Question 24: A 30-year-old woman has a 3-year history of fluctuating mood states. She experiences periods of mild depression alternating with periods of mild elevation in mood and energy, but has never met full criteria for major depressive, manic, or hypomanic episodes. What is the most likely diagnosis?
A) Bipolar I disorder
B) Bipolar II disorder
C) Cyclothymic disorder
D) Borderline personality disorder
Answer: C) Cyclothymic disorder
Explanation: Cyclothymic disorder (cyclothymia) is characterized by chronic, fluctuating mood disturbances involving numerous periods of hypomanic symptoms and depressive symptoms that do not meet full criteria for hypomanic or major depressive episodes.
DSM-5 Criteria:
1. For at least 2 years, numerous periods with hypomanic symptoms (sub-threshold) and numerous periods with depressive symptoms (sub-threshold).
2. Symptoms present for at least half the time; not without symptoms for more than 2 months.
3. Criteria for a major depressive, manic, or hypomanic episode have NEVER been met.
Key features: Chronic mood instability; unpredictable mood shifts; often perceived as a “moody” personality.
Why other options are incorrect:
Bipolar I requires at least one full manic episode.
Bipolar II requires at least one hypomanic episode AND one major depressive episode.
Borderline personality disorder mood changes are typically reactive to interpersonal events and last hours to days, rather than the sustained periods seen in cyclothymia.
Note: 15-50% of people with cyclothymia eventually develop bipolar I or II disorder.
Question 25: A 45-year-old man is brought to the emergency department by police after being found running naked in the street, shouting that he is “God’s messenger.” He has not slept in 5 days, demonstrates rapid, pressured speech, and appears highly agitated. What is the most likely diagnosis?
A) Schizophrenia
B) Bipolar I disorder, current episode manic with psychotic features
C) Delusional disorder, grandiose type
D) Substance-induced psychotic disorder
Answer: B) Bipolar I disorder, current episode manic with psychotic features
Explanation: This patient is experiencing a severe manic episode with psychotic features.
Manic symptoms present:
Severely decreased need for sleep (5 days).
Increased goal-directed activity/psychomotor agitation.
Pressured speech.
Psychotic features present:
Grandiose delusion (being “God’s messenger”).
Bizarre behavior (running naked).
Why other options are incorrect:
Schizophrenia requires symptoms for at least 6 months and is not primarily a mood disturbance. Psychosis here is in the context of acute mania.
Delusional disorder involves non-bizarre delusions for at least 1 month with otherwise preserved functioning; this patient is severely impaired and bizarre.
Substance-induced psychotic disorder (e.g., from stimulants) can mimic this, but toxicology is needed to confirm.
Emergency management: Immediate safety assessment, toxicology screen, and likely involuntary hospitalization. Treatment includes atypical antipsychotics (Haloperidol/Olanzapine) and mood stabilizers (Lithium/Valproate).
Question 26: A 50-year-old woman presents with sudden onset of severe anxiety, palpitations, sweating, trembling, shortness of breath, chest pain, and a feeling that she is going to die. The episode lasted 10 minutes and occurred “out of the blue” while she was grocery shopping. What is the most likely diagnosis?
A) Generalized anxiety disorder
B) Panic disorder
C) Social anxiety disorder
D) Myocardial infarction
Answer: B) Panic disorder
[Image of symptoms of a panic attack]
Explanation: This patient is experiencing a panic attack. Panic disorder involves recurrent unexpected panic attacks followed by at least 1 month of persistent concern about more attacks or behavioral changes.
Symptoms present (at least 7): Palpitations, sweating, trembling, shortness of breath, chest pain, fear of dying, and intense fear.
Key features:
Abrupt onset (“out of the blue”).
Rapid peak (within minutes).
Short duration (10-20 minutes).
Why other options are incorrect:
Generalized anxiety disorder involves chronic, diffuse worry over 6 months, not discrete “attacks.”
Social anxiety disorder involves fear of social scrutiny; this attack was unexpected and not triggered by evaluation.
Myocardial infarction must be ruled out, but the sudden onset, brief duration, and specific anxiety symptoms (fear of dying) in this context point to panic.
Workup: ECG and TSH should be checked to rule out cardiac issues or hyperthyroidism. First-line treatment includes SSRIs and CBT.
