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?
Q2
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 The patient's mother explained to the psychiatrist that her son had withdrawn from family and friends, appeared to have no emotions, and had delusions that he was working for the CIA.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?
Q3
A 20-year-old student is referred to his college's student health department because his roommates are concerned about his recent behavior. He rarely leaves his room, has not showered in several days, appears to be praying constantly even though he is not religious, and has not been studying despite previously being an extremely good student. After evaluating this patient, a physician decides to recommend initiation of pharmacological treatment. The patient's family is concerned because they heard that the drug being recommended may be associated with heart problems. Which of the following characteristics is a property of the most likely drug that was prescribed in this case?
Q4
A 24-year-old woman is brought to the hospital by her mother because she has "not been herself" for the past 3 months. The patient says she hears voices in her head. The mother said that when she is talking to her daughter she can’t seem to make out what she is saying; it is as if her thoughts are disorganized. When talking with the patient, you notice a lack of energy and an apathetic affect. Which of the following is the most likely diagnosis for this patient?
Q5
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?
Q6
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?
Q7
A 27-year-old woman is brought to the office at the insistence of her fiancé to be evaluated for auditory hallucinations for the past 8 months. The patient’s fiancé tells the physician that the patient often mentions that she can hear her own thoughts speaking aloud to her. The hallucinations have occurred intermittently for at least 1-month periods. Past medical history is significant for hypertension. Her medications include lisinopril and a daily multivitamin both of which she frequently neglects. She lost her security job 7 months ago after failing to report to work on time. The patient’s vital signs include: blood pressure 132/82 mm Hg; pulse 72/min; respiratory rate 18/min, and temperature 36.7°C (98.1°F). On physical examination, the patient has a flat affect and her focus fluctuates from the window to the door. She is disheveled with a foul smell. She has difficulty focusing on the discussion and does not quite understand what is happening around her. A urine toxicology screen is negative. Which of the following is the correct diagnosis for this patient?
Q8
A 25-year-old woman is brought to a psychiatrist's office by her husband who states that he is worried about her recent behavior, as it has become more violent. The patient's husband states that his family drove across the country to visit them and that his wife 'threatened his parents with a knife' at dinner last night. Police had to be called to calm her down. He states that she has been acting 'really crazy' for the last 9 months, and the initial behavior that caused him alarm was her admission that his deceased sister was talking to her through a decorative piece of ceramic art in the living room. Initially, he thought she was joking, but soon realized her complaints of 'hearing ghosts' talking to her throughout the house were persisting and 'getting worse'. Over the past 9 months, she has experienced multiple periods of profound sadness, with persistent insomnia and an unintentional weight loss of 12 pounds over several months. She has been complaining of feeling 'worthless' and has had markedly diminished interest in activities for much of this time period. Her general hygiene has also suffered from her recent lack of motivation and she insists that the 'ghosts' are asking her to kill as many people as she can so they won't be alone in the house. Her husband is extremely concerned that she may harm herself or someone else. He states that she currently does not take any medications or illicit drugs as far as he knows. She does not smoke or drink alcohol. The patient herself does not make eye contact or want to speak to the psychiatrist, allowing her husband to speak on her behalf. Which of the following is the most likely diagnosis in this patient?
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?
Schizophreniform disorder US Medical PG Practice Questions and MCQs
Question 1: 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 2: 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 3: A 20-year-old student is referred to his college's student health department because his roommates are concerned about his recent behavior. He rarely leaves his room, has not showered in several days, appears to be praying constantly even though he is not religious, and has not been studying despite previously being an extremely good student. After evaluating this patient, a physician decides to recommend initiation of pharmacological treatment. The patient's family is concerned because they heard that the drug being recommended may be associated with heart problems. Which of the following characteristics is a property of the most likely drug that was prescribed in this case?
