Behavior 2 DSM V Questions

Which of the following symptoms is incompatible with a diagnosis of conver- sion disorder (functional neurological symptom disorder)? A. Light-headedness upon standing up. B. Dystonicmovements. C. Tunnel vision. D. Touch and temperature anesthesia with intact pinprick sensation over the left forearm. E. Transientlegweaknessinapatientwithknownmultiplesclerosis.

A The diagnosis of conversion disorder requires the presence of a voluntary motor or sensory symptom; "autonomic" symptoms such as ortho- static light-headedness would not be included in this category and would be better accommodated by a diagnosis of somatic symptom disorder. Tunnel vi- sion ("tubular visual field") and localized anesthesia for some but not all sen- sory modalities that are carried in the same nerve distribution are classic examples of sensory deficit symptoms that would be considered functional or psychogenic neurological symptoms. In a patient with a medical/neurological diagnosis such as multiple sclerosis that might account for a new neurological symptom, great caution should be exercised before labeling a symptom as psy- chogenic or functional, but it is possible even for patients with such illnesses to have functional symptoms.

Whichofthefollowingpresentationsischaracteristicofschizotypalpersonal- ity disorder? A. A pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. B. Apatternofacutediscomfortincloserelationships,cognitiveorperceptual distortions, and eccentricities of behavior. C. A pattern of submissive and clinging behavior related to an excessive need to be taken care of. D. A pattern of instability in interpersonal relationships, self-image, and af- fects, and marked impulsivity. E. Apatternofgrandiosity,needforadmiration,andlackofempathy.

B The essential feature of schizotypal personality disorder is a per- vasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior. This pattern begins by early adulthood and is present in a variety of contexts.

A 60-year-old man with a history of coronary disease and emphysema contin- ues to smoke one pack of cigarettes daily despite his doctor's clear advice that abstinence is important for his survival. He says he's tried to quit a dozen times but has always relapsed due to withdrawal symptoms or feelings of tension re- lieved by smoking. What is the most likely diagnosis? A. Psychological factors affecting other medical conditions. B. Tobaccousedisorder. C. Denial of illness. D. Nonadherence to medical treatment. E. Adjustmentdisorder.

B When a substance use disorder adversely affects a physical con- dition, the substance use disorder diagnosis is "usually sufficient" and the di- agnosis of psychological factor affecting a physical condition would be superfluous. If subthreshold substance use affects the course of the medical condition, the "psychological factors" diagnosis would be applied. In this vi- gnette, the patient does not manifest denial of illness, nonadherence to medical treatment (neither of which is a DSM diagnosis), or a maladaptive psycholog- ical response to a stressor (the sine qua non for an adjustment disorder.)

A 45-year-old man with a family history of early-onset coronary artery disease avoids climbing stairs, eschews exercise, and abstains from sexual activity for fear of provoking a heart attack. He frequently checks his pulse, reads exten- sively about preventive cardiology, and tries many health food supplements alleged to be good for the heart. When he experiences an occasional twinge of chest discomfort, he rests in bed for 24 hours; however, he does not go to doctors because he fears hearing bad news about his heart from them. What diag- nosis best fits this clinical picture? A. Persistent complex bereavement disorder. B. Adjustmentdisorder. C. Illness anxiety disorder. D. Unspecified somatic symptom and related disorder. E. Somaticsymptomdisorder.

C This man has the anxiety and preoccupation about somatic ill- ness and the reassurance seeking without relief that are characteristic of illness anxiety disorder. The fact that he does not go to doctors does not preclude the diagnosis. (He would fit the "care-avoidant" type.) One might surmise that his family history fuels his anxiety, and perhaps bereavement after the early death of a loved one from coronary disease plays a role in his illness, but we are pro- vided with no data to support this conjecture. Major life stress, including the death of a loved one, is considered a risk factor for illness anxiety disorder. So- matic symptoms are not a prominent part of the clinical presentation; rather, worry and preoccupation with having a disease are the main feature, so a so- matic symptom disorder diagnosis would be inappropriate.

Which of the following symptoms is a recognized consequence of the abrupt termination of daily or near-daily cannabis use? A. Hallucinations. B. Delusions. C. Hunger. D. Irritability. E. Apathy.

D Cannabis withdrawal is a newly recognized disorder in DSM-5. Common symptoms of cannabis withdrawal include irritability, anger, or ag- gression; nervousness or anxiety; sleep difficulty; decreased appetite or weight loss; restlessness; and depressed mood. Although typically not as severe as withdrawal from alcohol, sedative/hypnotics, or opioids, cannabis withdrawal can cause significant distress, contribute to difficulty quitting, and in- crease the risk of relapse.

Which personality disorder has the highest prevalence among individuals with cannabis use disorder? A. Obsessive-compulsive personality disorder. B. Paranoidpersonalitydisorder. C. Schizotypal personality disorder. D. Borderline personality disorder. E. Antisocialpersonalitydisorder.

E Antisocial personality disorder is the most prevalent (30%) per- sonality disorder among individuals with cannabis use disorder, followed by obsessive-compulsive personality disorder (19%) and paranoid personality disorder (18%).

Which of the following presentations is characteristic of avoidant personality disorder? A. A pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. B. Apatternofacutediscomfortincloserelationships,cognitiveorperceptual distortions, and eccentricities of behavior. C. A pattern of submissive and clinging behavior related to an excessive need to be taken care of. D. A pattern of instability in interpersonal relationships, self-image, and af- fects, and marked impulsivity. E. Apatternofgrandiosity,needforadmiration,andlackofempathy.

The essential feature of avoidant personality disorder is a perva- sive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation that begins by early adulthood and is present in a variety of contexts. Individuals with avoidant personality disorder avoid work activi- ties that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.

Whichofthefollowingisoneofthegeneralcriteriaforapersonalitydisorder in DSM-5? A. An enduring pattern of inner experience that deviates markedly from the expectations of the individual's culture. B. Thepatternisflexibleandconfinedtoasinglepersonalorsocialsituation. C. The pattern is fluctuating and of short duration. D. The pattern leads to occasional mild distress. E. The pattern's onset can be traced to a specific traumatic event in the indi- vidual's recent history.

A A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adult- hood, is stable over time, and leads to distress or impairment.

In addition to negative affectivity, which of the following maladaptive trait do- mains is most associated with avoidant personality disorder? A. Detachment. B. Antagonism. C. Disinhibition. D. Compulsivity. E. Psychoticism.

A Avoidant personality disorder is characterized by avoidance of social situations and inhibition in interpersonal relationships related to feel- ings of ineptitude and inadequacy, anxious preoccupation with negative eval- uation and rejection, and fears of ridicule or embarrassment. In the Alternative DSM-5 Model for Personality Disorders, the specific maladaptive trait do- mains are Negative Affectivity and Detachment. In addition, characteristic dif- ficulties are apparent in the personality functioning areas of identity, self- direction, empathy, and/or intimacy.

What is the relationship between a history of conduct disorder before age 15 and the diagnosis of antisocial personality after age 18? A. A history of some conduct disorder symptoms before age 15 is one of the required criteria for a diagnosis of antisocial personality disorder in adult- hood. B. Allchildrenwithconductdisorderwillgoontoreceiveadiagnosisofanti- social personality disorder in adulthood. C. Antisocial personality disorder diagnosis is independent of conduct disor- der. D. Conduct disorder is the same as antisocial personality disorder, except that financial irresponsibility is also a required feature of antisocial personality disorder. E. Conductdisorderisthesameasantisocialpersonalitydisorderexceptthat remorse is present in conduct disorder.

A Criterion C for the diagnosis of antisocial personality disorder states, "there is evidence of conduct disorder with onset before age 15 years." Like antisocial personality disorder, conduct disorder involves a repetitive and persistent pattern of behavior in which the basic rights of others or major age- appropriate societal norms or rules are violated. The specific behaviors charac- teristic of conduct disorder fall into one of four categories: aggression to people and animals, destruction of property, deceitfulness or theft, or serious violation of rules. The likelihood of developing antisocial personality disorder in adult life is increased if the individual experienced childhood onset of conduct dis- order (before age 10 years) and accompanying attention-deficit/hyperactivity disorder.

In addition to an assessment of pathological personality traits, a personality disorder diagnosis in the alternative DSM-5 model requires an assessment of which of the following? A. Level of impairment in personality functioning. B. ComorbiditywithAxisIdisorders. C. Degree of introversion versus extroversion. D. Stability of the personality traits over time. E. Familialinheritanceofspecifictraits.

A In the Alternative DSM-5 Model for Personality Disorders, a diagnosis of a personality disorder requires two determinations: 1) an assess- ment of the level of impairment in personality functioning, which is needed for Criterion A, and 2) an evaluation of pathological personality traits, which is re- quired for Criterion B. The impairments in personality functioning and person- ality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations (Criterion C); relatively stable across time, with onsets that can be traced back to at least adolescence or early adult- hood (Criterion D); not better explained by another mental disorder (Criterion E); not attributable to the effects of a substance or another medical condition (Criterion F); and not better understood as normal for an individual's develop- mental stage or sociocultural environment (Criterion G). All Section III person- ality disorders described by criteria sets, as well as personality disorder—trait specified (PD-TS), meet these general criteria, by definition.

WhichsubstanceorclassofsubstancesintheSubstance-RelatedandAddictive Disorders chapter of DSM-5 is not associated with a substance use disorder? A. Caffeine. B. Hallucinogens. C. Inhalants. D. Stimulants. E. Tobacco.

A Some caffeine users display symptoms consistent with problem- atic use, including tolerance and withdrawal. However, there are insufficient data to determine the clinical significance or prevalence of a caffeine use disor- der.Therefore, caffeine use disorder does not appear in the Substance-Related and Addictive Disorders chapter of DSM-5 but instead is included as a pro- posed criteria set in the "Conditions for Further Study" chapter of DSM-5 Sec- tion III to encourage further research. In contrast, there is evidence that caffeine withdrawal and caffeine intoxication are clinically significant and sufficiently prevalent.

Which of the following is a descriptive specifier included in the diagnostic cri- teria for somatic symptom disorder? A. With predominant pain. B. Withhypochondriasis. C. With psychological comorbidity. D. Psychotic type. E. Undifferentiated.

A The "with predominant pain" specifier is used for individuals whose somatic symptoms predominantly involve pain.

The Criterion A symptoms listed for other hallucinogen use disorder are the same as those listed for use disorders of most other substance classes, with one ex- ception. Which of the following is not a recognized symptom associated with hallucinogen use? A. Withdrawal. B. Tolerance. C. A persistent desire or unsuccessful efforts to cut down or control use of the substance. D. Recurrent use of the substance in situations in which it is physically hazard- ous. E. Craving,orastrongdesireorurgetousethesubstance.

A The Criterion A symptoms listed for other hallucinogen use disorder are the same as those listed for use disorders of most other substance classes, with the exception of withdrawal. A clinically significant withdrawal syn- drome associated with hallucinogens has not been consistently documented in humans, and therefore the diagnosis of other hallucinogen withdrawal is not in- cluded in DSM-5.

Inmostsubstance/medication-inducedmentaldisorders(withtheexception of substance/medication-induced major or mild neurocognitive disorder and hallucinogen persisting perception disorder), if the person abstains from sub- stance use, the disorder will eventually disappear or no longer be clinically rel- evant even without formal treatment. In what time frame is this likely to happen? A. One hour. B. Onemonth. C. Three months. D. One year. E. "Relativelyquickly"butnospecificperiodoftime.

B Although the symptoms of substance/medication-induced men- tal disorders can be identical to those of independent mental disorders (e.g., delusions, hallucinations, psychoses, major depressive episodes, anxiety syn- dromes), and although they can have the same severe consequences (e.g., sui- cide), most induced mental disorders are likely to improve relatively quickly with abstinence and are unlikely to remain clinically relevant for more than 1 month after complete cessation of use.

A 36-year-old woman is approached by her new boss, who has noticed that de- spite 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 be- cause 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. Avoidantpersonalitydisorder. C. Obsessive-compulsive personality disorder. D. Schizoid personality disorder. E. Borderlinepersonalitydisorder.

B Avoidant personality disorder is characterized by feelings of in- adequacy, 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 occupa- tional 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 disor- der is an unstable self-image, rather than persistently low self-esteem. Long work hours and rechecking work can be seen with obsessive-compulsive per- sonality disorder, but in that disorder the cause is a perfectionistic or rigid style of approach, not fear of criticism or humiliation. People with schizoid person- ality disorder are generally relatively indifferent to criticism from others.

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 al- most always works night shifts to avoid interactions with others. He tries to re- main 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.

B 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 dis- order. 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 con- stantly seek out nurturance and support from others.

Over a period of several years, a 50-year-old woman visits her dermatologist's office every few weeks to be evaluated for skin cancer, showing the dermatol- ogist various freckles, nevi, and patches of dry skin about which she has be- come concerned. None of the skin findings have ever been abnormal, and the dermatologist has repeatedly reassured her. The woman does not have pain, itching, bleeding, or other somatic symptoms. She does have a history of occa- sional panic attacks. What is the most likely diagnosis? A. Unspecified anxiety disorder. B. Illnessanxietydisorder. C. Hypochondriasis. D. Somatic symptom disorder. E. Factitiousdisorder.

B One should consider the possibility that the presenting problem is better accounted for by another psychiatric disorder that would preclude a diagnosis of illness anxiety disorder, but the mere presence of another anxiety symptom (panic attacks) is not sufficient to conclude that another anxiety dis- order diagnosis better explains the patient's problem. Illness anxiety disorder is the appropriate diagnosis because the patient has no somatic symptom but does have a persistent worry that she has a serious illness (skin cancer), is eas- ily alarmed by minor somatic changes (patches of dry skin), and repeatedly and excessively seeks reassurance through medical checkups, with persistence of the problem for more than 6 months. The term hypochondriasis as a synonym for illness anxiety is no longer used as a diagnostic label. The absence of a so- matic symptom rules out somatic symptom disorder. Factitious disorder en- tails willful falsification of signs or symptoms.

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 super- natural 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. Schizotypalpersonalitydisorder. C. Paranoid personality disorder. D. Delusional disorder. E. Schizophrenia.

B 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 pres- ent. 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 char- acterized by marked oddness or eccentricity.

What is the essential diagnostic feature of factitious disorder? A. Somatic symptoms. B. Consciousmisrepresentationanddeception. C. External gain associated with illness. D. Absence of another medical disorder that may cause the symptoms. E. Normalphysicalexaminationandlaboratorytests.

