Cognitive Disorders
An 80-year-old woman is brought to the clinic by her son. Over the past year she often forgets things like where she placed her car keys. Two days ago she forgot that she had left food cooking on the stove and nearly started a fire. She has been misplacing her medications and money throughout her home. Physical examination shows no abnormalities. She is oriented to person, place, and time. On mental status examination, she cannot recall words after five minutes. She also cannot perform serial subtraction. Which of the following additional findings is most likely in this woman?
(A) Presenilin gene mutation
(B) Atrophy of mammillary bodies
(C) Disrupted sleep-wake cycle
(D) Normal electroencephalogram
(E) Waxing and waning sensorium
Answer D (correct answer): This woman has dementia, a chronic, progressive loss of cognitive functions, including memory and reasoning. Symptoms may also include changes in behavior, mood, and personality. The inability to recall words after five minutes is a sign of impaired short-term memory. Inability to perform serial subtraction is evidence of impaired attention and concentration. Both are common features of dementia.
A 64-year-old woman comes to the emergency department because of visual hallucinations mostly during the evenings while in her long-term care facility. Symptoms began two nights ago. Prior to that, she was forgetful but otherwise functioned well in her facility. She has been up most of the night for the past two nights and has been napping during the day. On physical examination, she is easily distracted and unable to sustain attention. Which of the following is the most likely explanation for this woman’s current symptoms?
(A) Brain tumor
(B) Delirium
(C) Dementia
(D) Drug withdrawal
(E) Urinary infection
Answer B (correct answer): This woman suffers from delirium, which is characterized by poor focus and attention, disorganized thinking, hallucinations, and altered sleep-wake cycles. Delirium develops over hours or days, and the acute (rapid) onset is a helpful feature in differentiating delirium from dementia, a chronic disorder. This woman’s history of forgetfulness suggests she may have underlying dementia that predisposed her to delirium. In elderly patients with dementia, delirium commonly occurs at night, when lighting is poor, causing disorientation.
A 14-year-old boy comes to the office with a six-month history of anxiety when using public restrooms. He has to go home from school every day at lunch to use the toilet. If he tries to enter a public restroom, he experiences anxiety and is unable to void. He fears someone may walk in, see him urinating, and laugh at him. Which of the following is the most likely diagnosis?
(A) Adjustment disorder
(B) Agoraphobia
(C) Delusional disorder
(D) Social anxiety disorder
(E) Specific phobia
Answer D (correct answer): Social anxiety disorder (SAD), also known as social phobia, is defined by fear, anxiety, and avoidance of social situations in which one may be scrutinized or judged negatively. The illness usually begins in childhood or adolescence. In situations that cause symptoms, patients may exhibit blushing, sweating, trembling, palpitations, or panic attacks. Individuals will often avoid situations that cause anxiety and may become socially withdrawn and isolated as a result of anxiety. A diagnosis of SAD requires persistent symptoms for at least six months.
A 12-year-old girl comes to the pediatrician's office with her mother because of an intense fear of leaving the house for the past year. She refuses to take the school bus and will not go to the park to play with other children. The patient says that she feels uncomfortable in big spaces that are far from home. The patient has missed many days of school because she does not want to leave the house, and her grades are beginning to suffer as a result. She denies any bullying at school. Which of the following is the most likely diagnosis?
(A) Agoraphobia
(B) Post-traumatic stress disorder
(C) Separation anxiety disorder
(D) Social anxiety disorder
(E) Specific phobia
Answer A (correct answer): Agoraphobia is a marked fear or anxiety about being in situations where escape is difficult or where help may be unavailable. Individuals with agoraphobia may fear using public transportation or being trapped in open or enclosed spaces outside of the home. The hallmark of agoraphobia is the fear of being unable to escape or get help.
A 72-year-old man is brought into the office by his wife. He has been refusing to eat for a week because he feels depressed and wants to end his life. He tried to commit suicide twice in the past week, both times by running into oncoming traffic. His symptoms have not been relieved by several medications, including sertraline, citalopram, and phenelzine, and he does not want to take any new medications. He has had multiple crying spells throughout the day because he believes that his wife and children are plotting to kill him. He has suicidal thoughts and has a gun in his home. His past medical history is notable for two myocardial infarctions and poorly controlled hypertension. He is referred for electroconvulsive therapy. Which of the following side effect is most likely to occur after receiving this treatment?
(A) Anterograde amnesia
(B) Aspiration pneumonia
(C) Hypertensive emergency
(D) Myocardial infarction
(E) Stroke
Answer A (correct answer): This elderly man has major depression with psychotic features that have not responded to multiple classes of antidepressants, including a monoamine oxidase inhibitor (MAOI). He also has a high risk for suicide. Electroconvulsive therapy (ECT) should be considered in the management of this patient’s illness. In psychotic depression, ECT is more effective than antidepressants alone and has higher response rates in the elderly population.
