Trauma & Stressor Related Disorders
Dissociative disorders involve disruptions or discontinuities in the operation and integration of many areas of psychological functioning. Which of the following is not a functional area affected in dissociative disorders?
A. Memory.
B. Consciousness.
C. Perception.
D. Delusional beliefs.
E. Emotional responses.
Correct Answer: D. Delusional beliefs. Explanation: Dissociative disorders encompass disruptions and discontinuities in many areas of psychological functioning, including normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. If frank psychotic symptoms such as delusional beliefs are present, one must consider a diagnosis outside the dissociative disorders arena to account for the symptoms.
A 3-year-old boy has rather severe temper tantrums that have occurred at least weekly for a 6-week period. Although the tantrums can sometimes be associated with defiant behavior, they often result from a change in routine, fatigue, or hunger, and he only rarely does anything destructive. He is generally well behaved in nursery school and during periods between his tantrums. Which of the following conclusions best fits this child’s presentation?
A. The boy does not meet criteria for oppositional defiant disorder (ODD).
B. The boy meets criteria for ODD because of the presence of tantrums and defiant behavior.
C. The boy could be diagnosed with ODD as long as it does not appear that his home environment is harsh, neglectful, or inconsistent.
D. The boy’s symptoms more likely represent intermittent explosive disorder than ODD. E. The boy’s symptoms more likely represent disruptive mood dysregulation disorder than ODD
Correct Answer: A. The boy does not meet criteria for oppositional defiant disorder (ODD). Explanation: Criterion A for ODD requires a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling: Angry/Irritable Mood 1. Loses temper. 2. Is touchy or easily annoyed by others. 3. Is angry and resentful. Defiant/Headstrong Behavior 4. Argues with adults. 5. Actively defies or refuses to comply with adults’ request or rules. 6. Deliberately annoys people. 7. Blames others for his or her mistakes or misbehavior. Vindictiveness 8. Has been spiteful or vindictive at least twice within the past 6 months. In this vignette, the child’s tantrums are the sole symptom; therefore, he would not meet Criterion A. In addition, whereas his tantrums have occurred at least weekly for a 6-week period, DSM-5 specifically notes that for a child younger than 5 years, behavior meeting Criterion A can be considered a symptom of ODD only if it occurs on most days for the preceding 6 months. Finally, the tantrums do not appear to cause significant distress or impairment in functioning (Criterion B) and could be developmental in nature.
A 43-year-old warehouse security guard comes to your office complaining of vague feelings of depression for the last few months. He denies any particular sense of fear or anxiety. As he gets older, he wonders if he should try harder to form relationships with other people. He feels little desire for this but notes that his coworkers seem happier than he, and they have many relationships. He has never felt comfortable with other people, not even with his own family. He has lived alone since early adulthood and has been self-sufficient. He almost always works night shifts to avoid interactions with others. He tries to remain low-key and undistinguished to discourage others from striking up conversations with him, as he does not understand what they want when they talk to him. Which personality disorder would best fit with this presentation?
A. Paranoid.
B. Schizoid.
C. Schizotypal.
D. Avoidant.
E. Dependent.
Correct Answer: B. Schizoid.
Explanation: His avoidance of others is not based on fears of being exploited, deceived, or harmed, as in paranoid personality disorder, nor is it based on a fear of being found inadequate, as might be seen in avoidant personality disorder. There is no mention of odd or eccentric behavior, and he even makes a deliberate effort not to appear unusual in any way. Individuals with dependent personality disorder often feel uncomfortable or helpless when alone, and constantly seek out nurturance and support from others.
Which of the following statements about ataque de nervios is false?
A. Ataque is a cultural syndrome as well as a cultural idiom of distress.
B. Ataque is related to panic disorder, other specified or unspecified dissociative disorder, conversion disorder (functional neurological symptom disorder), and other specified or unspecified trauma- and stressor-related disorder.
