Question 12: A 25-year-old man presents with multiple physical complaints including headaches, abdominal pain, and fatigue that have persisted for over a year. He is excessively worried about these symptoms and spends considerable time and energy focused on his health concerns. What is the most likely diagnosis?
A) Illness anxiety disorder
B) Somatic symptom disorder
C) Generalized anxiety disorder
D) Major depressive disorder
Answer: B) Somatic symptom disorder
Explanation: Somatic symptom disorder is characterized by one or more somatic symptoms that are distressing or result in significant disruption of daily life, plus excessive thoughts, feelings, or behaviors related to the symptoms (disproportionate thoughts about seriousness, high anxiety, or excessive time/energy devoted to them). This patient has persistent symptoms (>6 months) and excessive preoccupation.
Why other options are incorrect:
Illness anxiety disorder would have minimal or no somatic symptoms. Focus is on having a disease, not the symptoms.
Generalized anxiety disorder involves worry about various events (work, family), not predominantly physical symptoms.
Major depressive disorder primary syndrome involves depressed mood/anhedonia.
Note:
Somatic symptom disorder: significant symptoms + excessive preoccupation.
Illness anxiety disorder: minimal/no symptoms + preoccupation with having a disease.
Question 13: A 50-year-old woman intentionally feigns symptoms of chest pain to gain admission to the hospital. She has a history of multiple hospitalizations at different facilities. There is no apparent external reward such as financial gain. What is the most likely diagnosis?
A) Malingering
B) Factitious disorder
C) Somatic symptom disorder
D) Conversion disorder
Answer: B) Factitious disorder
Explanation: Factitious disorder involves the falsification of physical/psychological signs or symptoms associated with identified deception, where the individual presents themselves as ill. The key is that deceptive behavior is evident in the absence of obvious external rewards (distinguishes it from malingering).
Key features:
Pattern of seeking hospitalization (“hospital addiction”).
History of “doctor shopping.”
Dramatic presentation (formerly Munchausen syndrome).
Symptoms that don’t fit typical patterns.
Why other options are incorrect:
Malingering involves external incentives (money, avoiding work, drugs).
Somatic symptom disorder involves symptoms that are not intentionally produced.
Conversion disorder involves neurological symptoms that are not intentionally produced.
Note:
Factitious disorder: intentional production, psychological motivation (sick role).
Malingering: intentional production, external motivation (money, avoiding duty).
Question 14: A 32-year-old man complains of chronic back pain and seeks disability benefits. During examination, his reported pain seems exaggerated and inconsistent with objective findings. He has recently been fired from his job. What should be considered?
A) Somatic symptom disorder
B) Conversion disorder
C) Malingering
D) Factitious disorder
Answer: C) Malingering
Explanation: Malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding work, obtaining financial compensation, or evading prosecution. It is not a mental disorder.
Red flags for malingering:
Medicolegal context (seeking disability/litigation).
Marked discrepancy between claimed distress and objective findings.
Lack of cooperation during evaluation.
Presence of antisocial personality disorder.
Why other options are incorrect:
Somatic symptom disorder involves genuine symptoms (not intentionally produced).
Conversion disorder involves neurological symptoms that are not intentionally produced.
Factitious disorder involves intentional production for psychological reasons (sick role), not external gain.
Question 15: A 19-year-old woman is preoccupied with a perceived defect in her nose, which she believes is “too big and crooked.” Objective examination reveals a normal-appearing nose. She spends hours checking mirrors and has sought multiple cosmetic surgery consultations. What is the most likely diagnosis?
A) Obsessive-compulsive disorder
B) Body dysmorphic disorder
C) Delusional disorder, somatic type
D) Social anxiety disorder
Answer: B) Body dysmorphic disorder
Explanation: Body dysmorphic disorder (BDD) is characterized by preoccupation with one or more perceived defects in physical appearance that are not observable or appear slight to others. The person performs repetitive behaviors (mirror checking, excessive grooming) or mental acts in response to these concerns.
DSM-5 Criteria:
Preoccupation with perceived defect(s).
Repetitive behaviors or mental acts.
Significant distress or impairment.
Not better explained by eating disorder concerns.
Why other options are incorrect:
OCD involves obsessions/compulsions not limited to appearance.
Delusional disorder, somatic type involves fixed false beliefs. In BDD, insight varies; it is only “delusional” if insight is completely absent.
Social anxiety disorder involves fear of social scrutiny, not specifically preoccupation with a perceived physical flaw.
Treatment note: BDD responds to SSRIs (often high doses) and specialized CBT. Cosmetic procedures typically do not help.
Question 16: A 55-year-old man with a history of chronic alcoholism presents with memory impairment and confabulation. He cannot form new memories but can recall events from his distant past. Physical examination reveals nystagmus and ataxia. What is the most likely diagnosis?
A) Alzheimer’s disease
B) Wernicke-Korsakoff syndrome
C) Alcohol-induced major neurocognitive disorder
D) Delirium tremens
Answer: B) Wernicke-Korsakoff syndrome
Explanation: This is a two-stage disorder caused by thiamine (vitamin B1) deficiency, common in chronic alcoholism.
Stage 1: Wernicke’s encephalopathy (acute):
Triad: Confusion, Ataxia, and Ophthalmoplegia/nystagmus. It is a medical emergency.
Stage 2: Korsakoff’s syndrome (chronic):
Develops if Wernicke’s is untreated. Features severe anterograde amnesia (cannot form new memories) and confabulation (fabricating stories to fill gaps).
Pathophysiology: Damage to mammillary bodies and dorsomedial thalamus.
Why other options are incorrect:
Alzheimer’s is a progressive neurodegenerative disorder without acute neurological signs (nystagmus/ataxia).
Alcohol-induced major neurocognitive disorder involves global cognitive decline, not the specific amnesia/confabulation pattern.
Delirium tremens is an acute withdrawal syndrome (autonomic hyperactivity, hallucinations) 48-96 hours after the last drink.
Treatment: Immediate high-dose parenteral thiamine (given before glucose).
