A 21-year-old woman has frequent sexual fantasies about female coworkers. When she is with her friends in public, she never misses an opportunity to make derogatory comments about same-sex couples she sees. Which of the following psychological defense mechanisms is she demonstrating?
Q42
An 11-year-old boy is brought to the clinic by his parents for poor academic performance. The patient’s parents say that his teacher told them that he may have to repeat a grade because of his lack of progress, as he does not pay attention to the lessons, tends to fidget about in his seat, and often blurts out comments when it is someone else’s turn to speak. Furthermore, his after-school karate coach says the patient no longer listens to instructions and has a hard time focusing on the activity at hand. The patient has no significant past medical history and is currently not on any medications. The patient has no known learning disabilities and has been meeting all developmental milestones. The parents are vehemently opposed to using any medication with a potential for addiction. Which of the following medications is the best course of treatment for this patient?
Q43
A 5-year-old boy is brought to the physician by his mother because he claims to have spoken to his recently-deceased grandfather. The grandfather, who lived with the family and frequently watched the boy for his parents, died 2 months ago. The boy was taken out of preschool for 3 days after his grandfather's death but has since returned. His teachers report that the boy is currently doing well, completing his assignments, and engaging in play with other children. When asked about how he feels, the boy becomes tearful and says, “I miss my grandpa. I sometimes talk to him when my mom is not around.” Which of the following is the most likely diagnosis?
Q44
A 14-year-old boy is brought to the clinic by his mother for temper tantrums for the past year. She is concerned as he gets abnormally irritated and angry towards the smallest things. After asking the mother to leave the room, the patient reports that he is simply annoyed by his mother's constant nagging. He denies any violent tendencies, suicidal ideations, depressive symptoms, or intention to hurt others. The patient states he finds the physician irritating and that he reminds him of his mother in his mannerisms and demeanor. Without provocation, the patient shouts at the physician saying that he does not understand or really care about him and he never would. What is the likely explanation for this patient's behavior toward the physician?
Q45
A 43-year-old female presents to the ED with a severe case of left leg cellulitis. She is admitted for IV antibiotics. After 24 hours, the area of erythema has receded approximately 30%. The following day she is being prepared for discharge when she suddenly begins to complain of nausea and abdominal pain. On physical exam, she is febrile and has mydriasis and piloerection. What is the most likely cause of these new findings?
Q46
A 33-year-old man is brought to a psychiatric emergency room in St. Louis by policemen who report that they found him loitering at the main bus station. The patient is unable to recall why he was at the bus station, but he does have a bus ticket in his pocket from Chicago to St. Louis. When asked what his name is, he replies “I don’t know.” He has no source of identification and cannot recall his own past medical history or medications. His temperature is 98.8°F (37.1°C), blood pressure is 130/75 mmHg, pulse is 85/min, and respirations are 20/min. On examination, the patient is alert but is not oriented to person, place, or time. He appears anxious and upset but is appropriately conversant and cooperative with the examination. His pupils are equally round and reactive to light. The rest of the examination is normal. A urine toxicology screen is negative. A family member of the patient contacts the hospital the next morning and reports that the patient is a soldier who recently returned from a deployment in Afghanistan. He was last seen at his home in Chicago. Which of the following is most consistent with this patient’s condition?
Q47
A mother brings her 3-year-old son to the doctor because she is worried that he might be harming himself by constantly banging his head on the wall. He has been exhibiting this behavior for a few months. She is also worried because he has started to speak less than he used to and does not respond when his name is called. He seems aloof during playtime with other children and seems to have lost interest in most of his toys. What is the most likely diagnosis?
Q48
A previously healthy 21-year-old woman is brought to the physician because of weight loss and fatigue. Over the past 12 months she has lost 10.5 kg (23.1 lb). She feels tired almost every day and says that she has to go running for 2 hours every morning to wake up. She had been a vegetarian for 2 years but decided to become a vegan 6 months ago. She lives with her mother, who has obsessive-compulsive disorder. The mother reports that her daughter refuses to eat with the family and only eats food that she has prepared herself. When asked about her weight, the patient says that despite her weight loss, she still feels “chubby”. She is 160 cm (5 ft 3 in) tall and weighs 42 kg (92.6 lb); BMI is 16.4 kg/m2. Her temperature is 35.7°C (96.3°F), pulse is 39/min, and blood pressure is 100/50 mm Hg. Physical examination shows emaciation. There is dry skin, covered by fine, soft hair all over the body. On mental status examination, she is oriented to person, place, and time. Serum studies show:
Na+ 142 mEq/L
Cl 103 mEq/L
K+ 4.0 mEq/L
Urea nitrogen 10 mg/dL
Creatinine 1.0 mg/dL
Glucose 65 mg/dL
Which of the following is the most appropriate next step in management?