B The essential feature of factitious disorder is the falsification of medical or psychological signs and symptoms in oneself or others that are as- sociated with the identified deception. Individuals with factitious disorder can also seek treatment for themselves or another following induction of injury or disease. The diagnosis requires demonstrating that the individual is taking surreptitious actions to misrepresent, simulate, or cause signs or symptoms of illness or injury in the absence of obvious external rewards. Methods of illness falsification can include exaggeration, fabrication, simulation, and induction. While a preexisting medical condition may be present, the deceptive behavior or induction of injury associated with deception causes others to view such in- dividuals (or another) as more ill or impaired, and this can lead to excessive clinical intervention.

Whichofthefollowingpresentationsischaracteristicofparanoidpersonality disorder? A. A pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. B. Apatternofdistrustandsuspiciousnesssuchthatothers'motivesareinter- preted as malevolent. C. A pattern of submissive and clinging behavior related to an excessive need to be taken care of. D. A pattern of instability in interpersonal relationships, self-image, and af- fects, and marked impulsivity. E. Apatternofgrandiosity,needforadmiration,andlackofempathy.

B The essential feature of paranoid personality disorder is a pattern of pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent. This pattern begins by early adulthood and is pres- ent in a variety of contexts. Individuals with this disorder assume that other people will exploit, harm, or deceive them, even if no evidence exists to sup- port this expectation.

In order to meet the proposed diagnostic criteria for antisocial personality dis- order (ASPD) in the Alternative DSM-5 Model for Personality Disorders, an in- dividual must have maladaptive personality traits in which of the following domains? A. Negative affectivity. B. Detachment. C. Antagonism. D. Suicidality. E. Psychoticism.

C ASPD is characterized by maladaptive traits in the domains of an- tagonism (especially manipulativeness, deceitfulness, callousness, and hostility) and disinhibition (especially irresponsibility, impulsivity, and risk taking). Neg- ative affectivity is more characteristic of borderline personality disorder; detach- ment of schizotypal or avoidant personality disorders; and psychoticism of schizotypal personality disorder. Individuals with ASPD do not have a mark- edly increased incidence of suicidality (which is not a personality trait).

In DSM-IV, a patient with a high level of anxiety about having a disease and many associated somatic symptoms would have been given the diagnosis of hypochondriasis. What DSM-5 diagnosis would apply to this patient? A. Hypochondriasis. B. Illnessanxietydisorder. C. Somatic symptom disorder. D. Generalized anxiety disorder. E. Unspecifiedsomaticsymptomandrelateddisorder.

C All of these disorders are characterized by the prominent focus on somatic concerns and their initial presentation mainly in medical rather than mental health care settings. Somatic symptom disorder offers a more clin- ically useful method of characterizing individuals who may have been consid- ered in the past for a diagnosis of somatization disorder. Furthermore, approximately 75% of individuals previously diagnosed with hypochondriasis are subsumed under the diagnosis of somatic symptom disorder. However, about 25% of individuals with hypochondriasis have high health anxiety in the absence of somatic symptoms, and many such individuals' symptoms would not qualify for an anxiety disorder diagnosis. The DSM-5 diagnosis of illness anxiety disorder is for this latter group of individuals. Illness anxiety disorder can be considered either in this diagnostic section or as an anxiety disorder. Be- cause of the strong focus on somatic concerns, and because illness anxiety dis- order is most often encountered in medical settings, for utility it is listed with the somatic symptom and related disorders. Hypochondriasis has been elimi- nated as a diagnostic label. Individuals with a high level of anxiety about hav- ing an illness but without prominent somatic symptoms are now included in illness anxiety disorder.

Why is la belle indifférence (apparent lack of concern about the symptom) not in- cluded as a diagnostic criterion for conversion disorder (functional neurologi- cal symptom disorder)? A. It has poor interrater reliability. B. Ithaspoorspecificity. C. It has poor sensitivity. D. It pathologizes stoicism. E. Ithaspoortest-retestreliability.

C Although classically described as a feature of conversion disor- der, la belle indifférence (i.e., apparent lack of concern about the nature or impli- cations of the symptom) is not specific for conversion disorder and should not be used to make the diagnosis.

A 25-year-old woman with a history of intravenous heroin abuse is admitted to the hospital with infective endocarditis. Blood cultures are positive for sev- eral fungal species. Search of the patient's belongings discloses hidden sy- ringes and needles and a small bag of dirt, which, when cultured, yields the same fungal species. Which of the following diagnoses are likely to apply? A. Infective endocarditis, opioid use disorder, malingering, factitious disorder, and antisocial personality disorder. B. Opioidusedisorderandmalingering. C. Infective endocarditis, opioid use disorder, and factitious disorder. D. Malingering and antisocial personality disorder. E. Malingeringandfactitiousdisorder.

C Although intravenous drug use is often the route of infection in infective endocarditis, in this vignette the infection is due to soil flora, suggest- ing that the patient injected dirt from the sample hidden in her belongings to cause the infection. Factitious illness includes some instances in which the pa- tient actually surreptitiously causes a medical condition, not just cases in which the patient deceives others about factitious signs and symptoms. We have no evidence of external reward to justify considering a diagnosis of ma- lingering, and, apart from deception about her illness, nothing to suggest anti- social personality disorder.

Whichsubstanceusedisorderofanillicitsubstanceisthemostprevalentinthe United States? A. Alcohol use disorder. B. Caffeineusedisorder. C. Cannabis use disorder. D. Opioid use disorder. E. Stimulantusedisorder.

C Cannabinoids are the most widely used illicit psychoactive sub- stances in the United States. The 12-month prevalence of cannabis use disorder is approximately 3.4% among 12- to 17-year-olds and 1.5% among adults age 18 years or older. Alcohol use disorder is the most prevalent of all of the sub- stance use disorders in the United States. The 12-month prevalence of alcohol use disorder is estimated to be 4.6% among 12- to 17-year-olds and 8.5% among adults age 18 years or older in the United States. Although caffeine is the most widely used behaviorally active substance in the world, there are insufficient data to determine the clinical significance of caffeine use disorder and its preva- lence at this time. Thus, caffeine use disorder is not an officially recognized DSM-5 diagnosis but rather is included in "Conditions for Further Study" (Sec- tion III) as a proposed diagnostic set. The 12-month prevalence of opioid use dis- order is approximately 0.37% among adults age 18 years or older in the community population. Regarding stimulant use disorders, the 12-month preva- lence of cocaine use disorder in the United States is approximately 0.2% among 12- to 17-year-olds and 0.3% among adults age 18 years or older, and the 12- month prevalence of amphetamine-type stimulant use disorder in the United States is approximately 0.2% among 12- to 17-year-olds and 0.2% among adults age 18 years or older.

A 60-year-old man has prostate cancer with bony metastases that cause persis- tent pain. He is being treated with antiandrogen medications that result in hot flashes. Although (by his own assessment) his pain is well controlled with an- algesics, he states that he is unable to work because of his symptoms. Despite reassurance that his medications are controlling his metastatic disease, every instance of pain leads him to worry that he has new bony lesions and is about to die, and he continually expresses fears about his impending death to his wife and children. Which diagnosis best fits this patient's presentation? A. Panic disorder. B. Illnessanxietydisorder. C. Somatic symptom disorder. D. Psychological factors affecting other medical conditions. E. Adjustmentdisorderwithanxiousmood.

C In this vignette the patient's somatic symptoms are "medically explained" by the metastatic disease and antiandrogen therapy; however, their presence in conjunction with an excessively high level of anxiety, anticipatory fearfulness, and behavioral reactivity point to a diagnosis of somatic symptom disorder. It is not the experience of uncontrolled pain that is the patient's prob- lem, it is his conviction that pain signifies progression of his cancer. The diagnosis of psychological factors affecting another medical condition applies when a medical symptom or condition is present AND psychological or behavioral factors adversely affect the medical condition in one of the fol- lowing ways: 1) close temporal association of the psychological factor and the onset or exacerbation or delay in recovery of the medical condition; 2) the fac- tors interfere with treatment; 3) the factors add to the individual's health risk; 4) the factors influence the pathophysiology to precipitate or exacerbate symp- toms. When dysfunctional illness anxiety accompanies a prominent somatic symptom, somatic symptom disorder is a more appropriate diagnosis than ill- ness anxiety disorder. If the patient had no somatic symptoms but had recently been told that his illness had taken a turn for the worse, and then transiently experienced worry, jitteriness, and sleeplessness, one might label his condition an adjustment disorder with anxious mood.

Individuals with obsessive-compulsive personality disorder are primarily mo- tivated by a need for which of the following? A. Efficiency. B. Admiration. C. Control. D. Intimacy. E. Autonomy.

C Individuals with obsessive-compulsive personality disorder at- tempt to maintain a sense of control through a rigid preoccupation with order and detail. Unlike individuals with narcissistic personality disorder, their de- sire for perfection comes from this need for control rather than a need for ad- miration. The individual's rigidity and perfectionism can cause a debilitating degree of inefficiency. Individuals with this disorder may have difficulty ex- pressing affection or tolerating expressions of affection from others and tend to avoid intimacy, but they do have the capacity for intimacy. They are sensitive to hierarchies and can be rigidly deferential to the authority figures they re- spect.

Whichmentaldisorderordisorderclasshasthehighestprevalenceamongin- dividuals with cannabis use disorder? A. Major depressive disorder. B. BipolarIdisorder. C. Anxiety disorders. D. Schizophrenia spectrum and other psychotic disorders. E. Conductdisorder.

C Individuals with past-year or lifetime diagnoses of cannabis use disorder have high rates of concurrent mental disorders. Anxiety disorders are the most prevalent (24%), followed by bipolar I disorder (13%) and major de- pressive disorder (11%).

Because opioid withdrawal and sedative, hypnotic, or anxiolytic withdrawal can involve very similar symptoms, distinguishing between the two can be dif- ficult. Which of the following presenting symptoms would aid in making the correct diagnosis? A. Nausea or vomiting. B. Anxiety. C. Yawning. D. Restlessness or agitation. E. Insomnia.

C Opioid withdrawal is characterized by a pattern of signs and symptoms that are opposite to the acute agonist effects. The first of these are subjective and consist of complaints of anxiety, restlessness, and an "achy feel- ing" that is often located in the back and legs, along with irritability and in- creased sensitivity to pain. Three or more of the following must be present to make a diagnosis of opioid withdrawal: dysphoric mood; nausea or vomiting; muscle aches; lacrimation or rhinorrhea; pupillary dilation, piloerection, or in- creased sweating; diarrhea; yawning; fever; insomnia (Criterion B). Piloerection and fever are associated with more severe withdrawal and are not often seen in routine clinical practice because individuals with opioid use disorder usually obtain substances before withdrawal becomes that far advanced. Sedative, hypnotic, or anxiolytic withdrawal also includes anxiety and psy- chomotor agitation among its DSM-5 symptom criteria. These are not criteria included in the DSM-5 definition of opioid withdrawal, but withdrawal from opioids is nonetheless often accompanied by anxiety and restlessness. Only opioid withdrawal presents with yawning, rhinorrhea or lacrimation, pupil- lary dilation, or muscle aches, any of which may be used to fulfill Criterion B for a withdrawal diagnosis.

When a mother knowingly and deceptively reports signs and symptoms of ill- ness in her preschool-aged child, resulting in the child's hospitalization and subjection to numerous tests and procedures, what diagnosis would be re- corded for the child? A. Munchausen syndrome by proxy. B. Factitiousdisorderbyproxy. C. No diagnosis. D. Munchausen syndrome imposed on another. E. Factitiousdisorderimposedonanother.

C Situations in which an individual falsifies illness in another in the absence of obvious external rewards and presents that person to others as ill, impaired, or injured qualify for a diagnosis of factitious disorder imposed on another. This diagnosis pertains to the perpetrator of the falsification, not the victim. In addition to other people, animals (e.g., pets) may be victims of such falsification. The diagnosis of factitious disorder is not made when the behav- ior is better explained by another mental disorder. The victim of this kind of fal- sification is not coded as having a mental disorder diagnosis (unless another diagnosis is present). The term Munchausen syndrome is not used in DSM-5, and the DSM-IV term by proxy has been replaced with imposed on another. DSM-5 states that the victim "may" be given an abuse diagnosis (if warranted).

In DSM-III and DSM-IV, a large number of somatic symptoms were needed to qualify for the diagnosis of somatization disorder. How many somatic symp- toms are needed to meet symptom criteria for the DSM-5 diagnosis of somatic symptom disorder? A. Four: at least one pseudoneurological, one pain, one sexual, and one gastro- intestinal symptom. B. Fifteen,distributedacrossseveralorgansystems. C. One. D. At least one that is medically unexplained. E. None.

C The diagnosis of somatic symptom disorder requires one or more somatic symptoms that are distressing or result in disruption of daily life (Cri- terion A). The individual must also manifest "excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns" (Cri- terion B). with persistence of the symptomatic state (typically for more than 6 months) (Criterion C). The excessive symptoms in Criterion B may manifest in one of the following ways: 1) disproportionate and persistent thoughts about the seriousness of one's symptoms; 2) persistently high level of anxiety about health or symptoms; 3) excessive time and energy devoted to these symptoms or health concerns. A symptom need not be medically unex- plained—it is the presence of the symptom along with the "excessive" cogni- tive-affective-behavioral response that defines the disorder.

Whichofthefollowingpresentationsischaracteristicofborderlinepersonality disorder? A. A pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior. B. Apatternofsubmissiveandclingingbehaviorrelatedtoanexcessiveneed to be taken care of. C. A pattern of instability in interpersonal relationships, self-image, and af- fects, and marked impulsivity. D. A pattern of grandiosity, need for admiration, and lack of empathy. E. Apatternofexcessiveemotionalityandattentionseeking.

C The diagnostic criteria for borderline personality disorder re- quire the presence of a pervasive pattern of instability of interpersonal relation- ships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts. Individuals with borderline personality disorder make frantic efforts to avoid real or imagined abandonment (Criterion 1). The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, affect, cognition, and behavior.

Whichofthefollowingpresentationsischaracteristicofobsessive-compulsive personality disorder? A. A pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. B. Apatternofacutediscomfortincloserelationships,cognitiveorperceptual distortions, and eccentricities of behavior. C. A pattern of preoccupation with orderliness, perfectionism, and control. D. A pattern of detachment from social relationships and a restricted range of emotional expression. E. Apatternofgrandiosity,needforadmiration,andlackofempathy.

C The essential feature of obsessive-compulsive personality disor- der is a preoccupation with orderliness, perfectionism, and mental and inter- personal control, at the expense of flexibility, openness, and efficiency. This pattern begins by early adulthood and is present in a variety of contexts. Indi- viduals with obsessive-compulsive personality disorder attempt to maintain a sense of control through painstaking attention to rules, trivial details, proce- dures, lists, schedules, or form to the extent that the major point of the activity is lost.

The diagnosis of personality disorder—trait specified in the Alternative DSM- 5 Model of Personality Disorders differs from the DSM-IV diagnosis of person- ality disorder not otherwise specified in that the DSM-5 diagnosis includes personality trait domains based on which of the following? A. The level of impairment. B. TheirresemblancetoAxisIdisorders. C. The five-factor model of personality. D. Cognitive theories of behavior. E. Neurobiologicalcorrelatesofbehavior.

C The personality trait system presented in the Alternative DSM-5 Model for Personality Disorders includes five broad domains of personality trait variation—Negative Affectivity (vs. Emotional Stability), Detachment (vs. Extraversion), Antagonism (vs. Agreeableness), Disinhibition (vs. Conscien- tiousness), and Psychoticism (vs. Lucidity)—comprising 25 specific personal- ity trait facets. These five broad domains are maladaptive variants of the five domains of the extensively validated and replicated personality model known as the "Big Five," or Five Factor Model of personality (FFM), and are also sim- ilar to the domains of the Personality Psychopathology Five (PSY-5).

Which of the following is a domain of the Alternative DSM-5 Model for Per- sonality Disorders? A. Neuroticism. B. Extraversion. C. Disinhibition. D. Agreeableness. E. Conscientiousness.

C The personality trait system presented in the Alternative DSM-5 Model for Personality Disorders includes five broad domains of personality trait variation—Negative Affectivity (vs. Emotional Stability), Detachment (vs. Extraversion), Antagonism (vs. Agreeableness), Disinhibition (vs. Conscien- tiousness), and Psychoticism (vs. Lucidity)—comprising 25 specific personality trait facets. These five broad domains are maladaptive variants of the five do- mains of the extensively validated and replicated personality model known as the "Big Five," or Five Factor Model of personality (FFM), and are also similar to the domains of the Personality Psychopathology Five (PSY-5). The specific 25 facets represent a list of personality facets chosen for their clinical relevance.

Which of the following statements about the development, course, and prog- nosis of borderline personality disorder (BPD) is true? A. The risk of suicide in individuals with BPD increases with age. B. Achildhoodhistoryofneglect,ratherthanabuse,isunusualinindividuals 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 lon- ger meet full criteria for the disorder. D. Individuals with BPD have relatively low rates of improvement in social or occupational functioning. E. ThereislittlevariabilityinthecourseofBPD.

C The prognosis for symptomatic improvement in BPD is better than many clinicians realize, and there is considerable variability in the disor- der'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 voca- tional functioning in their 30s and 40s. Individuals with BPD do have an in- creased incidence of childhood neglect as well as an increased incidence of childhood physical and sexual abuse.

A 20-year-old man presents with the complaint of acute onset of decreased vi- sual acuity in his left eye. Physical, neurological, and laboratory examinations are entirely normal, including stereopsis testing, fogging test, and brain mag- netic resonance imaging. The remainder of the history is negative except for the patient's report that since his midteens he has felt that his left cheekbone and eyebrow are too big. He spends a lot of time comparing the right and left sides of his face in the mirror. He is planning to have plastic surgery as soon as he graduates from college. Which of the following diagnoses are suggested? A. Somatic symptom disorder and delusional disorder, somatic subtype. B. Somaticsymptomdisorderandillnessanxietydisorder. C. Body dysmorphic disorder and conversion disorder (functional neurologi- cal symptom disorder). D. Somatic symptom disorder, illness anxiety disorder, and body dysmorphic disorder. E. Delusionaldisorder,somaticsubtype.

C The vision complaint and normal examinations are consistent with a diagnosis of a functional neurological symptom disorder, specifically a functional visual acuity problem ("special sensory" subtype of conversion dis- order). The long-standing concern about the appearance of the left side of his face is consistent with a diagnosis of body dysmorphic disorder, as is the plan for plastic surgery in the absence of any visible cosmetic defect. An individual can have both of these diagnoses. One might speculate about the relationship, in this case, of preoccupation with the appearance of the left side of the face in particular and the development of functional symptoms in the left eye, but these speculations are beyond the scope of DSM-5 diagnosis.

A25-year-oldmedicalstudentpresentstothestudenthealthserviceat7A.M. complaining of having a "panic attack." He reports that he stayed up all night studying for his final gross anatomy exam, which starts in an hour, but he feels too anxious to go. He reports vomiting twice. The patient is restless and ap- pears flushed, with visible muscle twitching. He is urinating excessively, has tachycardia, and his electrocardiogram shows premature ventricular com- plexes. His thoughts and speech appear to be rambling in nature. His urine tox- icology screen is negative. What is the most likely diagnosis? A. Panic disorder. B. Amphetamineintoxication,amphetamine-likesubstance. C. Caffeine intoxication. D. Cocaine intoxication. E. Alcoholwithdrawal.

C This patient is exhibiting signs of restlessness, flushed face, gas- trointestinal disturbance, muscle twitching, diuresis, rambling flow of speech, and cardiac abnormalities, all of which are consistent with caffeine intoxica- tion. While a panic episode might be associated with tachycardia or gastroin- testinal distress, it would not cause muscle twitching or cardiac arrhythmias. Intoxication with stimulants such as amphetamine or cocaine would present very similarly with psychomotor agitation and cardiac arrhythmias, but these substances would not cause diuresis and would be expected to show up on a urine toxicology screen. Alcohol withdrawal could also present similarly but is typically characterized by tremor rather than muscle twitching, and it also does not cause diuresis.

Which of the following statements about caffeine-related disorders is true? A. Culturally appropriate levels of caffeine intake should be considered when making the diagnosis of caffeine intoxication. B. Inordertodiagnosecaffeineintoxication,atleastonesymptommustbegin during caffeine use. C. The diagnosis of caffeine withdrawal requires the preceding use of caffeine on a daily basis. D. Caffeine withdrawal may be diagnosed even in the absence of clinically sig- nificant distress or impairment in social, occupational, or other important areas of functioning. E. Extensivedataareavailableregardingtheprevalenceofcaffeineusedisor- der.

C. Criterion A of caffeine withdrawal is "prolonged daily use of caf- feine." Caffeine intoxication may be diagnosed regardless of the individual's cultural background, and all symptoms may begin either during or shortly af- ter caffeine use. In caffeine withdrawal, as in other substance withdrawal diag- noses, the symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Currently there is insufficient evidence regarding the prevalence of the proposed diagnosis of caffeine use disorder, which is listed in the "Conditions for Further Study" chapter in DSM-5 Section III to encourage research.

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-compulsivedisorder(OCD). C. Avoidant personality disorder. D. Obsessive-compulsive personality disorder (OCPD). E. Unspecifiedpersonalitydisorder.

D OCPD describes a series of enduring, maladaptive traits and be- haviors characterized by excessive perfectionism, preoccupation with orderli- ness 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, includ- ing narcissistic personality disorder and avoidant personality disorder. Whereas individuals with narcissistic personality disorder may profess a de- sire to strive for perfection, this is in the service of self-aggrandizement. Indi- viduals 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 eas- ily distinguished from OCPD by the presence of true obsessions and compul- sions in OCD. When criteria for both OCPD and OCD are met, both diagnoses should be recorded.

Whichofthefollowingsubstanceusedisordersismorecommonamongado- lescent males than among adolescent females? A. Other hallucinogen use disorder. B. Inhalantusedisorder. C. Sedative, hypnotic, or anxiolytic use disorder. D. Stimulant use disorder, cocaine subtype. E. Stimulantusedisorder,amphetamine-typesubstancesubtype.

D Although for the majority of substances the prevalence of a sub- stance use disorder is higher in adult men versus women, among adolescents there are a number of substances in which this trend is reversed. The 12-month prevalence of stimulant use disorder, cocaine subtype among 12- to 17-year-olds is greater in males (0.4%) relative to females (0.1%). The 12-month prevalence of other hallucinogen use disorder is slightly higher in adolescent females (0.6%) than in males (0.4%). For 12- to 17-year-olds, the rate of sedative, hypnotic, or anxiolytic use disorder in females (0.4%) exceeds that of males (0.2%). Among 12- to 17-year-olds, the rate of stimulant use disorder, amphetamine-type substance sub- type in females (0.3%) is greater than the rate in males (0.1%). The rate of inhalant use disorder is 0.4% in both 12- to 17-year-old boys and girls. Of note, adolescent males are overall more likely than adolescent females to experiment with and use substances.

Which of the following is not a characteristic of narcissistic personality disorder (NPD)? A. Excessive reference to others for self-definition and self-esteem regulation. B. Impairedabilitytorecognizeoridentifywiththefeelingsandneedsofothers. C. Excessive attempts to attract and be the focus of the attention of others. D. Persistence at tasks long after the behavior has ceased to be functional or ef- fective. E. Preoccupationwithfantasiesofunlimitedsuccessorpower.

D Although individuals with NPD and those with obsessive-com- pulsive personality disorder (OCPD) may both profess a commitment to per- fection, persistence at tasks long after the behavior has ceased to be functional is more characteristic of the perfectionism of individuals with OCPD rather than that of individuals with NPD. In contrast to the self-criticism of individu- als with OCPD, individuals with NPD are more likely to believe that they have reached perfection. The other options are all characteristic traits of individuals with NPD.

Illness anxiety disorder involves a preoccupation with having or acquiring a serious illness. How severe must the accompanying somatic symptoms be to meet criteria for the diagnosis of illness anxiety disorder? A. Mild to moderate severity. B. Moderatetohighseverity. C. Any level of severity. D. Mild severity at most, but there need not be any somatic symptoms. E. Noneoftheabove;thepresenceofanysomaticsymptomsrulesoutthedi- agnosis of illness anxiety disorder.

D Criterion B for illness anxiety disorder states, "Somatic symp- toms are not present or, if present, are only mild in intensity." The hallmark of the disorder is chronic, excessive, and disproportionate preoccupation and worry about having or acquiring a serious medical illness, rather than a so- matic complaint. If somatic symptoms are present, it is likely that a diagnosis of somatic symptom disorder is more appropriate.

In the Alternative DSM-5 Model for Personality Disorders, which of the fol- lowing is not an element used to assess level of impairment in personality func- tioning? A. Identity. B. Self-direction. C. Empathy. D. Work performance. E. Intimacy.

D Disturbances in self and interpersonal functioning constitute the core of personality psychopathology. Self functioning involves identity and self-direction; interpersonal functioning involves empathy and intimacy. Al- though work performance was used in the DSM-IV Global Assessment of Functioning Scale, it is not used for the assessment of personality functioning.

Whatisthehallmarkfeatureofcaffeinewithdrawal? A. Vomiting. B. Drowsiness. C. Flu-like symptoms. D. Headache. E. Dysphoria.

D Headache is the hallmark feature of caffeine withdrawal. The re- maining options are also symptoms of caffeine withdrawal and could occur in absence of headache. Caffeine is the most widely consumed behaviorally ac- tive drug in the world. Because caffeine ingestion is often integrated into social customs and daily rituals (e.g., coffee break, tea time), some caffeine consumers may be unaware of their physical dependence on caffeine and thus withdrawal symptoms could be unexpected and misattributed to other causes (e.g., the flu, migraine). Caffeine withdrawal symptoms may occur when individuals are re- quired to abstain from foods and beverages prior to medical procedures or when a usual caffeine dose is missed because of a change in routine (e.g., dur- ing travel, weekends).

Which of the following cognitive or perceptual disturbances are associated with borderline personality disorder? A. Odd thinking and speech. B. Ideasofreference. C. Odd beliefs. D. Transient, stress-related paranoid ideation. E. Superstitiousness.

D In borderline personality disorder, transient paranoid ideation or dissociative symptoms (e.g., depersonalization) may occur during periods of extreme stress, but these are generally of insufficient severity or duration to warrant an additional diagnosis. These episodes occur most frequently in re- sponse to a real or imagined abandonment. Symptoms tend to be transient, lasting minutes or hours. Odd thinking and speech, ideas of reference, odd beliefs, and superstitious- ness are characteristic of schizotypal personality disorder rather than border- line personality disorder.

A 25-year-old woman with asthma becomes extremely anxious when she gets an upper respiratory infection. She presents to the emergency department with complaints of being unable to breathe. While there, she begins to hyperventi- late and then reports feeling extremely dizzy. Her hyperventilation causes her to become fatigued, and when the medical evaluation indicates that she is re- taining carbon dioxide (CO2), it becomes necessary to admit her. The woman denies any other symptoms beyond anxiety. What is the most appropriate di- agnosis? A. Acute stress disorder. B. Generalizedanxietydisorder. C. Adjustment disorder with anxiety. D. Psychological factors affecting other medical conditions. E. Factitiousdisorder.

D In psychological factors affecting other medical conditions, spe- cific psychological entities (e.g., psychological symptoms, behaviors, other fac- tors) exacerbate a medical condition. These psychological factors can precipitate, exacerbate, or put an individual at risk for medical illness, or they can worsen an existing condition. In contrast, an adjustment disorder is a reac- tion to the stressor (e.g., having a medical illness).

Which of the following findings would rule out the diagnosis of obsessive- compulsive personality disorder (OCPD)? A. A concurrent diagnosis of obsessive-compulsive disorder. B. Aconcurrentdiagnosisofantisocialpersonalitydisorder. C. Evidence of psychotic symptoms. D. Evidence that the behavioral patterns reflect culturally sanctioned interper- sonal styles. E. Aconcurrentdiagnosisofcocaineusedisorder.

D OCPD must be distinguished from behavior that remains within a normal range; for example, if an individual's OCPD-like behaviors are cul- turally sanctioned (e.g., they occur within the context of a culture that places substantial emphasis on work and productivity), then a personality disorder diagnosis would not be appropriate. OCPD can coexist with a number of other disorders. For example, OCPD can be comorbid with obsessive-compulsive disorder (OCD), and an OCD diagnosis carries an elevated risk for OCPD, even though the majority of those with OCD do not have OCPD. Substance use disorders can be comorbid with OCPD, and there may be an association be- tween OCPD and depressive disorders, bipolar and related disorders, and eat- ing disorders. Psychotic disorders may also coexist with OCPD.

Somatoform Disorders in DSM-IV are referred to as Somatic Symptom and Re- lated Disorders in DSM-5. Which of the following features characterizes the major diagnosis in this class, somatic symptom disorder? A. Medically unexplained somatic symptoms. B. Underlyingpsychicconflict. C. Masochism. D. Distressing somatic symptoms and abnormal thoughts, feelings, and be- haviors in response to these symptoms. E. Comorbiditywithanxietyanddepressivedisorders.

D Somatic symptom disorder emphasizes diagnosis made on the basis of positive symptoms and signs (distressing somatic symptoms plus ab- normal thoughts, feelings, and behaviors in response to these symptoms) rather than the absence of a medical explanation for somatic symptoms. A dis- tinctive characteristic of many individuals with somatic symptom disorder is not the somatic symptoms per se, but instead the way they present and inter- pret them. Incorporating affective, cognitive, and behavioral components into the criteria for somatic symptom disorder provides a more comprehensive and accurate reflection of the true clinical picture than can be achieved by assessing the somatic complaints alone.

