A 5-year-old girl is brought to the physician because her mother has found her to be inattentive at home and has received multiple complaints from her teachers at school. She does not complete her assignments and does not listen to her teachers' instructions. She refuses to talk to her parents or peers. Her mother says, “She ignores everything I say to her!” She prefers playing alone, and her mother reports that she likes playing with 5 red toy cars, repeatedly arranging them in a straight line. She avoids eye contact with her mother and the physician throughout the visit. Physical and neurological examination shows no abnormalities. Which of the following is the most likely diagnosis?
Q2
A 3-year-old boy is brought in by his mother because she is concerned that he has been “acting differently recently”. She says he no longer seems interested in playing with his friends from preschool, and she has noticed that he has stopped making eye contact with others. In addition, she says he flaps his hands when excited or angry and only seems to enjoy playing with objects that he can place in rows or rigid patterns. Despite these behaviors, he is meeting his language goals for his age (single word use). The patient has no significant past medical history. He is at the 90th percentile for height and weight for his age. He is afebrile and his vital signs are within normal limits. A physical examination is unremarkable. Which of the following is the most likely diagnosis in this patient?
Q3
A 9-year-old boy is brought to a pediatric psychologist by his mother because of poor academic performance. The patient’s mother mentions that his academic performance was excellent in kindergarten and first grade, but his second and third-grade teachers complain that he is extremely talkative, does not complete schoolwork, and frequently makes careless mistakes. They also complain that he frequently looks at other students or outside the window during the class and is often lost during the lessons. At home, he is very talkative and disorganized. When the pediatrician asks the boy his name, he replies promptly. He was born at full term by spontaneous vaginal delivery. He is up-to-date on all vaccinations and has met all developmental milestones on time. A recent IQ test scored him at 95. His physical examination is completely normal. When he is asked to read from an age-appropriate children’s book, he reads it fluently and correctly. Which of the following is the most likely diagnosis in this patient?
Q4
A 6-year-old boy presents to the pediatrician with his parents. He is fully vaccinated and met most developmental milestones. His fine motor milestones are delayed; at present, he cannot eat by himself and has difficulty in self-dressing. His intelligence quotient (IQ) is 65. He listens quietly while spoken to and engages in play with his classmates. He neither talks excessively nor remains mute, but engages in normal social conversation. There is no history of seizures and he is not on any long-term medical treatment. On his physical examination, his vital signs are stable. His height and weight are normal for his age and sex, but his occipitofrontal circumference is less than the 3rd percentile for his age and sex. His neurologic examination is also normal. Which of the following is the most likely diagnosis?
Q5
A 9-year-old girl is brought to the pediatrician for a wellness checkup. The girl's past medical history is non-contributory, and she has met all her developmental milestones. Her parents were recently called into the office as the girl was found touching the genitals of one of her classmates. She was trying to insert a toy into her classmate's genitals. The girl is asked what has happened and what she thinks is going on but she is too shy to reply to the physician. The girl and her mother recently moved in with a family member. They live in low-income housing subsidized by the government and are currently on food stamps. The mother states that her daughter has been particularly argumentative lately and that they have gotten into arguments in which her daughter screamed at her and locked herself in the bathroom. Which of the following is the most likely diagnosis?
Q6
A 4-year-old girl is brought to the pediatrician by her parents after her mother recently noticed that other girls of similar age talk much more than her daughter. Her mother reports that her language development has been abnormal and she was able to use only 5–6 words at the age of 2 years. Detailed history reveals that she has never used her index finger to indicate her interest in something. She does not enjoy going to birthday parties and does not play with other children in her neighborhood. The mother reports that her favorite “game” is to repetitively flex and extend the neck of a doll, which she always keeps with her. She is sensitive to loud sounds and starts screaming excessively when exposed to them. There is no history of delayed motor development, seizures, or any other major illness; perinatal history is normal. When she enters the doctor’s office, the doctor observes that she does not look at him. When he gently calls her by her name, she does not respond to him and continues to look at her doll. When the doctor asks her to look at a toy on his table by pointing a finger at the toy, she looks at neither his finger nor the toy. The doctor also notes that she keeps rocking her body while in the office. Which of the following is an epidemiological characteristic of the condition the girl is suffering from?
