work. During this time, he has barely left his apartment because he believes that the FBI is spying on him and controlling his mind. He used to smoke marijuana occasionally in high school but quit 5 years ago. Physical and neurologic examinations show no abnormalities. On mental status examination, he is confused and suspicious with marked psychomotor agitation. His speech is disorganized and his affect is labile. Which of the following is the most likely diagnosis?
Q5
Two dizygotic twins present to the university clinic because they believe they are being poisoned through the school's cafeteria food. They have brought these concerns up in the past, but no other students or cafeteria staff support this belief. Both of them are average students with strong and weak subject areas as demonstrated by their course grade-books. They have no known medical conditions and are not known to abuse illicit substances. Which statement best describes the condition these patients have?
Q6
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?
Q7
A 21-year-old man presents to the emergency room requesting surgery to remove "microchips," which he believes were implanted in his brain by "Russian spies" 6 months ago to control his thoughts. He also reports hearing the "spies" talk to each other through embedded "microspeakers." You notice that his hair appears unwashed and some of his clothes are on backward. Urine toxicology is negative for illicit drugs. Which of the following additional findings are you most likely to see in this patient during the course of his illness?
Q8
A 23-year-old woman is brought to the physician by her father because of irritability, mood swings, and difficulty sleeping over the past 10 days. A few days ago, she quit her job and spent all of her savings on supplies for a “genius business plan.” She has been energetic despite sleeping only 1–2 hours each night. She was diagnosed with major depressive disorder 2 years ago. Mental status examination shows pressured speech, a labile affect, and flight of ideas. Throughout the examination, she repeatedly states “I feel great, I don't need to be here.” Urine toxicology screening is negative. Which of the following is the most likely diagnosis?
Q9
A 31-year-old woman comes to the physician because she thinks that her “right wrist is broken.” She says that she has severe pain and that “the bone is sticking out.” She has not had any trauma to the wrist. Her medical records indicate that she was diagnosed with schizophrenia 2 years ago and treated with olanzapine; she has not filled any prescriptions over the past 4 months. Three weeks ago, she stopped going to work because she “did not feel like getting up” in the morning. Vital signs are within normal limits. Physical examination of the right wrist shows no visible injury; there is no warmth, swelling, or erythema. Range of motion is limited by pain. On mental status examination, she has a flat affect. Her speech is pressured and she frequently changes the topic. She has short- and long-term memory deficits. Attention and concentration are poor. There is no evidence of suicidal ideation. Urine toxicology screening is negative. An x-ray of the wrist shows no abnormalities. Which of the following is the most appropriate response to this patient's concerns?
Q10
A 27-year-old woman is brought to the office at the insistence of her fiancé to be evaluated for auditory hallucinations for the past 8 months. The patient’s fiancé tells the physician that the patient often mentions that she can hear her own thoughts speaking aloud to her. The hallucinations have occurred intermittently for at least 1-month periods. Past medical history is significant for hypertension. Her medications include lisinopril and a daily multivitamin both of which she frequently neglects. She lost her security job 7 months ago after failing to report to work on time. The patient’s vital signs include: blood pressure 132/82 mm Hg; pulse 72/min; respiratory rate 18/min, and temperature 36.7°C (98.1°F). On physical examination, the patient has a flat affect and her focus fluctuates from the window to the door. She is disheveled with a foul smell. She has difficulty focusing on the discussion and does not quite understand what is happening around her. A urine toxicology screen is negative. Which of the following is the correct diagnosis for this patient?
Types of delusional disorder (persecutory, jealous, etc.) US Medical PG Practice Questions and MCQs
Question 1: A 35-year-old woman is brought to the inpatient psychiatric unit by the police after she was found violating the conditions of her restraining order by parking on the side street of her "lover’s" home every night for the past week. Her "lover", a famous hometown celebrity, has adamantly denied any relationship with the patient over the past 6 months. The patient insists that ever since he signed a copy of his album at a local signing, she knew they were in love. Despite him having his own wife and children, the patient insists that he is in love with her and goes to his house to meet in secret. Physical examination of the patient is unremarkable. Urine toxicology is negative. Which of the following statements best describes this patient’s condition?
