A 55-year-old male was picked up by police in the public library for harassing the patrons and for public nudity. He displayed disorganized speech and believed that the books were the only way to his salvation. Identification was found on the man and his sister was called to provide more information. She described that he recently lost his house and got divorced within the same week although he seemed fine three days ago. The man was sedated with diazepam and chlorpromazine because he was very agitated. His labs returned normal and within three days, he appeared normal, had no recollection of the past several days, and discussed in detail how stressful the past two weeks of his life were. He was discharged the next day. Which of the following is the most appropriate diagnosis for this male?
Q2
A 29-year-old woman is brought to the physician by her father because of a change in her behavior over the past 8 months. The father says that his daughter has become increasingly withdrawn; she has not answered any phone calls or visited her family and friends. The patient says that she has to stay at home because a foreign intelligence service is monitoring her. She thinks that they are using a magnetic field to read her mind. Mental status exam shows disjointed and perseverative thinking. She is anxious and has a flat affect. Which of the following is the most likely diagnosis?
Q3
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 His wife reports that the patient has become withdrawn and at times depressed for the past 3 months.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?
Q4
A 26-year-old woman is brought to the emergency department by her husband due to her disturbing behavior over the past 24 hours. Her husband says that he has noticed his wife talking to herself and staying in a corner of a room throughout the day without eating or drinking anything. She gave birth to their son 2 weeks ago but has not seen or even acknowledged her baby’s presence ever since he was born. He says that he didn’t think much of it because she seemed overwhelmed during her pregnancy and he considered that she was probably unable to cope with being a new mother; however, last night, he says, his wife told him that their child was the son of the devil and they ought to get rid of him as soon as possible. Which of the following describes this patient’s abnormal reaction to her child?
Q5
A 25-year-old man presents to his primary care physician with a chief complaint of "failing health." He states that he typically can converse with animals via telepathy, but is having trouble right now due to the weather. He has begun taking an assortment of Peruvian herbs to little avail. Otherwise he is not currently taking any medications. The patient lives alone and works in a health food store. He states that his symptoms have persisted for the past eight months. On physical exam, you note a healthy young man who is dressed in an all burlap ensemble. When you are obtaining the patient's medical history there are several times he is attempting to telepathically connect with the animals in the vicinity. Which of the following is the most likely diagnosis?
Q6
A 20-year-old male is involuntarily admitted to the county psychiatric unit for psychotic behavior over the past three months. The patient's mother explained to the psychiatrist that her son had withdrawn from family and friends, appeared to have no emotions, and had delusions that he was working for the CIA. When he spoke, his sentences did not always seem to have any connection with each other. The mother finally decided to admit her son after he began stating that he "revealed too much information to her and was going to be eliminated by the CIA." Which of the following diagnoses best fits this patient's presentation?
Q7
A 50-year-old woman with a history of schizophrenia is being admitted to a locked inpatient psychiatry unit after discontinuing her medication. She was found wandering the streets, screaming in the air. According to her medical records, she was diagnosed with schizophrenia in her early 20s. She was initially living with her family but because of issues with medication compliance, substance abuse, and interpersonal problems, she has been homeless for the past 10 years. In addition to schizophrenia, her complicated medical history includes hypertension, diabetes, hypothyroidism, hyperlipidemia, morbid obesity, and substance abuse. She is not taking any medications at this time. At the hospital, her heart rate is 90/min, respiratory rate is 17/min, blood pressure is 110/65 mm Hg, and temperature is 37.0°C (98.6°F). She appears nervous and dirty. The clothes she was wearing are tattered and smell of urine and feces. She is too agitated and disruptive to perform a proper physical exam. Which of the following medications would be the most appropriate treatment for schizophrenia in this patient?
Q8
A 27-year-old man is brought to the emergency department from a homeless shelter because of bizarre behavior. He avoids contact with others and has complained to the supervising staff that he thinks people are reading his mind. Three days ago, he unplugged every electrical appliance on his floor of the shelter because he believed they were being used to transmit messages about him to others. The patient has schizophrenia and has been prescribed risperidone but has been unable to comply with his medications because of his unstable living situation. He is disheveled and malodorous. His thought process is disorganized and he does not make eye contact. Which of the following is the most appropriate long-term pharmacotherapy?