A 50-year-old man with a twenty-five-year history of alcohol use disorder is evaluated for loss of appetite, abdominal pain, and fever for the past 24 hours. He states that he consumed a bottle of vodka 2 days ago. He is treated and is discharged after being put in contact with social services. A recommendation is made for him to attend alcohol counseling and participate in a support group. Six months later he returns with diplopia, nystagmus, confusion, and loss of balance. Which of the following is the most likely an associated finding in this patient?
(A) Delirium
(B) Folic acid deficiency
(C) Hypoalbuminemia
(D) Thiamine deficiency
(E) Vitamin B3 deficiency
Answer D (correct answer): This man has Wernicke’s encephalopathy (WE), caused by thiamine deficiency. Chronic use of alcohol is associated with depletion of important vitamins, particularly vitamin B1 (thiamine). Long-standing thiamine deficiency can lead to WE, although not all thiamine-deficient patients develop this condition. WE is characterized by a classic triad of altered mental status, eye movement abnormalities (nystagmus), and gait instability, as seen in this man.
A 58-year-old homeless man is brought to the emergency department by police. The man was found screaming near a shopping mall. When taken into custody, he was aggressive and claimed he was a local landlord, although he could not provide his address. When asked about his personal information, the patient looks apathetic. He has no recollection of who he is or where he is from. He has to be reminded that he is in the hospital. On physical examination, the patient appears malnourished. His blood alcohol level is not elevated. His medical records show a history of alcohol use for many years. His temperature is 97.8°F (36.6°C), pulse is 102/min, respirations are 20/min, and blood pressure is 130/80 mmHg. Serum electrolytes are normal. Which of the following is the most likely diagnosis?
(A) Alcoholic cerebellar degeneration
(B) Hepatic encephalopathy
(C) Korsakoff's syndrome
(D) Methanol poisoning
(E) Wernicke's encephalopathy
Answer C (correct answer): This patient’s presents with fabricated memories of himself (that he is a landlord) in addition to severe memory loss (no recall of who he is) with a long-standing history of alcohol use. Korsakoff’s syndrome is a neurological disorder caused by a chronic thiamine (vitamin B1) deficiency. This syndrome is seen in patients with long-term alcohol use disorders.
An 18-year-old female presents to the office with a two-month history of recurrent intrusive thoughts of her brother driving off a cliff. She ruminates frequently about him driving off a cliff and has started to call her brother several times per day to relieve her fears. She knows her brother is alive and well but cannot stop these thoughts from occurring. Which of the following is the most likely diagnosis?
(A) Antisocial personality disorder
(B) Generalized anxiety disorder
(C) Major depressive disorder
(D) Obsessive-compulsive disorder
(E) Schizophrenia
Answer D (correct answer): Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by obsessions, repeated thoughts, urges, or mental images that cause distress, anxiety, and compulsions, which are repetitive behaviors done to relieve the distress caused by an obsession. The distress secondary to this woman’s obsession about her brother’s death is alleviated by her compulsion to telephone her brother several times per day. Other examples of compulsions include washing hands repeatedly to avoid the distress of germs and checking door locks to alleviate an obsession about home invasion.
A 61-year-old male comes to the office because of uncontrollable feelings of fear and sadness for the past six months. These feelings occur on most days, at home and at work, and have begun to affect his quality of life. He is otherwise in good health and he uses no medications or recreational drugs, including alcohol and tobacco. Examination shows no abnormalities. Which of the following is the most likely diagnosis?
(A) Generalized anxiety disorder
(B) Panic attack
(C) Panic disorder
(D) Post-traumatic stress disorder
(E) Specific phobia
Answer A (correct answer): Generalized anxiety disorder (GAD) is defined by a persistent and uncontrollable fear or worry for at least six months or more that causes distress and impairment in functioning. GAD has a substantial impact on an individual’s quality of life.
A 42-year-old woman is evaluated for decreased need for sleep and irritability. Over the past 4 days she has slept only 1 to 2 hours per night. Despite this, she has felt restless and not lethargic. She has cleaned her entire home to keep active. She has gone to work each day and has been able to perform her work duties. Four years ago she had a history of a major depressive episode requiring hospitalization. She occasionally drinks a bottle of wine. Her temperature is 98.8°F (37.1°C), pulse is 80/min, respiratory rate is 12/min, and blood pressure is 110/75 mmHg. Physical examination is normal. Which of the following is the most likely diagnosis?
