Childhood Disorders
A 5-year-old boy is brought to the psychiatrist because he has difficulty paying attention in school. He fidgets and squirms and will not stay seated in class. It is noted that at home he talks excessively and has difficulty waiting for his turn. His language and motor skills are appropriate for his age. Which of the following is the most likely diagnosis?
ADHD
Excessive motor activity, usually with intrusive and annoying qualities, poor sustained attention, difficulties inhibiting impulsive behaviors in social situations and on cognitive tasks, and difficulties with peers are the main characteristics of ADHD, combined type. Symptoms must be present in two or more settings (in this case, home and school) and must cause significant impairment.
A 19-year-old man is brought to the physician by his parents after he called them from college, asking to be taken home because it is ‘too dangerous here.’ He reports that he drinks nothing but bottled water because “you never know what people will put in your drink.” He believes that the WiFi signal in his dorm room is sending special messages to him, attempting to control his behavior. His roommate states that for the past 2 months, since around the time those midterms were given, the patient has been increasingly withdrawn and suspicious. What is the most likely diagnosis?
Schizophreniform disorder
Schizophreniform disorder and chronic schizophrenia differ only in the duration of the symptoms and the fact that the impaired social or occupational functioning associated with chronic schizophrenia is not required to diagnose schizophreniform disorder. As with schizophrenia, schizophreniform disorder is characterized by the presence of delusions, hallucinations, disorganized thoughts and speech, and negative symptoms. The total duration of the illness, including prodromal and residual phases, is at least 1 month and less than 6 months. Approximately one-third of patients diagnosed with schizophreniform disorder experience a full recovery, while the rest progress to schizophrenia and schizoaffective disorder.
A 25-year-old man comes to the psychiatrist with a chief complaint of depressed mood for 1 month. His mother, to whom he was very close, died 1 month ago, and since that time he has felt sad and very tearful. He has difficulty concentrating, has lost 3 lb, and is not sleeping soundly through the night. What is the most likely diagnosis?
Uncomplicated bereavement
The loss of a loved one is often accompanied by symptoms reminiscent of major depression, such as sadness, weepiness, insomnia, reduced appetite, and weight loss. When these symptoms do not persist beyond 2 months after the loss, they are considered a normal manifestation of bereavement. A diagnosis of major depressive disorder in these circumstances requires the presence of marked functional impairment, morbid preoccupations with unrealistic guilt or worthlessness, suicidal ideation, marked psychomotor retardation, and psychotic symptoms, on top of the symptoms listed in the first sentence above. A diagnosis of adjustment disorder with depressed mood would not normally be given to someone when the “adjustment” is to the recent death of a loved one—instead, bereavement is the diagnosis given (persistent complex or uncomplicated).
A 34-year-old secretary climbs 12 flights of stairs every day to reach her office because she is terrified by the thought of being trapped in the elevator. She has never had any traumatic event occur in an elevator; nonetheless, she has been terrified of them since childhood. Which of the following is the most likely diagnosis?
Specific phobia
Specific phobias are characterized by an unreasonable or excessive fear of an object, an animal, or a situation (flying, being trapped in close spaces, heights, blood, spiders, etc). Since exposure to the feared situation, animal, or object causes an immediate surge of anxiety, patients carefully avoid the phobic stimuli. The diagnosis of specific phobia requires the presence of reduced functioning and interference with social activities and relationships because of the avoidant behavior, anticipatory anxiety, and distress caused by the exposure to the feared stimulus. In social phobias and performance anxiety, patients fear social interactions (in general or limited to specific situations) and public performance (public speaking, acting, playing an instrument), respectively. In generalized anxiety disorder, the anxiety is more chronic and less intense than in a phobic disorder and is not limited to a specific situation or item.
