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).”Front
Question 17: A 30-year-old woman presents with sudden onset of blindness in both eyes following a heated argument with her husband. Ophthalmologic examination reveals no abnormalities. What is the most likely diagnosis?
A) Conversion disorder
B) Malingering
C) Factitious disorder
D) Occipital stroke
Answer: A) Conversion disorder
Explanation: This is another example of conversion disorder (functional neurological symptom disorder), presenting with sensory symptoms (blindness).
Key diagnostic features:
Sudden onset of neurological symptom (blindness).
Temporal association with psychological stressor (heated argument).
Normal objective examination (ophthalmologic exam shows no abnormalities).
Symptoms not intentionally produced.
Common sensory presentations: Visual disturbances (blindness, tunnel vision), anesthesia/paresthesia, or deafness.
Clinical findings suggesting conversion in blindness:
Pupillary reflexes remain intact.
Patient may avoid objects when walking.
Normal optokinetic nystagmus test.
“Tunnel vision” (visual fields don’t expand with distance).
Why other options are incorrect:
Malingering involves conscious fabrication for external gain.
Factitious disorder involves intentional production of symptoms to assume the sick role without external reward.
Occipital stroke would show abnormalities on imaging and typically wouldn’t have such sudden onset related to emotional stress.
Note: Conversion disorder symptoms are NOT intentionally produced—the person genuinely experiences the symptom.
Question 18: A 40-year-old man presents with a firm belief that he is dead and that his internal organs are rotting. He has lost a significant amount of weight and appears severely depressed. What is the most likely diagnosis?
A) Schizophrenia
B) Delusional disorder, somatic type
C) Major depressive disorder with psychotic features
D) Body dysmorphic disorder
Answer: C) Major depressive disorder with psychotic features
Explanation: This patient is presenting with Cotard’s syndrome (nihilistic delusion), where a person believes they are dead, do not exist, or their organs are rotting.
Cotard’s syndrome occurs in the context of severe illness, most commonly:
1. Major depressive disorder with psychotic features (most common).
2. Bipolar disorder.
3. Schizophrenia.
This patient shows:
Nihilistic delusion (belief he is dead).
Severe depression.
Significant weight loss (neurovegetative symptom).
Mood-congruent psychotic features in MDD:
Nihilistic delusions (Cotard’s).
Delusions of guilt or poverty.
Somatic delusions (belief body is rotting).
Why other options are incorrect:
Schizophrenia could present with bizarre delusions, but this presentation is dominated by mood-congruent depressive themes.
Delusional disorder, somatic type involves delusions without the full depressive syndrome.
Body dysmorphic disorder involves preoccupation with appearance defects, not being dead.
Treatment: Antidepressant + antipsychotic or Electroconvulsive therapy (ECT).
Question 19: A 25-year-old graduate student presents with a 3-week history of difficulty concentrating, decreased appetite, insomnia, and feelings of worthlessness. She reports that these symptoms began after receiving a rejection letter from her dream job. What is the most likely diagnosis?
A) Major depressive disorder
B) Adjustment disorder with depressed mood
C) Persistent depressive disorder (dysthymia)
D) Normal bereavement
Answer: B) Adjustment disorder with depressed mood
Explanation: Adjustment disorder involves emotional or behavioral symptoms in response to an identifiable stressor occurring within 3 months of the stressor’s onset.
DSM-5 Criteria:
Symptoms in response to a stressor within 3 months.
Marked distress out of proportion to stressor or significant impairment.
Does not meet criteria for another mental disorder.
Symptoms do not persist for more than 6 months once stressor/consequences end.
Why this is adjustment disorder:
Clear temporal relationship (job rejection).
Symptom duration (3 weeks).
Context/Proportionality: Reactive response to a meaningful life stressor.
Why other options are incorrect:
Major depressive disorder requires 5+ symptoms (this patient has 4: concentration, appetite, insomnia, worthlessness).
Persistent depressive disorder (dysthymia) requires chronicity (at least 2 years).
Normal bereavement applies to responses to death of a loved one.
Treatment: Psychotherapy is first-line. Focus on coping strategies. Good prognosis.
Question 20: A 35-year-old woman has had a depressed mood, low energy, and poor self-esteem for the past 3 years. The symptoms are present more days than not but have never been severe enough to meet criteria for major depression. What is the most likely diagnosis?
A) Major depressive disorder
B) Persistent depressive disorder (dysthymia)
C) Cyclothymic disorder
D) Adjustment disorder with depressed mood
Answer: B) Persistent depressive disorder (dysthymia)
Explanation: Persistent depressive disorder (PDD) is characterized by chronic depressive symptoms present more days than not for at least 2 years in adults.
DSM-5 Criteria:
Depressed mood for at least 2 years.