Q49
A 40-year-old woman presents with an acute loss of vision in her right eye. Past medical history is significant for depression diagnosed 2 years ago and well-managed medically. Further history reveals that the patient recently came to know that her trusted neighbor was sexually abusing her younger daughter. Physical examination is unremarkable and reveals no abnormality that can explain her acute unilateral blindness. Which of the following features is most characteristic of this patient’s condition?
Q50
A 30-year-old man is brought to the emergency department by the police after starting a fight at a local bar. He has several minor bruises and he appears agitated. He talks incessantly about his future plans. He reports that he has no history of disease and that he is "super healthy" and "never felt better". His temperature is 38.0°C (100.4°F), pulse is 110/min, respirations are 16/min, and blood pressure is 155/80 mm Hg. On physical examination reveals a euphoric and diaphoretic man with slightly dilated pupils. An electrocardiogram is obtained and shows tachycardia with normal sinus rhythm. A urine toxicology screen is positive for cocaine. The patient is held in the ED for observation. Which of the following symptoms can the patient expect to experience as he begins to withdraw from cocaine?
Mood Disorders US Medical PG Practice Questions and MCQs
Question 41: A 21-year-old woman has frequent sexual fantasies about female coworkers. When she is with her friends in public, she never misses an opportunity to make derogatory comments about same-sex couples she sees. Which of the following psychological defense mechanisms is she demonstrating?
A. Acting out
B. Reaction formation (Correct Answer)
C. Sublimation
D. Sexualization
E. Intellectualization
Explanation: ***Reaction formation***
- The woman's derogatory comments about same-sex couples are a classic example of **reaction formation**, where an unacceptable impulse (sexual fantasies about female coworkers) is transformed into its opposite.
- This defense mechanism allows her to hide her true feelings from herself and others by outwardly expressing feelings that are completely contrary to her unconscious desires.
*Acting out*
- **Acting out** involves expressing unconscious emotional conflicts or stressors through actions rather than words.
- This typically manifests as destructive or maladaptive behaviors, not verbal expressions that contradict internal desires.
*Sublimation*
- **Sublimation** is a mature defense mechanism where unacceptable impulses are channeled into socially acceptable or even highly productive activities.
- Her comments are derogatory and not a productive or socially acceptable channeling of her impulses.
*Sexualization*
- **Sexualization** involves endowing an object or function with sexual significance, which is not the primary defense being used here.
- While her fantasies involve sexual themes, her public behavior is a defensive response to those themes, not a direct sexualizing of situations.
*Intellectualization*
- **Intellectualization** involves using excessive abstract thinking or reasoning to avoid confronting unpleasant emotions or conflicts.
- Her behavior involves active expression of an opposing viewpoint, rather than detaching emotionally through abstract thought.
Question 42: An 11-year-old boy is brought to the clinic by his parents for poor academic performance. The patient’s parents say that his teacher told them that he may have to repeat a grade because of his lack of progress, as he does not pay attention to the lessons, tends to fidget about in his seat, and often blurts out comments when it is someone else’s turn to speak. Furthermore, his after-school karate coach says the patient no longer listens to instructions and has a hard time focusing on the activity at hand. The patient has no significant past medical history and is currently not on any medications. The patient has no known learning disabilities and has been meeting all developmental milestones. The parents are vehemently opposed to using any medication with a potential for addiction. Which of the following medications is the best course of treatment for this patient?
A. Sertraline
B. Diazepam
C. Olanzapine
D. Methylphenidate
E. Atomoxetine (Correct Answer)
Explanation: ***Atomoxetine***
- This medication is a **non-stimulant** selective norepinephrine reuptake inhibitor. It is a good choice for **ADHD patients** whose parents are opposed to any medication with a potential for addiction because it does not have the same addictive potential as stimulants.
- It works by increasing the levels of **norepinephrine** in the brain, improving attention and hyperactivity symptoms typically seen in ADHD.
