DSM-Self-Exam-Questions.pdf

DSM-5® Self-Exam Questions Test Questions for the Diagnostic Criteria This page intentionally left blank Note: The authors have worked to ensure that all information in this book is accurate at the time of publication and consistent with general psychiatric and medical stan- dards, and that information concerning drug dosages, schedules, and routes of ad- ministration is accurate at the time of publication and consistent with standards set by the U.S. Food and Drug Administration and the general medical community. As medical research and practice continue to advance, however, therapeutic standards may change. Moreover, specific situations may require a specific therapeutic response not included in this book. For these reasons and because human and mechanical er- rors sometimes occur, we recommend that readers follow the advice of physicians di- rectly involved in their care or the care of a member of their family. 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American Psychiatric Publishing, a Division of American Psychiatric Association 1000 Wilson Boulevard Arlington, VA 22209-3901 www.appi.org Contents Contributors............................................ ix Preface................................................ xi Part I: Questions DSM-5 Introduction.......................................2 CHAPTER 1 Neurodevelopmental Disorders..............................3 CHAPTER 2 Schizophrenia Spectrum and Other Psychotic Disorders.........25 CHAPTER 3 Bipolar and Related Disorders..............................34 CHAPTER 4 Depressive Disorders.....................................39 CHAPTER 5 Anxiety Disorders........................................49 CHAPTER 6 Obsessive-Compulsive and Related Disorders.................55 CHAPTER 7 Trauma- and Stressor-Related Disorders.....................61 CHAPTER 8 Dissociative Disorders....................................70 CHAPTER 9 Somatic Symptom and Related Disorders.....................73 CHAPTER 10 Feeding and Eating Disorders..............................80 C H A P T E R 1 1 Elimination Disorders..................................... 84 C H A P T E R 1 2 Sleep-Wake Disorders.................................... 87 C H A P T E R 1 3 Sexual Dysfunctions..................................... 95 C H A P T E R 1 4 Gender Dysphoria....................................... 99 C H A P T E R 1 5 Disruptive, Impulse-Control, and Conduct Disorders........... 101 C H A P T E R 1 6 Substance-Related and Addictive Disorders.................. 109 C H A P T E R 1 7 Neurocognitive Disorders................................ 120 C H A P T E R 1 8 Personality Disorders................................... 128 C H A P T E R 1 9 Paraphilic Disorders.................................... 136 C H A P T E R 2 0 Assessment Measures (DSM-5 Section III)................... 139 C H A P T E R 2 1 Cultural Formulation (DSM-5 Section III) and Glossary of Cultural Concepts of Distress (DSM-5 Appendix).... 142 C H A P T E R 2 2 Alternative DSM-5 Model for Personality Disorders (DSM-5 Section III)..................................... 147 C H A P T E R 2 3 Glossary of Technical Terms (DSM-5 Appendix).............. 151 Part II: Answer Guide DSM-5 Introduction.....................................156 CHAPTER 1 Neurodevelopmental Disorders............................159 CHAPTER 2 Schizophrenia Spectrum and Other Psychotic Disorders........206 CHAPTER 3 Bipolar and Related Disorders.............................226 CHAPTER 4 Depressive Disorders....................................237 CHAPTER 5 Anxiety Disorders.......................................258 CHAPTER 6 Obsessive-Compulsive and Related Disorders................273 CHAPTER 7 Trauma- and Stressor-Related Disorders....................285 CHAPTER 8 Dissociative Disorders...................................303 CHAPTER 9 Somatic Symptom and Related Disorders....................310 CHAPTER 10 Feeding and Eating Disorders.............................325 CHAPTER 11 Elimination Disorders....................................333 CHAPTER 12 Sleep-Wake Disorders...................................339 CHAPTER 13 Sexual Dysfunctions....................................355 C H A P T E R 1 4 Gender Dysphoria...................................... 363 C H A P T E R 1 5 Disruptive, Impulse-Control, and Conduct Disorders........... 367 C H A P T E R 1 6 Substance-Related and Addictive Disorders.................. 383 C H A P T E R 1 7 Neurocognitive Disorders................................ 406 C H A P T E R 1 8 Personality Disorders................................... 423 C H A P T E R 1 9 Paraphilic Disorders.................................... 438 C H A P T E R 2 0 Assessment Measures (DSM-5 Section III)................... 443 C H A P T E R 2 1 Cultural Formulation (DSM-5 Section III) and Glossary of Cultural Concepts of Distress (DSM-5 Appendix).... 449 C H A P T E R 2 2 Alternative DSM-5 Model for Personality Disorders (DSM-5 Section III)..................................... 458 C H A P T E R 2 3 Glossary of Technical Terms (DSM-5 Appendix).............. 465 Contributors Lawrence Amsel, M.D., M.P.H. Assistant Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York Elizabeth L. Auchincloss, M.D. Vice-Chair, Graduate Medical Education, Department of Psychiatry, Weill Cornell Medical College; Senior Associate Director, Columbia University Center for Psycho- analytic Training and Research, New York, New York Robert J. Boland, M.D. Professor of Psychiatry and Human Behavior; Associate Director, Residency Training, Alpert School of Medicine, Brown University, Providence, Rhode Island Joyce T. Chen, M.D. Public Psychiatry Postdoctoral Clinical Fellow, Department of Psychiatry, New York State Psychiatric Institute/Columbia University Medical Center, New York, New York Christina Kitt Garza, M.D. Instructor in Psychiatry, NY-Presbyterian Hospital/Columbia University Medical Center, New York, New York Philip R. Muskin, M.D. Professor of Psychiatry, Columbia University Medical Center; Chief of Service, Con- sultation-Liaison Psychiatry at NY-Presbyterian Hospital/Columbia University Medical Center, New York, New York Michelle B. Riba, M.D., M.S. Professor and Associate Chair for Integrated Medical and Psychiatric Services, De- partment of Psychiatry; Associate Director, University of Michigan Comprehensive Depression Center; Director, PsychOncology Program, University of Michigan Com- prehensive Cancer Center; Associate Director, Michigan Institute for Clinical and Health Research, Ann Arbor, Michigan Julie K. Schulman, M.D. Assistant Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons; Consultation-Liaison Psychiatry at NY–Presbyterian Hospital/Co- lumbia University Medical Center, New York, New York ix Peter A. Shapiro, M.D. Professor of Psychiatry, Columbia University Medical Center; Associate Director, Consultation-Liaison Psychiatry Service, and Director, Fellowship Training Program in Psychosomatic Medicine, NY–Presbyterian Hospital/Columbia University Medi- cal Center, New York, New York Jonathan A. Slater, M.D. Clinical Professor of Psychiatry (in Pediatrics), Columbia University College of Phy- sicians and Surgeons; Director, Consultation and Emergency Service, Morgan Stanley Children’s Hospital of New York, NY–Presbyterian Hospital/Columbia University Medical Center, New York, New York Disclosure of Interests The contributors have declared all forms of support received within the 12 months prior to manuscript submittal that may represent a competing interest in relation to their work published in this volume, as follows: Philip R. Muskin, M.D. Speakers Bureau: Otsuka. The following contributors stated that they had no competing interests during the year preceding man- uscript submission: Lawrence Amsel, M.D., M.P.H.; Elizabeth L. Auchincloss, M.D.; Robert J. Boland, M.D.; Joyce T. Chen, M.D.; Christina Kitt Garza, M.D.; Michelle B. Riba, M.D., M.S.; Julie K. Schulman, M.D.; Peter A. Shapiro, M.D.; Jonathan A. Slater, M.D. x | Contributors Preface This self-examination guide is a companion to, not a replacement for, a thorough reading of DSM-5. The most recent edition of the diagnostic manual brings a new set of diagnoses while retaining many familiar diagnoses. There are new approaches to diagnosis in DSM-5. Our framework in preparing this self-examination guide was to challenge the reader, hopefully engagingly, to learn about the new diag- noses, to understand the changes from DSM-IV, and to self-educate about new ap- proaches to the diagnostic endeavor. Some questions will seem obvious or easy and some questions will be quite difficult. As you work through the book, let it guide you to diagnostic sections where you would like to learn more as well as reassure you about those areas in which you are already well versed. The contributors took on a daunting task—i.e., to write a book about a book that was itself being written. The contributors to this book are a group of clinicians and educators who undertook the task of learning about DSM-5 in order to help others self-educate. There is no com- mentary or politics about diagnosis in this study guide. The contributors have gra- ciously donated the proceeds from this book to a charitable foundation. Philip R. Muskin, M.D. New York, New York xi This page intentionally left blank PART I Questions DSM-5 Introduction I.1 DSM-IV employed a multiaxial diagnostic system. Which of the following statements best describes the multiaxial system in DSM-5? A. There is a different multiaxial system in DSM-5. B. The multiaxial system in DSM-IV has been retained in DSM-5. C. DSM-5 has moved to a nonaxial documentation of diagnosis. D. Axis I (Clinical Disorders) and Axis II (Personality Disorders) have been re- tained in DSM-5. E. Axis IV (Psychosocial and Environmental Problems) and Axis V (Global Assessment of Functioning) have been retained in DSM-5. I.2 True or False: The Global Assessment of Functioning (GAF) Scale (DSM-IV Axis V) remains a separate category that should be coded in DSM-5. A. True. B. False. I.3 To enhance diagnostic specificity, DSM-5 replaced the previous “not otherwise specified” (NOS) designation with two options for clinical use: Other Specified [disorder] and Unspecified [disorder]. Which of the following statements about use of the Unspecified designation is true? A. The Unspecified designation is used when the clinician chooses not to spec- ify the reason that criteria for a specific disorder were not met. B. The Unspecified designation is used when there is no recognized Other Specified disorder (e.g., recurrent brief depression, sexual aversion). C. The Unspecified designation is used when the individual has fewer than three symptoms of any of the recognized disorders within the diagnostic class. D. The Unspecified designation is used when the individual presents with symptomatology of disorders in two or more diagnostic classes. E. The Unspecified designation is used when the clinician believes the condi- tion is of a temporary nature. 