Q7
A parent-teacher conference is called to discuss the behavior of a 9 year-old boy. According to the boy's teacher, he has become progressively more disruptive during class. When asked to help clean up or read out-loud, he replies with "You're not the boss of me." or "You can't make me." He refuses to participate in gym class, but will play the same games during recess. He gets along with and is well-liked by his peers. His mother reports that her son can "sometimes be difficult," but he is helpful around the house and is very good playing with his 7-year-old sister. What is the most likely diagnosis?
Q8
A 7-year-old girl is brought to the physician by her mother because she has been increasingly reluctant to speak at school over the past 4 months. Her teachers complain that she does not answer their questions and it is affecting her academic performance. She was born at 35 weeks' gestation and pregnancy was complicated by preeclampsia. Previous well-child examinations have been normal. Her older brother was diagnosed with a learning disability 4 years ago. She is at 65th percentile for height and weight. Physical examination shows no abnormalities. She follows commands. She avoids answering questions directly and whispers her answers to her mother instead who then mediates between the doctor and her daughter. Which of the following is the most likely diagnosis?
Q9
A 45-year-old woman repetitively visits the general surgery clinic worried that her inguinal hernia is incarcerated. 2 months ago, she was seen in the emergency department where she presented with a left lower abdominal swelling. The mass was easily reduced and the patient was referred to the general surgery clinic for elective surgical repair. Because her condition was deemed not urgent, she was informed that she was down on the surgical waiting list. Despite this, she continues to visit the clinic and the ED worried that her bowels are ‘trapped and dying.’ Each time she is reassured and any protrusion present is quickly reduced. She has previously frequently visited her primary care physician for complaints of abdominal pain and inconsistent bowel habits, but no etiology could be identified. She continues to intermittently have these symptoms and spends hours every day worrying about what may be going on. She has no other significant past medical history. Which of the following is the most appropriate diagnosis?
Q10
A 29-year-old woman presents with convulsions. The patient’s brother says that he found her like that an hour ago and immediately called an ambulance. He also says that she has been extremely distraught and receiving supportive care from a social worker following a sexual assault by a coworker a few days ago. He says that the patient has no history of seizures. She has no significant past medical history and takes no medications. The patient’s vital signs include: temperature 37.0°C (98.6°F), pulse 101/min, blood pressure 135/99 mm Hg, and respiratory rate 25/min. On physical examination, the patient is rolling from side to side, arrhythmically thrashing around, and muttering strangely. Her eyes are closed, and there is resistance to opening them. Which of the following is the most likely diagnosis in this patient?
Communication disorders US Medical PG Practice Questions and MCQs
Question 1: A 5-year-old girl is brought to the physician because her mother has found her to be inattentive at home and has received multiple complaints from her teachers at school. She does not complete her assignments and does not listen to her teachers' instructions. She refuses to talk to her parents or peers. Her mother says, “She ignores everything I say to her!” She prefers playing alone, and her mother reports that she likes playing with 5 red toy cars, repeatedly arranging them in a straight line. She avoids eye contact with her mother and the physician throughout the visit. Physical and neurological examination shows no abnormalities. Which of the following is the most likely diagnosis?
A. Rett syndrome
B. Conduct disorder
C. Oppositional defiant disorder
D. Attention deficit hyperactivity disorder
E. Autism spectrum disorder (Correct Answer)
Explanation: ***Autism spectrum disorder***
- The child exhibits core features of **autism spectrum disorder (ASD)**, including **social communication deficits** (refuses to talk, ignores parents, avoids eye contact) and **restricted, repetitive patterns of behavior** (playing with 5 red toy cars, repeatedly arranging them in a straight line).
- Her inattention and difficulty following instructions are also common in ASD, often related to focus on their specific interests rather than external demands, and **sensory processing differences** or **executive dysfunction**.
*Rett syndrome*
- This is a neurodevelopmental disorder almost exclusively affecting **females** and typically presents with a period of normal development followed by **regression of acquired skills**, especially **language and motor skills**.