(A) Alcohol intoxication
(B) Korsakoff's syndrome
(C) Bipolar disorder
(D) Cyclothymia
(E) Atypical depression
Answer C (correct answer): This woman has bipolar II disorder, which is defined by at least one or more hypomanic episodes and one or more major depressive episodes. Her symptoms are consistent with hypomania, an episode of decreased need for sleep and high energy that is not as severe as mania. Hypomania often does not cause occupational or social impairment, as seen in this case in which the patient continued working. Bipolar II can be difficult to diagnose, since hypomanic episodes may simply be periods of high productivity and because depressive symptoms may predominate, with only rare episodes of hypomania. Diagnosis of bipolar II disorder can be made only in patients who have never experienced a full manic episode.
A 45-year-old man is brought to the family medicine clinic by his wife because of memory loss. Two days ago their home was destroyed by a tornado. The patient was trapped under debris for several hours until a rescue team arrived. Since then the wife states that her husband has no memory of having lived in their home before the tornado. He also has no memory of the details of the house, such as its size or color. Physical examination reveals a well-appearing man in no distress. A mini–mental status examination shows a score of 27 out of 30. Which of the following is the most likely diagnosis?
(A) Dementia
(B) Depersonalization disorder
(C) Dissociative amnesia
(D) Dissociative identity disorder
(E) Major depressive disorder
Answer C (correct answer): This man has dissociative amnesia, a unique form of amnesia that usually occurs following a psychologically traumatic event, such as the tornado in this man’s case. The main clinical feature of this disorder is sudden memory loss that is more severe than normal forgetfulness. With dissociative amnesia, patients may forget their names, their addresses, or the names of friends and family. The classic presentation is sudden memory loss following a psychologically traumatic event, such as physical abuse or death of a loved one. Most cases of dissociative amnesia are temporary.
A 69-year-old woman is brought to the emergency department by the police. The officers found the patient wandering in the park. She claimed to live in a nearby apartment building but was unable to direct the officers to the building. She also claimed to work at a local supermarket, but the supermarket manager has never heard of her. When asked for her name, she has no recollection of who she is or what happened prior to being found by the police. She has to be reminded that she is in the hospital. Her medical records show a history of alcohol use. On physical examination, the patient looks disheveled. Blood alcohol level is not elevated. Her temperature is 97.8°F (36.6°C), pulse is 102/min, respirations are 20/min, and blood pressure is 120/90 mmHg. Which of the following is present in this patient?
(A) Confabulation
(B) Delirium
(C) Delusional disorder
(D) Dissociative amnesia
(E) Malingering
Answer A (correct answer): The patient is experiencing confabulation related to Korsakoff’s syndrome. The key part of the diagnosis is the fabrication of autobiographical memories (where she lives, where she works) in the context of chronic alcohol use disorder without evidence of acute intoxication. Confabulation is a memory disturbance characterized by the fabrication of distorted or misinterpreted memories about oneself or the world without the conscious intention to deceive.
A 36-year-old man is evaluated for an episode of dizziness while driving. Yesterday, while driving, he suddenly felt dizzy, developed palpitations, started shaking, and had profuse sweating. He briefly felt that he was losing control of his vehicle, which almost made him crash. He stopped driving, and the sensation faded in about an hour. He has no history of similar episodes, takes no daily medication, and has no unusual stressors in his life. Cardiac and neurologic testing are normal. Which of the following is the most likely diagnosis?
(A) Acute stress disorder
(B) Panic attack
(C) Panic disorder
(D) Post-traumatic stress disorder
(E) Specific phobia
Answer B (correct answer): Panic attacks are spontaneous episodes of fear or distress that reach a peak within minutes and may last for an hour. During a panic attack, four or more of the following thirteen symptoms must occur:
A 55-year-old woman comes to the office with complaints of poor sleep. She has always had difficulty sleeping, but for the past seven months she has noticed new-onset fatigue throughout the day as well as difficulty completing daily tasks. She describes uncontrollable worry about her children, her job, her family's financial situation, and her relationship with her husband. She has no history of alcohol consumption and no chronic medical conditions. Which of the following is necessary to make a diagnosis of generalized anxiety disorder?
(A) Childhood history of an anxiety disorder
(B) Family history of generalized anxiety disorder
(C) History of post-traumatic stress disorder
(D) Difficulty with concentration
(E) Recent loss of a loved one
Answer D (correct answer): According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), the following criteria must be satisfied for a diagnosis of generalized anxiety disorder (GAD):
A 40-year-old woman is brought to the emergency room following a suicide attempt in which she slit her wrists. She has a history of depressive episodes. Between episodes she has periods of high energy and insomnia, during which she will spend thousands of dollars on useless items. She also believes that she will be the next American Idol winner if she were to enter the contest. Which of the following would be the most likely mental status observation in this patient if she presented during one of her high-energy episodes?