*Sertraline*
- This is a **selective serotonin reuptake inhibitor (SSRI)** and is primarily used to treat depression, anxiety disorders, and obsessive-compulsive disorder.
- Sertraline would not be effective for ADHD symptoms like inattention and hyperactivity.
*Diazepam*
- This is a **benzodiazepine** primarily used for anxiety, seizures, and muscle spasms due to its sedative and anxiolytic properties.
- It would likely worsen the patient's inattention and academic performance due to its **sedative effects** and has a significant potential for addiction.
*Olanzapine*
- This is an **atypical antipsychotic** medication used to treat conditions like schizophrenia and bipolar disorder.
- Olanzapine is not indicated for ADHD and could cause severe side effects like **sedation, weight gain, and metabolic issues**.
*Methylphenidate*
- This is a **stimulant medication** commonly used to treat ADHD and is highly effective in improving attention and reducing hyperactivity.
- While effective, methylphenidate has a **potential for abuse and addiction**, which the patient's parents are explicitly against.
Question 43: A 5-year-old boy is brought to the physician by his mother because he claims to have spoken to his recently-deceased grandfather. The grandfather, who lived with the family and frequently watched the boy for his parents, died 2 months ago. The boy was taken out of preschool for 3 days after his grandfather's death but has since returned. His teachers report that the boy is currently doing well, completing his assignments, and engaging in play with other children. When asked about how he feels, the boy becomes tearful and says, “I miss my grandpa. I sometimes talk to him when my mom is not around.” Which of the following is the most likely diagnosis?
A. Normal grief (Correct Answer)
B. Major depressive disorder
C. Brief psychotic disorder
D. Adjustment disorder
E. Schizophreniform disorder
Explanation: ***Normal grief***
- The boy's reaction, including talking to his deceased grandfather and expressing sadness, is a **common and normal part of the grief process in children**, especially given his close relationship with his grandfather and the recent timing of the death.
- His continued functioning at school, engaging with peers, and the absence of significant functional impairment indicate that these are likely **age-appropriate coping mechanisms** rather than a pathological condition.
*Major depressive disorder*
- This diagnosis typically involves **persistent sadness, anhedonia, significant changes in appetite or sleep, fatigue, feelings of worthlessness, or recurrent thoughts of death**, lasting for at least two weeks.
- The boy's ability to engage in play and complete schoolwork, along with the episodic nature of his sadness, suggests he does not meet the criteria for **major depressive disorder**.
*Brief psychotic disorder*
- This disorder is characterized by the sudden onset of **psychotic symptoms** such as delusions, hallucinations, disorganized speech, or grossly disorganized behavior, lasting from one day to one month.
- While the boy reports "speaking" to his grandfather, this is more indicative of a **grief-related fantasy or coping mechanism** rather than a true hallucination, especially since he understands his grandfather is deceased and it does not impair his daily functioning.
*Adjustment disorder*
- This involves **emotional or behavioral symptoms** that develop within three months of an identifiable stressor and cause significant distress or functional impairment.
- Although there is a stressor (grandfather's death), the boy's symptoms are part of a **normal grieving process** and do not appear to cause significant impairment in his social or academic functioning.
*Schizophreniform disorder*
- This is a psychotic disorder with symptoms similar to **schizophrenia** (delusions, hallucinations, disorganized speech, negative symptoms) but lasting between one and six months.
- The boy's claims of speaking to his grandfather are more consistent with **grief-induced fantasy** rather than a true psychotic symptom, and he lacks other hallmark features of a psychotic disorder.
Question 44: A 14-year-old boy is brought to the clinic by his mother for temper tantrums for the past year. She is concerned as he gets abnormally irritated and angry towards the smallest things. After asking the mother to leave the room, the patient reports that he is simply annoyed by his mother's constant nagging. He denies any violent tendencies, suicidal ideations, depressive symptoms, or intention to hurt others. The patient states he finds the physician irritating and that he reminds him of his mother in his mannerisms and demeanor. Without provocation, the patient shouts at the physician saying that he does not understand or really care about him and he never would. What is the likely explanation for this patient's behavior toward the physician?