2 | DSM-5 Introduction—QUESTIONS C H A P T E R 1 Neurodevelopmental Disorders 1.1 Which of the following is not required for a DSM-5 diagnosis of intellectual dis- ability (intellectual developmental disorder)? A. Full-scale IQ below 70. B. Deficits in intellectual functions confirmed by clinical assessment. C. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social respon- sibility. D. Symptom onset during the developmental period. E. Deficits in intellectual functions confirmed by individualized, standardized intelligence testing. 1.2 A 7-year-old boy in second grade displays significant delays in his ability to reason, solve problems, and learn from his experiences. He has been slow to develop reading, writing, and mathematics skills in school. All through devel- opment, these skills lagged behind peers, although he is making slow progress. These deficits significantly impair his ability to play in an age-appropriate manner with peers and to begin to acquire independent skills at home. He re- quires ongoing assistance with basic skills (dressing, feeding, and bathing him- self; doing any type of schoolwork) on a daily basis. Which of the following diagnoses best fits this presentation? A. Childhood-onset major neurocognitive disorder. B. Specific learning disorder. C. Intellectual disability (intellectual developmental disorder). D. Communication disorder. E. Autism spectrum disorder. 1.3 A 7-year-old boy in second grade displays significant delays in his ability to reason, solve problems, and learn from his experiences. He has been slow to develop reading, writing, and mathematics skills in school. All through devel- opment, these skills lagged behind peers, although he is making slow progress. These deficits significantly impair his ability to play in an age-appropriate manner with peers and to begin to acquire independent skills at home. He re- quires ongoing assistance with basic skills (dressing, feeding, and bathing him- self; doing any type of schoolwork) on a daily basis. What is the appropriate severity rating for this patient’s current presentation? Neurodevelopmental Disorders—QUESTIONS | 3 A. Mild. B. Moderate. C. Severe. D. Profound. E. Cannot be determined without an IQ score. 1.4 Which of the following statements about intellectual disability (intellectual de- velopmental disorder) is false? A. Individuals with intellectual disability have deficits in general mental abil- ities and impairment in everyday adaptive functioning compared with age- and gender-matched peers from the same linguistic and sociocultural group. B. For individuals with intellectual disability, the full-scale IQ score is a valid assessment of overall mental abilities and adaptive functioning, even if sub- test scores are highly discrepant. C. Individuals with intellectual disability may have difficulty in managing their behavior, emotions, and interpersonal relationships and in maintain- ing motivation in the learning process. D. Intellectual disability is generally associated with an IQ that is 2 standard deviations from the population mean, which equates to an IQ score of about 70 or below (r5 points). E. Assessment procedures for intellectual disability must take into account factors that may limit performance, such as sociocultural background, na- tive language, associated communication/language disorder, and motor or sensory handicap. 1.5 Which of the following statements about the diagnosis of intellectual disability (intellectual developmental disorder) is false? A. An individual with an IQ of less than 70 would receive the diagnosis if there were no significant deficits in adaptive functioning. B. An individual with an IQ above 75 would not meet diagnostic criteria even if there were impairments in adaptive functioning. C. In forensic assessment, severe deficits in adaptive functioning might allow for a diagnosis with an IQ above 75. D. Adaptive functioning must take into account the three domains of concep- tual, social, and practical functioning. E. The specifiers mild, moderate, severe, and profound are based on IQ scores. 1.6 Which of the following is not a diagnostic feature of intellectual disability (in- tellectual developmental disorder)? A. A full-scale IQ of less than 70. B. Inability to perform complex daily living tasks (e.g., money management, medical decision making) without support. 4 | Neurodevelopmental Disorders—QUESTIONS C. Gullibility, with naiveté in social situations and a tendency to be easily led by others. D. Lack of age-appropriate communication skills for social and interpersonal functioning. E. All of the above are diagnostic features of intellectual disability. 1.7 Which of the following statements about adaptive functioning in the diagnosis of intellectual disability (intellectual developmental disorder) is true? A. Adaptive functioning is based on an individual’s IQ score. B. “Deficits in adaptive functioning” refers to problems with motor coordina- tion. C. At least two domains of adaptive functioning must be impaired to meet Cri- terion B for the diagnosis of intellectual disability. D. Adaptive functioning in intellectual disability tends to improve over time, although the threshold of cognitive capacities and associated developmen- tal disorders can limit it. E. Individuals diagnosed with intellectual disability in childhood will typi- cally continue to meet criteria in adulthood even if their adaptive function- ing improves. 1.8 Which of the following statements about development of and risk factors for intellectual disability (intellectual developmental disorder) is true? A. Intellectual developmental disorder should not be diagnosed in the pres- ence of a known genetic syndrome, such as Lesch-Nyhan or Prader-Willi syndrome. B. Etiologies are confined to perinatal and postnatal factors and exclude pre- natal events. C. In severe acquired forms of intellectual developmental disorder, onset may be abrupt following an illness (e.g., meningitis) or head trauma occurring during the developmental period. D. When intellectual disability results from a loss of previously acquired cog- nitive skills, as in severe traumatic brain injury (TBI), only the TBI diagnosis is assigned. E. Prenatal, perinatal, and postnatal etiologies of intellectual developmental disorder are demonstrable in approximately 33% of cases. 1.9 Which of the following statements about the developmental course of intellec- tual disability (intellectual developmental disorder) is true? A. Delayed motor, language, and social milestones are not identifiable until af- ter the first 2 years of life. B. Intellectual disability caused by an illness (e.g., encephalitis) or by head trauma occurring during the developmental period would be diagnosed as Neurodevelopmental Disorders—QUESTIONS | 5 a neurocognitive disorder, not as intellectual disability (intellectual devel- opmental disorder). C. Intellectual disability is always nonprogressive. D. Major neurocognitive disorder may co-occur with intellectual developmen- tal disorder. E. Even if early and ongoing interventions throughout childhood and adult- hood lead to improved adaptive and intellectual functioning, the diagnosis of intellectual disability would continue to apply. 1.10 The DSM-5 diagnosis of intellectual developmental disorder includes severity specifiers—Mild, Moderate, Severe, and Profound—with which to indicate the level of supports required in various domains of adaptive functioning. Which of the following features would not be characteristic of an individual with a “Severe” level of impairment? A. The individual generally has little understanding of written language or of concepts involving numbers, quantity, time, and money. B. The individual’s spoken language is quite limited in terms of vocabulary and grammar. C. The individual requires support for all activities of daily living, including meals, dressing, bathing, and toileting. D. In adulthood, the individual may be able to sustain competitive employ- ment in a job that does not emphasize conceptual skills. E. The individual cannot make responsible decisions regarding the well-being of self or others. 1.11 A 10-year-old boy with a history of dyslexia, who is otherwise developmen- tally normal, is in a skateboarding accident in which he experiences severe traumatic brain injury. This results in significant global intellectual impairment (with a persistent reading deficit that is more pronounced than his other newly acquired but stable deficits, along with a full-scale IQ of 75). There is mild im- pairment in his adaptive functioning such that he requires support in some ar- eas of functioning. He is also displaying anxious and depressive symptoms in response to his accident and hospitalization. What is the least likely diagnosis? A. Intellectual disability (intellectual developmental disorder). B. Traumatic brain injury. C. Specific learning disorder. D. Major neurocognitive disorder due to traumatic brain injury. E. Adjustment disorder. 1.12 In which of the following situations would a diagnosis of global developmen- tal delay be inappropriate? A. The patient is a child who is too young to fully manifest specific symptoms or to complete requisite assessments. 6 | Neurodevelopmental Disorders—QUESTIONS B. The patient, a 7-year-old boy, has a full-scale IQ of 65 and severe impair- ment in adaptive functioning. C. The patient’s scores on psychometric tests suggest intellectual disability (in- tellectual developmental disorder), but there is insufficient information about the patient’s adaptive functional skills. D. The patient’s impaired adaptive functioning suggests intellectual develop- mental disorder, but there is insufficient information about the level of cog- nitive impairment measured by standardized instruments. E. The patient’s cognitive and adaptive impairments suggest intellectual de- velopmental disorder, but there is insufficient information about age at on- set of the condition. 1.13 Which of the following statements about global developmental delay is true? A. The diagnosis is typically made in children younger than 5 years of age. B. The etiology can usually be determined. C. The prevalence is estimated to be between 0.5% and 2%. D. The condition is progressive. E. The condition does not generally occur with other neurodevelopmental dis- orders. 