A 40-year-old woman’s cognitive functions have progressively deteriorated for several years, to the point where she needs nursing home-level care. She is depressed, easily irritated, and prone to aggressive outbursts, a dramatic change from her premorbid personality. She also presents with irregular, purposeless, and asymmetrical movements of her face, limbs, and trunk, which worsen when she is upset and disappear in sleep. Her MRI shows atrophy of the caudal nucleus and the putamen. Which of the following is the most likely diagnosis of this patient?
a. Creutzfeldt-Jakob disease
b. Wilson disease
c. Huntington disease
d. Alzheimer disease
e. Vascular dementia
c. Huntington disease
Huntington disease is a neurodegenerative disorder characterized by choreic movements of the face, limbs, and trunk; progressive dementia; and psychiatric symptoms. Deficits in sustained attention, memory retrieval, procedural memory (ability to acquire new skills), and visuospatial skills are predominant and early manifestations of the disorder. Language skills are usually preserved until the late stages of the disease. Personality changes and mood disturbances, including depression and mania, are frequent and can predate the onset of dementia and movement disorder. Neuroimaging reveals atrophy of the caudate and the putamen.
A 6-year-old boy has been diagnosed with ADHD and started on methylphenidate. About which of the following serious side effects should the child psychiatrist warn the boy’s parents?
a. Appetite suppression & weight loss
b. Cardiac conduction abnormalities
c. Choreiform movements
d. Leukopenia
e. Hepatitis
A. Appetite suppression & weight loss
Common side effects of methylphenidate include loss of appetite and weight, irritability, oversensitivity and crying spells, headaches, and abdominal pain. Insomnia may occur, particularly when this agent is dispensed late in the day. Tics, while a less frequent complication of stimulant treatment, can cause significant impairment. (Whether this is the drug causing tics or the unmasking of a previous tic predisposition is unclear.)
A 40-year-old woman is arrested by the police after she is found crawling through the window of a movie star’s home. She states that the movie star invited her into his home because the two are secretly married and “it just wouldn’t be good for his career if everyone knew.” The movie star denies the two have ever met, but notes that the woman has sent him hundreds of letters over the past 2 years. The woman has never been in trouble before and lives an otherwise isolated and unremarkable life. What is the most likely diagnosis?
Delusional disorder
This patient is suffering from an erotomanic delusion—the delusion of having a special relationship with another person, often someone famous.
A 37-year-old woman comes to the physician with a chief complaint of a depressed mood. The patient states she has anhedonia, anergia, a 10-lb weight loss in the last 3 weeks, and states she “just doesn’t care about anything anymore.” She also admits to suicidal ideation without intent or plan. The patient is started on an SSRI. After 1 week of the medication, no improvement is seen and the dosage is raised to the maximum recommended level. Assuming there is no improvement shown, for how many weeks should this new dosage be maintained before determining that the drug trial is unsuccessful?
4-6 weeks
The most common clinical mistake made when treating a patient with a major depressive disorder is to put the patient on a dose of an antidepressant that is too low, or is used for too short a time. Doses of antidepressants should generally be raised to their maximal doses and kept there for 4 to 6 weeks before a drug trial is considered unsuccessful. However, if a patient is doing well on a low dose of an antidepressant, that dosage should not be raised unless clinical improvement stops before the patient has reached his maximum benefit from the drug.
A 23-year-old woman arrives at the emergency room complaining that, out of the blue, she had been seized by an overwhelming fear associated with shortness of breath and a pounding heart. These symptoms lasted for approximately 20 minutes, and while she was experiencing them, she feared that she was dying or going crazy. The patient has had four similar episodes during the past month, and she has been worrying that they will continue to recur. Which of the following is the most likely diagnosis?
Panic disorder
This patient displays typical symptoms of recurrent panic attacks. Panic attacks can occur under a wide variety of psychiatric and medical conditions. The patient is diagnosed with panic disorder when there are recurrent episodes of panic and there is at least 1 month of persistent concern, worry, or behavioral change associated with the attacks. The attacks are not because of the direct effect of medical illness, medications, or substance abuse and are not better accounted for by another psychiatric disorder. While anxiety can be intense in generalized anxiety disorder, posttraumatic stress disorder, acute psychosis, and illness anxiety disorder, it does not have the typical presentation (ie, a discrete episode or panic attack) described in this question.
