Somatic and Sexual Disorders

A 42-year-old woman is hospitalized for severe abdominal pain. After an extensive evaluation, the clinicians have reached a diagnosis of factitious disorder. Which of the following is most likely the motivation behind this patient's behavior? A) The motivation is unconscious, and thus the patient is unaware of it B) Desire to avoid jail C) Desire to take on the patient role D) Desire to obtain compensation E) Desire to obtain narcotics

Desire to take on the patient role

What is a common differential for dissociative disorders that must be ruled out before starting psychotherapy?

Dissociation related to substance abuse

A 23-year-old female is reported missing by her parents in California. Years later, it is discovered that she is living in New York. She has no recollection of her previous life in California.

Dissociative amnesia

A dissociative disorder characterized by the sudden and extensive inability to recall important personal information, usually of a traumatic or stressful nature.

Dissociative amnesia

A 43-year-old schoolteacher is surprised when a parent states that she saw him at a strip club several days ago. He denies these accusations and truly hasno memory of the event.

Dissociative identity disorder

A rare dissociative disorder in which a person exhibits two or more distinct and alternating personalities. Also called multiple personality disorder.

Dissociative identity disorder

A dissociative disorder characterized by experiences of unreality or being detached from one's thoughts, feelings, sensations, or actions. i.e. feeling like an outside observer

Depersonalization

Which of the following presentations is characteristic of dissociative amnesia? A) A 29 year old nun is surprised when a man states that he saw her at an exotic dancing establishment several days ago. She denies these accusations and truly has no memory of the event B) A 39 year old man presents stating that several times in the last month he felt as if he was outside of his body. He struggles to describe the experience but says the feeling best approximates "watching a movie of himself" C) A 21 year old woman is reported missing by her parents in Miami. Years later it is discovered that she is living in Texas. She has no recollection of her previous life in Miami D) A 25 year old woman is brought to the emergency room by EMS when she was found naked in a clothing store. Her family and friends said that for the last 2 weeks she has been increasingly grandiose, had been sleeping 3-4 hours per night, and had not gone to work E) An 82 year old man is found several states away from his home and is not oriented to person, place, or time

A 21 year old woman is reported missing by her parents in Miami. Years later it is discovered that she is living in Texas. She has no recollection of her previous life in Miami

Which of the following is required for the diagnosis of gender dysphoria in children but not in adolescents or adults? A) A strong desire to be treated as the other gender B) A strong desire to be of the other gender or an insistence that one is the other gender C) A strong preference for playmates of the other gender D) A strong desire for the primary and/or secondary sex characteristics that match one's experienced gender E) A strong preference for cross-gender roles in make-believe or fantasy play

A strong desire to be of the other gender or an insistence that one is the other gender

Ms. K, a 60-year-old woman, is brought by her sister to see a psychiatrist at a local mental health center with complaints that Ms. K has "changed" over the past year. According to the sister, Ms. K appears anxious all the time and stays by herself in her room, not socializing with anyone. She even quit her "very good" job at the local school. Ms. K has not been eating well and has lost significant weight within the time. She used to be a "fun-loving" person before. The sister wants the physician to "bring her sister back." Ms. K denies that she is sad. She worries about her health because she is convinced that mercury poisoning has caused all her symptoms, but the doctors "do not seem to believe her." She reports that about a year ago, she visited her dentist and was informed that her dental filling had fallen off. That night, her husband jokingly said that she may have mercury poisoning since "silver dental fillings may cause it." Ms. K then began to research mercury poisoning on the Internet. Within several months, she developed all the symptoms of mercury poisoning that were mentioned on various websites. She started to isolate herself in her room to further look up the symptoms on the Internet. She often gets into arguments with her husband because he thinks that "she is getting paranoid." She gets irritable when her sisters visit and refuses to go out to eat with them. Ms. K cannot sleep well because thinking about her illness keeps her awake at night. She reports she cannot eat much. After 6 months of symptoms at home, her family took her to see her primary care provider (PCP), who performed a thorough physical and neurologic exam and ran several tests, including blood and urine tests, to measure mercury levels. All of these tests were within normal limits. Ms. K seemed relieved for few days but the Internet searches began again, and so did all the symptoms. She was taken back to her PCP, who then referred her to the psychiatrist. There is no personal or family history of major psychiatric illnesses or substance abuse. Psychiatric review of systems reveals mild to moderate anxiety, which has never been treated with psychotropic medications. Mental status exam reveals no paranoid thoughts or hallucinations. Ms. K has a calm demeanor with no agitation and very rational thinking. She states, "I know I may be having anxiety for no reason, but I am still having all the symptoms of mercury poisoning." A) What is the most likely diagnosis for this patient? B) What is the next step in treating this patient?

A) Illness anxiety disorder B) Patients with illness anxiety disorder may or may not be willing to receive care from a mental health provider, in which case a PCP may need to continue care with such patients. Either way, first work on building a solid rapport with the patient. Providing supportive psychotherapy, validating the patient's symptoms without reinforcing illness behavior, and providing psychoeducation is important. It should be understood that this disorder may be perpetuated by the patient's use of the sick role as a solution to her problems. Invasive diagnostic techniques or procedures should be avoided unless there is convincing objective evidence that they are necessary. Group therapy, behavioral therapy, insight-oriented therapy, and hypnosis may help. Although there is no long-term benefit, pharmacotherapy to target anxiety might help.

A 24 year old man is admitted to the neurology service with new-onset blindness. The patient awoke on the morning of his admission entirely unable to see. A detailed workup by the neurology service, including physical, laboratory studies, and imaging, revealed no clear medical reason for this abnormality -- the patient was found to be otherwise healthy. A psychiatric consultation was subsequently ordered. The patient tells the psychiatrist that he does not know why he is blind. He emigrated from Mexico several years ago, coming to the United States to make money to support his sick mother. She remained ill for several years, but he was unable to send her money because he lost the money gambling. She died recently, and he became despondent because he would never see her again. On mental status exam, the patient is alert and oriented to person, place, and time. His appearance and hygiene are good, and he does not seem to be overly concerned with his blindness, His mood is described as "okay," and his affect is congruent and full rate. He has normal thought processes and denies having suicidal or homicidal ideation, delusions, or hallucinations. A) What is the most likely diagnosis for this patient? B) What is the most appropriate treatment for this patient?

A) Conversion disorder (functional neurologic symptom disorder) B) Educating the patient about the illness often results in resolution of symptoms, CBT and/or PT can also be useful

A 22 year old woman is brought to the clinic by her brother, who voices concern about the patient's strange behavior. He states that his sister struggles with depression and that it acutely worsened after a painful breakup with her abusive boyfriend. She did not return home for several days, after which he finally found her at a bar across town. She had facial bruising and appeared disheveled. His sister acted like a "completely different person" and spoke with a French accent. He was unaware of his sister ever learning French. He finally convinced her to come back home with him that night. Since returning home, the woman has "been her normal self." The brother admits that they had a rough childhood, often suffering from physical abuse at the hands of their father. He states that despite an unstable upbringing, "We have done pretty well for ourselves. Both of us are clean and employed." The patient denies any recollection of the past few days. Her last memory before the episode was her boyfriend yelling at her and his fist flying at her face. She felt herself disconnect from her body and cannot recall what happened next. She states that her boyfriend has been increasingly jealous and possessive of her. He accused her of cheating on him, which she adamantly denied. The patient reports that her boyfriend became abusive over the past few months when she began receiving late night phone calls from strange men asking "for the French girl" to "meet up again." She denies straying in her relationship and feels bewildered about these phone calls. The patient does not remember much of her childhood and has "blocked out" the abuse. On memory testing, the patient is oriented to person, place, and time and does not exhibit any gross impairment. A)What is the most likely diagnosis for this patient? B) What could be a causal factor and is highly associated with this disorder?

A) Dissociative Identity Disorder (DID) B) Most DID patients have experienced significant physical and sexual trauma, often during their childhood. Creation of an alternate identity can be conceptualized as a protective but maladaptive mechanism for the core personality

A 41-year-old nurse presents to the emergency department with concerns that she has hypoglycemia from an insulinoma. She reports repeated episodes of headache, sweating, tremor, and palpitations. She denies any past medical problems and only takes nonsteroidal anti-inflammatory medications for menstrual cramps. On physical examination, she is a well-dressed woman who is intelligent, polite, and cooperative. Her vital signs are stable except for slight tachycardia. The examination is remarkable for diaphoresis, tachycardia, and numerous scars on her abdomen, as well as needle marks on her arms. When asked about this, she says that she feels confused because of her hypoglycemia. The patient is subsequently admitted to the medical service. Laboratory evaluations demonstrate a decreased fasting blood sugar level and an increased insulin level, but a decreased level of plasma C-peptide, which indicates exogenous insulin injection. When she is confronted with this information, she quickly becomes angry, claims the hospital staff is incompetent, and requests that she be discharged against medical advice. A) What is the most likely diagnosis? B) How should yo best approach this patient?

A) Factitious Disorder B) In order to engage the patient in psychiatric treatment, attempt to ally with her. Working in conjunction with the patient's primary care provider is often more effective than working with the patient alone. Focus on patient management versus curing the patient. Personal awareness of one's own feelings toward the patient must be maintained, as it is often very easy to get angry with such patients and behave punitively

A 19-year-old man presents to a psychiatrist insisting, "I have schizophrenia and need to be admitted." He describes hearing voices telling him to kill himself for the past several days. He says that he is possessed by the devil. The patient denies feeling depressed but insists he will hurt himself if he is not admitted to a hospital immediately. He has vague suicidal plans and says he will find some ways to kill himself but cannot be more specific. He has no prior history of psychiatric treatment or complaints, no medical problems, and is not taking any medication. He drinks one or two beers a week and denies using drugs. At the end of the interview, he again requests hospitalization. He then adds that he is currently on leave from the Navy and is due back on his ship, which is leaving in 2 days. On a mental status examination, the patient is initially cooperative and forthcoming but becomes increasingly irritated when asked to give more details about his symptoms. He has good hygiene and maintains good eye contact. His mood and affect are euthymic and full range. His thought processes are logical, without looseness of association or thought blocking. His thought content is notable for suicidal ideation but no homicidal ideation. He reports having delusions and auditory hallucinations but doesn't seem to be responding to any internal stimuli. His insight seems good considering the severity of his symptoms. A) What is the most likely diagnosis? B) How would you approach this patient?

A) Malingering B) Obtain collateral information (if possible) from family and/or friends. Approach the patient in a nonthreatening manner, remaining neutral and avoiding abrupt confrontations or accusations of lying. Be aware of implicit countertransference reactions. Explore and validate the patient's feelings regarding his military duty. Discuss that findings indicate no medical basis for the patient's symptoms, and therefore no diagnosis can be made. Refer him for an appropriate follow-up (if possible).

A 32-year-old man and his 28-year-old wife come to a psychiatrist because of problems in their relationship. The wife states that the two have been married for 6 months and that they dated for 2 months prior to that. During all their sexual encounters, the husband insists that the wife wear very high-heeled shoes at all times. Although the wife initially thought that this behavior was sensual, she now worries that it is the shoes that the husband finds attractive and not her. She thinks the behavior is "freaky" and has asked the husband to stop, which he has refused to do. This has led to arguments between them. The husband states that he is unable to achieve an erection or orgasm without the presence of the shoes. He notes that for as long as he can remember, he has needed high-heeled shoes as part of his sexual play. He feels no shame or guilt about this behavior, although he is worried that it is causing problems between him and his wife. A) What is the most likely diagnosis for the husband? B) What is the course of and prognosis for this disorder?

A) Fetishistic disorder B) The course of this disorder is chronic, and it has a poor prognosis

A 14-year-old girl presents to the psychiatrist for a new patient evaluation. She endorses depression, anxiety, and feeling like "there is a pit in my stomach and things are spiraling downward." She states she has a lot she wants to do with her life and does not think she will achieve it. She is a straight-A student and enjoys band and art. She states she has been crying a lot and sometimes it feels as if "I do not exist." She describes herself as a tomboy and states she has always been interested in sports. She states she feels more comfortable in boy's clothing. She states she is uncomfortable with her body, especially the development of her breasts. She feels she should have been born a male. She has felt this way since she was 10 years old but was fearful of telling her family due to their strong religious beliefs. She wishes to wear a binder for her breasts and wants to start hormone therapy. She was attracted to both males and females initially and believed she was bisexual. She now reports an exclusive interest in girls. She states she did some research because she didn't feel she identified with being bisexual or lesbian and now identifies as transgender. She recently disclosed to her family 2 months ago that she identified as a male and states this is stressful because her parents do not understand. She states she prefers the use of male pronouns with regard to herself, and she has picked a male name. She is afraid to disclose these facts to her family. On mental status exam, she is well-groomed and cooperative. She is dressed in boy's clothing brands consisting of jeans and a t-shirt with a button-down shirt over it. Her hair is shortly cropped, and she is wearing a baseball cap. She is alert and oriented to person, place, and time. No abnormalities were found on her mental status examination. A) What is the most likely diagnosis? B) What options are open to the patient other than sex reassignment surgery?

A) Gender dysphoria B) It is recommended that fully reversible steps precede partially reversible procedures, which should precede irreversible procedures. Fully reversible steps include living as the desired gender and pubertal suppression. Partially reversible procedures include administration of gonadal hormones to bring out desired secondary sex hormone characteristics. Irreversible procedures include gender-affirming surgeries.

A 42-year-old woman presents to her primary care provider with a chief complaint of back pain for the past 6 months that began after she was knocked down by a man attempting to elude the police. She states that she has extreme pain on the right side of her lower back, near L4 and L5. The pain does not radiate, and nothing makes it better or worse. She says that since the injury she has been unable to function and spends most of her days lying in bed or sitting up, immobile, in a chair. Immediately after the accident, she was taken to an emergency department, where a workup revealed back strain but no fractures. Since then, the patient has repeatedly sought help from a variety of specialists, but the ongoing pain has been neither adequately explained nor relieved. She denies other medical problems, although she mentions a past history of domestic violence that resulted in several visits to the emergency department for treatment of bruises and lacerations. On mental status examination, the patient is alert and oriented to person, place, and time. She is cooperative and maintains good eye contact. She holds herself absolutely still, sitting rigidly in her chair and grimacing when she has to move even the smallest amount. Her mood is depressed, and her affect is congruent. Her thought processes are logical, and her thought content is negative for suicidal or homicidal ideation, delusions, or hallucinations. A) What is the most likely diagnosis of this patient? B) What is the best approach to this patient?

A) Somatic symptom disorder with predominant pain B) Validate the patient's experience of pain. Explain the role of psychological factors as a cause and consequence of pain. Consider antidepressants, therapy, alternative therapies such as yoga, and referral to a pain clinic

A 55-year-old man complains of inability to achieve an erection. He has been worried about his health recently and takes antihypertensive medication. Which of the following would most likely differentiate between an organic and psychiatric condition? A) A lower-extremity myographic examination B) Magnetic resonance imaging of the lumbosacral spine C) An erection on awakening in the morning D) The interpretation of projective tests E) An electroencephalographic reading

An erection on wakening in the morning

The patient in Questions 29.1 and 29.2 (grandmother with somatic symptom disorder) feels that her headaches are now unbearable. Which of the following treatments is the most appropriate? A) Acetaminophen B) Biofeedback C) Lorazepam D) Non-steroidal anti-inflammatory medication E) Oxycodone

Biofeedback

A 26-year-old woman presents to her provider with the chief complaint of "I have epilepsy." She states that for the past 3 weeks she has had seizures almost daily. She describes the episodes as falling on the ground, followed by her arms and legs shaking uncontrollably. These events last for approximately 10 minutes. She is unable to otherwise move during the time, although she denies any loss of consciousness or bladder or bowel functions. The patient seems to be rather indifferent when stating her complaints. She has never injured herself during these episodes, but as a result, she has been unable to continue her job. She is somewhat bothered because she received a promotion 1 month ago. Which of the following is the most likely diagnosis? A) Body dysmorphic disorder B) Conversion disorder C) Illness anxiety disorder D) Seizure disorder E) Somatic symptom disorder

Conversion disorder

A 23-year-old pregnant woman complains of an inability to feel her legs. She wonders if the fetus is grabbing her spinal cord. Although she does not appear concerned about her condition, on further questioning she admits that her pregnancy was unplanned and that it has been a source of stress for her and her husband. Her neurologic examination is unremarkable except for decreased sensation below her waist. The results of a computed tomography scan and magnetic resonance imaging of her brain and spine are normal. Which of the following best describes the situation? A) Factitious disorder B) Malingering C) Conversion disorder D) Somatic symptom disorder E) Illness anxiety disorder

Conversion disorder

A 34-year-old female who reports that several times last month she felt as if she was outside of her body. She struggles to describe the experience but says the feeling best approximates "watching a movie of herself."

Depersonalization/derealization disorder. Depersonalization disorderoften starts manifesting in early adulthood, and is usually preceded by a traumatic event

Thought to be the main risk factorfor dissociative identity disorder.

Childhood abuse

A 29-year-old man presents to his primary care provider with back pain for the past year since he slipped on a wet floor at work. He has been unable to work since the accident. A comprehensive medical workup has been entirely normal, and his only symptom is pain in the middle of his back that is present constantly. He has had multiple visits (more than two dozen) to the emergency department, where he is frequently given opioids and alprazolam to help with the pain. At today's visit, he tells you he is applying for disability designation and benefits. If the patient truly has pain and limitations without a medical physiologic explanation, which of the following is most likely to be present? A) Somatic symptom disorder B) Malingering C) Conversion disorder D) Posttraumatic stress disorder

Conversion disorder

A 13 year old girl is admitted to the pediatric unit for the evaluation of seizures. Her first seizure occurred 1 week ago, and she has had three since then. Episodes are described by her parents as a generalized shaking and jerking of the body, lasting 1 to 2 minutes, with eyes rolled back. During one seizure, there was urinary incontinence. The girl denies feeling depressed but does mention feeling "stressed out" due to school and recently not getting along with her stepmother. There is a history of sexual abuse by her stepfather 5 years ago. She has diagnoses of depressive disorder and anxiety for which she takes fluoxetine 20mg daily. Her physical examination and neurologic workup are unremarkable. Laboratory studies are also within normal limits. Which of the following is the most likely diagnosis? A) Body dysmorphic disorder B) Conversion disorder (functional neurologic symptoms disorder) C) Factitious disorder D) Illness anxiety disorder E) Malingering

Conversion disorder (functional neurologic symptoms disorder)

A 20-year-old female with dizziness, along with numbness and severe weakness on the left side of her body and her left leg. She also complains of moderate low back pain. The patient was recently involved in a bicycle collision with a motor vehicle 3 days ago where she was clipped while crossing an intersection, causing her to crash hard on her left side. She doesn't remember if she hit her head, but she was wearing a helmet. She was taken to the local, rural hospital to screen for a concussion, which came back negative. She had a CT of the head in the ED which was normal and she was released quickly from the hospital. Since the injury 3 days ago, the patient reports her dizziness has converted to double vision, has difficulty swallowing like there is a lump in her throat, and notices occasional slurred words. She continues to have difficulty walking and loss of balance since the accident. She reports having increased stress and difficulty completing school work in the past couple of weeks. Her physical exam and vital signs are all normal. Her neurological exam reveals inconsistent paresthesia in dermatomes of the LLE.

Conversion disorder (functional neurological symptom disorder) / treatment = therapy +/- short-term anxiolytics

A 22-year-old woman is referred for neuropsychological testing after reporting confusion and amnestic episodes. She has received bills in the mail for credit cards she does not remember opening. The woman has found clothing in her closet that she does not recall purchasing. She has been tagged in numerous pictures on Facebook with people she does not know and has been checked into venues unfamiliar to her. What is the most likely diagnosis? A) BPD B) DID C) Factitious DIsorder D) Malingering E) PTSD

DID

A 38-year-old barista presents to her primary care provider with concern about memory problems. She has had trouble recalling significant personal information and life events. The patient reports that dating has been problematic because during intimate encounters, "I just disconnect. I feel so scared and ashamed. I'm floating above my body, looking down on what's happening." Her current boyfriend has described that sometimes she talks like a "little girl" and other times like a "sophisticated southern belle." He finds it endearing, but news of this behavior frightened the patient, as she has no recollection of acting this way. Her boyfriend has said he loves the way she plays piano, but she cannot remember ever touching the instrument. She drinks socially on the weekends but denies heavy use, blackouts, or withdrawal symptoms. Which of the following is the most likely diagnosis? A) Alcohol Use Disorder B) BPD C) Dissociative amnesia D) DID E) PTSD

DID

A 35-year-old woman has been hospitalized repeatedly for severe diarrhea and dehydration. Multiple extensive evaluations including culture for infectious etiologies, stool analysis, upper and lower gastrointestinal endoscopy, and biopsies have returned negative. During her current hospitalization, the attending physician orders a lab analysis, which reveals the presence of laxative use. Which of the following is the most appropriate next step in approaching this patient? A) Confronting her with the feigning of symptoms B) Discharging her from the hospital without follow-up C) Establishing a therapeutic alliance D) Pharmacotherapy E) Referring them to legal authorities

Establishing a therapeutic alliance

A 23-year-old male who goes to city park during the summer months in an overcoat. He enjoys walking around the park exposing his genitals to strangers. He then runs away so as to avoid getting caught.

Exhibitionistic disorder

Sexual gratification attained by exposing genitals to unsuspecting strangers

Exhibitionistic disorder

A 32 year old woman is admitted for second- and third-degree burns of her right hand, which she attributes to accidentally spilling hot oil while she was cooking dinner. Upon evaluation, the surgeon recognizes the patient as someone he treated for a similar burn on the same hand 3 months ago. Further detailed review of her medical records reveals that this is her sixth burn-related injury in 2 years. Upon further questioning, there does not seem to be an attached secondary gain. Which of the following is the most likely diagnosis? A) Body dysmorphic disorder B) Conversion disorder (functional neurological symptom disorder) C) Factitious disorder D) Illness anxiety disorder E) Malingering

Factitious disorder

A 35-year-old female with c/o palpitations and chest pain for 2 days. She reports that she had been sweating with nausea and vomiting. She reports that she "checked her pulse which was about 156." She denies any personal or family history of heart disease or anxiety disorders. She rated her chest pain as 10/10 "which radiates down my left arm and up my jaw." ECG reads normal sinus rhythm.Troponin, CKMB, and other labs were normal. When she was told that her labs were normal, she flopped onto the bed and started "seizing." She stated, "I am seizing. Why won't you help me?" When the ER PA calls her out, she got angry and left against medical advice.

Factitious disorder

A 38-year-old woman comes in for evaluation of an abscess on her thigh. Her chart documents frequent outpatient and hospital visits. She is admitted, her abscess is drained, and she is treated with antibiotics. Culture studies demonstrate microorganisms consistent with fecal matter, and a further physical examination reveals many old scars, presumably self-inflicted. Which of the following best describes the situation? A) Factitious disorder B) Malingering C) Conversion disorder D) Somatic symptom disorder E) Illness anxiety disorder

Factitious disorder

A 12-year-old girl is hospitalized with severe abdominal pain that has not responded to numerous medications. The comprehensive evaluation, including blood tests and imaging, has been normal. The patient's mother was noted to be very cooperative with medical personnel, but when a psychiatric evaluation was requested, the mother was very unhappy and stopped the consultation after 5 minutes. Investigation revealed that the patient and her mother had been seen in various emergency departments around the county over the past several years. After separating the mother from the patient for several hours, the patient began to improve. Which of the following is the most likely diagnosis? A) Body dysmorphic disorder B) Conversion disorder C) Factitious disorder imposed on another (Munchausen by proxy) D) Drug withdrawal

Factitious disorder imposed on another (Munchausen by proxy)

A 33-year-old woman with a chief complaint of trouble having intercourse. She is completely disinterested in sex and she is not receptive to her partner's attempts to initiate foreplay. She reports that when they do have sex she never achieves orgasm. This is affecting her current relationship with her boyfriend.

Female sexual interest/arousal disorder

A female dysfunction marked by a persistent reduction or lack of interest in sex and low sexual activity, as well as, in some cases, limited excitement and few sexual sensations during sexual activity

Female sexual interest/arousal disorder

A female brings her 29-year-old boyfriend to a couples therapist because she is uncomfortable with his behavior. She found him clutching her feet during intercourse, and noticed that he insists on being able to see her feet while they engage in sexual acts.

Fetishistic disorder

A paraphilic disorder consisting of recurrent and intense sexual urges, fantasies, or behaviors that involve the use of a nonliving object or nongenital part, often to the exclusion of all other stimuli, accompanied by clinically significant distress or impairment

Fetishistic disorder

A 36-year-old man presents to his PCP for evaluation of his complaints. He is convinced that he has colon cancer despite being told that it is unlikely because of his young age. He occasionally notices traces of red blood on the toilet paper, which he had previously attributed to hemorrhoids, and abdominal cramps when he eats too much. A review of the records demonstrates numerous prior appointments in connection with the same or similar complaints, including repeatedly negative results from tests for occult fecal blood and normal results from colonoscopies. He continues to be worried about dying of cancer and requests another colonoscopy. Which of the following is the most likely diagnosis? A) Body dysmorphic disorder B) Illness anxiety disorder C) Somatic symptom disorder with predominant pain D) Somatic symptom disorder E) Conversion disorder

Illness anxiety disorder

A 42 year old man returns to his internist for the fourth time in 5 months with the same complaints of intermittent numbness of his fingers and indigestion. Although his medical workup has been unremarkable, this has failed to reassure him. He remains anxious and is now concerned that he has Celiac disease and requests a GI consultation. Which of the following is the most likely diagnosis? A) Body dysmorphic disorder B) Conversion disorder (functional neurological symptom disorder) C) Factitious disorder D) Illness anxiety disorder E) Malingering

Illness anxiety disorder

A healthy 25-year-old man becomes preoccupied with his health after his father has a stroke. This man monitors his blood pressure several times a day, starts an aggressive cardiovascular exercise program, and becomes a vegan. He spends 2 to 3 hours per day reading the latest research in strokes and other cardiovascular disease. He attempts to make quarterly appointments with his primary care provider even though there is no apparent reason to do so. Which of the following best describes the situation? A) Factitious disorder B) Malingering C) Conversion disorder D) Somatic symptom disorder E) Illness anxiety disorder

Illness anxiety disorder

A 25-year-old male graduate engineering student who is at your office for the fourth time in 1 week to be sure he does not have chlamydia. Despite having one sex partner, he learned there is an increase in the incidence of STDs on campus. He reports that he has only had sex once but learned that chlamydia is hard to culture. He reports he may have dysuria intermittently but is not sure. He has been evaluated at each visit, and physical and laboratory examination has been completely normal each time.

Illness anxiety disorder (hypochondriasis) / treatment = group/insight-oriented therapy, medications (SSRIs) if concurrent/underlying anxiety or major depressive disorder

A 13-year-old boy presents to a psychiatrist for the first time and gives a history indicative of gender dysphoria. He states that he wishes to undergo treatment to suspend puberty. Which of the following treatment steps is most appropriate? A) Screening the patient for psychopathology B) Treating the patient with an antidepressant before surgery C) Treating the patient with hormones D) Real-life experience in the community E) Ongoing supportive psychotherapy

Screening the patient for psychopathology

A 23-year-old male who concerned that his behavior has resulted in his inability to maintain a relationship. He reveals that he requires his partners to strangle him and humiliate him in order for him to achieve and maintain an erection.

Sexual masochism disorder

A 53-year-old male complaining of a lack of desire for sex with his wife causing him marked distress for the past year. His wife has been very hurt by his lack of response to her advances and he reports that this is having a significant strain on their relationship. Prior to this, he was interested in sex and he and his wife would have intercourse 1-2x per month. He is very active and continues to compete in triathlons. He has no significant past medical history.

Male hypoactive sexual desire disorder

A male dysfunction marked by a persistent reduction or lack of interest in sex and hence a low level of sexual activity

Male hypoactive sexual desire disorder

A 34-year-old woman is admitted to the inpatient psychiatric unit after being brought to the emergency department by police because of an episode of aggression in which she destroyed her brother's house during an argument. She initially states she has no recollection of the incident. She then goes on to provide vague details about how she ended up at her brother's and discloses that she was told she did 5000 dollars' worth of property damage. She verbalizes repeatedly that she is concerned about the legal consequences of her actions. She reports she has never had an episode like this but doesn't appear particularly distressed about it. She refuses to allow consent for collateral information to be gathered. What is the most likely diagnosis? A) BPD B) DID C) Factitious disorder D) Malingering E) PTSD

Malingering

A 45-year-old man complains of lower back pain and weakness in his legs after lifting heavy boxes while at work. He says that he has not been able to go to work for several days. He requests treatment and a letter excusing him from work. On examination, he is found to have significant lumbar pain without spasms. The strength in his legs is decreased because of a lack of effort. His reflexes are within normal limits. He was observed to be ambulating without any problem in the waiting area prior to the appointment. Which of the following best describes the situation? A) Factitious disorder B) Malingering C) Conversion disorder D) Somatic symptom disorder E) Illness anxiety disorder

Malingering

A 50-year-old man is referred to a clinician because he has ongoing migraine headaches. His headaches are chronic and bilateral, are worse with loud noises and light, and occur without aura or vomiting. His physical examination is unremarkable except that the patient does not appear to be in significant distress. When he is presented with various options for treatment, including nonsteroidal anti-inflammatory medications, he becomes angry, demanding that acetaminophen with codeine is "the only thing that has ever helped" him. When he is told that non-narcotic medications should be tried first, he accuses the provider of not believing him and storms out of the clinic. Which of the following best describes the situation? A) Factitious disorder B) Malingering C) Conversion disorder D) Somatic symptom disorder E) Illness anxiety disorder

Malingering

A 33-year-old male gymnastics teacher insists that all his students take a shower after class. He supervises the children showering and becomes sexually aroused.

Pedophilic disorder

A paraphilic disorder in which a person has repeated and intense sexual urges or fantasies about watching, touching, or engaging in sexual acts with children, and either acts on these urges or experiences clinically significant distress or impairment

Pedophilic disorder

Which of the following scenarios is most consistent with factitious disorder? A) Feigning psychosis to avoid criminal charges B) Lying about back pain to receive time off from work C) Psychogenic non epileptic seizures in the context of family conflict D) Placing feces in urine to receive treatment for a urinary tract infection E) Recurrent fears of having a serious illness

Placing feces in urine to receive treatment for a urinary tract infection

Which of the following is a poor prognostic indicator in the treatment of fetishists? A) A stable adult relationship B) Presence of another paraphilia C) Normal intelligence D) Self-referral for treatment E) History of sexual relations without the paraphilia

Presence of another paraphilia

Which of the following initial strategies by the PCP would be the most effective in treating a patient with somatic symptom disorder? A) Antianxiety medication Extensive medical workups to provide reassurance C) Referral for psychotherapy D) Regularly scheduled appointments with reassurance E) An antipsychotic medication

Regularly scheduled appointments with reassurance

A 12-year-old girl with a history of complex trauma is admitted to the inpatient child psychiatry unit for the management of disruptive behaviors. On the unit, she has a verbal altercation with a staff member. She stops responding directly to the staff member and appears very frightened. She turns away and begins wailing, "Don't hurt me, daddy. Please, please don't..." If the patient is forcibly placed into physical restraints, what would be the most likely result? A) Mortality B) Psychotic break C) Retraumatization D) Symptom resolution

Retraumatization

A paraphilic disorder characterized by repeated and intense sexual urges, fantasies, or behaviors that involve being humiliated, beaten, bound, or otherwise made to suffer.

Sexual masochism disorder

A 23-year-old man comes to his clinician asking for sexual reassignment surgery. He states that for "as long as I can remember," he has felt that he was born in the wrong body. He states that he believes that "truly I am a woman" and is disgusted by his male body habitus. He has been living as a woman since he moved out of his parents' house several years ago. He wishes to have his penis removed and would like female breasts and genitalia. He considers himself a heterosexual because he is attracted to men. When talking with the patient, which of the following should be used to describe this man? A) He has a paraphilia disorder B) He has fetishistic disorder C) He has gender dysphoria D) She has gender dysphoria E) He is a sadist

She has gender dysphoria

A 25-year-old female who presents today with multiple complaints that have been ongoing for more than 6 months. She reports that "it all started about 10 months ago with pain in my neck, shoulders, back, legs, and feet." She denies any trauma. There is no family history of juvenile rheumatoid arthritis or osteoarthritis. She stated that the pains do not respond to treatments, and they "just come and go making it difficult to hold a job." She is constantly worried about her symptoms. Now, she has a headache, abdominal pain, bloating, and "some seizures." She previously had seen a headache specialist, gastroenterologist, and obtained a number of electrocardiograms in the emergency department. Their respective thorough workup was negative. Her mother had similar episodes as well. On physical exam, you note an anxious woman with a depressed affect. No significant physical exam findings are noted. Labs/imaging are all within normal range.