A. Passive aggression
B. Transference (Correct Answer)
C. Displacement
D. Projection
E. Acting out
Explanation: ***Transference***
- **Transference** occurs when a patient unconsciously redirects feelings and attitudes from a significant past relationship (e.g., with a parent) onto the physician. The patient explicitly states the physician reminds him of his mother in mannerisms and demeanor, triggering a hostile outburst.
- The patient's anger towards the physician "without provocation" and his declaration that the physician "doesn't understand or care" mirrors his expressed annoyance with his mother's "constant nagging," which he perceives as a lack of understanding or validation.
*Passive aggression*
- **Passive aggression** involves indirect resistance to the demands of others and an avoidance of direct confrontation, often through procrastination, stubbornness, or intentional inefficiency.
- The patient's behavior is a direct, overt verbal outburst, not an indirect form of aggression.
*Displacement*
- **Displacement** is a defense mechanism where hostile or aggressive impulses are redirected from the original source of the frustration (mother) to a less threatening target (the physician).
- While there is redirection of feelings, the key for transference is the *perception* that the physician *reminds* him of the original target, rather than just being a convenient, safer target for displaced feelings. The prompt explicitly states the patient sees the physician as his mother.
*Projection*
- **Projection** is a defense mechanism where undesirable thoughts, feelings, or qualities are attributed to another person.
- The patient is expressing his own feelings of annoyance and anger, not attributing his own *unacceptable* feelings to the physician. He is responding to the physician as if the physician *is* his mother.
*Acting out*
- **Acting out** refers to the expression of unconscious emotional conflicts or impulses through behavior, rather than through verbal expression or introspection. It's often impulsive and can be self-destructive or defiant.
- While the patient is expressing emotions through behavior (shouting), the specific underlying mechanism described (physician reminding him of his mother) points more directly to transference as the primary defense.
Question 45: A 43-year-old female presents to the ED with a severe case of left leg cellulitis. She is admitted for IV antibiotics. After 24 hours, the area of erythema has receded approximately 30%. The following day she is being prepared for discharge when she suddenly begins to complain of nausea and abdominal pain. On physical exam, she is febrile and has mydriasis and piloerection. What is the most likely cause of these new findings?
A. The patient's bacterial infection is no longer responding to the antibiotic regimen and she is showing signs of sepsis
B. The patient has acquired a nosocomial enteritis, as a result of her hospitalization and her antibiotic regimen
C. The patient is most likely withdrawing from an opiate that she uses chronically (Correct Answer)
D. The patient is having an allergic reaction to the antibiotic regimen
E. The patient is now showing signs of a pulmonary embolism as a result of a deep vein thrombosis
Explanation: ***The patient is most likely withdrawing from an opiate that she uses chronically***
- The constellation of **nausea**, **abdominal pain**, **fever**, **mydriasis** (dilated pupils), and **piloerection** (goosebumps) is highly characteristic of **opiate withdrawal syndrome**.
- Opiate withdrawal symptoms typically manifest when a chronic user stops or significantly reduces their opiate intake, which could occur during hospitalization if their usual supply is interrupted or not continued.
*The patient's bacterial infection is no longer responding to the antibiotic regimen and she is showing signs of sepsis*
- While sepsis can present with fever and abdominal pain, **mydriasis** and **piloerection** are not typical signs of sepsis; these point more strongly to autonomic nervous system dysregulation seen in withdrawal.
- The initial cellulitis was improving ("erythema has receded approximately 30%"), making worsening sepsis less likely as the primary driver of these *new* and distinct symptoms.
*The patient has acquired a nosocomial enteritis, as a result of her hospitalization and her antibiotic regimen*
- **Nosocomial enteritis** might cause nausea and abdominal pain, but it would typically involve **diarrhea** and would not explain the prominent findings of **mydriasis** and **piloerection**.
- While antibiotics can cause gastrointestinal upset, these specific autonomic signs are not typical for antibiotic-associated enteritis.
*The patient is having an allergic reaction to the antibiotic regimen*
- An **allergic reaction** would typically present with symptoms like **rash**, **hives**, **pruritus**, **angioedema**, or **bronchospasm**, which are not described.
- While fever can occur with drug reactions, the specific combination of pupillary changes and piloerection is not characteristic of an allergic response.
*The patient is now showing signs of a pulmonary embolism as a result of a deep vein thrombosis*
- A **pulmonary embolism (PE)** characteristically presents with **dyspnea**, **chest pain**, **tachycardia**, and potentially **hypoxia**.