A. May cause weight gain and metabolic changes
B. Lower risk of extrapyramidal symptoms
C. High affinity for serotonin 5-HT2A receptors
D. Prolongs the QT interval (Correct Answer)
E. Generally less sedating than older antipsychotics
Explanation: ***Prolongs the QT interval***
- The patient presents with **first-episode psychosis** (social withdrawal, poor hygiene, bizarre behavior, academic decline in a previously high-functioning young adult)
- The family's specific concern about **"heart problems"** is the key clue pointing to **QT interval prolongation**
- Among antipsychotics used for first-episode psychosis, **ziprasidone** is most notably associated with QT prolongation and carries an FDA warning about this cardiac effect
- While other antipsychotics may also prolong QT to varying degrees, ziprasidone's association with this adverse effect is well-established and would prompt specific family counseling about cardiac risks
- QT prolongation increases risk of **torsades de pointes**, a potentially fatal arrhythmia
*May cause weight gain and metabolic changes*
- **Weight gain and metabolic syndrome** (hyperglycemia, dyslipidemia) are common adverse effects of many **atypical antipsychotics**, particularly olanzapine and clozapine
- While these are serious long-term concerns, they would typically be described as "weight" or "diabetes" problems rather than acute "heart problems"
- This is not the distinguishing feature being emphasized by the family's concern
*Lower risk of extrapyramidal symptoms*
- **Lower EPS risk** is a characteristic feature of **atypical (second-generation) antipsychotics** compared to typical (first-generation) agents
- This is actually a therapeutic advantage and would not be a concern for the family
- This property applies to most atypical antipsychotics, not specifically to the one causing family concern about cardiac effects
*High affinity for serotonin 5-HT2A receptors*
- **5-HT2A receptor antagonism** is a defining pharmacological property of **atypical antipsychotics** that contributes to their lower EPS risk and efficacy for negative symptoms
- This mechanism applies broadly to the atypical antipsychotic class
- It does not explain the specific family concern about "heart problems"
*Generally less sedating than older antipsychotics*
- Sedation profiles vary widely among antipsychotics; some atypicals (quetiapine) are quite sedating while others (aripiprazole, ziprasidone) are less so
- Sedation is not typically characterized as a "heart problem"
- This does not address the cardiac safety concern highlighted in the question
Question 4: A 24-year-old woman is brought to the hospital by her mother because she has "not been herself" for the past 3 months. The patient says she hears voices in her head. The mother said that when she is talking to her daughter she can’t seem to make out what she is saying; it is as if her thoughts are disorganized. When talking with the patient, you notice a lack of energy and an apathetic affect. Which of the following is the most likely diagnosis for this patient?
A. Major depressive disorder
B. Schizophrenia
C. Brief psychotic disorder
D. Schizotypal disorder
E. Schizophreniform disorder (Correct Answer)
Explanation: ***Schizophreniform disorder***
- The patient exhibits core **psychotic symptoms** (hearing voices, disorganized thoughts) for a duration of **3 months**, which is characteristic of schizophreniform disorder (symptoms lasting **1 to 6 months**).
- Her **lack of energy** and **apathetic affect** align with the negative symptoms commonly seen in psychotic disorders.
*Major depressive disorder*
- While **lack of energy** and **apathetic affect** can be present, the prominent **hallucinations** (hearing voices) and **disorganized thoughts** are not primary features of major depressive disorder.
- A diagnosis of depression alone would not fully account for her psychotic symptoms.
*Schizophrenia*
- Schizophrenia requires symptoms to be present for **at least 6 months**, including at least one month of **active phase symptoms**. This patient's symptoms have only been present for 3 months.
- While the symptoms are consistent with schizophrenia, the **duration criterion** has not yet been met.
*Brief psychotic disorder*
- Brief psychotic disorder is characterized by psychotic symptoms lasting **less than 1 month**. This patient's symptoms have been ongoing for 3 months.
- The chronicity of symptoms makes this diagnosis unlikely.
*Schizotypal disorder*
- Schizotypal disorder is a **personality disorder** characterized by peculiar thoughts and behaviors, but typically **without overt psychotic episodes** or pronounced disorganized speech/hallucinations as described.
- While there may be odd beliefs or ideas of reference, the clear **auditory hallucinations** and **thought disorder** in this case point to a more severe psychotic condition.
Question 5: 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 6: 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 7: A 27-year-old woman is brought to the office at the insistence of her fiancé to be evaluated for auditory hallucinations for the past 8 months. The patient’s fiancé tells the physician that the patient often mentions that she can hear her own thoughts speaking aloud to her. The hallucinations have occurred intermittently for at least 1-month periods. Past medical history is significant for hypertension. Her medications include lisinopril and a daily multivitamin both of which she frequently neglects. She lost her security job 7 months ago after failing to report to work on time. The patient’s vital signs include: blood pressure 132/82 mm Hg; pulse 72/min; respiratory rate 18/min, and temperature 36.7°C (98.1°F). On physical examination, the patient has a flat affect and her focus fluctuates from the window to the door. She is disheveled with a foul smell. She has difficulty focusing on the discussion and does not quite understand what is happening around her. A urine toxicology screen is negative. Which of the following is the correct diagnosis for this patient?
A. Schizoaffective disorder
B. Schizophrenia (Correct Answer)
C. Schizoid personality disorder
D. Schizophreniform disorder
E. Schizotypal personality disorder
Explanation: ***Schizophrenia***
- The patient exhibits core symptoms of schizophrenia, including **auditory hallucinations** (hearing thoughts speaking aloud), **disorganized thinking** (difficulty focusing, fluctuating focus), and **negative symptoms** (flat affect, disheveled, foul smell, loss of job due to poor function). These symptoms have been present for **at least 6 months** (8 months of hallucinations, 7 months of job loss), which meets the diagnostic criteria.
- The duration of symptoms (over 6 months) differentiates it from schizophreniform disorder, and the absence of prominent mood episodes rules out schizoaffective disorder.
*Schizoaffective disorder*
- This diagnosis requires a **major mood episode** (depressive or manic) concurrent with Criterion A of schizophrenia, along with a period of **at least 2 weeks of delusions or hallucinations in the absence of prominent mood symptoms**.