Q9
A 4-year-old boy is brought to the physician by his parents because of concerns about his behavior during the past year. His parents report that he often fails to answer when they call him and has regular unprovoked episodes of crying and screaming. At kindergarten, he can follow and participate in group activities, but does not follow his teacher's instructions when these are given to him directly. He is otherwise cheerful and maintains eye contact when spoken to but does not respond when engaged in play. He gets along well with friends and family. He started walking at the age of 11 months and can speak in two-to-three-word phrases. He often mispronounces words. Which of the following is the most likely diagnosis?
Q10
A 31-year-old man comes to the emergency department because of chest pain for the last 3 hours. He describes the pain as a sharp, substernal chest pain that radiates to the right shoulder; he says “Please help me. I'm having a heart attack.” He has been admitted to the hospital twice over the past week for evaluation of shortness of breath and abdominal pain but left the hospital the following day on both occasions. The patient does not smoke or drink alcohol but is a known user of intravenous heroin. He has been living in a homeless shelter for the past 2 weeks after being evicted from his apartment for failure to pay rent. His temperature is 37.6°C (99.6°F), pulse is 90/min, respirations are 18/min, and blood pressure is 125/85 mm Hg. The patient seems anxious and refuses a physical examination of his chest. His cardiac troponin I concentration is 0.01 ng/mL (N = 0–0.01). An ECG shows a normal sinus rhythm with nonspecific ST-T wave changes. While the physician is planning to discharge the patient, the patient reports numbness in his arm and insists on being admitted to the ward. On the following day, the patient leaves the hospital without informing the physician or the nursing staff. Which of the following is the most likely diagnosis?
Brief psychotic disorder US Medical PG Practice Questions and MCQs
Question 1: A 55-year-old male was picked up by police in the public library for harassing the patrons and for public nudity. He displayed disorganized speech and believed that the books were the only way to his salvation. Identification was found on the man and his sister was called to provide more information. She described that he recently lost his house and got divorced within the same week although he seemed fine three days ago. The man was sedated with diazepam and chlorpromazine because he was very agitated. His labs returned normal and within three days, he appeared normal, had no recollection of the past several days, and discussed in detail how stressful the past two weeks of his life were. He was discharged the next day. Which of the following is the most appropriate diagnosis for this male?
A. Brief psychotic disorder (Correct Answer)
B. Schizotypal personality disorder
C. Schizophreniform disorder
D. Schizophrenia
E. Schizoid personality disorder
Explanation: ***Brief psychotic disorder***
- This patient exhibited characteristic symptoms such as **sudden onset of psychotic symptoms** (disorganized speech, delusions, public nudity) that lasted **less than one month** and were preceded by a **severe psychosocial stressor** (loss of house, divorce).
- The **full return to premorbid functioning** and lack of recollection after the episode further support brief psychotic disorder, distinguishing it from other chronic psychotic disorders.
*Schizotypal personality disorder*
- Characterized by a pervasive pattern of **social and interpersonal deficits**, cognitive or perceptual distortions, and eccentricities of behavior, which are usually **long-standing** and not episodic.
- While there may be odd beliefs or magical thinking, the dramatic and time-limited psychotic episode in the scenario is not typical of schizotypal personality disorder.
*Schizophreniform disorder*
- This disorder is diagnosed when psychotic symptoms (like those seen in schizophrenia) are present for **at least one month but less than six months**.
- Although the patient presented with psychotic symptoms, their rapid resolution within three days makes a diagnosis of schizophreniform disorder unlikely.
*Schizophrenia*
- Requires continuous signs of disturbance for **at least six months**, including at least one month of active-phase symptoms, along with significant impairment in social or occupational functioning.
- The rapid resolution of symptoms and return to baseline within days in this case immediately rules out schizophrenia, which is a chronic condition.
*Schizoid personality disorder*
- Characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of expression of emotions in interpersonal settings.
- This disorder does not involve psychotic symptoms, disorganized speech, or delusions of the intensity described in the patient's presentation.