- Key features include **stereotypic hand movements** (hand-wringing, squeezing), **gait abnormalities**, and **deceleration of head growth**, none of which are described in the patient.
*Conduct disorder*
- Characterized by a **persistent pattern of behavior** in which the basic rights of others or major age-appropriate societal norms or rules are violated, such as **aggression to people and animals**, **destruction of property**, deceitfulness or theft, and serious rule violations.
- The presented symptoms of social communication deficits and repetitive behaviors are not indicative of conduct disorder.
*Oppositional defiant disorder*
- Involves a pattern of **angry/irritable mood, argumentative/defiant behavior**, or **vindictiveness** lasting at least 6 months, often directed at authority figures.
- While the child may appear defiant by not listening, the broader constellation of **social communication deficits** and **repetitive behaviors** points away from ODD as the primary diagnosis.
*Attention deficit hyperactivity disorder*
- Presents with a persistent pattern of **inattention and/or hyperactivity-impulsivity** that interferes with functioning or development.
- Although the child is inattentive, the presence of **social communication difficulties** and **restricted, repetitive behaviors** are not characteristic of ADHD and are better explained by ASD.
Question 2: A 3-year-old boy is brought in by his mother because she is concerned that he has been “acting differently recently”. She says he no longer seems interested in playing with his friends from preschool, and she has noticed that he has stopped making eye contact with others. In addition, she says he flaps his hands when excited or angry and only seems to enjoy playing with objects that he can place in rows or rigid patterns. Despite these behaviors, he is meeting his language goals for his age (single word use). The patient has no significant past medical history. He is at the 90th percentile for height and weight for his age. He is afebrile and his vital signs are within normal limits. A physical examination is unremarkable. Which of the following is the most likely diagnosis in this patient?
A. Pervasive developmental disorder, not otherwise specified
B. Autism spectrum disorder (Correct Answer)
C. Rett’s disorder
D. Childhood disintegrative disorder
E. Asperger’s disorder
Explanation: ***Autism spectrum disorder***
- This patient exhibits **persistent deficits in social communication and social interaction** (e.g., lack of interest in friends, poor eye contact) and **restricted, repetitive patterns of behavior, interests, or activities** (e.g., hand flapping, lining up objects). These are the core diagnostic criteria for **autism spectrum disorder (ASD)**.
- The symptoms are presenting in **early childhood** (age 3) and are causing **clinically significant impairment** in social, occupational, or other important areas of current functioning, consistent with an ASD diagnosis.
*Pervasive developmental disorder, not otherwise specified*
- This diagnosis was previously used when a child met some, but not all, criteria for autistic disorder or when there was atypical presentation. However, under **DSM-5**, these conditions are now unified under the single diagnosis of **Autism Spectrum Disorder**.
- Its usage has been largely superseded by the broader diagnosis of **Autism Spectrum Disorder** in the DSM-5.
*Rett’s disorder*
- **Rett's disorder** primarily affects **females** and is characterized by a period of normal development followed by a loss of acquired hand skills, severe intellectual disability, and characteristic hand-wringing movements. This patient is a male and does not exhibit these specific features.
- Patients typically experience **regression** in language and motor skills after normal early development, which is not described in this case, and they develop **microcephaly**.
*Childhood disintegrative disorder*
- This diagnosis involves a **marked regression** in multiple areas of functioning (social, communication, motor) after at least **2 years of normal development**.
- The patient's mother notes recent changes, but there is no indication of previous normal development followed by significant loss of skills across multiple domains after age 2, which differentiates it from the insidious onset of ASD symptoms.
*Asperger’s disorder*
- **Asperger’s disorder** was characterized by **significant difficulties in social interaction** and **restricted, repetitive patterns of behavior**, but with **no clinically significant delay in language or cognitive development**.
- In **DSM-5**, Asperger's disorder is no longer a distinct diagnosis and is now subsumed under the umbrella of **Autism Spectrum Disorder**, which better reflects the spectrum of symptom severity.