- **Nausea**, **abdominal pain**, **mydriasis**, and **piloerection** are not typical symptoms of a PE.
Question 46: A 33-year-old man is brought to a psychiatric emergency room in St. Louis by policemen who report that they found him loitering at the main bus station. The patient is unable to recall why he was at the bus station, but he does have a bus ticket in his pocket from Chicago to St. Louis. When asked what his name is, he replies “I don’t know.” He has no source of identification and cannot recall his own past medical history or medications. His temperature is 98.8°F (37.1°C), blood pressure is 130/75 mmHg, pulse is 85/min, and respirations are 20/min. On examination, the patient is alert but is not oriented to person, place, or time. He appears anxious and upset but is appropriately conversant and cooperative with the examination. His pupils are equally round and reactive to light. The rest of the examination is normal. A urine toxicology screen is negative. A family member of the patient contacts the hospital the next morning and reports that the patient is a soldier who recently returned from a deployment in Afghanistan. He was last seen at his home in Chicago. Which of the following is most consistent with this patient’s condition?
A. Depersonalization disorder
B. Bipolar I disorder
C. Dissociative fugue disorder (Correct Answer)
D. Dissociative identity disorder
E. Post-traumatic stress disorder
Explanation: ***Dissociative fugue disorder***
- The patient exhibits sudden, unexpected **travel away from home** or one's customary workplace, coupled with **amnesia for identity** or other important autobiographical information, which are core features of dissociative fugue.
- The history of being a soldier recently returned from deployment suggests a possible **stressor** that could precipitate a dissociative episode.
*Depersonalization disorder*
- This involves persistent or recurrent experiences of feeling **detached from one's mental processes or body**, as if one is an outside observer.
- The patient's inability to recall identity, place, and time, along with travel, goes beyond mere feelings of detachment.
*Bipolar I disorder*
- Characterized by episodes of **mania and depression**, which are primarily mood disturbances.
- The patient's symptoms are focused on **memory loss and identity confusion**, not elevated or depressed mood primarily.
*Dissociative identity disorder*
- Involves the presence of **two or more distinct personality states** or an experience of possession, which is not described.
- While there is memory loss, it's typically for everyday events or important personal information associated with different identities, not a complete loss of personal identity and travel.
*Post-traumatic stress disorder*
- Involves symptoms like **intrusive thoughts, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity** following a traumatic event.
- While the patient's military service and trauma could be an underlying factor, the primary presentation of **identity amnesia and travel** is more consistent with dissociative fugue than the immediate symptoms of PTSD itself.
Question 47: A mother brings her 3-year-old son to the doctor because she is worried that he might be harming himself by constantly banging his head on the wall. He has been exhibiting this behavior for a few months. She is also worried because he has started to speak less than he used to and does not respond when his name is called. He seems aloof during playtime with other children and seems to have lost interest in most of his toys. What is the most likely diagnosis?
A. Autism spectrum disorder (Correct Answer)
B. Attention deficit hyperactivity disorder
C. Generalized anxiety disorder
D. Bipolar disorder
E. Obsessive-compulsive disorder
Explanation: ***Autism spectrum disorder***
- The child's symptoms of **head banging** (a repetitive, self-stimulatory behavior), **decreased speech**, **lack of response to his name**, **social aloofness**, and **loss of interest in toys** are classic indicators of **Autism Spectrum Disorder (ASD)**.
- ASD involves persistent deficits in **social communication and interaction** across multiple contexts, as well as **restricted, repetitive patterns of behavior, interests, or activities**.
*Attention deficit hyperactivity disorder*
- **ADHD** is characterized primarily by **inattention, hyperactivity, and impulsivity**, which are not the prominent or primary concerns described in this case.
- While children with ADHD may have social difficulties, their core symptoms do not typically include severe **social aloofness, communication regression**, or **self-injurious repetitive behaviors** like head banging.
*Generalized anxiety disorder*
- **Generalized anxiety disorder (GAD)** in children typically presents with excessive worry about multiple events or activities, often accompanied by **physical symptoms of anxiety** such as restlessness, fatigue, and difficulty concentrating.
- It does not explain the **communication regression, social deficits**, or **stereotypical behaviors** like head banging observed in this child.