Whichofthefollowingpresentationsischaracteristicofantisocialpersonality disorder? A. A pattern of preoccupation with orderliness, perfectionism, and control. B. Apatternofdetachmentfromsocialrelationshipsandarestrictedrangeof emotional expression. C. Apatternofdistrustandsuspiciousnesssuchthatothers'motivesareinter- preted as malevolent. D. A pattern of disregard for, and violation of, the rights of others. E. A pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

D The essential feature of antisocial personality disorder is a perva- sive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. This pattern has also been referred to as psychopathy, sociopathy, or dyssocial personality dis- order. Because deceit and manipulation are central features of antisocial per- sonality disorder, it may be especially helpful to integrate information acquired from systematic clinical assessment with information collected from collateral sources. For this diagnosis to be given, the individual must be at least age 18 years (Criterion B) and must have had a history of some symptoms of conduct disorder before age 15 years.

A 25-year-old woman is hospitalized for evaluation of episodes in which she appears to lose consciousness, rocks her head from side to side, and moves her arms and legs in a nonsynchronous, bicycling pattern. The episodes occur a few times per day and last for 2-5 minutes. Electroencephalography during the episodes does not reveal any ictal activity. Immediately after a fit, her senso- rium appears clear. What is the most likely diagnosis? A. Epilepsy. B. Malingering. C. Somatic symptom disorder. D. Conversion disorder (functional neurological symptom disorder), with at- tacks or seizures. E. Factitiousdisorder.

D The essential feature of conversion disorder (functional neuro- logical symptom disorder) is the presence of one or more symptoms that cause clinically significant distress or impairment in social, occupational, or other im- portant areas of functioning (or warrant medical attention); are incompatible with recognized neurological or medical conditions; and cannot be better explained by another mental disorder. This patient's pattern of movement, dura- tion of attack, and return to clear consciousness at the end of the attack are incompatible with a diagnosis of epilepsy (as is underscored by the electroen- cephalogram) and lack resemblance to any other medical or neurological dis- order that would account for them. Although factitious disorder, with conscious feigning of symptoms, has not been absolutely ruled out, the diag- nosis of conversion disorder does not require certainty that symptoms are not consciously feigned, in recognition of the fact that reliability in ascertaining conscious feigning is poor. Positive evidence of feigning would rule out con- version disorder; in that case, the diagnosis would be factitious disorder.

A 27-year-old woman presents for psychiatric evaluation after almost hitting someone with her car while driving under the influence of marijuana. She re- ports that she was prompted to seek treatment by her husband, with whom she has had several conflicts over the past year about her ongoing marijuana use. She has continued to smoke two joints daily and drive while under the influ- ence of marijuana since this event. What is the appropriate diagnosis? A. Cannabis abuse. B. Cannabisdependence. C. Cannabis intoxication. D. Cannabis use disorder. E. Unspecifiedcannabis-relateddisorder

D The patient described in this vignette meets criteria for cannabis use disorder, which is manifested by recurrent cannabis use in situations in which it is physically hazardous and continued use despite having persistent interpersonal problems due to cannabis. Although this particular patient would have met DSM-IV criteria for cannabis abuse, in DSM-5 the separate di- agnoses of cannabis abuse and cannabis dependence are subsumed under thediagnosis of cannabis use disorder. There is no information in the vignette to suggest that the patient is currently intoxicated. Because she meets criteria for a specific cannabis-related disorder, the diagnosis "unspecified cannabis- related disorder" would not be appropriate.

A 25-year-old man has a childhood history of repeated instances of torturing animals, setting fires, stealing, running away from home, and school truancy, beginning at the age of 9 years. As an adult he has a history of repeatedly lying to others; engaging in petty thefts, con games, and frequent fights (including episodes in which he used objects at hand—pipe wrenches, chairs, steak knives—to injure others); and using aliases to avoid paying child support. There is no history of manic, depressive, or psychotic symptoms. He is dressed in expensive clothing and displays an expensive wristwatch for which he de- mands admiration; he expresses feelings of specialness and entitlement; the be- lief that he deserves exemption from ordinary rules; feelings of anger that his special talents have not been adequately recognized by others; devaluation, contempt, and lack of empathy for others; and lack of remorse for his behavior. There is no sign of psychosis. What is the appropriate diagnosis? A. Antisocial personality disorder. B. Malignantnarcissism. C. Narcissistic personality disorder. D. Antisocial personality disorder and narcissistic personality disorder. E. Otherspecifiedpersonalitydisorder(mixedpersonalityfeatures).

D This individual's history indicates 1) a pervasive pattern of disre- gard for and violation of the rights of others, 2) age over 18 years, 3) features of conduct disorder beginning before age 15 years, and 4) no evidence of bipolar disorder or schizophrenia. Therefore, he meets the criteria for a diagnosis of an- tisocial personality disorder. In addition, he can be described as demonstrating grandiosity, feelings of specialness, need for admiration, and lack or empathy for the needs and feelings of others, suggesting that he also meets the criteria for a diagnosis of narcissistic personality disorder. Other personality disorders may be confused with antisocial personality disorder because they have certain fea- tures in common. It is therefore important to distinguish among these disorders based on differences in their characteristic features. If an individual has person- ality features that meet criteria for one or more personality disorders in addition to antisocial personality disorder, all can be diagnosed. Individuals with antiso- cial personality disorder and narcissistic personality disorder share a tendency to be tough-minded, glib, superficial, exploitative, and lack empathy; however, narcissistic personality disorder does not include characteristics of impulsivity, aggression, and deceit. In addition, individuals with antisocial personality disor- der may not be as needy of the admiration and envy of others, and persons with narcissistic personality disorder usually lack the history of conduct disorder in childhood or criminal behavior in adulthood. Malignant narcissism is not a DSM-5 diagnostic term. The diagnosis of "other specified personality disorder" applies to presentations in which symptoms characteristic of a personality disor- der that cause clinically significant distress or impairment in social, occupa- tional, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the personality disorders diagnostic class.

A 50-year-old man with hard-to-control hypertension acknowledges to his physician that he regularly "takes breaks" from his medication regimen be- cause he was brought up with the belief that pills are bad and natural remedies are better. He is well aware that his blood pressure becomes dangerously high when he does not follow the regimen. Which diagnosis best fits this case? A. Nonadherence to medical treatment. B. Unspecifiedanxietydisorder. C. Denial of medical illness. D. Adjustment disorder. E. Psychologicalfactorsaffectingothermedicalconditions.

E DSM-5 includes nonadherence to medical treatment as a matter that may be the subject of clinical attention but not as a diagnosis per se. It re- ceives a V code. If noncompliance becomes the major focus of clinical attention, then the V code would apply. We do not have evidence to support a diagnosis of an anxiety disorder. Denial of illness is not a diagnosis, although it may cer- tainly command clinical attention, and the use of denial as a coping mecha- nism, if it interferes with obtaining treatment in a timely way, would be an example of a psychological factor affecting another medical condition; how- ever, this patient does not deny his hypertension or the potential consequences. An adjustment disorder diagnosis applies to a clinically significant psycholog- ical response to a stressor, such as mood or anxiety symptoms. The diagnosis of psychological factors affecting another medical condition applies when a medical symptom or condition is present AND psychological or behavioral factors adversely affect the medical condition in one of the following ways: 1) close temporal association of the psychological factor and the onset or exacer- bation or delay in recovery of the medical condition; 2) the factors interfere with treatment; 3) the factors add to the individual's health risk; 4) the factors influence the pathophysiology to precipitate or exacerbate symptoms. In this vignette, the patient's long-standing belief that pills are "bad" interferes with treatment adherence for his acknowledged hypertension, adding to his health risk.