Question 3: A 9-year-old boy is brought to a pediatric psychologist by his mother because of poor academic performance. The patient’s mother mentions that his academic performance was excellent in kindergarten and first grade, but his second and third-grade teachers complain that he is extremely talkative, does not complete schoolwork, and frequently makes careless mistakes. They also complain that he frequently looks at other students or outside the window during the class and is often lost during the lessons. At home, he is very talkative and disorganized. When the pediatrician asks the boy his name, he replies promptly. He was born at full term by spontaneous vaginal delivery. He is up-to-date on all vaccinations and has met all developmental milestones on time. A recent IQ test scored him at 95. His physical examination is completely normal. When he is asked to read from an age-appropriate children’s book, he reads it fluently and correctly. Which of the following is the most likely diagnosis in this patient?
A. Intellectual disability
B. Autism spectrum disorder
C. Dyslexia
D. Persistent depressive disorder
E. Attention-deficit/hyperactivity disorder (Correct Answer)
Explanation: **Attention-deficit/hyperactivity disorder**
* The child's symptoms of being **extremely talkative**, not completing schoolwork, making **careless mistakes**, and being easily distracted and disorganized are classic signs of **ADHD (Attention-deficit/hyperactivity disorder)**.
* His normal IQ, early developmental milestones, and reading fluency rule out other neurological or intellectual disabilities, while his persistent inattention and hyperactivity across settings support ADHD.
* *Intellectual disability*
* **Intellectual disability** is characterized by significant limitations in both intellectual functioning (IQ below 70) and adaptive behavior, which is contradicted by this patient's **IQ of 95** and normal developmental milestones.
* Patients with intellectual disability would typically struggle with academic performance from the start and would not have had "excellent" performance in kindergarten and first grade.
* *Autism spectrum disorder*
* **Autism spectrum disorder** involves persistent deficits in **social communication and interaction** and **restricted, repetitive patterns of behavior, interests, or activities**. This child's prompt response to his name and ability to read fluently do not align with common autistic features.
* While some social difficulties might arise from inattention, the primary symptoms do not point to core deficits in social reciprocity or communication typical of ASD.
* *Dyslexia*
* **Dyslexia** is a **specific learning disorder** primarily characterized by difficulties with **accurate and/or fluent word recognition, poor decoding, and poor spelling abilities**, despite normal intelligence.
* This patient can **read fluently and correctly from an age-appropriate children’s book**, making dyslexia an unlikely diagnosis.
* *Persistent depressive disorder*
* **Persistent depressive disorder** (dysthymia) involves a **chronically depressed mood** for at least one year in children and adolescents, often accompanied by symptoms such as low energy, poor concentration, sleep disturbance, and feelings of hopelessness.
* While poor academic performance and some difficulty concentrating could be present, the prominent symptoms of **hyperactivity** (talkativeness) and impulsivity (careless mistakes) are not typical features of depression, and a depressed mood is not reported.
Question 4: A 6-year-old boy presents to the pediatrician with his parents. He is fully vaccinated and met most developmental milestones. His fine motor milestones are delayed; at present, he cannot eat by himself and has difficulty in self-dressing. His intelligence quotient (IQ) is 65. He listens quietly while spoken to and engages in play with his classmates. He neither talks excessively nor remains mute, but engages in normal social conversation. There is no history of seizures and he is not on any long-term medical treatment. On his physical examination, his vital signs are stable. His height and weight are normal for his age and sex, but his occipitofrontal circumference is less than the 3rd percentile for his age and sex. His neurologic examination is also normal. Which of the following is the most likely diagnosis?
A. Attention deficit hyperactivity disorder
B. Autism
C. Intellectual disability (Correct Answer)
D. Obsessive-compulsive disorder
E. Tic disorder
Explanation: ***Intellectual disability***
- The boy's **IQ of 65** falls below the diagnostic threshold of 70 for intellectual disability, and he exhibits **adaptive deficits** in fine motor skills (difficulty eating and dressing) and **developmental delays**.
- His **microcephaly (occipitofrontal circumference less than 3rd percentile)** is also associated with certain forms of intellectual disability, further supporting this diagnosis.
*Attention deficit hyperactivity disorder*
- This condition is characterized by **inattention, hyperactivity, and impulsivity**, none of which are prominently described in the boy's presentation (he listens quietly and engages in normal conversation).