*Bipolar disorder*
- **Bipolar disorder** in children often manifests with severe mood dysregulation, including distinct periods of **elevated or irritable mood (mania/hypomania)** and depression.
- The symptoms described, such as social withdrawal and communication difficulties, are not characteristic of the primary presentations of bipolar disorder.
*Obsessive-compulsive disorder*
- **OCD** is characterized by the presence of **obsessions (recurrent, persistent thoughts, urges, or images)** and/or **compulsions (repetitive behaviors or mental acts)**.
- While head banging can be a repetitive behavior, the broader constellation of symptoms, including social and communication deficits, is not typical of primary OCD in young children.
Question 48: A previously healthy 21-year-old woman is brought to the physician because of weight loss and fatigue. Over the past 12 months she has lost 10.5 kg (23.1 lb). She feels tired almost every day and says that she has to go running for 2 hours every morning to wake up. She had been a vegetarian for 2 years but decided to become a vegan 6 months ago. She lives with her mother, who has obsessive-compulsive disorder. The mother reports that her daughter refuses to eat with the family and only eats food that she has prepared herself. When asked about her weight, the patient says that despite her weight loss, she still feels “chubby”. She is 160 cm (5 ft 3 in) tall and weighs 42 kg (92.6 lb); BMI is 16.4 kg/m2. Her temperature is 35.7°C (96.3°F), pulse is 39/min, and blood pressure is 100/50 mm Hg. Physical examination shows emaciation. There is dry skin, covered by fine, soft hair all over the body. On mental status examination, she is oriented to person, place, and time. Serum studies show:
Na+ 142 mEq/L
Cl 103 mEq/L
K+ 4.0 mEq/L
Urea nitrogen 10 mg/dL
Creatinine 1.0 mg/dL
Glucose 65 mg/dL
Which of the following is the most appropriate next step in management?
A. Hospitalization and topiramate therapy
B. Hospitalization and fluoxetine therapy
C. Food diary and outpatient follow-up
D. Inpatient nutritional rehabilitation (Correct Answer)
E. Outpatient psychodynamic psychotherapy
Explanation: ***Inpatient nutritional rehabilitation***
- This patient exhibits severe **anorexia nervosa** with a **BMI of 16.4 kg/m²**, **bradycardia (39/min)**, **hypothermia (35.7°C)**, **hypotension (100/50 mm Hg)**, and **emaciation with lanugo hair**. These symptoms indicate an urgent need for medical stabilization.
- Inpatient nutritional rehabilitation is crucial for safe **weight restoration**, correction of electrolyte imbalances, and medical monitoring to prevent serious complications like **refeeding syndrome**.
*Hospitalization and topiramate therapy*
- While hospitalization is indicated, **topiramate** is an anticonvulsant sometimes used for binge-eating disorder or bulimia nervosa, but it is **contraindicated** in anorexia nervosa due to its potential to cause **further weight loss**.
- **Hospitalization** alone without a clear plan for nutritional rehabilitation and weight restoration is insufficient for a patient with severe anorexia nervosa.
*Hospitalization and fluoxetine therapy*
- **Fluoxetine** (an SSRI) is generally **not effective** for weight restoration in the acute phase of anorexia nervosa and is typically reserved for comorbid depression or anxiety **after significant weight restoration** has occurred.
- Starting fluoxetine during severe malnutrition can be ineffective and may even carry risks without addressing the primary need for nutritional rehabilitation.
*Food diary and outpatient follow-up*
- This option is **inappropriate** given the patient's critically low BMI, significant bradycardia, hypothermia, and hypotension, which are all signs of medical instability requiring **immediate inpatient care**.
- **Outpatient management** would be insufficient and potentially dangerous for a patient with such severe signs of malnutrition and organ compromise.
*Outpatient psychodynamic psychotherapy*
- While **psychotherapy** is a cornerstone of long-term treatment for anorexia nervosa, **outpatient psychodynamic psychotherapy** is not the appropriate first step for a patient with significant medical instability.
- Medical stabilization and weight restoration through **inpatient nutritional rehabilitation** must precede or occur concurrently with intensive psychotherapy for optimal and safe recovery.
Question 49: A 40-year-old woman presents with an acute loss of vision in her right eye. Past medical history is significant for depression diagnosed 2 years ago and well-managed medically. Further history reveals that the patient recently came to know that her trusted neighbor was sexually abusing her younger daughter. Physical examination is unremarkable and reveals no abnormality that can explain her acute unilateral blindness. Which of the following features is most characteristic of this patient’s condition?