A. The patient will have concurrent psychotic disorders.
B. The disorder must meet 2 out of the 5 core criteria.
C. Symptoms must be present for at least 4 weeks. (Correct Answer)
D. This disorder has a high prevalence rate.
E. Patients may have a contributing medical condition.
Explanation: ***Symptoms must be present for at least 4 weeks.***
- This patient presents with symptoms highly suggestive of **delusional disorder, erotomanic type**, where the primary delusion is that another person, usually of higher status, is in love with them. For a diagnosis of delusional disorder, the DSM-5 criteria state that the presence of one or more delusions must persist for **at least 1 month**.
- The patient's unwavering belief in a secret relationship with a celebrity, despite clear evidence to the contrary and the celebrity's denial, aligns with the characteristics of a **fixed, nonbizarre delusion**, which is the hallmark of delusional disorder.
*The patient will have concurrent psychotic disorders.*
- In **delusional disorder**, by definition, the patient typically does **not experience other psychotic symptoms** like prominent hallucinations, disorganized speech, or grossly disorganized/catatonic behavior.
- If other psychotic symptoms are prominent, the diagnosis would likely shift to **schizophrenia** or **schizoaffective disorder**, not delusional disorder.
*The disorder must meet 2 out of the 5 core criteria.*
- This statement refers to the diagnostic criteria for **schizophrenia**, which requires two or more of the five core symptoms (delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behavior, negative symptoms).
- Delusional disorder is characterized primarily by the presence of **nonbizarre delusions** without meeting the full criteria for schizophrenia.
*This disorder has a high prevalence rate.*
- **Delusional disorder** is relatively **uncommon**, with an estimated lifetime prevalence of about 0.2%.
- It is one of the **less common psychotic disorders**, especially when compared to schizophrenia or mood disorders with psychotic features.
*Patients may have a contributing medical condition.*
- While medical conditions can sometimes cause psychotic symptoms (e.g., **substance-induced psychosis** or psychosis due to another medical condition), this is typically excluded in the diagnosis of **primary delusional disorder**.
- The patient's urine toxicology is negative, and her physical examination is unremarkable, suggesting that her symptoms are not due to a medical condition or substance use.
Question 2: A 26-year-old man is brought to the emergency department by his wife because of bizarre and agitated behavior for the last 6 weeks. He thinks that the NSA is spying on him and controlling his mind. His wife reports that the patient has become withdrawn and at times depressed for the past 3 months. He lost his job because he stopped going to work 4 weeks ago. Since then, he has been working on an invention that will block people from being able to control his mind. Physical and neurologic examinations show no abnormalities. On mental status examination, he is confused and suspicious with marked psychomotor agitation. His speech is disorganized and his affect is labile. Which of the following is the most likely diagnosis?
A. Brief psychotic disorder
B. Schizophreniform disorder (Correct Answer)
C. Schizotypal personality disorder
D. Schizophrenia
E. Delusional disorder
Explanation: ***Schizophreniform disorder***
- The patient's symptoms, including **delusions** (fixed false beliefs that the NSA is spying and controlling his mind), **disorganized speech**, and **agitated behavior**, are consistent with a psychotic disorder.
- The duration of active psychotic symptoms (6 weeks), which is more than 1 month but less than 6 months, fits the diagnostic criteria for **schizophreniform disorder**.
- The prodromal phase (withdrawn and depressed for 3 months) plus the active phase does not yet meet the 6-month requirement for schizophrenia.
*Brief psychotic disorder*
- This disorder is characterized by a sudden onset of psychotic symptoms lasting less than 1 month, followed by a full return to premorbid functioning.
- The patient's active psychotic symptoms have persisted for 6 weeks, exceeding the maximum duration for brief psychotic disorder.
*Schizotypal personality disorder*
- This disorder primarily involves a pervasive pattern of social and interpersonal deficits marked by acute discomfort with close relationships, as well as cognitive or perceptual distortions and eccentricities.
- While there might be odd beliefs or magical thinking, it does not typically involve the persistent and severe delusions and disorganized speech seen in this case.
- This is a personality disorder, not a psychotic disorder.
*Schizophrenia*
- Schizophrenia requires continuous signs of disturbance for at least 6 months, which includes at least 1 month of active-phase symptoms (delusions, hallucinations, disorganized speech).