- While academic difficulties might occur, **significant adaptive and intellectual delays** as described are not typical primary features of ADHD.
*Autism*
- Autism spectrum disorder involves persistent deficits in **social communication and interaction** and **restricted, repetitive patterns of behavior, interests, or activities**.
- The boy's ability to engage in "normal social conversation" and play with classmates, along with an absence of repetitive behaviors or restricted interests, makes autism less likely.
*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)**.
- The boy's symptoms do not include any mention of obsessions or compulsions.
*Tic disorder*
- Tic disorders involve **sudden, rapid, recurrent, nonrhythmic motor movements or vocalizations**.
- There is no mention of tics in the boy's presentation, making this diagnosis unlikely.
Question 5: A 9-year-old girl is brought to the pediatrician for a wellness checkup. The girl's past medical history is non-contributory, and she has met all her developmental milestones. Her parents were recently called into the office as the girl was found touching the genitals of one of her classmates. She was trying to insert a toy into her classmate's genitals. The girl is asked what has happened and what she thinks is going on but she is too shy to reply to the physician. The girl and her mother recently moved in with a family member. They live in low-income housing subsidized by the government and are currently on food stamps. The mother states that her daughter has been particularly argumentative lately and that they have gotten into arguments in which her daughter screamed at her and locked herself in the bathroom. Which of the following is the most likely diagnosis?
A. Adjustment disorder
B. Normal variant of development
C. Attention deficit hyperactivity disorder
D. Precocious puberty
E. Sexual abuse (Correct Answer)
Explanation: ***Sexual abuse***
- The girl's recent behavioral changes, including **argumentativeness**, locking herself in the bathroom, and the incident of inappropriately touching a classmate's genitals, are strong indicators of potential sexual abuse.
- Inappropriate sexualized behaviors, especially when coupled with sudden behavioral shifts and exposure to stressful living conditions (like moving and low-income housing), warrant a thorough investigation for **sexual abuse**.
*Adjustment disorder*
- This diagnosis involves **emotional or behavioral symptoms** in response to an identifiable stressor, but the specific sexualized behavior observed here points to a more specific and severe underlying issue.
- While the girl is experiencing stressors (like moving and financial difficulties), an adjustment disorder alone does not fully explain the **sexualized behavior** and aggression.
*Normal variant of development*
- **Touching a classmate's genitals** and attempting to insert a toy is **not a normal variant of childhood development** at age 9; it is an atypical and concerning sexualized behavior.
- Normal developmental curiosity about bodies typically does not involve such actions, especially when accompanied by other disruptive behaviors.
*Attention deficit hyperactivity disorder*
- This disorder is characterized by persistent patterns of **inattention and/or hyperactivity-impulsivity**, which are not fully described in this case, although some difficulties with impulse control may be present.
- While the girl may be argumentative, ADHD alone does not explain the **sexually inappropriate behavior** or the sudden onset of these specific issues.
*Precocious puberty*
- **Precocious puberty** involves the early onset of physical pubertal signs (e.g., breast development, pubic hair, menstruation) before age 8 in girls, which are not mentioned in this case.
- While hormonal changes can influence behavior, precocious puberty does not directly account for **sexualized behavior toward others** or the described aggressive outbursts.
Question 6: A 4-year-old girl is brought to the pediatrician by her parents after her mother recently noticed that other girls of similar age talk much more than her daughter. Her mother reports that her language development has been abnormal and she was able to use only 5–6 words at the age of 2 years. Detailed history reveals that she has never used her index finger to indicate her interest in something. She does not enjoy going to birthday parties and does not play with other children in her neighborhood. The mother reports that her favorite “game” is to repetitively flex and extend the neck of a doll, which she always keeps with her. She is sensitive to loud sounds and starts screaming excessively when exposed to them. There is no history of delayed motor development, seizures, or any other major illness; perinatal history is normal. When she enters the doctor’s office, the doctor observes that she does not look at him. When he gently calls her by her name, she does not respond to him and continues to look at her doll. When the doctor asks her to look at a toy on his table by pointing a finger at the toy, she looks at neither his finger nor the toy. The doctor also notes that she keeps rocking her body while in the office. Which of the following is an epidemiological characteristic of the condition the girl is suffering from?
A. There has been a steady decline in prevalence in the United States over the last decade.
B. There is an increased risk if the mother smoked during pregnancy.
C. There is an increased risk with low prenatal maternal serum vitamin D level.
D. There is an increased incidence if the mother gives birth before 25 years of age.
E. This condition is 4 times more common in boys than girls. (Correct Answer)
Explanation: **_This condition is 4 times more common in boys than girls._**
- The clinical presentation, including **impaired social interaction** (not looking at the doctor, not responding to her name, not playing with other children, not enjoying parties), **communication deficits** (delayed language, lack of pointing), **repetitive behaviors** (flexing doll's neck, body rocking) and **sensory sensitivities** (screaming at loud sounds), is highly suggestive of **Autism Spectrum Disorder (ASD)**.
- **ASD** is indeed diagnosed approximately four times more often in boys than in girls, making this a characteristic epidemiological feature.
*There has been a steady decline in prevalence in the United States over the last decade.*
- The **prevalence of ASD** has actually been **steadily increasing** in the United States and globally over the last few decades, partly due to increased awareness, improved diagnostic criteria, and better screening.
- This statement is contrary to current epidemiological trends for **ASD**.
*There is an increased risk if the mother smoked during pregnancy.*
- While maternal smoking during pregnancy is linked to other developmental issues like **ADHD** and **premature birth**, a definitive, strong, and consistent causal link to a significantly increased risk of **ASD** has not been established.
- Research on environmental risk factors for **ASD** is ongoing, but maternal smoking is not a primary, well-established epidemiological characteristic.
*There is an increased risk with low prenatal maternal serum vitamin D level.*
- Some studies suggest a potential association between low prenatal maternal vitamin D levels and an increased risk of **ASD**, but this link is **not yet definitively established** and requires further research to confirm causation.
- It is considered a potential risk factor, but not a widely accepted or strong epidemiological characteristic for the condition.
*There is an increased incidence if the mother gives birth before 25 years of age.*
- The risk of **ASD** has been more consistently associated with **advanced parental age** (both maternal and paternal), not with younger maternal age.
- Studies generally indicate a **higher risk for children born to older parents**, making this statement inaccurate.
Question 7: A parent-teacher conference is called to discuss the behavior of a 9 year-old boy. According to the boy's teacher, he has become progressively more disruptive during class. When asked to help clean up or read out-loud, he replies with "You're not the boss of me." or "You can't make me." He refuses to participate in gym class, but will play the same games during recess. He gets along with and is well-liked by his peers. His mother reports that her son can "sometimes be difficult," but he is helpful around the house and is very good playing with his 7-year-old sister. What is the most likely diagnosis?
A. Conduct disorder
B. Attention deficit disorder
C. Separation anxiety disorder
D. Oppositional defiant disorder (Correct Answer)
E. Antisocial personality disorder
Explanation: ***Oppositional defiant disorder***
- The boy exhibits a pattern of **defiant and disobedient behavior** towards authority figures (teacher) but a generally good relationship with peers and family, which is characteristic of ODD.
- His refusal to participate in formal class activities while still engaging in informal play highlights a specific defiance towards structured rules rather than a general aversion to activity.
*Conduct disorder*
- This disorder involves a more severe pattern of **aggression, destruction of property, deceitfulness, or serious rule violations**, which are not described in the boy's behavior.
- The boy's ability to get along with peers and be helpful at home suggests he does not meet the criteria for significant social impairment or callousness seen in conduct disorder.
*Attention deficit disorder*
- This disorder is characterized by **inattention, hyperactivity, and impulsivity**, which are not the primary symptoms described here.
- While defiance might be a secondary issue, the core problem is not difficulty sustaining attention or controlling impulsive behaviors.
*Separation anxiety disorder*
- This involves **excessive fear or anxiety concerning separation from home or attachment figures**, which is not indicated by any of the behavioral descriptions.
- The boy's issues are related to defiance and authority, not fear of separation.
*Antisocial personality disorder*
- This diagnosis can only be made in individuals **18 years or older** and requires a pervasive pattern of disregard for and violation of the rights of others.