A. Pseudologia fantastica
B. Hyperactive insula
C. Seeking tangible reward
D. Desire for the sick-role
E. La belle indifférence (Correct Answer)
Explanation: ***La belle indifférence***
- This term describes a patient's **lack of concern** or emotional response toward their significant and unexplained physical symptoms, which is characteristic of **conversion disorder**.
- In this case, the patient presents with acute, unexplained blindness following a severe psychosocial stressor, and if she reacted with calmness or disinterest regarding her sudden loss of vision, it would strongly suggest this phenomenon.
*Pseudologia fantastica*
- This refers to a tendency to **fabricate elaborate and fantastical lies** that the individual often comes to believe themselves.
- It is more commonly associated with conditions like **factitious disorder** or certain personality disorders, not the presentation described.
*Hyperactive insula*
- An overactive insula is implicated in conditions involving heightened emotional processing and body awareness, such as **anxiety disorders** and **somatic symptom disorder**.
- It does not specifically characterize conversion disorder, where neurological symptoms are often inconsistent with known pathways.
*Seeking tangible reward*
- This is a hallmark of **malingering**, where individuals consciously feign illness for **external incentives** like financial gain, avoiding work, or obtaining drugs.
- In conversion disorder, the symptoms are not consciously produced for such rewards.
*Desire for the sick-role*
- While individuals with **factitious disorder** often exhibit a strong desire to assume the "sick role" and gain attention from healthcare providers, this is driven by an unconscious psychological need.
- This is distinct from conversion disorder, where symptoms arise as an unconscious coping mechanism for stress, without the primary goal of the sick role.
Question 50: A 30-year-old man is brought to the emergency department by the police after starting a fight at a local bar. He has several minor bruises and he appears agitated. He talks incessantly about his future plans. He reports that he has no history of disease and that he is "super healthy" and "never felt better". His temperature is 38.0°C (100.4°F), pulse is 110/min, respirations are 16/min, and blood pressure is 155/80 mm Hg. On physical examination reveals a euphoric and diaphoretic man with slightly dilated pupils. An electrocardiogram is obtained and shows tachycardia with normal sinus rhythm. A urine toxicology screen is positive for cocaine. The patient is held in the ED for observation. Which of the following symptoms can the patient expect to experience as he begins to withdraw from cocaine?
A. Psychosis
B. Seizures
C. Lacrimation
D. Increased appetite (Correct Answer)
E. Increased sympathetic stimulation
Explanation: ***Increased appetite***
- **Cocaine withdrawal** is characterized by a "crash" phase, which includes severe fatigue, **dysphoria**, and increased appetite, often leading to binge eating as the body attempts to replenish depleted neurotransmitters.
- This symptom, combined with **hypersomnia** and a reduction in pleasure, represents a rebound effect from the intense stimulation caused by cocaine use.
*Psychosis*
- While acute cocaine intoxication can induce **psychotic symptoms** like paranoia and hallucinations, psychosis is not a typical feature of the *withdrawal* phase.
- Instead, the withdrawal period is often marked by a decrease in stimulation, leading to symptoms like depression and anhedonia rather than further agitation or psychosis.
*Seizures*
- **Seizures** are a potential complication of acute cocaine intoxication due to its stimulant effects on the central nervous system, but they are generally not a primary symptom of uncomplicated **cocaine withdrawal**.
- Withdrawal is more commonly associated with a state of brain hyperexcitability that manifests as cravings and dysphoria, not typically grand mal seizures.
*Lacrimation*
- **Lacrimation** (tearing) is a common symptom of **opioid withdrawal**, often accompanied by rhinorrhea, muscle aches, and piloerection.
- These **cholinergic rebound** symptoms are not characteristic of cocaine withdrawal, which primarily involves dopaminergic and noradrenergic system dysregulation.
*Increased sympathetic stimulation*
- Acute cocaine use directly causes increased sympathetic stimulation, resulting in **tachycardia**, **hypertension**, and dilated pupils, as seen in this patient.
- **Cocaine withdrawal**, conversely, leads to a *decrease* in sympathetic tone, often accompanied by fatigue, bradycardia, and a general depressive state, as the body rebounds from overstimulation.