- The patient's total duration of illness (3 months of prodromal symptoms plus 6 weeks of active symptoms) totals approximately 4.5 months, which is less than the 6-month minimum duration required for a diagnosis of schizophrenia.
*Delusional disorder*
- The primary feature of delusional disorder is the presence of one or more delusions for at least 1 month, without other prominent psychotic symptoms such as disorganized speech or behavior.
- This patient exhibits prominent **disorganized speech**, **labile affect**, and **disorganized behavior** (bizarre invention work), which are not characteristic of delusional disorder.
- Functioning is more impaired than typically seen in delusional disorder.
Question 3: A 24-year-old man is brought to your emergency department under arrest by the local police. The patient was found naked at a busy intersection jumping up and down on top of a car. Interviewing the patient, you discover that he has not slept in 2 days because he does not feel tired. He reports hearing voices. The patient was previously hospitalized 1 year ago with auditory hallucinations, paranoia, and a normal mood. What is the most likely diagnosis?
A. Schizophrenia
B. Bipolar disorder
C. Brief psychotic disorder
D. Schizotypal disorder
E. Schizoaffective disorder (Correct Answer)
Explanation: ***Schizoaffective disorder***
- This patient demonstrates the **hallmark feature** of schizoaffective disorder: **psychotic symptoms occurring both during AND independent of mood episodes**.
- **Current presentation**: Clear **manic episode** (decreased need for sleep, grandiose/disinhibited behavior, psychomotor agitation) with psychotic features (auditory hallucinations).
- **Previous hospitalization**: **Psychotic symptoms (hallucinations, paranoia) in the absence of a mood episode** ("normal mood"), requiring hospitalization for at least 2 weeks - this is the **key diagnostic criterion** for schizoaffective disorder.
- The diagnosis requires an **uninterrupted period of illness** with both psychotic symptoms (meeting Criterion A for schizophrenia) and a major mood episode, PLUS psychotic symptoms for **≥2 weeks without prominent mood symptoms**.
*Bipolar disorder*
- In bipolar disorder with psychotic features, psychotic symptoms occur **exclusively during mood episodes** (manic, hypomanic, or depressive).
- This patient's previous hospitalization with psychosis but **"normal mood"** indicates psychotic symptoms independent of mood episodes, which **rules out** bipolar disorder and points to schizoaffective disorder.
- While the current presentation shows mania with psychosis, the longitudinal course is critical for diagnosis.
*Schizophrenia*
- Schizophrenia involves **continuous psychotic symptoms** without prominent mood episodes dominating the clinical picture.
- This patient has **prominent manic symptoms** (decreased sleep, grandiose behavior, agitation) that are central to the current presentation, making schizophrenia less likely.
- The presence of full mood episodes that occupy a **substantial portion** of the illness duration favors schizoaffective disorder over schizophrenia.
*Brief psychotic disorder*
- Brief psychotic disorder involves psychotic symptoms lasting **<1 month** with full return to baseline functioning.
- This patient has a **recurrent course** with hospitalization 1 year ago, indicating a chronic/recurring condition rather than a brief, self-limited episode.
*Schizotypal disorder*
- This is a **personality disorder** characterized by social deficits, cognitive/perceptual distortions, and eccentric behavior, but **NOT overt psychotic episodes**.
- Does not involve acute psychotic breaks with severe symptoms like hallucinations requiring hospitalization or manic episodes.
Question 4: A 23-year-old man is brought to the emergency department by his girlfriend because of acute agitation and bizarre behavior. The girlfriend reports that, over the past 3 months, the patient has become withdrawn and stopped pursuing hobbies that he used to enjoy. One month ago, he lost his job because he stopped going to work. During this time, he has barely left his apartment because he believes that the FBI is spying on him and controlling his mind. He used to smoke marijuana occasionally in high school but quit 5 years ago. Physical and neurologic examinations show no abnormalities. On mental status examination, he is confused and suspicious with marked psychomotor agitation. His speech is disorganized and his affect is labile. Which of the following is the most likely diagnosis?