Question 2: A 29-year-old woman is brought to the physician by her father because of a change in her behavior over the past 8 months. The father says that his daughter has become increasingly withdrawn; she has not answered any phone calls or visited her family and friends. The patient says that she has to stay at home because a foreign intelligence service is monitoring her. She thinks that they are using a magnetic field to read her mind. Mental status exam shows disjointed and perseverative thinking. She is anxious and has a flat affect. Which of the following is the most likely diagnosis?
A. Delusional disorder
B. Schizophrenia (Correct Answer)
C. Paranoid personality disorder
D. Schizophreniform disorder
E. Schizoid personality disorder
Explanation: ***Schizophrenia***
- The patient's presentation with **delusions of persecution and thought broadcasting**, accompanied by **disjointed, perseverative thinking**, and **flat affect** for 8 months, is highly indicative of schizophrenia.
- Schizophrenia is characterized by a combination of positive symptoms (delusions, hallucinations, disorganized speech), negative symptoms (flat affect, social withdrawal), and cognitive symptoms (disorganized thinking) lasting for at least 6 months.
*Delusional disorder*
- Delusional disorder is characterized by the presence of **non-bizarre delusions for at least 1 month** without other significant psychotic symptoms or marked impairment in functioning.
- The patient's symptoms include **disorganized thinking and flat affect**, which are not typical of delusional disorder and suggest a broader psychotic illness.
*Paranoid personality disorder*
- Characterized by a pervasive distrust and suspicion of others, where their motives are interpreted as malevolent, but **without the presence of frank delusions or other psychotic symptoms**.
- The patient is experiencing **fixed, false beliefs (delusions)** involving mind reading and foreign intelligence, which goes beyond the pervasive distrust seen in paranoid personality disorder.
*Schizophreniform disorder*
- Schizophreniform disorder presents with symptoms identical to schizophrenia, but the **duration is between 1 and 6 months**.
- Since the patient's symptoms have been present for **8 months**, it exceeds the diagnostic criteria for schizophreniform disorder, making schizophrenia a more likely diagnosis.
*Schizoid personality disorder*
- Characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of expression of emotions in interpersonal settings.
- While the patient exhibits social withdrawal, this condition does **not involve delusions, disorganized thinking, or other psychotic features**.
Question 3: 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 4: A 26-year-old woman is brought to the emergency department by her husband due to her disturbing behavior over the past 24 hours. Her husband says that he has noticed his wife talking to herself and staying in a corner of a room throughout the day without eating or drinking anything. She gave birth to their son 2 weeks ago but has not seen or even acknowledged her baby’s presence ever since he was born. He says that he didn’t think much of it because she seemed overwhelmed during her pregnancy and he considered that she was probably unable to cope with being a new mother; however, last night, he says, his wife told him that their child was the son of the devil and they ought to get rid of him as soon as possible. Which of the following describes this patient’s abnormal reaction to her child?
A. Brief psychotic disorder
B. Schizoaffective disorder
C. Postpartum psychosis (Correct Answer)
D. Major depressive disorder
E. Postpartum blues
Explanation: **Postpartum psychosis**
- This patient exhibits **psychotic symptoms** (delusions about the child, hallucinations like talking to herself) and **severe disorganization** (staying in a corner, not eating/drinking, neglecting her baby) within two weeks postpartum.
- This severe and acute onset of psychosis in the **postpartum period** is characteristic of postpartum psychosis, which is a medical emergency requiring immediate intervention.
*Brief psychotic disorder*
- While it involves psychotic symptoms of acute onset and short duration (less than one month), this diagnosis typically applies when symptoms are not directly attributable to a specific precipitating factor like childbirth.
- The clear temporal association with childbirth in this case makes postpartum psychosis a more specific and accurate diagnosis.
*Schizoaffective disorder*
- This disorder typically involves a combination of **mood symptoms** (depressive or manic) and **psychotic symptoms**, where psychotic symptoms are present for at least two weeks in the absence of a major mood episode.
- The sudden onset and direct link to the postpartum period distinguish this case from schizoaffective disorder, which usually has a more chronic or episodic course.
*Major depressive disorder*
- Although the patient shows signs of severe withdrawal and neglect, the presence of **frank psychotic symptoms** (delusions about the child being the "son of the devil") goes beyond the typical presentation of major depressive disorder, even with psychotic features.