1.14 A 3½-year-old girl with a history of lead exposure and a seizure disorder dem- onstrates substantial delays across multiple domains of functioning, including communication, learning, attention, and motor development, which limit her ability to interact with same-age peers and require substantial support in all ac- tivities of daily living at home. Unfortunately, her mother is an extremely poor historian, and the child has received no formal psychological or learning eval- uation to date. She is about to be evaluated for readiness to attend preschool. What is the most appropriate diagnosis? A. Major neurocognitive disorder. B. Developmental coordination disorder. C. Autism spectrum disorder. D. Global developmental delay. E. Specific learning disorder. 1.15 A 5-year-old boy has difficulty making friends and problems with initiating and sustaining back-and-forth conversation; reading social cues; and sharing his feelings with others. He makes good eye contact, has normal speech into- nation, displays facial gestures, and has a range of affect that generally seems appropriate to the situation. He demonstrates an interest in trains that seems abnormal in intensity and focus, and he engages in little imaginative or sym- bolic play. Which of the following diagnostic requirements for autism spec- trum disorder are not met in this case? Neurodevelopmental Disorders—QUESTIONS | 7 A. Deficits in social-emotional reciprocity. B. Deficits in nonverbal communicative behaviors used for social interaction. C. Deficits in developing and maintaining relationships. D. Restricted, repetitive patterns of behavior, interests, or activities as mani- fested by symptoms in two of the specified four categories. E. Symptoms with onset in early childhood that cause clinically significant impairment. 1.16 Which of the following statements about the development and course of au- tism spectrum disorder (ASD) is false? A. Symptoms of ASD are typically recognized during the second year of life (12–24 months of age). B. Symptoms of ASD are usually not noticeable until 5–6 years of age or later. C. First symptoms frequently involve delayed language development, often accompanied by lack of social interest or unusual social interactions. D. ASD is not a degenerative disorder, and it is typical for learning and com- pensation to continue throughout life. E. Because many normally developing young children have strong prefer- ences and enjoy repetition, distinguishing restricted and repetitive behav- iors that are diagnostic of ASD can be difficult in preschoolers. 1.17 Which of the following was a criterion symptom for autistic disorder in DSM- IV that was eliminated from the diagnostic criteria for autism spectrum disor- der in DSM-5? A. Stereotyped or restricted patterns of interest. B. Stereotyped and repetitive motor mannerisms. C. Inflexible adherence to routines. D. Persistent preoccupation with parts of objects. E. None of the above. 1.18 A 7-year-old girl presents with a history of normal language skills (vocabulary and grammar intact) but is unable to use language in a socially pragmatic man- ner to share ideas and feelings. She has never made good eye contact, and she has difficulty reading social cues. Consequently, she has had difficulty making friends, which is further complicated by her being somewhat obsessed with cartoon characters, which she repetitively scripts. She tends to excessively smell objects. Because she insists on wearing the same shirt and shorts every day, regardless of the season, getting dressed is a difficult activity. These symp- toms date from early childhood and cause significant impairment in her func- tioning. What diagnosis best fits this child’s presentation? A. Asperger’s disorder. B. Autism spectrum disorder. C. Pervasive developmental disorder not otherwise specified (NOS). 8 | Neurodevelopmental Disorders—QUESTIONS D. Social (pragmatic) communication disorder. E. Rett syndrome. 1.19 A 15-year-old boy has a long history of nonverbal communication deficits. As an infant he was unable to follow someone else directing his attention by point- ing. As a toddler he was not interested in sharing events, feelings, or games with his parents. From school age into adolescence, his speech was odd in to- nality and phrasing, and his body language was awkward. What do these symptoms represent? A. Stereotypies. B. Restricted range of interests. C. Developmental regression. D. Prodromal schizophreniform symptoms. E. Deficits in nonverbal communicative behaviors. 1.20 A 10-year-old boy demonstrates hand-flapping and finger flicking, and he re- petitively flips coins and lines up his trucks. He tends to “echo” the last several words of a question posed to him before answering, mixes up his pronouns (re- fers to himself in the second person), tends to repeat phrases in a perseverative fashion, and is quite fixated on routines related to dress, eating, travel, and play. He spends hours in his garage playing with his father’s tools. What do these behaviors represent? A. Restricted, repetitive patterns of behaviors, interests, or activities character- istic of autism spectrum disorder. B. Symptoms of obsessive-compulsive disorder. C. Prototypical manifestations of obsessive-compulsive personality. D. Symptoms of pediatric acute-onset neuropsychiatric syndrome (PANS). E. Complex tics. 1.21 A 25-year-old man presents with long-standing nonverbal communication deficits, inability to have a back-and-forth conversation or share interests in an appropriate fashion, and a complete lack of interest in having relationships with others. His speech reflects awkward phrasing and intonation and is me- chanical in nature. He has a history of sequential fixations and obsessions with various games and objects throughout childhood; however, this is not cur- rently a major issue for him. This patient meets criteria for autism spectrum disorder; true or false? A. True. B. False. 1.22 A 9-year-old girl presents with a history of intellectual impairment, a structural language impairment, nonverbal communication deficits, disinterest in peers, and inability to use language in a social manner. She has extreme food and tac- tile sensitivities. She is obsessed with one particular computer game that she Neurodevelopmental Disorders—QUESTIONS | 9 plays for hours each day, and she scripts and imitates the characters in this game. She is clumsy, has an odd gait, and walks on her tiptoes. In the past year she has developed a seizure disorder and has begun to bang her wrists against the wall repetitively, causing bruising. On the other hand, she plays several musical instruments in an extremely precocious manner. Which feature of this child’s clinical presentation fulfills a criterion symptom for DSM-5 autism spectrum disorder? A. Motor abnormalities. B. Seizures. C. Structural language impairment. D. Intellectual impairment. E. Nonverbal communicative deficits. 1.23 An 11-year-old girl with autism spectrum disorder displays no spoken lan- guage and is minimally responsive to overtures from others. She can be some- what inflexible, which interferes with her ability to travel, do schoolwork, and be managed in the home; she has some difficulty transitioning; and she has trouble organizing and planning activities. These problems can usually be managed with incentives and reinforcers. What severity levels should be spec- ified in the DSM-5 diagnosis? A. Level 3 (requiring very substantial support) for social communication, and level 1 (requiring support) for restricted, repetitive behaviors. B. Level 1 (requiring support) for social communication, and level 3 (requiring very substantial support) for restricted, repetitive behaviors. C. Level 1 (requiring support) for social communication, and level 2 (requiring substantial support) for restricted, repetitive behaviors. D. Level 3 (requiring very substantial support) for social communication, and level 1 (requiring support) for restricted, repetitive behaviors. E. Level 2 (requiring substantial support) for social communication, and level 1 (requiring support) for restricted, repetitive behaviors. 1.24 Which of the following is not a specifier included in the diagnostic criteria for autism spectrum disorder? A. With or without accompanying intellectual impairment. B. With or without associated dementia. C. With or without accompanying language impairment. D. Associated with a known medical or genetic condition or environmental factor. E. Associated with another neurodevelopmental, mental, or behavioral disor- der. 10 | Neurodevelopmental Disorders—QUESTIONS 1.25 Which of the following is not characteristic of the developmental course of chil- dren diagnosed with autism spectrum disorder? A. Behavioral features manifest before 3 years of age. B. The full symptom pattern does not appear until age 2–3 years. C. Developmental plateaus or regression in social-communicative behavior is frequently reported by parents. D. Regression across multiple domains occurs after age 2–3 years. E. First symptoms often include delayed language development, lack of social interest or unusual social behavior, odd play, and unusual communication patterns. 1.26 A 5-year-old girl has some mild food aversions. She enjoys having the same book read to her at night but does not become terribly upset if her mother asks her to choose a different book. She occasionally spins around excitedly when her favorite show is on. She generally likes her toys neatly arranged in bins but is only mildly upset when her sister leaves them on the floor. These behaviors should be considered suspicious for an autism spectrum disorder; true or false? A. True. B. False. 1.27 Which of the following is not representative of the typical developmental course for autism spectrum disorder? A. Lack of degenerative course. B. Behavioral deterioration during adolescence. C. Continued learning and compensation throughout life. D. Marked presence of symptoms in early childhood and early school years, with developmental gains in later childhood in areas such as social interac- tion. E. Good psychosocial functioning in adulthood, as indexed by independent living and gainful employment. 