A 42-year-old retired professional boxer is brought to the physician by his wife because his memory is “not what it used to be.” She states that she first noticed a small decline in his memory about 15 years after he started boxing (at age 15). However, she notes that his memory has gotten so bad now that she cannot leave him alone in the house. On examination, he is noted to have a moderately severe cognitive impairment. He shows little facial expression and he walks with small, rigid steps. Which of the following is the most likely cause of his disorder?
a. An idiopathic degenerative process
b. Chronic trauma
c. An inborn error of metabolism
d. A familial disorder
e. A vitamin deficiency
b. Chronic trauma
A persisting dementia called chronic traumatic encephalopathy occurs with multiple head traumas, even of minor entity. A classic example is dementia pugilistica, or boxer’s dementia. In this disorder, cognitive decline and memory deficits are characteristically accompanied by parkinsonian symptoms.
A 5-year-old boy shows no interest in other children and ignores adults, other than his parents. He spends hours lining up his toy cars or spinning their wheels but does not use them for “make-believe” play. He rarely uses speech to communicate, and his parents state that he has never done so.
Physical examination indicates that his head is of normal circumference and his gait is normal. What is the most likely diagnosis for this boy?
Autism (ASD)
Autism spectrum disorders are characterized by lack of interest in social interactions, severely impaired verbal and nonverbal communication, stereotyped behaviors, and a very restricted range of interests. Children with these disorders do not involve themselves in imaginative and imitative play and can spend hours lining and spinning things or dismantling toys and putting them together. Patients with obsessive-compulsive disorder may spend hours on repetitive tasks (such as lining up toys) but do not show the difficulties with language and social interaction that this patient displays. Patients with Asperger syndrome show no clinically significant delay in spoken or receptive language development, making this diagnosis unlikely (and in addition, this particular presentation has been subsumed under autism spectrum disorders and is no longer recognized separately in DSM-5).
A 54-year-old man with a chronic mental illness seems to be constantly chewing. He does not wear dentures. His tongue darts in and out of his mouth, and he occasionally smacks his lips. He also grimaces, frowns, and blinks excessively. What disorder does this patient most likely have? What receptor is related?
Tardive dyskinesia (TD), D2 blocking
Tardive dyskinesia (TD) is characterized by involuntary choreoathetoid movements of the face, trunk, and extremities. Tardive dyskinesia is associated with prolonged use of medications that block dopamine receptors, most commonly antipsychotic medications. Typical antipsychotic medications (such as haloperidol, fluphenazine, and loxapine) and, in particular, high-potency drugs carry the highest risk of TD. Atypical antipsychotics are thought to be less likely to cause this disorder.
A 29-year-old man is brought to the hospital because he was found running around on the streets with no shoes on in the middle of winter, screaming to everyone that he was going to be elected president. Upon admission to the hospital, he was stabilized on olanzapine and lithium and then discharged home. Assuming the patient is maintained on the olanzapine and the lithium, which of the following tests should be performed at least once per year?
a. MRI of the brain
b. Liver function tests
c. Creatinine level
d. Rectal examination to look for the presence of blood in the stool
e. Electrocardiogram (ECG)
c. Creatinine level
This patient, likely suffering from bipolar I disorder, most recent episode mania, is being maintained on lithium and an antipsychotic. Patients on lithium, at minimum, should be monitored for the following: plasma lithium level (once every month or two until the patient is stable, and then less frequently if he or she is reliable), thyroid function tests, creatinine, and urinalysis. EKGs are part of the list of optional recommendations for patients on lithium but are generally reserved for patients over the age of 50. There are no standard blood tests or other examinations to monitor the use of olanzapine.