- While the patient has some signs of distress (lost job, disorganized), a full major mood episode is not described, and the primary symptoms are clearly psychotic.
*Schizoid personality disorder*
- This is characterized by a pervasive pattern of **detachment from social relationships** and a restricted range of emotional expression, often appearing indifferent to praise or criticism.
- The patient's symptoms are primarily psychotic (hallucinations, disorganized thought), not just social withdrawal or emotional flatness. She doesn't necessarily avoid social contact, but her psychosis interferes with it.
*Schizophreniform disorder*
- This disorder presents with symptoms identical to schizophrenia but with a **duration of at least 1 month but less than 6 months**.
- The patient's symptoms, particularly the auditory hallucinations, have been present for 8 months and are therefore outside the timeframe for schizophreniform disorder.
*Schizotypal personality disorder*
- This disorder involves a pervasive pattern of **social and interpersonal deficits** marked by acute discomfort with, and reduced capacity for, close relationships, as well as **cognitive or perceptual distortions** and eccentric behaviors.
- While there may be some odd beliefs or magical thinking, **full-blown psychotic symptoms like prominent auditory hallucinations** (hearing thoughts speaking aloud) are generally not present as consistently or severely as seen in this patient, who meets criteria for a major psychotic disorder.
Question 8: A 25-year-old woman is brought to a psychiatrist's office by her husband who states that he is worried about her recent behavior, as it has become more violent. The patient's husband states that his family drove across the country to visit them and that his wife 'threatened his parents with a knife' at dinner last night. Police had to be called to calm her down. He states that she has been acting 'really crazy' for the last 9 months, and the initial behavior that caused him alarm was her admission that his deceased sister was talking to her through a decorative piece of ceramic art in the living room. Initially, he thought she was joking, but soon realized her complaints of 'hearing ghosts' talking to her throughout the house were persisting and 'getting worse'. Over the past 9 months, she has experienced multiple periods of profound sadness, with persistent insomnia and an unintentional weight loss of 12 pounds over several months. She has been complaining of feeling 'worthless' and has had markedly diminished interest in activities for much of this time period. Her general hygiene has also suffered from her recent lack of motivation and she insists that the 'ghosts' are asking her to kill as many people as she can so they won't be alone in the house. Her husband is extremely concerned that she may harm herself or someone else. He states that she currently does not take any medications or illicit drugs as far as he knows. She does not smoke or drink alcohol. The patient herself does not make eye contact or want to speak to the psychiatrist, allowing her husband to speak on her behalf. Which of the following is the most likely diagnosis in this patient?
A. Schizophreniform disorder
B. Schizophrenia
C. Delusional disorder
D. Schizoaffective disorder (Correct Answer)
E. Brief psychotic disorder
Explanation: ***Schizoaffective disorder***
- This patient exhibits symptoms of both a **major depressive disorder** (multiple periods of profound **sadness**, persistent **insomnia**, **weight loss** over several months, feelings of **worthlessness**, and markedly **diminished interest in activities**) and a **psychotic disorder** (auditory **hallucinations**, command hallucinations, **delusions**, violent behavior).
- The total symptom duration is **9 months**, with **mood symptoms present for the majority of this period**, meeting the key DSM-5 criterion for schizoaffective disorder.
- The patient also demonstrates **psychotic symptoms (hallucinations) that persist throughout**, including periods when mood symptoms may fluctuate, satisfying the requirement for delusions or hallucinations for ≥2 weeks in the absence of a major mood episode.
- The combination of prominent mood episodes concurrent with schizophrenia-spectrum symptoms, with mood symptoms present for the majority of the illness duration, confirms schizoaffective disorder.
*Schizophreniform disorder*
- This disorder involves symptoms characteristic of **schizophrenia** lasting **between 1 and 6 months**.
- The patient's symptoms have been present for **9 months**, exceeding the maximum duration for schizophreniform disorder.
*Schizophrenia*
- Schizophrenia requires persistent psychotic symptoms lasting **at least 6 months**, with at least one month of active-phase symptoms.
- While this patient has psychotic symptoms for 9 months, the **prominent and prolonged depressive symptoms** that are present for the **majority of the illness duration** distinguish this from schizophrenia.
- In schizophrenia, mood symptoms, if present, are **brief relative to the total duration** of the psychotic illness, which is not the case here.
*Delusional disorder*
- Delusional disorder is characterized by **non-bizarre delusions** for at least 1 month, without other prominent psychotic symptoms.
- This patient experiences prominent **auditory hallucinations** ("hearing ghosts," "deceased sister talking to her") and **command hallucinations**, which are not features of delusional disorder.
- The presence of hallucinations rules out this diagnosis.
*Brief psychotic disorder*
- This diagnosis involves sudden onset of psychotic symptoms lasting **more than 1 day but less than 1 month**, with eventual full recovery.
- The patient's symptoms have persisted for **9 months**, far exceeding the duration criterion for brief psychotic disorder.
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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