1.28 A 21-year-old man, not previously diagnosed with a developmental disorder, presents for evaluation after taking a leave from college for psychological rea- sons. He makes little eye contact, does not appear to pick up on social cues, has become disinterested in friends, spends hours each day on the computer surf- ing the Internet and playing games, and has become so sensitive to smells that he keeps multiple air fresheners in all locations of the home. He reports that he has had long-standing friendships dating from childhood and high school (corroborated by his parents). He reports making many friends in his fraternity at college. His parents report good social and communication skills in child- hood, although he was quite shy and was somewhat inflexible and ritualistic at home. What is the least likely diagnosis? Neurodevelopmental Disorders—QUESTIONS | 11 A. Depression. B. Schizophreniform disorder or schizophrenia. C. Autism spectrum disorder. D. Obsessive-compulsive disorder. E. Social anxiety disorder (social phobia). 1.29 Which of the following characteristics is generally not associated with autism spectrum disorder? A. Anxiety, depression, and isolation as an adult. B. Catatonia. C. Poor psychosocial functioning. D. Insistence on routines and aversion to change. E. Successful adaptation in regular school settings. 1.30 Which of the following disorders is generally not comorbid with autism spec- trum disorder (ASD)? A. Attention-deficit/hyperactivity disorder (ADHD). B. Rett syndrome. C. Selective mutism. D. Intellectual disability (intellectual developmental disorder). E. Stereotypic movement disorder. 1.31 Which of the following is not a criterion for the DSM-5 diagnosis of attention- deficit/hyperactivity disorder (ADHD)? A. Onset of several inattentive or hyperactive-impulsive symptoms prior to age 12 years. B. Manifestation of several inattentive or hyperactive-impulsive symptoms in two or more settings (e.g., at home, school, or work; with friends or rela- tives; in other activities). C. Persistence of symptoms for at least 12 months. D. Clear evidence that symptoms interfere with, or reduce the quality of, so- cial, academic, or occupational functioning. E. Inability to explain symptoms as a manifestation of another mental disor- der (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal). 1.32 The parents of a 15-year-old female tenth grader believe that she should be do- ing better in high school, given how bright she seems and the fact that she re- ceived mostly A’s through eighth grade. Her papers are handed in late, and she makes careless mistakes on examinations. They have her tested, and the WAIS- IV results are as follows: Verbal IQ, 125; Perceptual Reasoning Index, 122; Full- Scale IQ, 123; Working Memory Index, 55th percentile; Processing Speed In- dex, 50th percentile. Weaknesses in executive function are noted. During a psy- 12 | Neurodevelopmental Disorders—QUESTIONS chiatric evaluation, she reports a long history of failing to give close attention to details, difficulty sustaining attention while in class or doing homework, failing to finish chores and tasks, and significant difficulties with time manage- ment, planning, and organization. She is forgetful, often loses things, and is easily distracted. She has no history of restlessness or impulsivity, and she is well liked by her peers. What is the most likely diagnosis? A. Adjustment disorder with anxiety. B. Specific learning disorder. C. Attention-deficit/hyperactivity disorder, predominantly inattentive. D. Developmental coordination disorder. E. Major depressive disorder. 1.33 A 7-year-old boy is having behavioral and social difficulties in his second- grade class. Although he seems to be able to attend and is doing “well” from an academic standpoint (though seemingly not what he is capable of), he is constantly interrupting, fidgeting, talking excessively, and getting out of his seat. He has friends, but he sometimes annoys his peers because of his diffi- culty sharing and taking turns and the fact that he is constantly talking over them. Although he seeks out play dates, his friends tire of him because he wants to play sports nonstop. At home, he can barely stay in his seat for a meal and is unable to play quietly. Although he shows remorse when the conse- quences of his behavior are pointed out to him, he can become angry in re- sponse and seems nevertheless unable to inhibit himself. What is the most likely diagnosis? A. Bipolar disorder. B. Autism spectrum disorder. C. Generalized anxiety disorder. D. Attention-deficit/hyperactivity disorder, predominantly hyperactive/im- pulsive. E. Specific learning disorder. 1.34 A 37-year-old Wall Street trader schedules a visit after his 8-year-old son is di- agnosed with attention-deficit/hyperactivity disorder (ADHD), combined in- attentive and hyperactive. Although he does not currently note motor restlessness like his son, he recalls being that way when he was a boy, along with being quite inattentive, being impulsive, talking excessively, interrupting, and having problems waiting his turn. He was an underachiever in high school and college, when he inconsistently did his work and had difficulty following rules. Nevertheless, he never failed any classes, and he was never evaluated by a psychologist or psychiatrist. He works about 60–80 hours a week and often gets insufficient sleep. He tends to make impulsive business decisions, can be impatient and short-tempered, and notes that his mind tends to wander both in one-on-one interactions with associates and his wife and during business meetings, for which he is often late; he is forgetful and disorganized. Neverthe- less, he tends to perform fairly well and is quite successful, although he can oc- Neurodevelopmental Disorders—QUESTIONS | 13 casionally feel overwhelmed and demoralized. What is the most likely diagnosis? A. Major depressive disorder. B. Generalized anxiety disorder. C. Specific learning disorder. D. ADHD, in partial remission. E. Oppositional defiant disorder. 1.35 A 5-year-old hyperactive, impulsive, and inattentive boy presents with hyper- telorism, highly arched palate, and low-set ears. He is uncoordinated and clumsy, he has no sense of time, and his toys and clothes are constantly strewn all over the house. He has recently developed what appears to be a motor tic involving blinking. He enjoys playing with peers, who tend to like him, al- though he seems to willfully defy all requests from his parents and kindergar- ten teacher, which does not seem to be due simply to inattention. He is delayed in beginning to learn how to read. What is the least likely diagnosis? A. Autism spectrum disorder. B. Developmental coordination disorder. C. Oppositional defiant disorder (ODD). D. Specific learning disorder. E. Attention-deficit/hyperactivity disorder (ADHD). 1.36 What is the prevalence of attention-deficit/hyperactivity disorder (ADHD) in children? A. 8%. B. 10%. C. 2%. D. 0.5%. E. 5%. 1.37 What is the prevalence of attention-deficit/hyperactivity disorder (ADHD) in adults? A. 8%. B. 10%. C. 2.5%. D. 0.5%. E. 5%. 1.38 What is the gender ratio of attention-deficit/hyperactivity disorder (ADHD) in children? A. Male:female ratio of 2:1. B. Male:female ratio of 1:1. 14 | Neurodevelopmental Disorders—QUESTIONS C. Male:female ratio of 3:2. D. Male:female ratio of 5:1. E. Male:female ratio of 1:2. 1.39 Which of the following is a biological finding in individuals with attention-def- icit/hyperactivity disorder (ADHD)? A. Decreased slow-wave activity on electroencephalograms. B. Reduced total brain volume on magnetic resonance imaging. C. Early posterior to anterior cortical maturation. D. Reduced thalamic volume. E. Both B and C. 1.40 Which of the following is not associated with attention-deficit/hyperactivity disorder (ADHD)? A. Reduced school performance. B. Poorer occupational performance and attendance. C. Higher probability of unemployment. D. Elevated interpersonal conflict. E. Reduced risk of substance use disorders. 1.41 Which of the following is not associated with attention-deficit/hyperactivity disorder (ADHD)? A. Social rejection. B. Increased risk of developing conduct disorder in childhood and antisocial personality disorder in adulthood. C. Increased risk of Alzheimer’s disease. D. Increased frequency of traffic accidents and violations. E. Increased risk of accidental injury. 1.42 A 15-year-old boy has developed concentration problems in school that have been associated with a significant decline in grades. When interviewed, he ex- plains that his mind is occupied with worrying about his mother, who has a se- rious autoimmune disease. As his grades falter, he becomes increasingly demoralized and sad, and he notices that his energy level drops, further com- promising his ability to pay attention in school. At the same time, he complains of feeling restless and unable to sleep. What is the most likely diagnosis? A. Bipolar disorder. B. Specific learning disorder. C. Attention-deficit/hyperactivity disorder (ADHD). D. Adjustment disorder with mixed anxiety and depressed mood. E. Separation anxiety disorder. Neurodevelopmental Disorders—QUESTIONS | 15 1.43 A 5-year-old boy is consistently moody, irritable, and intolerant of frustration. In addition, he is pervasively and chronically restless, impulsive, and inatten- tive. Which diagnosis best fits his clinical picture? A. Attention-deficit/hyperactivity disorder (ADHD). B. ADHD and disruptive mood dysregulation disorder (DMDD). C. Bipolar disorder. D. Oppositional defiant disorder (ODD). E. Major depressive disorder (MDD). 1.44 Which of the following statements about comorbidity in attention-deficit/hy- peractivity disorder (ADHD) is true? A. Oppositional defiant disorder co-occurs with ADHD in about half of chil- dren with the combined presentation and about a quarter of those with the predominantly inattentive presentation. B. Most children with disruptive mood dysregulation disorder do not also meet criteria for ADHD. C. Fifteen percent of adults with ADHD have some type of anxiety disorder. D. Intermittent explosive disorder occurs in about 5% of adults with ADHD. E. Specific learning disorder very seldom co-occurs with ADHD. 1.45 Specific learning disorder is defined by persistent difficulties in learning aca- demic skills, with onset during the developmental period. Which of the follow- ing statements about this disorder is true? A. It is part of a more general learning impairment as manifested in intellec- tual disability (intellectual developmental disorder). B. It can usually be attributed to a sensory, physical, or neurological disorder. C. It involves pervasive and wide-ranging deficits across multiple domains of information processing. D. It can be caused by external factors such as economic disadvantage or lack of education. E. It replaces the DSM-IV diagnoses of reading disorder, mathematics disor- der, disorder of written expression, and learning disorder not otherwise specified. 1.46 In distinction to DSM-IV, DSM-5 classifies all learning disorders under the di- agnosis of specific learning disorder, along with the requirement to “specify all academic domains and subskills that are impaired” at the time of assessment. Which of the following statements about specific learning disorder is false? A. There are persistent difficulties in the acquisition of reading, writing, arith- metic, or mathematical reasoning skills during the formal years of school- ing. 16 | Neurodevelopmental Disorders—QUESTIONS B. Current skills in one or more of these academic areas are well below the av- erage range for the individual’s age, gender, cultural group, and level of ed- ucation. C. There usually is a discrepancy of more than 2 standard deviations (SD) be- tween achievement and IQ. D. The learning difficulties significantly interfere with academic achievement, occupational performance, or activities of daily living that require these ac- ademic skills. E. The learning difficulties cannot be acquired later in life. 1.47 Which of the following statements about the diagnosis of specific learning dis- order is false? A. Specific learning disorder is distinct from learning problems associated with a neurodegenerative cognitive disorder. B. If intellectual disability (intellectual developmental disorder) is present, the learning difficulties must be in excess of those expected. C. An uneven profile of abilities is typical in specific learning disorder. D. Attentional difficulties and motor clumsiness that are subthreshold for at- tention-deficit/hyperactivity disorder or developmental coordination dis- order are frequently associated with specific learning disorder. E. There are four formal subtypes of specific learning disorder. 1.48 Which of the following statements about prevalence rates for specific learning disorder is false? A. Prevalence rates range from 5% to 15% among school-age children across languages and cultures. B. Prevalence in adults is approximately 4%. C. Specific learning disorder is equally common among males and females. D. Prevalence rates vary according to the range of ages in the sample, selection criteria, severity of specific learning disorder, and academic domains inves- tigated. E. Gender ratios cannot be attributed to factors such as ascertainment bias, definitional or measurement variation, language, race, or socioeconomic status. 1.49 Which of the following statements about comorbidity in specific learning dis- order is true? A. Attention-deficit/hyperactivity disorder (ADHD) does not co-occur with specific learning disorder more frequently than would be expected by chance. B. Speech sound disorder and specific language impairments are not com- monly comorbid with specific learning disorder. Neurodevelopmental Disorders—QUESTIONS | 17 C. Identified clusters of co-occurrences include severe reading disorders; fine motor problems and handwriting problems; and problems with arithmetic, reading, and gross motor planning. D. The co-occurrence of specific learning disorder and specific language im- pairments has been shown in up to 20% of children with language prob- lems. E. Co-occurring disorders generally do not influence the course or treatment of specific learning disorder. 1.50 Which of the following statements about developmental coordination disorder (DCD) is true? A. Some children with DCD show additional (usually suppressed) motor ac- tivity, such as choreiform movements of unsupported limbs or mirror movements. B. The prevalence of DCD in children ages 5–11 years is 1%–3%. C. In early adulthood, there is improvement in learning new tasks involving complex/automatic motor skills, including driving and using tools. D. DCD has no association with prenatal exposure to alcohol or with low birth weight or preterm birth. E. Impairments in underlying neurodevelopmental processes have not been found to primarily affect visuomotor skills. 1.51 Which of the following statements about developmental coordination disorder (DCD) is true? A. The disorder is usually not diagnosed before the age of 7 years. B. Symptoms have usually improved significantly at 1-year follow-up. C. In most cases, symptoms are no longer evident by adolescence. D. DCD has no clear relationship with prenatal alcohol exposure, preterm birth, or low birth weight. E. Cerebellar dysfunction is hypothesized to play a role in DCD. 1.52 Which of the following is not a criterion for the DSM-5 diagnosis of stereotypic movement disorder? A. Motor behaviors are present that are repetitive, seemingly driven, and ap- parently purposeless. B. Onset of the behaviors is in the early developmental period. C. The behaviors result in self-inflicted bodily injury that requires medical treatment. D. The behaviors are not attributable to the physiological effects of a substance or neurological condition or better explained by another neurodevelop- mental or mental disorder. E. The behaviors interfere with social, academic, or other activities. 18 | Neurodevelopmental Disorders—QUESTIONS 1.53 Which of the following statements about the developmental course of stereo- typic movement disorder is false? A. The presence of stereotypic movements may indicate an undetected neuro- developmental problem, especially in children ages 1–3 years. B. Among typically developing children, the repetitive movements may be stopped when attention is directed to them or when the child is distracted from performing them. C. In some children, the stereotypic movements would result in self-injury if protective measures were not used. D. Whereas simple stereotypic movements (e.g., rocking) are common in young typically developing children, complex stereotypic movements are much less common (approximately 3%–4%). E. Stereotypic movements typically begin within the first year of life. 1.54 Which of the following is a DSM-5 diagnostic criterion for Tourette’s disorder? A. Tics occur throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months. B. Onset is before age 5 years. C. The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset. D. Motor tics must precede vocal tics. E. The tics may occur many times a day for at least 4 weeks, but no longer than 12 consecutive months. 1.55 At her child’s third office visit, the mother of an 8-year-old boy with a 6-month history of excessive eye blinking and intermittent chirping says that she has noticed the development of grunting sounds since he started school this term. What is the most likely diagnosis? A. Tourette’s disorder. B. Provisional tic disorder. C. Temporary tic disorder. D. Persistent (chronic) vocal tic disorder. E. Transient tic disorder, recurrent. 1.56 A 5-year-old girl is referred to your care with a DSM-IV diagnosis of chronic motor or vocal tic disorder. Under DSM-5, she would meet criteria for persis- tent (chronic) motor or vocal tic disorder. Which of the following statements about her new diagnosis under DSM-5 is false? A. She may have single or multiple motor or vocal tics, but not both. B. Her tics must persist for more than 1 year since first tic onset without a tic- free period for 3 consecutive months to meet diagnostic criteria. Neurodevelopmental Disorders—QUESTIONS | 19 C. Her tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset. D. She has never met criteria for Tourette’s disorder. E. A specifier may be added to the diagnosis of persistent (chronic) motor or vocal tic disorder to indicate whether the girl has motor or vocal tics. 1.57 A highly functional 20-year-old college student with a history of anxiety symp- toms and attention-deficit/hyperactivity disorder, for which she is prescribed lisdexamfetamine (Vyvanse), tells her psychiatrist that she has been research- ing the side effects of her medication for one of her class projects. In addition, she says that for the past week she has been feeling stressed by her schoolwork, and her friends have been asking her why she intermittently bobs her head up and down multiple times a day. What is the most likely diagnosis? A. Provisional tic disorder. B. Unspecified tic disorder. C. Unspecified anxiety disorder. D. Obsessive-compulsive personality disorder. E. Unspecified stimulant-induced disorder. 1.58 Which of the following is not a DSM-5 diagnostic criterion for language disor- der? A. Persistent difficulties in the acquisition and use of language across modali- ties due to deficits in comprehension or production. B. Language abilities that are substantially and quantifiably below those ex- pected for age. C. Symptom onset in the early developmental period. D. Inability to attribute difficulties to hearing or other sensory impairment, motor dysfunction, or another medical or neurological condition. E. Failure to meet criteria for mixed receptive-expressive language disorder or a pervasive developmental disorder. 1.59 Which of the following statements about speech sound disorder is true? A. Speech sound production must be present by age 2 years. B. “Failure to use developmentally expected speech sounds” is assessed by comparison of a child with his or her peers of the same age and dialect. C. The difficulties in speech sound production need not result in functional impairment to meet diagnostic criteria. D. Symptom onset is in the early developmental period. E. Both A and C are true. 1.60 A mother brings her 4-year-old son to you for an evaluation with concerns that her son has struggled with speech articulation since very young. He has not sustained any head injuries, is otherwise healthy, and has a normal IQ. His pre- 20 | Neurodevelopmental Disorders—QUESTIONS school teacher reports that she does not always understand what he is saying and that other children tease him by calling him a “baby” due to his difficulty with communication. He does not have trouble relating to other people or un- derstanding nonverbal social cues. What is the most likely diagnosis? A. Selective mutism. B. Global developmental delay. C. Speech sound disorder. D. Avoidant personality disorder. E. Unspecified anxiety disorder. 1.61 A 6-year-old boy is failing school and continues to struggle significantly with grammar, sentence construction, and vocabulary. When he speaks, he also in- terjects “and” in between all his words. His teacher reports that he requires more verbal redirection than other students in order to stay on task. He is gen- erally quiet and does not cause trouble otherwise. Which of the following di- agnoses would be on your differential? A. Language disorder. B. Expressive language disorder. C. Childhood-onset fluency disorder. D. Attention-deficient/hyperactivity disorder (ADHD). E. A and D. 1.62 Which of the following types of disturbance in normal speech fluency/time patterning included in the DSM-IV criteria for stuttering was omitted in the DSM-5 criteria for childhood-onset fluency disorder (stuttering)? A. Sound prolongation. B. Circumlocution. C. Interjections. D. Words produced with an excess of physical tension. E. Sound and syllable repetitions. 