A 28-year-old business executive sees her physician because she is having difficulty in her new position, because it requires her to do frequent public speaking. She states that she is terrified that she will do or say something that will cause her extreme embarrassment. The patient says that when she must speak in public, she becomes extremely anxious and her heart beats uncontrollably. Other than in these performance situations, she does not find herself anxious generally. Based on this clinical picture, which of the following medications is likely to be the best choice for this patient?
a. Fluoxetine daily
b. Propranolol prn
c. Bupropion daily
d. Olanzapine daily
e. Clonazepam prn
b. Propranolol prn
While fluoxetine and clonazepam may both be used effectively in cases of generalized social phobia, this young woman reports feeling extremely anxious only under performance situations. For control of performance anxiety, either beta-adrenergic receptor antagonists (commonly atenolol or propranolol) or relatively short acting benzodiazepines (lorazepam or alprazolam) are the treatments of choice. The antipsychotic olanzapine would be an inappropriate choice in either case of generalized social phobia or social phobia related to performance anxiety.
A 37-year-old alcoholic is brought to the emergency room after he was found unconscious in the street. He is hospitalized for dehydration and pneumonia. While being treated, he becomes acutely confused and agitated. He cannot move his eyes upward or to the right, and he is ataxic. Which of the following is the most likely diagnosis?
a. Alcohol intoxication
b. Korsakoff syndrome
c. Delirium
d. Wernicke encephalopathy
e. Alcohol withdrawal seizures
d. Wernicke encephalopathy
Wernicke’s encephalopathy occurs in nutritionally deficient alcoholics and is because of thiamine deficiency and consequent damage of the thiamine-dependent brain structures, including the mammillary bodies and the dorsomedial nucleus of the thalamus. It presents with mental confusion, ataxia, and sixth-nerve paralysis. Wernicke’s encephalopathy is a medical emergency and can rapidly resolve with immediate supplementation of thiamine. Note that thiamine should be given with MgSO4 before glucose loading. This diagnosis should be considered in any patient brought into the emergency room unresponsive.
The parents of an 8-year-old boy with a normal IQ are concerned because he is a very slow reader and does not appear to understand what he reads. When the boy reads aloud, he misses words and changes the sequence of the letters. They also note that he has problems with spelling, though he is otherwise quite creative in his ability to write stories. On examination, the child displays verbal language defects as well, though primarily he communicates clearly. His hearing and vision are normal and he has no trouble with motor skills. What is the most likely diagnosis for this child?
Specific learning disorder with impairment in reading
Dyslexia (an alternative term for specific learning disorder with impairment in reading) occurs in 3% to 10% of the population. When a reading disorder is caused by a defect in visual or hearing acuity, it is excluded by diagnostic criteria from being a developmental reading disorder. Almost all patients with this problem have spelling difficulties, and nearly all have verbal language defects. Children do not grow out of the disorder by adulthood. It is believed that the most common etiology relates to cortical brain pathology. The child in this question is able to read and attend school without issue; thus, he cannot have an autism spectrum disorder. Dyslexia is a common comorbid finding with those diagnosed with ADHD.
A 24-year-old man with chronic schizophrenia is brought to the emergency room after his parents found him in his bed and were unable to communicate with him. On examination, the man is confused and disoriented. He has severe muscle rigidity and a temperature of 39.4°C (103°F). His blood pressure is elevated, and he has a leukocytosis. What does this patient have? Which of the following is the best first step in the pharmacologic treatment of this man?
Neuroleptic Malignant Syndrome (NMS); Dantrolene or Bromocriptine
The patient has neuroleptic malignant syndrome (NMS), a life-threatening complication of antipsychotic treatment. The symptoms include muscular rigidity and dystonia, akinesia, mutism, obtundation, and agitation. The autonomic symptoms include high fever, sweating, and increased blood pressure and heart rate. Mortality rates are reported to be 10% to 20%. In addition to supportive medical treatment, the most commonly used medications for the condition are dantrolene (Dantrium) followed by bromocriptine (Parlodel), although amantadine is sometimes used. Bromocriptine and amantadine possess direct dopamine receptor agonist effects and may serve to overcome the antipsychotic-induced dopamine receptor blockade. Dantrolene is a direct muscle relaxant.