A. Schizophreniform disorder (Correct Answer)
B. Schizoid personality disorder
C. Delusional disorder
D. Schizoaffective disorder
E. Brief psychotic disorder
Explanation: **Correct: Schizophreniform disorder**
- This patient presents with ***psychotic symptoms*** (delusions, disorganized speech, agitation) and ***negative symptoms*** (withdrawal, anhedonia, loss of job), which have been present for approximately ***3 months***.
- The ***duration of symptoms (1-6 months)*** is the key differentiating factor for schizophreniform disorder compared to brief psychotic disorder (<1 month) or schizophrenia (>6 months).
- Meets DSM-5 criteria: psychotic symptoms with functional impairment lasting between 1 and 6 months.
*Incorrect: Schizoid personality disorder*
- Characterized by a pervasive pattern of ***detachment from social relationships*** and a restricted range of emotional expression, which are ***ego-syntonic*** and typically stable over time.
- This is a personality disorder with chronic traits, not an acute psychotic disorder.
- Does not include acute psychotic symptoms like delusions or disorganized speech.
*Incorrect: Delusional disorder*
- Defined by the presence of ***non-bizarre delusions*** for at least one month, without other significant psychotic symptoms or major functional impairment.
- This patient has ***bizarre delusions*** (FBI controlling his mind), ***disorganized speech***, ***psychomotor agitation***, and ***marked functional impairment***, which exceed the criteria for delusional disorder.
*Incorrect: Schizoaffective disorder*
- Requires the presence of a ***major mood episode*** (depressive or manic) concurrent with symptoms of schizophrenia, AND ***delusions or hallucinations for at least 2 weeks*** in the absence of a major mood episode.
- While the patient exhibits labile affect, there is no evidence of a distinct, prolonged major mood episode (major depression or mania) as required for schizoaffective disorder.
*Incorrect: Brief psychotic disorder*
- Characterized by the sudden onset of psychotic symptoms (delusions, hallucinations, disorganized speech or behavior) that last for ***at least one day but less than one month***, followed by full return to premorbid functioning.
- The patient's symptoms have been ongoing for approximately ***3 months***, which exceeds the duration criteria for brief psychotic disorder.
Question 5: Two dizygotic twins present to the university clinic because they believe they are being poisoned through the school's cafeteria food. They have brought these concerns up in the past, but no other students or cafeteria staff support this belief. Both of them are average students with strong and weak subject areas as demonstrated by their course grade-books. They have no known medical conditions and are not known to abuse illicit substances. Which statement best describes the condition these patients have?
A. A trial separation is likely to worsen symptoms.
B. The disorder is its own disease entity in DSM-5.
C. Antipsychotic medications are rarely beneficial.
D. Can affect two or more closely related individuals. (Correct Answer)
E. Cognitive behavioral therapy is a good first-line.
Explanation: ***Can affect two or more closely related individuals.***
- The shared delusional belief in **folie à deux**, also known as **shared psychotic disorder**, typically occurs in two or more people who are closely associated.
- In this case, the **dizygotic twins** sharing the same delusional belief about being poisoned from cafeteria food fits this pattern.
*A trial separation is likely to worsen symptoms.*
- **Separating the individuals** involved in **folie à deux** is often a crucial step in treatment, as it can help break the cycle of shared delusion and allow for individual therapy.
- Separation typically IMPROVES rather than worsens symptoms by removing the reinforcement of the shared delusion.
*The disorder is its own disease entity in DSM-5.*
- In the **DSM-5**, **folie à deux** is no longer considered a separate diagnostic category.
- Instead, it is classified under **Other Specified Schizophrenia Spectrum and Other Psychotic Disorder** or **Unspecified Schizophrenia Spectrum and Other Psychotic Disorder**, with the specific context of shared delusion noted.
*Antipsychotic medications are rarely beneficial.*
- **Antipsychotics** are actually commonly used in treating folie à deux, particularly for the **primary individual** who initially developed the delusion.
- They can be an important component of treatment, often combined with separation and psychotherapy.
*Cognitive behavioral therapy is a good first-line.*
- **Cognitive Behavioral Therapy (CBT)** can be beneficial, particularly after separation, to help individuals challenge and reframe their delusional beliefs.
- However, the **first-line intervention** for shared psychotic disorder is **separation of the involved individuals**, followed by individual therapy (which may include CBT) and medication as needed.