1.63 A 14-year-old boy in regular education tells you that he thinks a girl in class likes him. His mother is surprised to hear this, because she reports that, since a young age, he has often struggled with making inferences or understanding nuances from what other people say. The teacher has also noticed that he some- times misses nonverbal cues. He tends to get along better with adults, perhaps because they are not as likely to be put off by his overly formal speech. When he makes jokes, his peers do not always find the humor appropriate. Although he enjoys spending time with his best friend, he can be talkative and struggles with taking turns in conversation. What is the most likely diagnosis? A. Social (pragmatic) communication disorder. B. Asperger’s disorder. C. Autism spectrum disorder. Neurodevelopmental Disorders—QUESTIONS | 21 D. Social anxiety disorder. E. Language disorder. 1.64 A 15-year-old boy with a prior diagnosis of Tourette’s disorder is referred to your care. His mother tells you that during middle school he was teased for having vocal and motor tics. Since starting ninth grade, his tics have become less frequent. Currently, only mild motor tics remain. What is the appropriate DSM-5 diagnosis? A. Tourette’s disorder. B. Persistent (chronic) motor tic disorder. C. Provisional tic disorder. D. Unspecified tic disorder. E. Persistent (chronic) vocal tic disorder. 1.65 Tics typically present for the first time during which developmental stage? A. Infancy. B. Prepuberty. C. Latency. D. Adolescence. E. Adulthood. 1.66 A 7-year-old boy who has speech delays presents with long-standing, repeti- tive hand waving, arm flapping, and finger wiggling. His mother reports that she first noticed these symptoms when he was a toddler and wonders whether they are tics. She says that he tends to flap more when he is engrossed in activ- ities, such as while watching his favorite television program, but will stop when called or distracted. Based on the mother’s report, which of the following conditions would be highest on your list of possible diagnoses? A. Provisional tic disorder. B. Persistent (chronic) motor or vocal tic disorder. C. Chorea. D. Dystonia. E. Motor stereotypies. 1.67 Assessment of co-occurring conditions is important for understanding the overall functional consequence of tics on an individual. Which of the following conditions has been associated with tic disorders? A. Attention-deficit/hyperactivity disorder (ADHD). B. Obsessive-compulsive and related disorders. C. Other movement disorders. D. Depressive disorders. E. All of the above. 22 | Neurodevelopmental Disorders—QUESTIONS 1.68 By what age should most children have acquired adequate speech and lan- guage ability to understand and follow social rules of verbal and nonverbal communication, follow rules for conversation and storytelling, and change language according to the needs of the listener or situation? A. Ages 2–3 years. B. Ages 3–4 years. C. Ages 4–5 years. D. Ages 5–6 years. E. Ages 6–7 years. 1.69 Having a family history of which of the following psychiatric disorders in- creases an individual’s risk of social (pragmatic) communication disorder? A. Social anxiety disorder (social phobia). B. Autism spectrum disorder. C. Attention-deficit/hyperactivity disorder (ADHD). D. Specific learning disorder. E. Either B or D. 1.70 A 6-year-old boy with a history of mild language delay is brought to your office by his mother, who is concerned that he is being teased in school because he misinterprets nonverbal cues and speaks in overly formal language with his peers. She tells you that her son was in an early intervention program, but his written and spoken language is now at grade level. The boy does not have a history of repetitive movements, sensory issues, or ritualized behaviors. Al- though he prefers constancy, he adapts fairly well to new situations. Addition- ally, he has a long-standing interest in trains and cars and is able to recite for you all the car models he memorized from a book on the history of transporta- tion. Which of the following disorders would be a primary consideration in the differential diagnosis? A. Social (pragmatic) communication disorder. B. Autism spectrum disorder. C. Global developmental delay. D. Language disorder. E. A and B. 1.71 Below what age is it difficult to distinguish a language disorder from normal developmental variations? A. Age 2 years. B. Age 3 years. C. Age 4 years. D. Age 5 years. E. Age 6 years. Neurodevelopmental Disorders—QUESTIONS | 23 1.72 Which of the following psychiatric diagnoses is strongly associated with lan- guage disorder? A. Attention-deficit/hyperactivity disorder. B. Developmental coordination disorder. C. Autism spectrum disorder. D. Social (pragmatic) communication disorder. E. All of the above. 1.73 Which of the following statements about the development of speech as it ap- plies to speech sound disorder is false? A. Most children with speech sound disorder respond well to treatment. B. Speech sound production should be mostly intelligible by age 3 years. C. Most speech sounds should be pronounced clearly and accurately accord- ing to age and community norms before age 10 years. D. Lisping may or may not be associated with speech sound disorder. E. It is abnormal for children to shorten words when they are learning to talk. 1.74 Which of the following would likely not be an important condition to rule out in the differential diagnosis of speech sound disorder? A. Normal variations in speech. B. Hearing or other sensory impairment. C. Dysarthria. D. Depression. E. Selective mutism. 1.75 Which of the following statements about the development of childhood-onset fluency disorder (stuttering) is true? A. Stuttering occurs by age 6 for 80%–90% of affected individuals. B. Stuttering always begin abruptly and is noticeable to everyone. C. Stress and anxiety do not exacerbate disfluency. D. Motor movements are not associated with this disorder. E. None of the above. 24 | Neurodevelopmental Disorders—QUESTIONS C H A P T E R 2 Schizophrenia Spectrum and Other Psychotic Disorders 2.1 Criterion A for schizoaffective disorder requires an uninterrupted period of ill- ness during which Criterion A for schizophrenia is met. Which of the following additional symptoms must be present to fulfill diagnostic criteria for schizoaf- fective disorder? A. An anxiety episode—either panic or general anxiety. B. Rapid eye movement (REM) sleep behavior disorder. C. A major depressive or manic episode. D. Hypomania. E. Cyclothymia. 2.2 There is a requirement for a major depressive episode or a manic episode to be part of the symptom picture for a DSM-5 diagnosis of schizoaffective disorder. In order to separate schizoaffective disorder from depressive or bipolar disor- der with psychotic features, which of the following symptoms must be present for at least 2 weeks in the absence of a major mood episode at some point dur- ing the lifetime duration of the illness? A. Delusions or hallucinations. B. Delusions or paranoia. C. Regressed behavior. D. Projective identification. E. Binge eating. 2.3 A 27-year-old unmarried truck driver has a 5-year history of active and resid- ual symptoms of schizophrenia. He develops symptoms of depression, includ- ing depressed mood and anhedonia, that last 4 months and resolve with treatment but do not meet criteria for major depression. Which diagnosis best fits this clinical presentation? A. Schizoaffective disorder. B. Unspecified schizophrenia spectrum and other psychotic disorder. C. Unspecified depressive disorder. Schizophrenia Spectrum and Other Psychotic Disorders—QUESTIONS | 25 D. Schizophrenia and unspecified depressive disorder. E. Unspecified bipolar and related disorder. 2.4 How common is schizoaffective disorder relative to schizophrenia? A. Much more common. B. Twice as common. C. Equally common. D. One-half as common. E. One-third as common. 2.5 A 30-year-old single woman reports having experienced auditory and perse- cutory delusions for 2 months, followed by a full major depressive episode with sad mood, anhedonia, and suicidal ideation lasting 3 months. Although the depressive episode resolves with pharmacotherapy and psychotherapy, the psychotic symptoms persist for another month before resolving. What di- agnosis best fits this clinical picture? A. Brief psychotic disorder. B. Schizoaffective disorder. C. Major depressive disorder. D. Major depressive disorder with psychotic features. E. Bipolar I disorder, current episode manic, with mixed features. 2.6 Which of the following statements about the incidence of schizoaffective disor- der is true? A. The incidence is equal in women and men. B. The incidence is higher in men. C. The incidence is higher in women. D. The incidence rates are unknown. E. The incidence rates vary based on seasonality of birth. 2.7 Substance/medication-induced psychotic disorder cannot be diagnosed if the disturbance is better explained by an independent psychotic disorder that is not induced by a substance/medication. Which of the following psychotic symptom presentations would not be evidence of an independent psychotic disorder? A. Psychotic symptoms that precede the onset of severe intoxication or acute withdrawal. B. Psychotic symptoms that meet full criteria for a psychotic disorder and that persist for a substantial period after cessation of severe intoxication or acute withdrawal. C. Psychotic symptoms that are substantially in excess of what would be ex- pected given the type or amount of the substance used or the duration of use. 26 | Schizophrenia Spectrum and Other Psychotic Disorders—QUESTIONS D. Psychotic symptoms that occur during a period of sustained substance ab- stinence. E. Psychotic symptoms that occur during a medical admission for substance withdrawal. 2.8 A 55-year-old man with a known history of alcohol dependence and schizo- phrenia is brought to the emergency department because of frank delusions and visual hallucinations. Which of the following would not be a diagnostic possibility for inclusion in the differential diagnosis? A. Schizophrenia. B. Substance/medication-induced psychotic disorder. C. Alcohol dependence. D. Psychotic disorder due to another medical condition. E. Borderline personality disorder with psychotic features. 2.9 Which of the following sets of specifiers is included in the DSM-5 diagnostic criteria for substance/medication-induced psychotic disorder? A. “With onset before intoxication” and “With onset before withdrawal.” B. “With onset during intoxication” and “With onset during withdrawal.” C. “With good prognostic features” and “Without good prognostic features.” D. “With onset prior to substance use” and “With onset after substance use.” E. “With catatonia” and ‘Without catatonia.” 2.10 A 65-year-old man with systemic lupus erythematosus who is being treated with corticosteroids witnesses a serious motor vehicle accident. He begins to have disorganized speech, which lasts for several days before resolving. What diagnosis best fits this clinical picture? A. Schizophrenia. B. Psychotic disorder associated with systemic lupus erythematosus. C. Steroid-induced psychosis. D. Brief psychotic disorder, with marked stressor. E. Schizoaffective disorder. 2.11 Which of the following psychotic symptom presentations would not be appro- priately diagnosed as “other specified schizophrenia spectrum and other psy- chotic disorder”? A. Psychotic symptoms that have lasted for less than 1 month but have not yet remitted, so that the criteria for brief psychotic disorder are not met. B. Persistent auditory hallucinations occurring in the absence of any other fea- tures. C. Postpartum psychosis that does not meet criteria for a depressive or bipolar disorder with psychotic features, brief psychotic disorder, psychotic disor- Schizophrenia Spectrum and Other Psychotic Disorders—QUESTIONS | 27 der due to another medical condition, or substance/medication-induced psychotic disorder. D. Psychotic symptoms that are temporally related to use of a substance. E. Persistent delusions with periods of overlapping mood episodes that are present for a substantial portion of the delusional disturbance. 2.12 Which of the following patient presentations would not be classified as psy- chotic for the purpose of diagnosing schizophrenia? A. A patient is hearing a voice that tells him he is a special person. B. A patient believes he is being followed by a secret police organization that is focused exclusively on him. C. A patient has a flashback to a war experience that feels like it is happening again. D. A patient cannot organize his thoughts and stops responding in the middle of an interview. E. A patient presents wearing an automobile tire around his waist and gives no explanation. 2.13 In which of the following disorders can psychotic symptoms occur? A. Bipolar and depressive disorders. B. Substance use disorders. C. Posttraumatic stress disorder. D. Other medical conditions. E. All of the above. 2.14 A 32-year-old man presents to the emergency department distressed and agi- tated. He reports that his sister has been killed in a car accident on a trip to South America. When asked how he found out, he says that he and his sister were very close and he “just knows it.” After putting him on the phone with his sister, who was comfortably staying with friends while on her trip, the man expressed relief that she was alive. Which of the following descriptions best fits this presentation? A. He had a delusional belief, because he believed it was true without good warrant. B. He did not have a delusional belief, because it changed in light of new evi- dence. C. He had a grandiose delusion, because he believed he could know things happening far away. D. He had a nihilistic delusion, because it involved an untrue, imagined catas- trophe. E. He did not have a delusion, because in some cultures people believe they can know things about family members outside of ordinary communica- tions. 28 | Schizophrenia Spectrum and Other Psychotic Disorders—QUESTIONS 2.15 Which of the following is not a commonly recognized type of delusion? A. Persecutory. B. Erotomanic. C. Alien abduction. D. Somatic. E. Grandiose. 2.16 A 64-year-old man who had been a widower for 3 months presents to the emer- gency department on the advice of his primary care physician after he reports to the doctor that he hears his deceased wife’s voice calling his name when he looks through old photos, and sometimes as he is trying to fall asleep. His pri- mary care physician tells him he is having a psychotic episode and needs to get a psychiatric evaluation. Which of the following statements correctly explains why these experiences are not considered to be psychotic? A. The voice he hears is from a family member. B. The experience occurs as he is falling asleep. C. He can invoke her voice with certain activities. D. The voice calls his name. E. Both B and C. 2.17 A 19-year-old college student is brought by ambulance to the emergency de- partment. His college dorm supervisor, who called the ambulance, reports that the student was isolating himself, was pacing in his room, and was not re- sponding to questions. In the emergency department, the patient gets down in a crouching position and begins making barking noises at seemingly random times. His urine toxicology report is negative, and all labs are within normal limits. What is the best description of these symptoms? A. An animal delusion—the patient believes he is a dog. B. Intermittent explosive rage. C. A paranoid stance leading to self-protective aggression. D. Catatonic behavior. E. Formal thought disorder. 2.18 Which of the following does not represent a negative symptom of schizophre- nia? A. Affective flattening. B. Decreased motivation. C. Impoverished thought processes. D. Sadness over loss of functionality. E. Social disinterest. Schizophrenia Spectrum and Other Psychotic Disorders—QUESTIONS | 29 2.19 Schizophrenia spectrum and other psychotic disorders are defined by abnor- malities in one or more of five domains, four of which are also considered psy- chotic symptoms. Which of the following is not considered a psychotic symptom? A. Delusions. B. Hallucinations. C. Disorganized thinking. D. Disorganized or abnormal motor behavior. E. Avolition. 2.20 What is the most common type of delusion? A. Somatic delusion of distorted body appearance. B. Grandiose delusion. C. Thought insertion. D. Persecutory delusion. E. Former life regression. 2.21 Label each of the following beliefs as a bizarre delusion, a nonbizarre delusion, or a nondelusion. A. A 25-year-old law student believes he has uncovered the truth about JFK’s assassination and that CIA agents have been dispatched to follow him and monitor his Internet communications. B. A 45-year-old homeless man presents to the psychiatric emergency room complaining of a skin rash. Upon removal of his clothes, it is seen that most of his body is wrapped in aluminum foil. The man explains that he is pro- tecting himself from the electromagnetic ray guns that are constantly target- ing him. C. A 47-year-old unemployed plumber believes he has been elected to the House of Representatives. When the Capitol police evict him and bring him to the emergency department, he says that they are Tea Party activists who are merely impersonating police officers. D. A 35-year-old high school physics teacher presents to your office with in- somnia and tells you that he has discovered and memorized the formula for cold fusion energy, only to have the formula removed from his memory by telepathic aliens. E. An 18-year-old recent immigrant from Eastern Europe believes that wear- ing certain colors will ward off the “evil eye” and prevent catastrophes that would otherwise occur. 2.22 Which of the following presentations would not be classified as disorganized behavior for the purpose of diagnosing schizophrenia spectrum and other psy- chotic disorders? 30 | Schizophrenia Spectrum and Other Psychotic Disorders—QUESTIONS A. Masturbating in public. B. Wearing slacks on one’s head. C. Responding verbally to auditory hallucinations in a conversational mode. D. Crouching on all fours and barking. E. Turning to face 180 degrees away from the interviewer when answering questions. 2.23 Which of the following statements about catatonic motor behaviors is false? A. Catatonic motor behavior is a type of grossly disorganized behavior that has historically been associated with schizophrenia spectrum and other psychotic disorders. B. Catatonic motor behaviors may occur in many mental disorders (such as mood disorders) and in other medical conditions. C. A behavior is considered catatonic only if it involves motoric slowing or ri- gidity, such as mutism, posturing, or waxy flexibility. D. Catatonia can be diagnosed independently of another psychiatric disorder. E. Catatonic behaviors involve markedly reduced reactivity to the environ- ment. 2.24 Which of the following statements about negative symptoms of schizophrenia is false? A. Negative symptoms are easily distinguished from medication side effects such as sedation. B. Negative symptoms include diminished emotional expression. C. Negative symptoms can be difficult to distinguish from medication side ef- fects such as sedation. D. Negative symptoms include reduced peer or social interaction. E. Negative symptoms include decreased motivation for goal-directed activi- ties. 2.25 Which of the following statements correctly describes a way in which schizoaf- fective disorder may be differentiated from bipolar disorder? A. Schizoaffective disorder involves only depressive episodes, never manic or hypomanic episodes. B. In bipolar disorder, psychotic symptoms do not last longer than 1 month. C. In bipolar disorder, psychotic symptoms are always cotemporal with mood symptoms. D. Schizoaffective disorder never includes full-blown episodes of major de- pression. E. In bipolar disorder, psychotic symptoms are always mood congruent. Schizophrenia Spectrum and Other Psychotic Disorders—QUESTIONS | 31 2.26 Which of the following symptom combinations, if present for 1 month, would meet Criterion A for schizophrenia? A. Prominent auditory and visual hallucinations. B. Grossly disorganized behavior and avolition. C. Disorganized speech and diminished emotional expression. D. Paranoid and grandiose delusions. E. Avolition and diminished emotional expression. 2.27 Which of the following statements about violent or suicidal behavior in schizo- phrenia is false? A. About 5%–6% of individuals with schizophrenia die by suicide. B. Persons with schizophrenia frequently assault strangers in a random fash- ion. C. Compared with the general population, persons with schizophrenia are more frequently victims of violence. D. Command hallucinations to harm oneself sometimes precede suicidal be- haviors. E. Youth, male gender, and substance abuse are factors that increase the risk for suicide among persons with schizophrenia. 