(A) Flight of ideas
(B) Ideas of references
(C) Magical thinking
(D) Thought blocking
(E) Word salad
Answer A (correct answer): This patient describes episodes of mania, a high-energy state associated with bipolar disorder. Mania symptoms can be remembered using the mnemonic “DIG FAST”: Distractibility, Irresponsibility, Grandiose delusions, Flight of ideas, Agitation, Sleep not needed, Talkative or pressured speech.
A 53-year-old man comes to his neurologist because of memory difficulties for the past month. He was recently diagnosed with a brain tumor and received chemotherapy. Two days ago he celebrated his twenty-fifth wedding anniversary but could not recall the events of his wedding day or his honeymoon. He also could not remember the names of his children. Which of the following best describes the type of cognitive impairment in this man?
(A) Anterograde amnesia
(B) Delirium
(C) Dissociative amnesia
(D) Korsakoff's amnesia
(E) Retrograde amnesia
Answer E (correct answer): This man has retrograde amnesia, a type of memory loss characterized by forgetting events that occurred before a central nervous system (CNS) insult such as a brain tumor, cranial trauma, hypoxia, or stroke. In contrast, anterograde amnesia is memory loss of events after a CNS insult. A useful mnemonic for remembering this is the following:
A 35-year-old homeless man is brought to the emergency department after he was found in an altered mental state while walking through a park at night. He appears malnourished. He is disoriented and cannot state the date or where he is. His temperature is 98.6°F (37.0°C), pulse is 95/min, respirations are 16/min, and blood pressure is 136/84 mmHg. He walks with a wide-based gait and slow, short-spaced steps. Blood alcohol testing is normal. Neurologic examination shows nystagmus. Which of the following is the most likely diagnosis?
(A) Alcohol intoxication
(B) Korsakoff's syndrome
(C) Vitamin B6 deficiency
(D) Vitamin B12 deficiency
(E) Wernicke's encephalopathy
Answer E (correct answer): Wernicke’s encephalopathy (WE) is a neurologic complication due to vitamin B1 (thiamine) deficiency. It is characterized by the classic triad of encephalopathy (presenting as confusion or altered mental status), gait ataxia, and oculomotor dysfunction (nystagmus or gaze palsies). WE is often associated with chronic alcohol use but may also occur with poor nutrition, as in this man’s case.
A 35-year-old woman is evaluated for a history of panic disorder. For the past four years, she experiences about four panic attacks per month. During a panic attack, she feels that the room around her is foggy. She feels as if she were living in a movie, and that she is no longer living in the present time. Which of the following best describes this woman’s symptoms?
(A) Ego-dystonic reaction
(B) Delusions
(C) Depersonalization
(D) Derealization
(E) Retrograde amnesia
Answer D (correct answer): Panic disorder is defined by the spontaneous and unexpected occurrence of panic attacks ranging from several attacks per day to only a few per year. “Panic attack” is defined as a period of intense fear in which symptoms develop abruptly, peaking a few minutes from symptom onset.
A 24-year-old man enters a psychiatric rehab facility after being arrested on a felony assault charge. He has a history of bipolar disorder and post-traumatic stress disorder (PTSD) from childhood trauma. He reports terrible dreams and trouble sleeping. He is prescribed a new medication to help treat his nightmares but then experiences dizziness upon standing due to a drop in his blood pressure. What is the mechanism of action of this medication?
(A) Serotonin and dopamine receptor antagonist
(B) Adrenergic antagonist with alpha-1 receptor selectivity
(C) Alters cation transport across cell membranes
(D) Dopamine D2 receptor antagonist
(E) Selective inhibitor of beta-1 adrenergic receptors
Answer B (correct answer): Post-traumatic stress disorder (PTSD) is characterized by flashbacks, intrusive thoughts, upsetting memories, and nightmares of past traumatic events. Other features include avoidance of reminders of trauma and physiological arousal that leads to interpersonal, occupational, and social dysfunction for one month or longer.
A 20-year-old man presents for follow-up for unipolar depression. Several trials of selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) have been ineffective at improving his symptoms. Psychiatric evaluation shows atypical features to his depressive episodes. Which of the following features would most likely be present during one of this patient’s depressive episodes?
(A) Emotional detachment, muteness, depersonalization
(B) Hurried speech, delusions, hallucinations
(C) Improved mood in reaction to positive events
(D) Inability to focus, need for control, excessive worrying
(E) Social or occupational conflicts, talkativeness, risky behaviors
Answer C (correct answer): According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), three atypical features must be present during depressive episodes for a diagnosis of depression with atypical features. One of these features must be improved mood in response to good news (i.e., “mood reactivity” to pleasurable stimuli). Other features include: