Question 31: A 28-year-old woman has recurrent, intrusive thoughts about germ contamination and washes her hands >50 times/day until bleeding. She recognizes these thoughts are excessive but cannot stop.
What is the most likely diagnosis?
A) GAD
B) OCD
C) Specific phobia
D) Illness anxiety disorder
Answer: B) Obsessive-compulsive disorder (OCD)
Diagnosis Summary:
* Obsessions: Recurrent, intrusive, ego-dystonic thoughts (contamination).
* Compulsions: Repetitive behaviors (hand washing) to reduce anxiety.
* Criteria: Time-consuming (>1 hr/day) or causing clinical distress.
Differential Diagnosis:
* OCD vs OCPD: OCD is ego-dystonic (distressing/unwanted) with specific rituals. OCPD is ego-syntonic (perceived as correct/reasonable) and involves a pervasive pattern of perfectionism without true rituals.
* GAD: Focuses on real-life concerns (finances, health) and is ego-syntonic.
Treatment:
* Psychotherapy: Exposure and Response Prevention (ERP) is the gold standard.
* Pharmacotherapy: First-line SSRIs (High doses, 10–12 week trial required).
* Second-line: Clomipramine (TCA).
Question 32: A 35-year-old combat veteran has recurrent war nightmares, avoids news/movies about conflict, feels emotionally numb, is hypervigilant, and has an exaggerated startle response. Symptoms began 3 months post-deployment.
What is the most likely diagnosis?
A) Acute stress disorder
B) PTSD
C) Adjustment disorder
D) GAD
Answer: B) Post-traumatic stress disorder (PTSD)
Diagnostic Criteria (Duration >1 month):
1. Intrusion: Nightmares, flashbacks, intrusive memories.
2. Avoidance: Avoiding external reminders or memories.
3. Negative Alterations (Cognition/Mood): Numbing, detachment, inability to feel positive emotions.
4. Hyperarousal: Hypervigilance, exaggerated startle, sleep disturbance.
Differentiators:
* Acute Stress Disorder (ASD): Symptoms last 3 days to 1 month.
* Adjustment Disorder: Response to a stressor within 3 months, but does not meet full PTSD criteria.
Treatment:
* Therapy: Trauma-focused CBT (Prolonged Exposure, Cognitive Processing Therapy) or EMDR.
* Medication: First-line SSRIs (Sertraline, Paroxetine). Prazosin for nightmares.
* Avoid: Benzodiazepines (interfere with processing, risk of dependence).
Question 33: A 25-year-old woman presents 2 weeks after a car accident where her friend died. She has intrusive memories, difficulty sleeping, feels detached from reality, and has dissociative amnesia regarding the details.
What is the most likely diagnosis?
A) PTSD
B) Acute stress disorder
C) Adjustment disorder
D) Brief psychotic disorder
Answer: B) Acute stress disorder (ASD)
Diagnosis Summary:
* Timeline: Symptoms occur 3 days to 1 month after trauma. (If >1 month, it becomes PTSD).
* Symptoms: Requires 9+ symptoms from: Intrusion, Negative Mood, Dissociation, Avoidance, and Arousal.
* Dissociation: Prominent features include depersonalization, derealization, and dissociative amnesia.
Clinical Significance:
* 50–80% of those with ASD progress to PTSD.
* Treatment: Trauma-focused CBT is most effective for preventing progression to PTSD.
* Psychological First Aid: Focus on safety and social support.
* Avoid: Critical Incident Stress Debriefing (CISD) and Benzodiazepines (may worsen outcomes).
