Behave Anxiety Somatoform Disorder

The patient's symptoms of recurrent vivid memories, intense anxiety, intrusive thoughts, nightmares, and symptom intensification after a recent traumatic event (coworker being raped) are consistent with post-traumatic stress disorder (PTSD). PTSD is a psychiatric disorder that can occur after experiencing or witnessing a traumatic event, and it is characterized by intrusive symptoms, avoidance behaviors, negative mood, and alterations in arousal and reactivity. Panic disorder and adjustment disorder may have some overlapping symptoms, but they do not fully capture the range and intensity of symptoms described in the case. Acute stress disorder is a possibility, but the duration of the symptoms (5 years) suggests a diagnosis of PTSD. Malingering is not a valid explanation as the symptoms are consistent with a genuine psychiatric condition.

The answer is G. This woman probably has body dysmorphic disorder, which is characterized by over-concern about a physical feature (e.g., "sagging" eyelids in this case), despite normal appearance

The answer is E. Robbery at knifepoint, a life-threatening event, is most likely to result in post-traumatic stress disorder (PTSD). While life events such as divorce, bankruptcy, illness, and changing residence are stressful, they are rarely life threatening. Psychological symptoms occurring after such less severe events may result in adjustment disorder, not PTSD.

The woman's symptoms of feeling "nervous" and having an upset stomach, including heartburn, indigestion, and diarrhea, are consistent with the criteria for generalized anxiety disorder. Additionally, the fact that she has had this problem since she was 25 years old and that other family members also experience being "tense and nervous" suggests a pattern of chronic anxiety that is characteristic of generalized anxiety disorder.

The answer is B. This man, who says that he has been "sickly" for most of his life and fears that he has stomach cancer, is showing evidence of hypochondriasis, exaggerated concern over normal physical sensations (e.g., stomach noises) and minor ailments. There are no physical findings or obvious evidence of depression in this patient.

This clinical presentation is an example of factitious disorder by proxy. Factitious disorder by proxy, also known as Munchausen syndrome by proxy, is a condition in which a caregiver, usually a parent, fabricates or induces illness in another person, typically a child. In this case, the mother is bringing her son to the physician's office multiple times with complaints of breathing problems and abdominal pain, but no abnormalities are found. The fact that the mother becomes angry and leaves the office when confronted with suspicion suggests that she may be intentionally causing or exaggerating the child's symptoms.

The answer is K. This teenager, who was formerly outgoing and a good student and now seems sad, loses interest in making friends, and begins to do poor work in school, probably has adjustment disorder (with depressed mood). It is likely that he is having problems adjusting to his new school. In contrast to adjustment disorder, in masked depression the symptoms are more severe and often include significant weight loss and suicidality.

The answer is H. This man, who experiences a sudden paralysis triggered by seeing his girlfriend with another man, is showing evidence of conversion disorder. This disorder is characterized by an apparent lack of concern about the symptoms (i.e., la belle indifférence).

The given clinical picture is consistent with panic disorder. Panic disorder is characterized by recurrent and unexpected panic attacks, which are sudden episodes of intense fear or discomfort that reach a peak within minutes. Symptoms of panic attacks often include increased heart rate, sweating, and shortness of breath. The individual may also have a fear of dying or losing control during the attack. The fact that the student has had similar episodes on multiple occasions over the past 2 weeks and has no history of asthma suggests that panic disorder is the most likely explanation for her symptoms.

The answer is J. This man probably has social phobia. He is afraid of humiliating himself in a public situation (e.g., eating dinner in front of others in a restaurant).

The answer is F. This presentation is an example of malingering, feigning illness for obvious gain (the $30,000 workers' compensation settlement). Evidence for this is that the woman has no further hand problems after she receives the money. In conversion disorder, somatization disorder, factitious disorder, and factitious disorder by proxy there is no obvious or material gain related to the symptoms.

The answer is D. This presentation is an example of factitious disorder by proxy. The mother has feigned the child's illness (episodes of breathing problems and abdominal pain) for attention from medical personnel. This faking has resulted in four abdominal surgical procedures in which no abnormalities were found. Since she knows she is lying, the mother will become angry and flee when confronted with the truth. The first thing the physician must do is to notify the state social service agency since factitious disorder by proxy is a form of child abuse. Waiting until the child's next visit before acting could result in the child's further injury or even death. Calling in specialists may be appropriate after the physician reports his suspicions to the state. It is not appropriate to take the child aside and ask him how he really feels. He probably is unaware of his mother's behavior.

A factitious disorder is characterized by the intentional production or feigning of physical or psychological symptoms in order to assume the sick role. In this case, the child's behavior suggests that he may be intentionally producing or exaggerating his pain symptoms, as evidenced by his contentment in the hospital and his bookmarked textbook on skeletal pain of unknown origin. This behavior is consistent with a factitious disorder.

The patient's symptoms of feeling "nervous" and having an "upset stomach" are suggestive of anxiety and gastrointestinal issues. The mention of other family members being "tense and nervous" suggests a possible genetic or familial predisposition to anxiety. Tingling in the extremities can be a common physical symptom of anxiety, known as paresthesia. Therefore, it is likely that this patient may also experience tingling in her extremities as an additional sign or symptom.

The most effective immediate treatment for this patient is a benzodiazepine. The patient is experiencing symptoms of anxiety, such as increased heart rate, sweating, and shortness of breath. These symptoms are not consistent with an asthma attack, as the patient has no history of asthma and physical findings are unremarkable. Benzodiazepines are commonly used to treat anxiety and can provide immediate relief of symptoms. Antidepressants, support groups, buspirone, and β-blockers are not the most appropriate options for immediate treatment of acute anxiety symptoms.

The answer is E. This woman with a 20-year history of unexplained vague and chronic physical complaints probably has somatization disorder. This can be distinguished from hypochondriasis, which is an exaggerated worry about normal physical sensations and minor ailments (see also answers 14-19).

The answer is A. The most effective long-term treatment for OCD is an antidepressant such as clomiprimine (see also answer to the Typical Board Question) or an SSRI.

The answer is B. This patient is most likely to have post-traumatic stress disorder (PTSD). This disorder, which is characterized by symptoms of anxiety and intrusive memories and nightmares of a life-threatening event such as rape, can last for many years in chronic form and may have been intensified in this patient by reexperiencing her own rape through the rape of her coworker. The most effective long-term treatment for this patient is a support group, in this case a rape survivor's group. Pharmacologic treatment can be used as an adjunct to psychological treatment.

The answer is C. This clinical presentation is an example of factitious disorder (note: most axis I disorders can also be seen in children). In contrast to patients with somatoform disorders who really believe that they are ill, patients with factitious disorder are conscious of the fact that they are feigning their illness. Pain is one of the most commonly feigned illnesses and this patient's nighttime reading is providing him with specific knowledge of how to feign the symptoms realistically. Although he is consciously producing his symptoms, this boy is not receiving tangible benefit for his behavior. Thus, in contrast to individuals who are consciously feigning illness for obvious gain, i.e., malingering (see question 21), the motivation for this patient's faking behavior is primarily unconscious.

The answer is A. This patient is showing evidence of panic disorder. Panic disorder is characterized by panic attacks, which include increased heart rate, dizziness, sweating, shortness of breath, and fainting, and the conviction that one is about to die. Attacks commonly occur twice weekly, last about 30 minutes, and are most common in young women, such as this patient. While the most effective immediate treatment for this patient is a benzodiazepine because it works quickly, the most effective long-term (maintenance) treatment is an antidepressant, particularly a selective serotonin reuptake inhibitor (SSRI) such as paroxetine (Paxil).

The answer is L. This man, who says that has been "sickly" for the past 3 months and fears that he has stomach cancer, probably has masked depression. In contrast to the hypochondriacal man in the previous question, evidence for depression in this patient includes the fact that, in addition to the somatic complaints, he shows symptoms of depression (e.g., he is not groomed, appears slowed down [psychomotor retardation], and has lost a significant amount of weight).

The answer is F. The triad of hypoglycemia, very high insulin level, and suppressed plasma C peptide indicates that this nurse has self-administered insulin, a situation known as factitious hyperinsulinism. In hyperinsulinism due to medical causes, e.g., insulinoma (pancreatic B-cell tumor), plasma C peptide is typically increased, not decreased. Factitious disorder is more common in people associated with the health professions. There is no evidence in this woman of a sleep disorder, seizure disorder, somatoform disorder, or endocrine disorder such as diabetes. Because there is no obvious or practical gain for this woman in being ill, malingering is unlikely.

The answer is D. This patient is most likely to have generalized anxiety disorder (GAD). This disorder, which includes chronic anxiety and gastrointestinal symptoms over a prolonged period, is more common in women and often starts in the 20s. Genetic factors are seen in the observation that other family members have similar problems with anxiety. Additional signs or symptoms of anxiety that this patient is likely to show include tingling in the extremities, often resulting from hyperventilation. Flight of ideas, hallucinations, ideas of reference, and neologisms are psychotic symptoms, which are not seen in the anxiety disorders or the somatoform disorders. Of the choices, the most effective long-term treatment for this patient is buspirone because, unlike the benzodiazepine alprazolam, it does not cause dependence or withdrawal symptoms with long-term use. The antidepressants venlafaxine and duloxetine and SSRIs also are effective for long-term treatment of GAD. Psychotherapy and β-blockers can be used as adjuncts to treat GAD, but are not the most effective long-term treatments.

The answer is D. When there is financial or other obvious gain to be obtained from an illness, the possibility that the person is malingering should be considered. In this case, a man who has committed a crime is feigning symptoms of narcolepsy to avoid prosecution. Knowledge of the details of his brother's illness has allowed him to feign the cataplexy (sudden loss of motor control) and daytime sleepiness associated with narcolepsy.