C. Ataque is most often associated with withdrawn and reserved behaviors and limited interaction.
D. Ataque often involves a sense of being out of control.
E. Community studies have found ataque to be associated with suicidal ideation, disability, and outpatient psychiatric service utilization
Correct Answer: C. Ataque is most often associated with withdrawn and reserved behaviors and limited interaction. Explanation: Ataque is often experienced with intense and outwardly expressed emotional upset representing a sense of being out of control, rather than withdrawn quiet internalization. Ataque is both a cultural syndrome (i.e., the cultures in which it occurs recognize it as a distinct syndrome) and a broader idiom of distress (i.e., the term ataque de nervios may also be used within the culture as a dimensional description of experienced distress rather than a defined syndromal category). Although no one-to-one correlation with a DSM-5 diagnosis exists, ataque de nervios is related to panic disorder, other specified or unspecified dissociative disorder, conversion disorder, and other specified or unspecified trauma- and stressor-related disorder, among others. Epidemiological research has established its association with suicidal ideation, disability, and outpatient psychiatric service utilization.
Which of the following stressful situations would meet Criterion A for the diagnosis of acute stress disorder (ASD)?
A. Finding out that one’s spouse has been fired.
B. Failing an important final examination.
C. Receiving a serious medical diagnosis.
D. Being in the cross fire of a police shootout but not being harmed.
E. Being in a subway train that gets stuck between stations.
Correct Answer: D. Being in the cross fire of a police shootout but not being harmed. Explanation: The essential feature of ASD is the development of characteristic symptoms lasting from 3 days to 1 month following exposure to one or more traumatic events. Traumatic events that are experienced directly include, but are not limited to, exposure to war as a combatant or civilian, threatened or actual violent personal assault (e.g., sexual assault, physical attack, active combat, mugging, childhood physical and/or sexual abuse, being kidnapped, being taken hostage, terrorist attack, or torture), natural or human-made disasters (e.g., earthquake, hurricane, airplane crash), and severe accidents (e.g., severe motor vehicle or industrial accident). Stressful events that do not meet Criterion A definitions for a diagnosis of ASD may nonetheless be sufficient to qualify for an adjustment disorder. In adjustment disorder, the stressor can be of any severity. The diagnosis of adjustment disorder is used when the response to an extreme stressor does not meet the full criteria for ASD (or another specific mental disorder) and for situations in which the stressor is not considered extreme (e.g., spouse leaving, being fired.)
Which of the following statements about depersonalization/derealization disorder is true?
A. Although transient symptoms of depersonalization/derealization are common in the general population, symptomatology that meets full criteria for depersonalization/derealization disorder is markedly less common.
B. Women are 1.5 times more likely than men to develop depersonalization/ derealization disorder.
C. Age at onset of the disorder is most commonly between 25 and 35 years.
D. During episodes of depersonalization/ derealization, individuals may feel that they are “going crazy” and typically lose reality testing. E. The most common childhood traumatic experience in persons with depersonalization/ derealization disorder is sexual abuse.
Correct Answer: A. Although transient symptoms of depersonalization/derealization are common in the general population, symptomatology that meets full criteria for depersonalization/derealization disorder is markedly less common. Explanation: Transient depersonalization/derealization symptoms lasting hours to days are common in the general population; approximately one-half of all adults have experienced at least one lifetime episode of depersonalization/derealization. However, symptomatology that meets full criteria for depersonalization/derealization disorder is markedly less common than transient symptoms. Women and men have the disorder with equal frequency (gender ratio of 1:1). The mean age at onset of the disorder is 16 years; only 5% of individuals experience onset after age 25. Individuals with depersonalization/derealization disorder may have difficulty describing their symptoms and may think they are “crazy” or “going crazy”; however, Criterion B specifies that reality testing remains intact during these experiences. There is a clear association between depersonalization/derealization disorder and childhood interpersonal traumas in a substantial portion of individuals, although this association is not as prevalent or as extreme in the nature of the traumas as in other dissociative disorders, such as dissociative identity disorder. In particular, emotional abuse and emotional neglect have been most strongly and consistently associated with the disorder. Other stressors can include physical abuse; witnessing domestic violence; growing up with a seriously impaired, mentally ill parent; or unexpected death or suicide of a family member or close friend. Sexual abuse is a much less common antecedent but can be encountered.
A 15-year-old boy has a history of episodic violent behavior that is out of proportion to the precipitant. During a typical episode, which will escalate rapidly, he will become extremely angry, punching holes in walls or destroying furniture in the home. There seems to be no specific purpose or gain associated with the outbursts, and within 30 minutes he is calm and “back to himself,” a state that is not associated with any predominant mood disturbance. What diagnosis best fits this clinical picture?
A. Bipolar disorder.
B. Disruptive mood dysregulation disorder (DMDD).
C. Intermittent explosive disorder (IED).
D. Conduct disorder.
E. Attention-deficit/hyperactivity disorder (ADHD)
Correct Answer: C. Intermittent explosive disorder (IED). Explanation: This boy’s presentation is characteristic of IED. The fact that there is no mood disturbance between episodes argues against bipolar disorder or DMDD. Although individuals with conduct disorder can exhibit aggressive behavior, the behavior of this patient lacks a proactive and predatory component. The aggression in IED is impulsive and is not associated with an overall disregard for rules and social or societal norms. ADHD can be comorbid with IED, but ADHD symptoms other than impulsivity (inattention and restlessness) are not described in this vignette.
Which of the following statements about the development, course, and prognosis of borderline personality disorder (BPD) is true?
A. The risk of suicide in individuals with BPD increases with age.
B. A childhood history of neglect, rather than abuse, is unusual in individuals with BPD.
C. Follow-up studies of individuals with BPD identified in outpatient clinics have shown that 10 years later, as many as half of these individuals no longer meet full criteria for the disorder.
D. Individuals with BPD have relatively low rates of improvement in social or occupational functioning.
E. There is little variability in the course of BPD
Correct Answer: C. Follow-up studies of individuals with BPD identified in outpatient clinics have shown that 10 years later, as many as half of these individuals no longer meet full criteria for the disorder. Explanation: The prognosis for symptomatic improvement in BPD is better than many clinicians realize, and there is considerable variability in the disorder’s course. Individuals with BPD are at increased risk of suicide, but the risk is greatest during early adulthood and decreases with age. Also, a majority of individuals with BPD attain greater stability in their relationships and vocational functioning in their 30s and 40s. Individuals with BPD do have an increased incidence of childhood neglect as well as an increased incidence of childhood physical and sexual abuse.
A young Haitian man from a prominent family becomes severely depressed after his first semester of university studies. The family brings the young man to a clinician and states that maladi moun has caused his problem. Which of the following statements about maladi moun is false?
A. It is similar to Mediterranean concepts of the “evil eye,” in which a person’s good fortune is envied by others who in turn cause misfortune to the individual.
B. It can present with a wide variety of symptoms, from anxiety to psychosis.
C. It is based on a shared social assumption that “rising tides lift all boats.”
D. It is a Haitian cultural explanation for a diverse set of medical and emotional presentations.
E. It is also referred to as “sent sickness.”
Correct Answer: C. It is based on a shared social assumption that “rising tides lift all boats.” Explanation: The cultural model of maladi moun is based on the idea that one’s good fortune, or the flaunting of good fortune, can cause another to have jealous feelings that can be reflected back as actual negative health consequences. It therefore captures a sentiment opposite to that of “rising tides,” which may also exist within the culture, as all cultures contain elements of competitive feelings (zero-sum games) and cooperative feelings (win-win games). Maladi moun is a cultural explanation of distress that can present in a wide variety of ways.
A 4-year-old boy in day care often displays fear that does not seem to be related to any of his activities. Although frequently distressed, he does not seek contact with any of the staff and does not respond when a staff member tries to comfort him. What additional caregiver-obtained information about this child would be important in deciding whether his symptoms represent reactive attachment disorder (RAD) or autism spectrum disorder (ASD)?
A. Age at first appearance of the behavior.
B. Family history about his siblings.
C. History of language delay.
D. Indications that he has experienced severe social neglect.
E. Presence of selective attachment behaviors.
Correct Answer: D. Indications that he has experienced severe social neglect. Explanation: Aberrant social behaviors manifest in young children with RAD, but they also are key features of ASD. Specifically, young children with either condition can manifest dampened expression of positive emotions, cognitive and language delays, and impairments in social reciprocity. As a result, RAD must be differentiated from ASD. These two disorders can be distinguished based on differential histories of neglect and on the presence of restricted interests or ritualized behaviors, specific deficit in social communication, and selective attachment behaviors. Children with RAD have experienced a history of severe social neglect, although it is not always possible to obtain detailed histories about the precise nature of their experiences, especially in initial evaluations. Children with ASD will only rarely have a history of social neglect. Children with ASD regularly show attachment behavior typical for their developmental level. In contrast, children with RAD do so only rarely or inconsistently, if at all.
Dissociative amnesia most often involves which of the following types of amnesia?
A. Continuous amnesia.
B. Permanent, irreversible amnesia.
C. Localized or selective amnesia for specific events.
D. Generalized amnesia similar to that seen in neurological toxicity.
E. Systematized amnesia.
Correct Answer: C. Localized or selective amnesia for specific events.
Explanation: The defining characteristic of dissociative amnesia is an inability to recall important autobiographical information that 1) should be successfully stored in memory and 2) ordinarily would be readily remembered (Criterion A). Dissociative amnesia differs from the permanent amnesias due to neurobiological damage or toxicity that prevent memory storage or retrieval in that it is always potentially reversible because the memory has been successfully stored. Criterion A notes that dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history. Localized amnesia, a failure to recall events during a circumscribed period of time, is the most common form of dissociative amnesia. In selective amnesia, the individual can recall some, but not all, of the events during a circumscribed period of time. Thus, the individual may remember part of a traumatic event but not other parts. Some individuals report both localized and selective amnesias. Generalized amnesia, a complete loss of memory for one’s life history, is rare. Individuals with generalized amnesia may forget personal identity. Some lose previous knowledge about the world (i.e., semantic knowledge) and can no longer access well-learned skills (i.e., procedural knowledge). Generalized amnesia may be more common among combat veterans, sexual assault victims, and individuals experiencing extreme emotional stress or conflict. Individuals with dissociative amnesia are frequently unaware (or only partially aware) of their memory problems. Many, especially those with localized amnesia, minimize the importance of their memory loss and may become uncomfortable when prompted to address it. In systematized amnesia, the individual loses memory for a specific category of information (e.g., all memories relating to one’s family, a particular person, or childhood sexual abuse). In continuous amnesia, an individual forgets each new event as it occurs.
A previously well-behaved 13-year-old girl begins to display extremely defiant and oppositional behavior, with vindictiveness. She is angry, argumentative, and refuses to accept responsibility for her behavior, which is affecting both her home life and school life in a significant way. What is the least likely diagnosis?
A. Major depressive disorder.
B. Bipolar disorder.
C. Oppositional defiant disorder.
D. Adjustment disorder.
E. Substance use disorder
Correct Answer: C. Oppositional defiant disorder. Explanation: Oppositional defiant disorder is an unlikely diagnosis if the onset is in adolescence after a childhood marked by compliant behavior. In this case, the relatively acute onset suggests a mood disorder (major depressive disorder or bipolar disorder), an adjustment disorder (to a stressor not described in the vignette), or a substance use disorder.
While collaborating on a presentation to their customers, the members of a sales team become increasingly frustrated with their team leader. The leader insists that the members of the team adhere to his strict rules for developing the project. This involves approaching the task in sequential manner such that no new task can be begun until the prior one is perfected. When other members suggest alternative approaches, the leader becomes frustrated and insists that the team stick to his approach. Although the results are inarguably of high quality, the team is convinced that they will not finish in time for the scheduled presentation. When voicing these concerns to the leader, he suggests that the real problem is that the other members of the team simply don’t share his high standards. Which of the following disorders would best explain the behavior of this team leader?
A. Narcissistic personality disorder.
B. Obsessive-compulsive disorder (OCD).
C. Avoidant personality disorder.
D. Obsessive-compulsive personality disorder (OCPD).
E. Unspecified personality disorder.
Correct Answer: D. Obsessive-compulsive personality disorder (OCPD). Explanation: OCPD describes a series of enduring, maladaptive traits and behaviors characterized by excessive perfectionism, preoccupation with orderliness and detail, and need for control over one’s emotions and environment. Although this borders on what might be considered a commendable work ethic, the frustration this leader causes among his team and the possibility that the project may not be completed in time raise the likelihood of a disorder. The differential diagnosis involves a number of other personality disorders, including narcissistic personality disorder and avoidant personality disorder. Whereas individuals with narcissistic personality disorder may profess a desire to strive for perfection, this is in the service of self-aggrandizement. Individuals with avoidant personality disorder may also wish for perfection, but they are highly self-critical. Neither of these disorders is characterized by the rigidity typical of OCPD. Despite the similarity in names, OCD is usually easily distinguished from OCPD by the presence of true obsessions and compulsions in OCD. When criteria for both OCPD and OCD are met, both diagnoses should be recorded
A 19-year-old man presents to the clinic complaining of headaches, irritability, emotional lability, and difficulty concentrating. He is accompanied by his mother, who tells you that her son has had nervios since childhood. Which of the following statements about nervios is false?
A. Unlike ataque de nervios, which is a syndrome, nervios is a cultural idiom of distress implying a state of vulnerability to stressful experiences.
B. The term nervios is used only when the individual has serious loss of functionality or intense symptoms.
C. Nervios can manifest with emotional symptoms, somatic disturbances, and an inability to function.
D. Nervios can be related to both trait characteristics of an individual and episodic psychiatric symptoms such as depression and dissociative episodes.
E. Nervios is a common term used by Latinos in the United States and Latin America.
Correct Answer: B. The term nervios is used only when the individual has serious loss of functionality or intense symptoms.
Explanation: Nervios is a cultural idiom of distress used by Latinos in the United States and Latin America to describe an individual with a general state of vulnerability to stressful experiences and difficult life circumstances. The symptoms of nervios range from very minor distress to severe incapacitation. Research studies indicate that individuals so labeled within the culture can manifest both characteristic trait features and discrete episodic symptoms.
A 25-year-old woman, new to your practice, tells you that a little more than 3 months ago she was accosted on her way home. The attacker told her he had a gun, was going to rape her, and would shoot her if she resisted. He walked her toward an alley. She was sure he would kill her afterward no matter what she did, and therefore she pushed away from him, aware that she might be shot. She was able to escape unharmed. She describes not being able to fall asleep for the first 2 nights after the attack and of avoiding that particular street in her neighborhood for 2 days following the event. She thinks that the attacker might have touched her breasts but cannot remember for sure. She has recently started feeling anxious all of the time and is tearful, and she has stopped going to work. She fears that something about her makes her “look like a victim.” What is the most likely diagnosis?
A. Posttraumatic stress disorder.
B. Acute stress disorder.
C. Adjustment disorder.
D. Dissociative amnesia.
E. Personality disorder.
Correct Answer: C. Adjustment disorder. Explanation: The patient developed emotional symptoms within 3 months of the stressor. The symptoms qualify as clinically significant, because although her distress is not out of proportion to the severity of the stressor precipitating the symptoms, she does demonstrate significant impairment in important areas of functioning. This symptom pattern is diagnostic for adjustment disorder. The essential feature of acute stress disorder is the development of acute posttraumatic symptoms within 1 month of exposure to extreme traumatic stressors. The full symptom picture of 9 or more (of a possible 12) symptoms must be present at least 3 days after the traumatic event and can be diagnosed up to 1 month after the event; symptoms that occur immediately after the event but resolve in less than 3 days would not qualify for a trauma- or stressor-related disorder diagnosis. The patient does not have dissociative experiences, flashbacks, dreams, or avoidance symptoms and does not meet the criteria for acute stress disorder or posttraumatic stress disorder. There is nothing to suggest that she has a personality disorder or that she has dissociative amnesia.
Criterion A for the diagnosis of dissociative identity disorder (DID) requires the presence of two or more distinct personality states or an experience of possession. Which of the following symptom presentations would not qualify as a manifestation of an alternate identity?
A. An intrusive but nonhallucinatory voice that is not recognized as being part of one’s own normal thought flow.
B. Suddenly emergent strong impulses or emotions.
C. Acute changes in personal preferences in areas such as food, clothing, or even political convictions.
D. An acute sense of being in a different body, such as an adult feeling like he or she is in a child’s body.
E. A religious experience of being reborn into a new spiritual state that affects multiple domains of the individual’s behavior.
Correct Answer: E. A religious experience of being reborn into a new spiritual state that affects multiple domains of the individual’s behavior. Explanation: Personality changes do not qualify as part of Criterion A symptoms if they are a normal part of a broadly accepted cultural or religious practice. Personality changes that do count toward Criterion A are related to discontinuities of experience that can affect any aspect of an individual’s functioning. Individuals with dissociative identity disorder may report the feeling that they have suddenly become depersonalized observers of their “own” speech and actions, which they may feel powerless to stop (sense of self). Such individuals may also report perceptions of voices (e.g., a child’s voice; crying; the voice of a spiritual being). In some cases, voices are experienced as multiple, perplexing, independent thought streams over which the individual experiences no control. Strong emotions, impulses, and even speech or other actions may suddenly emerge, without a sense of personal ownership or control (sense of agency). These emotions and impulses are frequently reported as ego-dystonic and puzzling. Attitudes, outlooks, and personal preferences (e.g., about food, activities, dress) may suddenly shift and then shift back. Individuals may report that their bodies feel different (e.g., like a small child, like the opposite gender, huge and muscular). Alterations in sense of self and loss of personal agency may be accompanied by a feeling that these attitudes, emotions, and behaviors—even one’s body—are “not mine” and/or are “not under my control.”
Which of the following statements about the differential diagnosis of conduct disorder (CD) and oppositional defiant disorder (ODD) is true?
A. In both diagnoses, individuals tend to have conflict with authority figures.
B. In both diagnoses, individuals display significant emotional dysregulation.
C. In both diagnoses, individuals display aggression toward people or animals.
D. In both diagnoses, individuals destroy property, steal, or lie.
E. If criteria for CD are met, then an individual cannot also receive a diagnosis of ODD.
Correct Answer: A. In both diagnoses, individuals tend to have conflict with authority figures. Explanation: Symptoms of significant emotional dysregulation are seen in ODD, not CD. Individuals with ODD do not typically display significant aggression toward people or animals, nor do they typically destroy property, steal, or lie. If criteria for ODD and CD are both met, then the individual can receive both diagnoses.
A 36-year-old woman is approached by her new boss, who has noticed that despite working for her employer for many years, she has not advanced beyond an entry level position. The boss hears that she is a good employee who works long hours. The woman explains that she has not asked for a promotion because she knows she’s not as good as other employees and doesn’t think she deserves it. She explains her long hours by saying that she is not very smart and has to check over all her work, because she’s afraid that people will laugh at her if she makes any mistakes. On reviewing her past evaluations, her boss notes that there are only minor critiques and her overall evaluations have been very positive. Which of the following personality disorders would best explain this woman’s lack of job advancement?
A. Narcissistic personality disorder.
B. Avoidant personality disorder.
C. Obsessive-compulsive personality disorder.
D. Schizoid personality disorder.
E. Borderline personality disorder
Correct Answer: B. Avoidant personality disorder
Explanation: Avoidant personality disorder is characterized by feelings of inadequacy, hypersensitivity to criticism, and a need for reassurance. As a result, a person with avoidant personality disorder tends to be reluctant to take risks or engage in challenging activities, which results in interpersonal and occupational impairment. People with narcissistic personality disorder or borderline personality disorder may also be highly sensitive to criticism, but a key feature of narcissistic disorder is grandiosity, and that of borderline personality disorder is an unstable self-image, rather than persistently low self-esteem. Long work hours and rechecking work can be seen with obsessive-compulsive personality disorder, but in that disorder the cause is a perfectionistic or rigid style of approach, not fear of criticism or humiliation. People with schizoid personality disorder are generally relatively indifferent to criticism from others.
A 22-year-old man from Zimbabwe presents to a clinic with a complaint of anxiety and pain in his chest. He tells the clinician that the cause of his symptoms is kufungisisa, or “thinking too much.” Which of the following statements about kufungisisa is true?
A. In cultures in which kufungisisa is a shared concept, thinking a lot about troubling issues is considered to be a helpful way of dealing with them.
B. The term kufungisisa is used as both a cultural explanation and a cultural idiom of distress.
C. Kufungisisa involves concerns about bodily deformity.
D. Kufungisisa is related to schizophrenia.
E. B and C.
Correct Answer: B. The term kufungisisa is used as both a cultural explanation and a cultural idiom of distress. Explanation: The term kufungisisa refers to both a cultural explanation and a cultural idiom of distress. It is believed to be caused by thinking too much, which is considered to be damaging to the mind and body. Because kufungisisa is associated with ruminations, it is possible that the concept of “thinking too much” refers to a cultural experience related to ruminations. It is not especially associated with schizophrenia.
Following discharge from the hospital, a 22-year-old man describes vivid and intrusive memories of his stay in the intensive care unit (ICU), where he received treatment for smoke inhalation. Now at home, he states that he has memories of people being tortured and hearing their screams. He dreams of this every night, waking from sleep in a terror. He talks about not feeling like himself after the experience, finding little pleasure in life after what happened to him, and being easily angered by his family; in addition, he avoids his physician out of fear that he will be told he needs to return to the ICU. What is the most likely explanation for this patient’s symptoms?
A. He has acute stress disorder because his life was in danger during the ICU stay.
B. He has posttraumatic stress disorder because his life was in danger during the ICU stay.
C. He has a delirium persisting from the ICU stay.
D. He had a delirium in the ICU and now has an adjustment disorder.
E. He has a psychotic disorder.
Correct Answer: D. He had a delirium in the ICU and now has an adjustment disorder. Explanation: Flashbacks in acute stress disorder must be distinguished from illusions, hallucinations, and other perceptual disturbances that may occur in schizophrenia, other psychotic disorders, depressive or bipolar disorder with psychotic features, a delirium, substance/medication-induced disorders, and psychotic disorders due to another medical condition. Acute stress disorder flashbacks are distinguished from these other perceptual disturbances by being directly related to the traumatic experience and occurring in the absence of other psychotic or substance/medication-induced features.
Criterion B for the diagnosis of dissociative identity disorder (DID) requires recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting. Which of the following statements about Criterion B–qualifying amnesia is false?
A. Gaps in recall of remote life events do not meet Criterion B definitions for amnesia.
B. It is common for individuals with DID to minimize their amnesia symptoms.
C. Individuals with DID may discover evidence of their past actions or experiences, such as finding clothing in the closet they do not recall buying, or seeing a photo of a trip they don’t recall taking.
D. Forgetting of skills such as those involved in playing a musical instrument would count as amnesia for the purposes of Criterion B.
E. Dissociative fugues in which an individual finds him- or herself in a location with no memory of having traveled there are common in DID and represent a form of amnesia.
Correct Answer: A. Gaps in recall of remote life events do not meet Criterion B definitions for amnesia. Explanation: The dissociative amnesia of individuals with DID manifests in three primary ways: as 1) gaps in remote memory of personal life events (e.g., periods of childhood or adolescence; some important life events, such as the death of a grandparent, getting married, giving birth); 2) lapses in dependable memory (e.g., of what happened today, of well-learned skills such as how to do their job, use a computer, read, drive); and 3) discovery of evidence of their everyday actions and tasks that they do not recollect doing (e.g., finding unexplained objects in their shopping bags or among their possessions; finding perplexing writings or drawings that they must have created; discovering injuries; “coming to” in the midst of doing something). Dissociative fugues, wherein the person discovers dissociated travel, are common. Thus, individuals with DID may report that they have suddenly found themselves at the beach, at work, in a nightclub, or somewhere at home (e.g., in the closet, on a bed or sofa, in the corner) with no memory of how they came to be there. Amnesia in individuals with DID is not limited to stressful or traumatic events; these individuals often cannot recall everyday events as well.
Which of the following statements about kleptomania is false?
A. The prevalence of kleptomania in the general population is generally very low, and the disorder more frequent among females.
B. First-degree relatives of individuals with kleptomania may have higher rates of obsessive-compulsive disorder and/or substance use disorders than the general population.
C. Kleptomania is similar to ordinary theft in that the act of shoplifting, whether planned or impulsive, is deliberate and often motivated by the usefulness of the object.
D. The age at onset is variable, but the disorder often begins in adolescence.
E. Individuals with kleptomania generally do not preplan their thefts.
Correct Answer: C. Kleptomania is similar to ordinary theft in that the act of shoplifting, whether planned or impulsive, is deliberate and often motivated by the usefulness of the object.
Explanation: The key feature of kleptomania is recurrent failure to resist impulses to steal items even though they are not needed and the individual is aware that the act is senseless. Shoplifting, by contrast, is typically motivated by the perceived utility or monetary value of an object. In adolescents, shoplifting may also be the consequence of a dare.
A cardiologist requests a psychiatric consultation for her patient, a 46-year-old man, because even though he is adherent to treatment, she is concerned that he “seems crazy.” On evaluation, the patient makes poor eye contact, tends to ramble, and makes unusual word choices. He is modestly disheveled and wears clothes with mismatched colors. He expresses odd beliefs about supernatural phenomena, but these beliefs do not seem to be of delusional intensity. Collateral information from his sister elicits the observation that “He’s always been like this—weird. He keeps to himself, and likes it that way.” Which of the following conditions best explains this man’s odd behaviors and beliefs?
A. Schizoid personality disorder.
B. Schizotypal personality disorder.
C. Paranoid personality disorder.
D. Delusional disorder.
E. Schizophrenia.
Correct Answer: B. Schizotypal personality disorder. Explanation: Schizotypal personality disorder is characterized by pervasive social and interpersonal deficits, which include odd behaviors, odd beliefs and speech, and social withdrawal. The odd beliefs may include ideas of reference or even paranoid ideation, but true delusions and hallucinations are not present. Individuals with schizoid personality disorder or paranoid personality disorder may also be loners, and either of these disorders may coexist with schizotypal personality disorder. However, neither of those disorders is characterized by marked oddness or eccentricity
Which of the following statements about shenjing shuairuo is false?
A. In the Chinese Classification of Mental Disorders, it is defined by a presentation of three out of five symptom clusters.
B. One of the psychosocial precipitants is an acute sense of failure.
C. It is related to traditional Chinese medicine concepts of depletion of qi (vital energy) and dysregulation of jing (bodily channels that convey vital forces).
D. Prominent psychotic symptoms must be present.
E. It is believed to be related in some cases to the inability to change a chronically frustrating and distressing situation.
Correct Answer: D. Prominent psychotic symptoms must be present.
Explanation: Shenjing shuairuo is a Mandarin Chinese term for a cultural syndrome that integrates conceptual categories of traditional Chinese medicine with the Western diagnosis of neurasthenia. Although well defined, it may not always correspond to DSM-5 disorders. It is believed to be precipitated by a sense of failure or loss of face. This includes situations in which someone feels incapable of changing an undesirable situation in which he or she is involved. Shenjing shuairuo has a proposed mechanism involving standard concepts in Chinese medicine such as qi and jing that involve the distribution of energy through the body