Question 6: 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 7: A 21-year-old man presents to the emergency room requesting surgery to remove "microchips," which he believes were implanted in his brain by "Russian spies" 6 months ago to control his thoughts. He also reports hearing the "spies" talk to each other through embedded "microspeakers." You notice that his hair appears unwashed and some of his clothes are on backward. Urine toxicology is negative for illicit drugs. Which of the following additional findings are you most likely to see in this patient during the course of his illness?
A. Anhedonia, guilty rumination, and insomnia
B. Grandiose delusions, racing thoughts, and pressured speech
C. Asociality, flat affect, and alogia (Correct Answer)
D. Amnesia, multiple personality states, and de-realization
E. Intrusive thoughts, ritualized behaviors, and anxious mood
Explanation: ***Asociality, flat affect, and alogia***
- This patient exhibits **delusions (persecutory, control)** and **auditory hallucinations**, classic positive symptoms of **schizophrenia**. The question asks about findings "during the course of his illness," which points to the **typical progression of schizophrenia**: patients initially present with **positive symptoms** (as seen in this case) and **over time develop negative symptoms** such as **asociality** (lack of motivation to engage in social interaction), **flat affect** (reduced emotional expression), and **alogia** (poverty of speech).
- The disorganized appearance (unwashed hair, clothes on backward) already demonstrates **disorganized behavior**, part of the schizophrenia spectrum. Negative symptoms typically emerge or worsen as the illness progresses, representing the most likely additional findings.
*Anhedonia, guilty rumination, and insomnia*
- While **anhedonia** and **insomnia** can be seen in schizophrenia, their presence alongside prominent **guilty rumination** would more strongly suggest a **depressive disorder with psychotic features**, rather than primary schizophrenia, especially with the patient's specific, classic psychotic symptoms.
- The primary symptoms described (delusions of control, auditory hallucinations) are more characteristic of primary psychotic disorders, and guilty rumination is not a typical feature of schizophrenia progression.
*Grandiose delusions, racing thoughts, and pressured speech*
- These symptoms are hallmark features of **mania** or a **manic episode with psychotic features**. While psychotic features can occur in bipolar disorder with mania, the patient's specific delusions of being controlled by spies and hearing voices discussing him are more typical of schizophrenia.
- The absence of information about elevated mood, increased energy, or decreased need for sleep also makes mania less likely compared to schizophrenia.
*Amnesia, multiple personality states, and de-realization*
- These symptoms are characteristic of **dissociative disorders**. **Amnesia** and **multiple personality states** (now known as identity alteration in dissociative identity disorder) involve disturbances in memory and identity.
- **De-realization** involves feelings of unreality regarding one's surroundings. None of these align with the patient's primary presentation of well-formed delusions and hallucinations characteristic of a psychotic disorder.
*Intrusive thoughts, ritualized behaviors, and anxious mood*
- These are core features of **obsessive-compulsive disorder (OCD)**. The patient's symptoms are clearly defined as delusions (fixed false beliefs) and hallucinations (perceptions without external stimuli), which are distinct from the ego-dystonic intrusive thoughts and ritualistic compulsions of OCD.
- While anxiety may be present in psychotic disorders, the primary presentation here is not dominated by OCD-like symptoms, and these would not be expected to develop as part of schizophrenia's natural course.
Question 8: A 23-year-old woman is brought to the physician by her father because of irritability, mood swings, and difficulty sleeping over the past 10 days. A few days ago, she quit her job and spent all of her savings on supplies for a “genius business plan.” She has been energetic despite sleeping only 1–2 hours each night. She was diagnosed with major depressive disorder 2 years ago. Mental status examination shows pressured speech, a labile affect, and flight of ideas. Throughout the examination, she repeatedly states “I feel great, I don't need to be here.” Urine toxicology screening is negative. Which of the following is the most likely diagnosis?
A. Schizoaffective disorder
B. Bipolar disorder type II
C. Bipolar disorder type I (Correct Answer)
D. Delusional disorder
E. Attention-deficit hyperactivity disorder
Explanation: ***Bipolar disorder type I***
- The patient's presentation of lasting **elevated mood**, decreased need for sleep, increased energy, pressured speech, flight of ideas, and impulsive behavior (quitting job, spending savings) are hallmark symptoms of a **manic episode**.