- While depression can coexist, the predominant and acute psychotic features point more directly to postpartum psychosis.
*Postpartum blues*
- Postpartum blues are **mild and transient mood disturbances** (tearfulness, irritability, anxiety) occurring in the first few days to two weeks postpartum, typically resolving on their own.
- The patient's symptoms are far more severe, involving **psychotic delusions and severe functional impairment**, making postpartum blues an inadequate diagnosis.
Question 5: A 25-year-old man presents to his primary care physician with a chief complaint of "failing health." He states that he typically can converse with animals via telepathy, but is having trouble right now due to the weather. He has begun taking an assortment of Peruvian herbs to little avail. Otherwise he is not currently taking any medications. The patient lives alone and works in a health food store. He states that his symptoms have persisted for the past eight months. On physical exam, you note a healthy young man who is dressed in an all burlap ensemble. When you are obtaining the patient's medical history there are several times he is attempting to telepathically connect with the animals in the vicinity. Which of the following is the most likely diagnosis?
A. Brief psychotic disorder
B. Schizoid personality disorder
C. Schizophrenia
D. Schizophreniform disorder
E. Schizotypal personality disorder (Correct Answer)
Explanation: ***Schizotypal personality disorder***
- This patient exhibits **eccentric behavior**, **magical thinking** (telepathy with animals), and **odd perceptions** that are characteristic of schizotypal personality disorder.
- The duration of symptoms (eight months) is consistent with a personality disorder, as these patterns are pervasive and long-standing.
*Brief psychotic disorder*
- Symptoms of brief psychotic disorder must last for **at least one day but less than one month**, with eventual full return to premorbid functioning.
- This patient's symptoms have persisted for eight months, making this diagnosis unlikely.
*Schizoid personality disorder*
- Characterized by **detachment from social relationships** and a restricted range of emotional expression, with no interest in social interactions.
- While this patient lives alone, his primary symptoms are **peculiar thoughts and behaviors**, not primarily a lack of social interest or flattened affect.
*Schizophrenia*
- Requires continuous signs of disturbance for **at least six months**, including at least one month of **active-phase symptoms** (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms).
- While this patient has some peculiar symptoms, they do not meet the full criteria for schizophrenia, lacking clear-cut delusions or hallucinations and having a more pervasive pattern of oddness.
*Schizophreniform disorder*
- Involves symptoms similar to schizophrenia but with a duration of **at least one month but less than six months**.
- This patient's symptoms have lasted eight months, exceeding the maximum duration for schizophreniform disorder.
Question 6: A 20-year-old male is involuntarily admitted to the county psychiatric unit for psychotic behavior over the past three months. The patient's mother explained to the psychiatrist that her son had withdrawn from family and friends, appeared to have no emotions, and had delusions that he was working for the CIA. When he spoke, his sentences did not always seem to have any connection with each other. The mother finally decided to admit her son after he began stating that he "revealed too much information to her and was going to be eliminated by the CIA." Which of the following diagnoses best fits this patient's presentation?
A. Schizophrenia
B. Brief psychotic disorder
C. Schizophreniform disorder (Correct Answer)
D. Schizoid personality disorder
E. Schizotypal personality disorder
Explanation: ***Schizophreniform disorder***
- The patient exhibits classic symptoms of **psychosis**, including delusions, disorganized speech, flat affect, and social withdrawal, which are characteristic of schizophrenia spectrum disorders.
- The duration of symptoms (3 months) fits the criteria for **schizophreniform disorder**, which is when psychotic symptoms last between 1 month and 6 months.
*Schizophrenia*
- Schizophrenia requires symptoms to be present for at least **6 months**, including at least 1 month of active-phase symptoms.
- While this patient's symptoms are consistent with psychotic disorder, the **duration criteria** for schizophrenia have not yet been met.
*Brief psychotic disorder*
- Brief psychotic disorder is characterized by symptoms lasting from **1 day to 1 month**, with eventual full return to premorbid functioning.
- The patient's symptoms have persisted for **3 months**, exceeding the maximum duration for brief psychotic disorder.
*Schizoid personality disorder*
- This disorder is characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression.