- The boy's age (9 years old) and his reported positive relationships with peers and family rule out this diagnosis.
Question 8: A 7-year-old girl is brought to the physician by her mother because she has been increasingly reluctant to speak at school over the past 4 months. Her teachers complain that she does not answer their questions and it is affecting her academic performance. She was born at 35 weeks' gestation and pregnancy was complicated by preeclampsia. Previous well-child examinations have been normal. Her older brother was diagnosed with a learning disability 4 years ago. She is at 65th percentile for height and weight. Physical examination shows no abnormalities. She follows commands. She avoids answering questions directly and whispers her answers to her mother instead who then mediates between the doctor and her daughter. Which of the following is the most likely diagnosis?
A. Selective mutism (Correct Answer)
B. Social anxiety disorder
C. Rett syndrome
D. Autism spectrum disorder
E. Reactive attachment disorder
Explanation: ***Selective mutism***
- The child's reluctance to speak in specific social situations (school) despite being able to speak in others (whispering to her mother), and the impact on academic performance, are classic signs of **selective mutism**
- **Selective mutism** typically involves anxiety and a consistent failure to speak in situations where speaking is expected, despite speaking in other situations
- This diagnosis fits the **DSM-5 criteria**: consistent failure to speak in specific social situations for >1 month, interfering with educational achievement
*Social anxiety disorder*
- While social anxiety can be **comorbid** with selective mutism, the hallmark of this presentation is the **specific refusal to speak** in certain settings, rather than generalized anxiety about social interactions
- A child with generalized social anxiety might interact nervously but would likely attempt to speak, which is not described here
*Rett syndrome*
- **Rett syndrome** is a neurodevelopmental disorder almost exclusively affecting girls, characterized by **normal early development followed by regression** of acquired skills, loss of purposeful hand use, and deceleration of head growth
- The presented symptoms of reluctance to speak in specific settings, without other regressive signs or developmental abnormalities, do not fit the diagnosis of Rett syndrome
*Autism spectrum disorder*
- **Autism spectrum disorder** is characterized by persistent deficits in **social communication and social interaction** across multiple contexts, and **restricted, repetitive patterns of behavior**
- This child's ability to speak to her mother and follow commands suggests intact communication skills in some contexts, making autism less likely than selective mutism for the primary presentation
*Reactive attachment disorder*
- **Reactive attachment disorder** typically arises from patterns of **extremely insufficient care** in early childhood, leading to emotionally withdrawn behavior toward caregivers and limited positive affect
- The child's selective non-speaking in school in this scenario, with normal previous well-child examinations and interaction with her mother, is inconsistent with the characteristic features of reactive attachment disorder
Question 9: A 45-year-old woman repetitively visits the general surgery clinic worried that her inguinal hernia is incarcerated. 2 months ago, she was seen in the emergency department where she presented with a left lower abdominal swelling. The mass was easily reduced and the patient was referred to the general surgery clinic for elective surgical repair. Because her condition was deemed not urgent, she was informed that she was down on the surgical waiting list. Despite this, she continues to visit the clinic and the ED worried that her bowels are ‘trapped and dying.’ Each time she is reassured and any protrusion present is quickly reduced. She has previously frequently visited her primary care physician for complaints of abdominal pain and inconsistent bowel habits, but no etiology could be identified. She continues to intermittently have these symptoms and spends hours every day worrying about what may be going on. She has no other significant past medical history. Which of the following is the most appropriate diagnosis?
A. Illness anxiety disorder
B. Conversion disorder
C. Factitious disorder
D. Malingering
E. Somatic symptom disorder (Correct Answer)
Explanation: ***Somatic symptom disorder***
- This patient exhibits **multiple somatic symptoms** (abdominal pain, inconsistent bowel habits, fear of incarcerated hernia), along with excessive thoughts, feelings, and behaviors related to these symptoms, causing significant distress and functional impairment.
- Her persistent worry about the incarcerated hernia despite reassurance, and frequent clinic visits for unrelated physical complaints without identifiable etiology, align with the diagnostic criteria for **somatic symptom disorder**.
*Illness anxiety disorder*
- Characterized by a preoccupation with having or acquiring a serious illness, but with **minimal or no somatic symptoms** present.