2 or more of: Poor appetite/overeating, Insomnia/hypersomnia, Low energy, Low self-esteem, Poor concentration, Hopelessness.
Never without symptoms for > 2 months.
No history of manic/hypomanic episodes.
This patient has:
Depressed mood for 3 years.
Low energy and low self-esteem (2 associated symptoms).
Symptoms never severe enough for MDD.
Why other options are incorrect:
Major depressive disorder requires 5 symptoms for 2 weeks. This is chronic but less severe.
Cyclothymic disorder involves alternating hypomanic and depressive symptoms.
Adjustment disorder is for symptoms within 3 months of a stressor that resolve within 6 months.
Treatment: Combination of psychotherapy (CBT) + antidepressants (SSRIs/SNRIs) is most effective.
Question 21: A 28-year-old woman presents with a 6-month history of persistent sadness, anhedonia, significant weight loss, insomnia, fatigue, feelings of worthlessness, and recurrent thoughts of death. She has difficulty functioning at work. What is the most likely diagnosis?
A) Persistent depressive disorder (dysthymia)
B) Major depressive disorder
C) Adjustment disorder with depressed mood
D) Bipolar II disorder
Answer: B) Major depressive disorder
Explanation: MDD is characterized by one or more major depressive episodes (5+ symptoms for 2 weeks).
Mnemonic: SIG E CAPS
Sleep, Interest (Anhedonia), Guilt (Worthlessness), Energy (Fatigue), Concentration, Appetite (Weight change), Psychomotor, Suicidal ideation.
This patient has 7 symptoms:
1. Persistent sadness.
2. Anhedonia.
3. Weight loss.
4. Insomnia.
5. Fatigue.
6. Worthlessness.
7. Thoughts of death.
Why other options are incorrect:
Persistent depressive disorder (dysthymia) requires 2 years of symptoms with fewer (2+) associated symptoms.
Adjustment disorder requires a specific stressor and failure to meet full MDD criteria.
Bipolar II requires a history of at least one hypomanic episode.
Treatment: SSRIs (first-line), SNRIs, and Psychotherapy (CBT/IPT). Combination therapy is often best.
Question 22: A 42-year-old man presents with a 1-week history of elevated mood, decreased need for sleep (sleeping only 3 hours per night), rapid speech, racing thoughts, and increased goal-directed activity. He has started multiple new business projects and spent his savings impulsively. He has a history of major depressive episodes. What is the most likely diagnosis?
A) Major depressive disorder
B) Bipolar I disorder
C) Bipolar II disorder
D) Cyclothymic disorder
Answer: B) Bipolar I disorder
Explanation: Bipolar I is defined by at least one manic episode (1 week duration or requiring hospitalization).
Mnemonic: DIG FAST
Distractibility, Irresponsibility (Risky behavior), Grandiosity, Flight of ideas, Activity increase, Sleep deficit (Decreased need), Talkativeness (Pressured speech).
This patient has 6 symptoms:
Elevated mood, Decreased sleep (3 hrs), Rapid speech, Racing thoughts, Increased activity (new projects), Risky behavior (spending savings).
Duration: 1 week.
Why other options are incorrect:
Major depressive disorder is ruled out by the manic episode.
Bipolar II requires hypomania (no marked impairment, no hospitalization) and MDD. This patient’s episode is full mania.
Cyclothymic disorder involves sub-threshold symptoms for 2 years.
Treatment: Lithium (Gold Standard), Valproate, or Atypical Antipsychotics (Quetiapine/Olanzapine). Antidepressants alone should be avoided.
Question 23: A 35-year-old woman has a history of recurrent major depressive episodes. She recently experienced a 5-day period of elevated mood, increased energy, decreased need for sleep, and increased productivity at work. Her functioning was not impaired, and she did not require hospitalization. What is the most likely diagnosis?
A) Bipolar I disorder
B) Bipolar II disorder
C) Cyclothymic disorder
D) Major depressive disorder
Answer: B) Bipolar II disorder
Explanation: Bipolar II is defined by at least one hypomanic episode AND at least one major depressive episode, but NEVER a full manic episode.
Hypomanic Episode (vs. Mania):
Duration: At least 4 consecutive days (Mania is 7).
Severity: Noticeable change in functioning but NOT severe impairment, no hospitalization, and NO psychotic features.
This patient has:
History of MDD.
5-day period (meets 4-day minimum).
Symptoms: Elevated mood, energy, decreased sleep, increased productivity.
No impairment/hospitalization.
Why other options are incorrect:
Bipolar I requires a full manic episode (7 days or impairment/hospitalization).
Cyclothymic disorder requires 2 years of sub-threshold symptoms without full MDD episodes.
Major depressive disorder is ruled out once a hypomanic episode occurs.
Treatment: Quetiapine, Lamotrigine, or Lithium. Sleep hygiene is critical as disruption can trigger episodes.