- While the patient exhibits social withdrawal, the presence of **delusions, disorganized speech, and flat affect** indicates a psychotic disorder, not merely a personality disorder.
*Schizotypal personality disorder*
- Schizotypal personality disorder involves pervasive social and interpersonal deficits with **cognitive or perceptual distortions** and eccentric behaviors.
- While it can involve odd beliefs, it does not typically include the prominent, fixed, and systematized **delusions and disorganized speech** seen in this patient's presentation.
Question 7: A 50-year-old woman with a history of schizophrenia is being admitted to a locked inpatient psychiatry unit after discontinuing her medication. She was found wandering the streets, screaming in the air. According to her medical records, she was diagnosed with schizophrenia in her early 20s. She was initially living with her family but because of issues with medication compliance, substance abuse, and interpersonal problems, she has been homeless for the past 10 years. In addition to schizophrenia, her complicated medical history includes hypertension, diabetes, hypothyroidism, hyperlipidemia, morbid obesity, and substance abuse. She is not taking any medications at this time. At the hospital, her heart rate is 90/min, respiratory rate is 17/min, blood pressure is 110/65 mm Hg, and temperature is 37.0°C (98.6°F). She appears nervous and dirty. The clothes she was wearing are tattered and smell of urine and feces. She is too agitated and disruptive to perform a proper physical exam. Which of the following medications would be the most appropriate treatment for schizophrenia in this patient?
A. Olanzapine (Correct Answer)
B. Clozapine
C. Risperidone
D. Haloperidol
E. Quetiapine
Explanation: ***Olanzapine***
- This patient presents with **acute agitation** in the context of **non-compliance** and chronic schizophrenia, making a rapidly acting, sedating antipsychotic beneficial. **Olanzapine** has a significant sedating effect and can be administered via intramuscular (IM) injection for rapid tranquilization, which is crucial given her current level of agitation and the inability to perform a proper physical exam.
- **Olanzapine IM** is FDA-approved for acute agitation in schizophrenia and has rapid onset (15-30 minutes), making it highly effective for immediate stabilization.
- **Important consideration**: While olanzapine has significant **metabolic side effects** (weight gain, hyperglycemia, dyslipidemia) that are concerning given her diabetes, morbid obesity, and hyperlipidemia, the **immediate priority** in this acute presentation is to stabilize her psychiatric symptoms and agitation. Once stabilized, transition to a medication with better metabolic profile should be considered for long-term management.
*Haloperidol*
- **Haloperidol** is a first-generation antipsychotic commonly used for acute agitation due to its rapid effect and IM availability. It has **minimal metabolic side effects**, which would be advantageous given her comorbidities.
- However, it carries a **high risk of extrapyramidal symptoms (EPS)**, including acute dystonia, akathisia, and parkinsonism, which can be distressing and worsen agitation. It also has risk of **QTc prolongation**, particularly with higher doses or IV administration.
- While haloperidol is a reasonable alternative, **olanzapine** provides comparable rapid tranquilization with **greater sedation** and potentially better tolerability in the acute phase, making it preferred for initial stabilization in severely agitated patients.
*Clozapine*
- **Clozapine** is an antipsychotic reserved for **treatment-resistant schizophrenia** (failed trials of at least two other antipsychotics) due to its superior efficacy in refractory cases. However, it carries a significant risk of **agranulocytosis** and requires weekly blood monitoring initially, making it inappropriate for acute agitation in a non-compliant patient.
- Its **slow titration** requirement (to minimize seizure risk) and need for close monitoring make it unsuitable for initial management of acute psychosis and agitation.
*Risperidone*
- **Risperidone** is a commonly used second-generation antipsychotic but is **less sedating** than olanzapine, making it less ideal for severe acute agitation requiring rapid tranquilization.
- While IM risperidone exists (Risperdal Consta), it is a **long-acting depot formulation** designed for maintenance therapy (releases over 2 weeks), not acute agitation management.
- It also carries dose-dependent risk of **extrapyramidal symptoms (EPS)** and **hyperprolactinemia**, which may be problematic.
*Quetiapine*
- **Quetiapine** has significant **sedative properties** due to antihistaminic effects, but it lacks an **immediate-acting IM formulation** for acute agitation (only extended-release oral forms available).