A 27-year-old woman has been feeling blue for the past 2 weeks. She has little energy and has trouble concentrating. She states that 6 weeks ago she had been feeling very good, with lots of energy and no need for sleep. She says that this pattern has been occurring for at least the past 3 years, though the episodes have never been so severe that she couldn’t work. Which of the following is the most likely diagnosis?
Cyclothymic disorder is characterized by recurrent periods of mild depression alternating with periods of hypomania. This pattern must be present for at least 2 years before the diagnosis can be made. During these 2 years, the symptom-free intervals should not be longer than 2 months. Cyclothymic disorder usually starts during adolescence or early adulthood and tends to have a chronic course. The marked shifts in mood of cyclothymic disorder can be confused with the affective instability of borderline personality disorder or may suggest a substance abuse problem.
A 26-year-old woman comes to the psychiatrist with a 1-month history of severe anxiety. The patient states that 1 month ago she was a “normal, laid-back person.” Since that time she rates her anxiety an 8 on a scale of 1 to 10, and also notes she is afraid to leave the house unless she checks that the door is locked at least five times. Which of the following medical conditions could commonly cause this kind of symptom presentation?
a. Hyperglycemia
b. Crohn disease
c. Hyperparathyroidism
d. Fibromyalgia
e. Mitral valve prolapse
c. Hyperparathyroidism
Medical conditions that can cause anxiety-related symptoms include the endocrinopathies (pheochromocytoma, hyperthyroidism, hypercortisolemic states, and hyperparathyroidism), metabolic problems (hypoxemia, hypercalcemia, and hypoglycemia) and neurologic disorders, including vascular, trauma, and degenerative types. Although mitral valve prolapse and panic attacks have long been associated, the mitral valve prolapse actually causing the panic attacks is not known.
A 65-year-old woman lives alone in a dilapidated house, although her family members have tried in vain to move her to a better dwelling. She wears odd and out-of-fashion clothes and rummages in the garbage cans of her neighbors to look for redeemable cans and bottles. She is very suspicious of her neighbors. She was convinced that her neighbors were plotting against her life for a brief time after she was mugged and thrown onto the pavement by a teenager, but now thinks that this is not the case. She believes in the “power of crystals to protect me” and has them strewn haphazardly throughout her house. What is the most likely diagnosis?
Schizotypal personality disorder
Schizotypal personality disorder, a cluster A disorder, is characterized by acute discomfort in close relationships, cognitive and perceptual distortions, and eccentric behavior beginning in early adulthood and present in a variety of contexts. Individuals with schizoid personality disorder do not present with the magical thinking, oddity, unusual perceptions, and odd appearance typical of schizotypal individuals. In schizophrenia, psychotic symptoms are much more prolonged and severe. Avoidant individuals avoid social interaction out of shyness and fear of rejection and not out of disinterest or suspiciousness. In autistic spectrum disorders, social interactions are more severely impaired and stereotyped behaviors are usually present.
A 12-year-old boy is brought to the psychiatrist because his mother says the boy is driving her “nuts.” She reports that he constantly argues with her and his father, does not follow any of the house rules, and incessantly teases his sister. She says that he is spiteful and vindictive and loses his temper easily. Once he is mad, he stays that way for long periods of time. The mother notes that the boy started this behavior only about 1 year previously. While she states that this behavior started at home, it has now spread to school, where his grades are dropping because he refuses to participate. The patient maintains that none of this is his fault—his parents are simply being unreasonable. He denies feeling depressed and notes that he sleeps well through the night. What is the most likely diagnosis?
oppositional defiant disorder (ODD)
The presence of the symptoms, including being angry, spiteful and vindictive, losing his temper quickly, and deliberately annoying others, for at least 6 months is characteristic of the disease. It is also characteristic that the boy denies that he has a problem, blaming it instead on others. While sometimes the behavior starts outside the home, other times, as in this question, the disorder starts at home and then is carried to school and other arenas. This patient has no history of aggressive behavior toward animals or others and has not been destructive or in trouble with the law, making conduct disorder less likely. He is under the age of 18, the minimum age for which antisocial personality disorder may be diagnosed. He denies mood symptoms and is sleeping well through the night, making early-onset bipolar disorder unlikely. No psychotic symptoms were noted, ruling out schizophrenia.