In the Alternative DSM-5 Model for Personality Disorders, personality func- tioning includes both self functioning (involving identity and self-direction) and interpersonal functioning (involving empathy and intimacy). Which of the following is a characteristic of healthy self functioning? A. Comprehension and appreciation of others' experiences and motivations. B. Variabilityofself-esteem. C. Tolerance of differing perspectives. D. Fluctuating boundaries between self and others. E. Experienceofoneselfasunique.

E Disturbances in self and interpersonal functioning constitute the core of personality psychopathology, and in Criterion A of the Alternative DSM-5 Model for Personality Disorders, these aspects of personality function- ing are evaluated on a continuum. The identity component of self functioning in- cludes experience of oneself as unique, with clear boundaries between self and others; stability of self-esteem and accuracy of self-appraisal; and capacity for, and ability to regulate, a range of emotional experience. The empathy compo- nent of interpersonal functioning includes comprehension and appreciation of others' experiences and motivations; tolerance of differing perspectives; and understanding the effects of one's own behavior on others.

Alcohol intoxication, inhalant intoxication, and sedative, hypnotic, or anxio- lytic intoxication have which of the following Criterion C signs/symptoms in common? A. Depressed reflexes. B. Generalizedmuscleweakness. C. Blurred vision. D. Impairment in attention or memory. E. Nystagmus.

E Nystagmus is a Criterion C sign of alcohol, inhalant, and seda- tive, hypnotic, or anxiolytic intoxication. Depressed reflexes, generalized mus- cle weakness, and blurred vision are Criterion C signs of inhalant intoxication but are not associated with either alcohol intoxication or sedative, hypnotic, or anxiolytic intoxication. Impairment in attention or memory is a Criterion C sign of both alcohol intoxication and of sedative, hypnotic, or anxiolytic intox- ication but is not a diagnostic feature of inhalant intoxication.

Whichofthefollowingpresentationsischaracteristicofhistrionicpersonality disorder? A. A pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior. B. Apatternofsubmissiveandclingingbehaviorrelatedtoanexcessiveneed to be taken care of. C. A pattern of instability in interpersonal relationships, self-image, and af- fects, and marked impulsivity. D. A pattern of grandiosity, need for admiration, and lack of empathy. E. Apatternofexcessiveemotionalityandattentionseeking.

E The essential feature of histrionic personality disorder is perva- sive and excessive emotionality and attention-seeking behavior. This pattern begins by early adulthood and is present in a variety of contexts. Individuals with histrionic personality disorder are uncomfortable or feel unappreciated when they are not the center of attention (Criterion 1). Often lively and dra- matic, they tend to draw attention to themselves and may initially charm new acquaintances by their enthusiasm, apparent openness, or flirtatiousness.

Whichofthefollowingpresentationsischaracteristicofnarcissisticpersonality disorder? A. A pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. B. Apatternofacutediscomfortincloserelationships,cognitiveorperceptual distortions, and eccentricities of behavior. C. A pattern of submissive and clinging behavior related to an excessive need to be taken care of. D. A pattern of instability in interpersonal relationships, self-image, and af- fects, and marked impulsivity. E. Apatternofgrandiosity,needforadmiration,andlackofempathy.

E The essential feature of narcissistic personality disorder is a per- vasive pattern of grandiosity, need for admiration, and lack of empathy that begins by early adulthood and is present in a variety of contexts. Individuals with this disorder have a grandiose sense of self-importance.

A 19-year-old man is brought to the emergency department by his family with acute onset of hemoptysis. Although he denies any role in the genesis of the symptom, he is observed in the waiting area to be surreptitiously inhaling a so- lution that provokes violent coughing. On confrontation he eventually ac- knowledges his action but explains that he heard an angel's voice instructing him to purify himself for a divine mission for which he will receive a heavenly reward. He was therefore trying to expunge all "evil vapors" from his lungs but felt obliged to keep this a secret. Why would this patient not be considered to have factitious disorder? A. Consequences of religious or culturally normative practices are exempt from consideration as fabricated illnesses. B. Factitiousdisorderoccursalmostexclusivelyinwomen. C. Repeatedinstancesofillnessfabricationarenecessaryforadiagnosisoffac- titious disorder. D. The patient expects to receive an external reward and therefore should be considered to be malingering. E. The presence of a psychotic illness that better accounts for the symptoms precludes the diagnosis of factitious disorder.

E The presence of bizarre delusions and command auditory hallu- cinations strongly suggests a psychotic disorder. When another mental illness better accounts for the presentation, a diagnosis of factitious disorder should not be made (Criterion D). DSM-5 seeks to be respectful of variations in expe- rience and modes of self-expression that are aspects of an individual's cultural and religious background, but it is unlikely that such factors would result in fabrication of illness presentation, and "rewards from heaven" would not gen- erally be considered to be "obvious external rewards." Factitious disorder is more common in women, but it also occurs in men. Both single and recurrent episodes of fabrication qualify for diagnosis and should be specified

A 60-year-old man has prostate cancer with bony metastases that cause persis- tent pain. He is treated with antiandrogen medications that result in hot flashes. He is unable to work because of his symptoms, but he is stoical, hope- ful, and not anxious. What is the appropriate diagnosis? A. Pain disorder. B. Illnessanxietydisorder. C. Somatic symptom disorder. D. Psychological factors affecting other medical conditions. E. Nodiagnosis.

E This patient has "medically explained" symptoms, but they are still somatic symptoms that result in disruption of important daily life func- tions. He therefore meets Criterion A for somatic symptom disorder; however, he does not meet Criterion B, which requires excessive thoughts, feelings, or behaviors related to the symptoms. Pain disorder is not a DSM-5 diagnostic category. The patient has a somatic symptom but is not anxious, so he does not have illness anxiety disorder. The diagnosis psychological factors affecting other medical conditions refers to emotional, cognitive, or behavioral issues that worsen prognosis or interfere with management of a physical condition; that diagnosis would not apply to the patient in this vignette.

After an airplane flight, a 60-year-old woman with a history of chronic anxiety develops deep vein thrombophlebitis and a subsequent pulmonary embolism. Over the next year, she focuses relentlessly on sensations of pleuritic chest pain and repeatedly seeks medical attention for this symptom, which she worries is due to recurrent pulmonary emboli, despite negative test results. Review of systems reveals that she also has chronic back pain and that she has consulted many physicians for symptoms of culture-negative cystitis. What diagnosis best fits this clinical picture? A. Post-pulmonary embolism syndrome. B. Chestpainsyndrome. C. Hypochondriasis. D. Pain disorder. E. Somaticsymptomdisorder.

E This patient's pain preoccupations, anxiety about her symptoms, and medical care-seeking behaviors in the aftermath of her pulmonary embo- lism are the basis for making the diagnosis of somatic symptom disorder. The issue of whether her pleuritic pain symptoms can be explained as caused by her previous pulmonary embolism is not relevant to this determination; what matters is her abnormal appraisal of, focus on, and behavioral response to the pain. In the DSM-IV classification, she might have received a dual diagnosis of hypochondriasis and pain disorder; in DSM-5 her anxiety about the signifi- cance of her somatic symptoms and her ongoing pain complaints point to a di- agnosis of somatic symptom disorder.