- A diagnosis of **Bipolar I Disorder** requires the occurrence of at least one manic episode, which is clearly evident here and distinguishes it from other mood disorders, especially given her prior history of major depressive disorder.
*Schizoaffective disorder*
- This disorder involves a period of illness during which there is an uninterrupted period of major mood episode (depressive or manic) concurrent with symptoms of **schizophrenia**, such as delusions or hallucinations, for at least 2 weeks in the absence of a major mood episode.
- The patient's symptoms are primarily mood-driven and do not include the characteristic psychotic features that persist independently of mood disturbances.
*Bipolar disorder type II*
- Bipolar II Disorder is characterized by at least one major depressive episode and at least one **hypomanic episode**.
- The patient's current symptoms, including significant impairment in social/occupational functioning, are indicative of a **manic episode**, not a hypomanic episode, which by definition does not cause marked impairment or require hospitalization.
*Delusional disorder*
- This disorder is characterized by the presence of **non-bizarre delusions** that last for at least one month, without other prominent psychotic symptoms or significant impairment in functioning.
- While the patient's "genius business plan" might seem delusional, her pervasive mood disturbance, flight of ideas, and significant functional impairment are not consistent with the primary features of delusional disorder.
*Attention-deficit hyperactivity disorder*
- ADHD is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, often presenting in childhood.
- While there is some overlap in symptoms like impulsivity and difficulty sleeping, the episodic nature, the extent of **mood disturbance**, grandiosity, and **pressured speech** are more characteristic of a manic episode than ADHD.
Question 9: A 31-year-old woman comes to the physician because she thinks that her “right wrist is broken.” She says that she has severe pain and that “the bone is sticking out.” She has not had any trauma to the wrist. Her medical records indicate that she was diagnosed with schizophrenia 2 years ago and treated with olanzapine; she has not filled any prescriptions over the past 4 months. Three weeks ago, she stopped going to work because she “did not feel like getting up” in the morning. Vital signs are within normal limits. Physical examination of the right wrist shows no visible injury; there is no warmth, swelling, or erythema. Range of motion is limited by pain. On mental status examination, she has a flat affect. Her speech is pressured and she frequently changes the topic. She has short- and long-term memory deficits. Attention and concentration are poor. There is no evidence of suicidal ideation. Urine toxicology screening is negative. An x-ray of the wrist shows no abnormalities. Which of the following is the most appropriate response to this patient's concerns?
A. “It seems as though you are having a schizophrenia relapse. If you don't follow my recommendations and take your medications, you will most likely have further and possibly more severe episodes.”
B. “I cannot see any injury of your wrist and the physical exam as well as the x-ray don't show any injury. I imagine that feeling as if your wrist was broken may be very uncomfortable. Can you tell me more about what it feels like?” (Correct Answer)
C. I understand your concerns; however, your symptoms seem to be psychological in nature. I would be happy to refer you to a mental health professional.
D. You are clearly distressed. However, your tests do not suggest a physical problem that can be addressed with medications or surgery. I suggest that we meet and evaluate your symptoms on a regular basis.
E. I can imagine that you are uncomfortable. That certainly looks painful. Let's take care of this injury first and then we should talk about your problems getting up in the morning.
Explanation: ***“I cannot see any injury of your wrist and the physical exam as well as the x-ray don't show any injury. I imagine that feeling as if your wrist was broken may be very uncomfortable. Can you tell me more about what it feels like?”***
- This response **validates the patient's experience of pain and distress** while gently reorienting them to the objective findings (no physical injury).
- It opens a dialog to explore the **patient's subjective experience** and build trust, which is crucial for addressing underlying psychiatric issues in a patient with schizophrenia.
*“It seems as though you are having a schizophrenia relapse. If you don't follow my recommendations and take your medications, you will most likely have further and possibly more severe episodes.”*
- This statement is **confrontational and judgmental**, potentially alienating the patient and making them less likely to engage in treatment.
- Directly labeling a relapse and warning of future severity without first building rapport can trigger **defensiveness and non-compliance**.