- In this case, the patient clearly has actual physical symptoms (abdominal pain, inconsistent bowel habits, and the inguinal swelling itself), differentiating it from illness anxiety disorder where the primary concern is the *fear* of illness rather than the experience of symptoms.
*Conversion disorder*
- Involves neurological symptoms (e.g., paralysis, blindness, seizures) that are **incompatible with recognized neurological conditions** and are not intentionally produced.
- The patient's symptoms are primarily somatic and not neurological, and she is worried about an *existing* medical issue (hernia) rather than developing unexplained neurological deficits.
*Factitious disorder*
- Individuals **consciously feign or induce symptoms** to assume the sick role, without obtaining external rewards.
- There is no indication the patient is intentionally producing her symptoms or faking her medical concerns; her distress appears genuine, and she is not seeking a "sick role" but rather relief from her worries.
*Malingering*
- Characterized by the **intentional production of false or grossly exaggerated physical or psychological symptoms** with an obvious external motivation (e.g., avoiding work, obtaining money, evading criminal prosecution).
- The patient's presentation does not suggest any clear external incentives for her exaggerated concerns; her anxiety about her health appears to be the primary driver.
- Note: Malingering is not classified as a mental disorder in DSM-5, but rather as a condition that may be a focus of clinical attention.
Question 10: A 29-year-old woman presents with convulsions. The patient’s brother says that he found her like that an hour ago and immediately called an ambulance. He also says that she has been extremely distraught and receiving supportive care from a social worker following a sexual assault by a coworker a few days ago. He says that the patient has no history of seizures. She has no significant past medical history and takes no medications. The patient’s vital signs include: temperature 37.0°C (98.6°F), pulse 101/min, blood pressure 135/99 mm Hg, and respiratory rate 25/min. On physical examination, the patient is rolling from side to side, arrhythmically thrashing around, and muttering strangely. Her eyes are closed, and there is resistance to opening them. Which of the following is the most likely diagnosis in this patient?
A. Body dysmorphic disorder
B. Somatic symptom disorder
C. Illness anxiety disorder
D. Somatic symptom disorder with predominant pain
E. Functional neurological symptom disorder (Conversion disorder) (Correct Answer)
Explanation: ***Functional neurological symptom disorder (Conversion disorder)***
- This patient presents with **neurological symptoms (pseudoseizures)** inconsistent with known neurological conditions, following a significant **psychological stressor (sexual assault).**
- Key features like **resistance to eye opening**, **arrhythmic thrashing**, **eyes closed during episode**, and general atypical presentation for a true seizure strongly suggest functional neurological symptom disorder (conversion disorder), as these are classic features of *psychogenic non-epileptic seizures (PNES)*.
- The temporal relationship to trauma and absence of prior seizure history further support this diagnosis.
*Body dysmorphic disorder*
- This disorder involves a **preoccupation with perceived flaws in physical appearance**, which are often minor or not observable to others.
- The patient's symptoms of pseudoseizures and thrashing are **neurological manifestations** and do not align with concerns about physical appearance.
*Somatic symptom disorder*
- This diagnosis involves **one or more somatic symptoms that are distressing or result in significant disruption** of daily life, with **excessive thoughts, feelings, or behaviors** related to the somatic symptoms.
- While somatic symptom disorder can include neurological complaints, the acute presentation of pseudoseizures with specific neurological signs (eye closure resistance, arrhythmic movements) directly linked to recent severe trauma makes functional neurological symptom disorder the more precise diagnosis.
*Illness anxiety disorder*
- Characterized by a **preoccupation with having or acquiring a serious illness** based on misinterpretation of bodily symptoms, with minimal or no somatic symptoms present.
- The patient is experiencing active neurological symptoms (pseudoseizures), not health anxiety or unfounded fear of having an illness.
*Somatic symptom disorder with predominant pain*
- In this specifier, the primary symptom is **pain**, which is distressing and associated with excessive thoughts, feelings, or behaviors related to the pain.
- The patient's primary presentation is **pseudoseizures with motor symptoms**, not pain, making this diagnosis inconsistent with her clinical picture.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