Somatic symptom disorder

A 42-year-old woman describes a 20-year history of numerous physical complaints, including joint pain, dysuria, headaches, chest pain, nausea, vomiting, irregular menses, and double vision. Although they do not all occur at the same time, she has been suffering from one or more of these problems throughout her adult life. Many medical evaluations have been performed, and she has undergone repeated hospitalizations, but no specific cause has yet been found. Discussion with her husband confirms no traumatic events in the patient's life. She is extremely anxious and has become significantly disabled as a result. Which of the following is the most likely diagnosis? A) Body dysmorphic disorder B) Illness anxiety disorder C) Somatic symptom disorder with predominant pain D) Somatic symptoms disorder E) Conversion disorder

Somatic symptom disorder

A 53-year-old man pulls a back muscle while doing his usual exercise routine 6 months ago. He sought out several medical opinions with sports medicine, orthopedics, and neurology, all of which assured him that he only experienced an unfortunate muscle strain. However, the patient currently exhibits high levels of anxiety and ascribes any ache or pain to some unknown malady. He is so fearful of reinjury that he no longer exercises, always walks with a cane, and is insistent that someone be with him at all times in case he becomes debilitated. Which of the following best describes the situation? A) Factitious disorder B) Malingering C) Conversion disorder D) Somatic symptom disorder E) Illness anxiety disorder

Somatic symptom disorder

A 63-year-old woman returns to her family care provider with continuing headaches for 9 months. She describes the pain as "constant ... always with me," around her entire scalp. She does not appreciate much variation throughout the day, and she cannot name any aggravating or alleviating factors. Although she occasionally feels lightheaded when in severe pain, she denies photophobia, visual changes, nausea, or vomiting. She is especially upset about the headaches, as she retired in the past year and has been unable to travel to visit her infant granddaughter. Complete neurologic examination, computed tomography, magnetic resonance imaging, laboratory studies, and lumbar punctures have been unremarkable. Which of the following is the most likely diagnosis? A) Factitious disorder B) Conversion disorder (functional neurological symptom disorder) C) Illness anxiety disorder D) Malingering E) Somatic symptom disorder with predominant pain

Somatic symptom disorder with predominant pain

Which of the following approaches would be the most effective for the patient in Question 27.1 (13yo with seizures)? A) Confrontation about intentionally producing symptoms B) Explanation that the symptoms are not real C) Reassurance that a cause will be found D) Suggestion that symptoms will improve with time E) Suggestion that the family begins therapy

Suggestion that the symptoms will improve with time

A paraphilic disorder in which sexual arousal is derived from observing unsuspecting individuals undressing or naked

Voyeuristic disorder

Are men or women more likely to suffer from dissociative identity disorder?

Women

Patients with schizophrenia or other psychotic disorders may present with delusional claims of cross-gender issues. Which of the following pieces of history would suggest that a male patient's claim of cross-gender identity is due to delusions? A) The patient says he feels as if he is a member of the other sex but does not believe that he is a member of the other sex B) The patient has felt that he was the wrong gender from a young age C) The patient dresses in the attire of the other sex D) The patient actually believes he is a member of the other sex

The patient actually believes he is a member of the other sex

A married pharmacist comes in for treatment at the insistence of his wife, who was disturbed to find that he was wearing some of her undergarments under his clothes. He admitted to her that he often masturbates when wearing her underwear and fantasizes about wearing it while having intercourse with her. Which of the following best describes this paraphilia? A) Fetishistic disorder B) Fetish behavior C) Transvestic disorder D) Transvestic behavior E) Masochism

Transvestic behavior

A 35-year-old man being seen for major depression shares that he enjoys dressing as a woman and masturbating in private. He finds cross-dressing very arousing sexually but is married, and his wife has become aware of this. She is very upset, and there have been marital problems over his behavior. At work and in other settings, he functions in typical male roles and activities. He had two sexual experiences with men before he got married. He feels very committed to his marriage and finds his wife sexually attractive. The best diagnosis for this patient would be which of the following? A) Mixed personality disorder with schizotypal and borderline features B) Gender dysphoria C) Transvestic fetishism D) No diagnosis E) Body dysmorphic disorder

Transvestic fetishism

Which of the following is the most useful approach for the patient in Question 29.1 (grandmother with somatic symptom disorder)? A) Confrontation regarding the psychological nature of her pain B) Prescription for non-narcotic pain medication C) Reassurance that there is no evidence of pain D) Referral to a mental health professional E) Validation of her experience of pain

Validation off her experience of pain

A 20-year-old male college student was reported by others for spying through the windows of his fellow female dormmates.

Voyeuristic disorder