*I understand your concerns; however, your symptoms seem to be psychological in nature. I would be happy to refer you to a mental health professional.*
- While accurate about the psychological nature of symptoms, this response **dismisses the patient's immediate physical complaint** and might make them feel unheard.
- It prematurely jumps to a referral without fully exploring the current presentation or establishing a therapeutic alliance, which can be perceived as the physician "passing the buck."
*I can imagine that you are uncomfortable. That certainly looks painful. Let's take care of this injury first and then we should talk about your problems getting up in the morning.*
- This response **validates a non-existent injury**, reinforcing the patient's delusion and potentially diverting attention from the underlying psychiatric condition.
- Prioritizing a non-existent injury would lead to inappropriate medical interventions and delay necessary psychiatric care.
*You are clearly distressed. However, your tests do not suggest a physical problem that can be addressed with medications or surgery. I suggest that we meet and evaluate your symptoms on a regular basis.*
- While acknowledging distress and the lack of physical pathology, this response is somewhat **vague and lacks a clear plan** for addressing the primary concern of perceived injury.
- "Regular evaluation" without specific intent to explore the psychological component or re-initiate psychiatric treatment may not be sufficient for a patient experiencing a schizophrenia relapse.
Question 10: A 27-year-old woman is brought to the office at the insistence of her fiancé to be evaluated for auditory hallucinations for the past 8 months. The patient’s fiancé tells the physician that the patient often mentions that she can hear her own thoughts speaking aloud to her. The hallucinations have occurred intermittently for at least 1-month periods. Past medical history is significant for hypertension. Her medications include lisinopril and a daily multivitamin both of which she frequently neglects. She lost her security job 7 months ago after failing to report to work on time. The patient’s vital signs include: blood pressure 132/82 mm Hg; pulse 72/min; respiratory rate 18/min, and temperature 36.7°C (98.1°F). On physical examination, the patient has a flat affect and her focus fluctuates from the window to the door. She is disheveled with a foul smell. She has difficulty focusing on the discussion and does not quite understand what is happening around her. A urine toxicology screen is negative. Which of the following is the correct diagnosis for this patient?
A. Schizoaffective disorder
B. Schizophrenia (Correct Answer)
C. Schizoid personality disorder
D. Schizophreniform disorder
E. Schizotypal personality disorder
Explanation: ***Schizophrenia***
- The patient exhibits core symptoms of schizophrenia, including **auditory hallucinations** (hearing thoughts speaking aloud), **disorganized thinking** (difficulty focusing, fluctuating focus), and **negative symptoms** (flat affect, disheveled, foul smell, loss of job due to poor function). These symptoms have been present for **at least 6 months** (8 months of hallucinations, 7 months of job loss), which meets the diagnostic criteria.
- The duration of symptoms (over 6 months) differentiates it from schizophreniform disorder, and the absence of prominent mood episodes rules out schizoaffective disorder.
*Schizoaffective disorder*
- This diagnosis requires a **major mood episode** (depressive or manic) concurrent with Criterion A of schizophrenia, along with a period of **at least 2 weeks of delusions or hallucinations in the absence of prominent mood symptoms**.
- While the patient has some signs of distress (lost job, disorganized), a full major mood episode is not described, and the primary symptoms are clearly psychotic.
*Schizoid personality disorder*
- This is characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression, often appearing indifferent to praise or criticism.
- The patient's symptoms are primarily psychotic (hallucinations, disorganized thought), not just social withdrawal or emotional flatness. She doesn't necessarily avoid social contact, but her psychosis interferes with it.
*Schizophreniform disorder*
- This disorder presents with symptoms identical to schizophrenia but with a **duration of at least 1 month but less than 6 months**.
- The patient's symptoms, particularly the auditory hallucinations, have been present for 8 months and are therefore outside the timeframe for schizophreniform disorder.
*Schizotypal personality disorder*
- This disorder involves a pervasive pattern of **social and interpersonal deficits** marked by acute discomfort with, and reduced capacity for, close relationships, as well as **cognitive or perceptual distortions** and eccentric behaviors.
- While there may be some odd beliefs or magical thinking, **full-blown psychotic symptoms like prominent auditory hallucinations** (hearing thoughts speaking aloud) are generally not present as consistently or severely as seen in this patient, who meets criteria for a major psychotic disorder.
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