- Its **anticholinergic** and **alpha-adrenergic blocking** effects can lead to **orthostatic hypotension** and **tachycardia**, which could be problematic in an acutely agitated patient requiring rapid intervention.
- While it has a better metabolic profile than olanzapine, the lack of IM formulation for acute use and slower onset make it less suitable for immediate tranquilization compared to IM olanzapine.
Question 8: A 27-year-old man is brought to the emergency department from a homeless shelter because of bizarre behavior. He avoids contact with others and has complained to the supervising staff that he thinks people are reading his mind. Three days ago, he unplugged every electrical appliance on his floor of the shelter because he believed they were being used to transmit messages about him to others. The patient has schizophrenia and has been prescribed risperidone but has been unable to comply with his medications because of his unstable living situation. He is disheveled and malodorous. His thought process is disorganized and he does not make eye contact. Which of the following is the most appropriate long-term pharmacotherapy?
A. Intravenous propranolol
B. Intramuscular benztropine
C. Oral haloperidol
D. Intramuscular risperidone (Correct Answer)
E. Oral diazepam
Explanation: ***Intramuscular risperidone***
- Given the patient's **non-compliance** due to an unstable living situation, a **long-acting injectable antipsychotic** like intramuscular risperidone is the most appropriate choice for long-term management. This ensures consistent medication delivery regardless of daily adherence.
- This medication directly addresses the **positive symptoms of schizophrenia** (paranoia, disorganized thought) that are evident in the patient's bizarre behavior and delusional beliefs.
*Intravenous propranolol*
- Propranolol is a **beta-blocker** used to treat anxiety, hypertension, and tremors, but it is **not an antipsychotic** and does not address the core symptoms of schizophrenia.
- It could potentially be used for symptom control like akathisia if present, but not as primary long-term pharmacotherapy for psychosis.
*Intramuscular benztropine*
- Benztropine is an **anticholinergic medication** primarily used to treat **extrapyramidal symptoms (EPS)** induced by antipsychotics (e.g., dystonia, parkinsonism).
- It does not have antipsychotic effects and would not treat the patient's psychotic symptoms.
*Oral haloperidol*
- While haloperidol is an **effective antipsychotic**, it is an **oral formulation**. Given the patient's history of **non-compliance** with oral medication (risperidone), switching to another oral antipsychotic, even one as potent as haloperidol, is unlikely to solve the adherence issue, especially in an unstable living situation.
- Long-term management requires a strategy that overcomes the compliance barrier.
*Oral diazepam*
- Diazepam is a **benzodiazepine** primarily used for anxiety, sedation, and seizure control.
- It has **no antipsychotic properties** and would not treat the underlying psychotic symptoms of schizophrenia. It would only provide temporary sedation.
Question 9: A 4-year-old boy is brought to the physician by his parents because of concerns about his behavior during the past year. His parents report that he often fails to answer when they call him and has regular unprovoked episodes of crying and screaming. At kindergarten, he can follow and participate in group activities, but does not follow his teacher's instructions when these are given to him directly. He is otherwise cheerful and maintains eye contact when spoken to but does not respond when engaged in play. He gets along well with friends and family. He started walking at the age of 11 months and can speak in two-to-three-word phrases. He often mispronounces words. Which of the following is the most likely diagnosis?
A. Selective mutism
B. Hearing impairment (Correct Answer)
C. Conduct disorder
D. Specific-learning disorder
E. Autistic spectrum disorder
Explanation: ***Hearing impairment***
- The child's inconsistent response to being called, failure to follow direct instructions, and unprovoked crying and screaming, despite maintaining eye contact and having normal social interactions, are all suggestive of a **hearing impairment**.
- His delayed and unusual speech patterns (two-to-three-word phrases, mispronouncing words) for his age further points to **auditory processing difficulties** due to hearing loss.
*Selective mutism*
- This condition involves a consistent failure to speak in specific social situations where speaking is expected, despite speaking in other situations. The child's issue is with comprehending and responding to speech, not with speaking itself.
- The behavior observed (not responding to calls or direct instructions) is more indicative of an inability to hear rather than a choice not to speak.
*Conduct disorder*
- Conduct disorder is characterized by a persistent pattern of behavior that violates the rights of others and major societal norms appropriate for the individual's age.
- The child's symptoms do not include aggression, destruction of property, deceitfulness, or serious rule violations and he gets along well with friends and family.
*Specific-learning disorder*
- A specific learning disorder involves difficulties with academic skills, despite normal intelligence. While he has speech difficulties, he can participate in group activities, and there is no information about his academic performance.
- The primary concern here is his inability to respond to auditory input, which precedes and likely causes any potential learning difficulties rather than being a learning disorder itself.
*Autistic 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, interests, or activities.
- This child maintains eye contact, is cheerful, gets along well with friends and family, and can participate in group activities, which argues against significant **social communication deficits** typical of autism.
Question 10: A 31-year-old man comes to the emergency department because of chest pain for the last 3 hours. He describes the pain as a sharp, substernal chest pain that radiates to the right shoulder; he says “Please help me. I'm having a heart attack.” He has been admitted to the hospital twice over the past week for evaluation of shortness of breath and abdominal pain but left the hospital the following day on both occasions. The patient does not smoke or drink alcohol but is a known user of intravenous heroin. He has been living in a homeless shelter for the past 2 weeks after being evicted from his apartment for failure to pay rent. His temperature is 37.6°C (99.6°F), pulse is 90/min, respirations are 18/min, and blood pressure is 125/85 mm Hg. The patient seems anxious and refuses a physical examination of his chest. His cardiac troponin I concentration is 0.01 ng/mL (N = 0–0.01). An ECG shows a normal sinus rhythm with nonspecific ST-T wave changes. While the physician is planning to discharge the patient, the patient reports numbness in his arm and insists on being admitted to the ward. On the following day, the patient leaves the hospital without informing the physician or the nursing staff. Which of the following is the most likely diagnosis?
A. Malingering (Correct Answer)
B. Factitious disorder
C. Somatic symptom disorder
D. Conversion disorder
E. Illness anxiety disorder
Explanation: ***Malingering***
- The patient exhibits several signs of **malingering**, including the claim of severe symptoms ("Please help me. I'm having a heart attack."), inconsistent presentation (refusing physical exam, insisting on admission after normal findings, then leaving AMA), and a clear external incentive (access to shelter, food, or drugs, as suggested by his homelessness and IV drug use).
- His normal vital signs, **negative troponin**, and nonspecific ECG changes despite dramatized symptoms further support that his complaints are not genuinely medical. Additionally, his repeated hospital visits and abrupt departure suggest a pattern of utilizing healthcare for secondary gain rather than actual illness.
*Factitious disorder*
- In **factitious disorder**, individuals *intentionally produce or feign* symptoms but lack a clear external incentive for their behavior, driven instead by an internal psychological need to assume the sick role or gain attention.
- This patient's history of homelessness and IV drug use suggests a strong **external incentive** (e.g., shelter, food, access to drugs), making malingering a more likely diagnosis.
*Somatic symptom disorder*
- **Somatic symptom disorder** involves genuine distress and preoccupation with physical symptoms, but these symptoms are *not intentionally produced or feigned*. The patient believes they are truly ill.
- This patient's behavior—dramatizing symptoms, refusing examination, and leaving quickly—suggests an **intentional deception** rather than a deeply held conviction of illness without an observable cause.
*Conversion disorder*
- **Conversion disorder** (functional neurological symptom disorder) involves neurological symptoms (e.g., numbness, paralysis, blindness) that are *not intentionally produced* and are incompatible with known neurological pathways, often precipitated by psychological stress.
- While the patient's report of numbness could be superficial, the overall pattern of behavior, including the seeking of admission and rapid departure, points away from an unconscious manifestation of psychological distress towards **conscious deception for gain.**
*Illness anxiety disorder*
- **Illness anxiety disorder** (formerly hypochondriasis) is characterized by a preoccupation with having or acquiring a serious illness, with minimal or no somatic symptoms, and a high level of anxiety about health despite medical reassurance.
- This patient's behavior is inconsistent with a genuine preoccupation with illness; instead, he appears to be **manipulating the system for immediate benefit**, rather than genuinely fearing a specific disease.
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