A 19-year-old woman is brought to the emergency room by her roommate after the patient told her that, “the voices are telling me to kill the teacher.” The roommate states the patient has always been isolative and “odd” but for the past 2 weeks she has been hoarding food, talking to herself, and appearing very paranoid. Which of the following features would be indicative of a poor prognosis with respect to this disease?
a. Late onset
b. Clear precipitating factor
c. Good support system
d. Family history of mood disorders
e. Negative symptoms present
e. Negative symptoms present
Factors weighting toward a poor prognosis in schizophrenia include: early and/or insidious onset of the disease, lack of obvious precipitating factors/stressors, poor premorbid functioning, neurological signs and symptoms, the presence of social isolation, a family history of schizophrenia, poor support systems, and the presence of negative symptoms.
A 26-year-old man comes to the physician with the chief complaint of a depressed mood for the past 5 weeks. He has been feeling down, with decreased concentration, energy, and interest in his usual hobbies. Six weeks prior to this office visit, he had been to the emergency room for an acute asthma attack and was started on prednisone. Which of the following is the most likely diagnosis?
a. Mood disorder due to another medical condition
b. Substance/Medication-induced depressive disorder
c. Major depressive disorder
d. Adjustment disorder with depressed mood
e. Persistent depressive disorder (dysthymia)
b. Substance/Medication-induced depressive disorder
According to DSM-5 criteria, patients developing a mood disorder after using a substance (either illicit or prescribed) are diagnosed with a substance/medication-induced mood disorder. The diagnosis of major depressive disorder cannot be made in the presence of either substance use or another medical condition that might be the cause of the mood disorder. Prednisone is a common culprit in causing mood disorders ranging from depression to mania to psychosis.
A young woman, who has a very limited memory of her childhood years but knows that she was removed from her parents because of their abuse and neglect, frequently cannot account for hours or even days of her life. She hears voices that alternately plead, reprimand, or simply comment on what she is doing. Occasionally, she does not remember how and when she arrived at a specific location. She finds clothes she does not like in her closet, and she does not remember having bought them. Her friends are puzzled because sometimes she acts in a childish, dependent way and at other times becomes uncharacteristically aggressive and controlling. These symptoms are most commonly seen in which of the following disorders?
a. Dissociative amnesia
b. Depersonalization/derealization disorder
c. Korsakoff syndrome
d. Dissociative identity disorder
e. Schizophrenia
d. Dissociative identity disorder
Losing time and memory gaps, including significant gaps in autobiographical memory, are typical symptoms of dissociative identity disorder (previously known as multiple personality disorder). Patients also report fluctuation in their skills, well-learned abilities, and habits. This is explained as a state-dependent disturbance of implicit memory. Hallucinations in all sensory modalities are common. Dramatic changes in mannerisms, tone of voice, and affect are manifestations of this disorder.
A 78-year-old man is brought to the physician by his wife because he is becoming increasingly confused. He has been found wandering along the streets unable to find his way home, and has left items in unusual places, like putting his sunglasses in the freezer. On mental status examination the physician would like to test for diffuse cortical degeneration. Which of the following would most likely demonstrate this problem if it is present?
a. Ask the patient about the presence of hallucinations.
b. Ask the patient to pick up a piece of paper in his left hand, fold it in half, and place it back on the table.
c. Ask the patient to spell the word ‘WORLD’ backward.
d. Ask the patient to copy a figure with multiple intersecting lines.
e. Ask the patient to tell the physician what year he and his wife were married.
b. Ask the patient to pick up a piece of paper in his left hand, fold it in half, and place it back on the table.
Ideational apraxia is the inability to put a sequence of skilled acts together in a row, though the individual may be able to perform each component of the sequence without error. The motor sequence representation of these acts may involve the left parietal cortex, as well as the sequencing and executive functions of the prefrontal cortex. This apraxia is a typical finding in those with cortical degeneration from Alzheimer’s disease.