2.28 Which of the following statements about childhood-onset schizophrenia is true? A. Childhood-onset schizophrenia tends to resemble poor-outcome adult schizophrenia, with gradual onset and prominent negative symptoms. B. Disorganized speech patterns in childhood are usually indicative of schizo- phrenia. C. Because of the childhood capacity for imagination, delusions and halluci- nations in childhood-onset schizophrenia are more elaborate than those in adult-onset schizophrenia. D. In a child presenting with disorganized behavior, schizophrenia should be ruled out before other childhood diagnoses are considered. E. Visual hallucinations are extremely rare in childhood-onset schizophrenia. 2.29 Which of the following statements about gender differences in schizophrenia is true? A. Women with schizophrenia tend to have fewer psychotic symptoms than do men over the course of the illness. B. A first onset of schizophrenia after age 40 is more likely in women than in men. C. Psychotic symptoms in women tend to burn out with age to a greater extent than they do in men. 32 | Schizophrenia Spectrum and Other Psychotic Disorders—QUESTIONS D. Negative symptoms and affective flattening are more frequently observed in women with schizophrenia than in men with the disorder. E. The overall incidence of schizophrenia is higher in women than it is in men. 2.30 A 19-year-old female college student is brought to the emergency department by her family over her objections. Three months ago, she suddenly started feel- ing “odd,” and she came home from college because she could not concentrate. Two weeks after she came home, she began hearing voices telling her that she is “a sinner” and must repent. Although never a religious person, she now be- lieves she must repent, but she does not know how, and feels confused. She is managing her activities of daily living despite the ongoing auditory hallucina- tions and delusions, and she is affectively reactive on examination. Which di- agnosis best fits this presentation? A. Schizophreniform disorder, with good prognostic features, provisional. B. Schizophreniform disorder, without good prognostic features, provisional. C. Schizophreniform disorder, with good prognostic features. D. Schizophreniform disorder, without good prognostic features. E. Unspecified schizophrenia spectrum and other psychotic disorder. 2.31 A 24-year-old male college student is brought to the emergency department by the college health service team. A few weeks ago he was involved in a car ac- cident in which one of his friends was critically injured and died in his arms. The man has not come out of his room or showered for the last 2 weeks. He has eaten only minimally, claimed that aliens have targeted him for abduction, and asserted that he could hear their radio transmissions. Nothing seems to con- vince him that this abduction will not happen or that the transmissions are not real. Which of the following diagnoses (and justifications) is most appropriate for this man? A. Brief psychotic disorder with a marked stressor, because the symptoms be- gan after the tragic car accident. B. Brief psychotic disorder without a marked stressor, because the content of the psychosis is unrelated to the accident. C. Unspecified schizophrenia spectrum and other psychotic disorder, because more information is needed. D. Schizophreniform disorder, because there are psychotic symptoms but not yet a full-blown schizophrenia picture. E. Delusional disorder, because the central symptom is a delusion of persecu- tion. Schizophrenia Spectrum and Other Psychotic Disorders—QUESTIONS | 33 C H A P T E R 3 Bipolar and Related Disorders 3.1 Which of the following statements accurately describes a change in DSM-5 from the DSM-IV criteria for bipolar disorders? A. Diagnostic criteria for bipolar disorders now include both changes in mood and changes in activity or energy. B. Diagnostic criteria for bipolar I disorder, mixed type, now require a patient to simultaneously meet full criteria for both mania and major depressive episode. C. Subsyndromal hypomania has been removed from the allowed conditions under other specified bipolar and related disorder. D. There is now a stipulation that manic or hypomanic episodes cannot be as- sociated with recent administration of a drug known to cause similar symp- toms. E. The clinical symptoms associated with hypomanic episodes have been sub- stantially changed. 3.2 A 32-year-old man reports 1 week of feeling unusually irritable. During this time, he has increased energy and activity, sleeps less, and finds it difficult to sit still. He also is more talkative than usual and is easily distractible, to the point of finding it difficult to complete his work assignments. A physical ex- amination and laboratory workup are negative for any medical cause of his symptoms and he takes no medications. What diagnosis best fits this clinical picture? A. Manic episode. B. Hypomanic episode. C. Bipolar I disorder, with mixed features. D. Major depressive episode. E. Cyclothymic disorder. 3.3 A 42-year-old man reports 1 week of increased activity associated with an ele- vated mood, a decreased need for sleep, and inflated self-esteem. Although the man does not object to his current state (“I’m getting a lot of work done!”), he is concerned because he recalls a similar episode 10 years ago during which he began to make imprudent business decisions. A physical examination and lab- oratory work are unrevealing for any medical cause of his symptoms. He had 34 | Bipolar and Related Disorders—QUESTIONS taken fluoxetine for a depressive episode but self-discontinued it 3 months ago because he felt that his mood was stable. Which diagnosis best fits this clinical picture? A. Bipolar I disorder. B. Bipolar II disorder. C. Cyclothymic disorder. D. Other specified bipolar disorder and related disorder. E. Substance/medication-induced bipolar disorder. 3.4 Approximately what percentage of individuals who experience a single manic episode will go on to have recurrent mood episodes? A. 90%. B. 50%. C. 25%. D. 10%. E. 1%. 3.5 Which of the following factors is most predictive of incomplete recovery be- tween mood episodes in bipolar I disorder? A. Being widowed. B. Living in a higher-income country. C. Being divorced. D. Having a family history of bipolar disorder. E. Having a mood episode accompanied by mood-incongruent psychotic symptoms. 3.6 Which of the following is more common in men with bipolar I disorder than in women with the disorder? A. Rapid cycling. B. Alcohol abuse. C. Eating disorders. D. Anxiety disorders. E. Mixed-state symptoms. 3.7 A patient with a history of bipolar I disorder presents with a new-onset manic episode and is successfully treated with medication adjustment. He notes chronic depressive symptoms that, on reflection, long preceded his manic epi- sodes. He describes these symptoms as “feeling down,” having decreased en- ergy, and more often than not having no motivation. He denies other depressive symptoms but feels that these alone have been sufficient to nega- tively affect his marriage. Which diagnosis best fits this presentation? Bipolar and Related Disorders—QUESTIONS | 35 A. Other specified bipolar and related disorder. B. Bipolar I disorder, current or most recent episode depressed. C. Cyclothymic disorder. D. Bipolar I disorder and persistent depressive disorder (dysthymia). E. Bipolar II disorder. 3.8 In which of the following ways do manic episodes differ from attention-defi- cit/hyperactivity disorder (ADHD)? A. Manic episodes are more strongly associated with poor judgment. B. Manic episodes are more likely to involve excessive activity. C. Manic episodes have clearer symptomatic onsets and offsets. D. Manic episodes are more likely to show a chronic course. E. Manic episodes first appear at an earlier age. 3.9 A patient with a history of bipolar disorder reports experiencing 1 week of el- evated and expansive mood. Evidence of which of the following would sug- gest that the patient is experiencing a hypomanic, rather than manic, episode? A. Irritability. B. Decreased need for sleep. C. Increased productivity at work. D. Psychotic symptoms. E. Good insight into the illness. 3.10 A 25-year-old graduate student presents to a psychiatrist complaining of feel- ing down and “not enjoying anything.” Her symptoms began about a month ago, along with insomnia and poor appetite. She has little interest in activities and is having difficulty attending to her schoolwork. She recalls a similar epi- sode 1 year ago that lasted about 2 months before improving without treat- ment. She also reports several episodes of increased energy in the past 2 years; these episodes usually last 1–2 weeks, during which time she is very produc- tive, feels more social and outgoing, and tends to sleep less, although she feels energetic during the day. Friends tell her that she speaks more rapidly during these episodes but that they do not see it as off-putting and in fact think she seems more outgoing and clever. She has no medical problems and does not take any medications or abuse drugs or alcohol. What is the most likely diag- nosis? A. Bipolar I disorder, current episode depressed. B. Bipolar II disorder, current episode depressed. C. Bipolar I disorder, current episode unspecified. D. Cyclothymic disorder. E. Major depressive disorder. 36 | Bipolar and Related Disorders—QUESTIONS 3.11 How do the depressive episodes associated with bipolar II disorder differ from those associated with bipolar I disorder? A. They are less frequent than those associated with bipolar I disorder. B. They are lengthier than those associated with bipolar I disorder. C. They are less disabling than those associated with bipolar I disorder. D. They are less severe than those associated with bipolar I disorder. E. They are rarely a reason for the patient to seek treatment. 3.12 How does the course of bipolar II disorder differ from the course of bipolar I disorder? A. It is more chronic than the course of bipolar I disorder. B. It is less episodic than the course of bipolar I disorder. C. It involves longer asymptomatic periods than the course of bipolar I disor- der. D. It involves shorter symptomatic episodes than the course of bipolar I disor- der. E. It involves a much lower number of lifetime mood episodes than the course of bipolar I disorder. 3.13 Which of the following features confers a worse prognosis for a patient with bipolar II disorder? A. Younger age. B. Higher educational level. C. Rapid-cycling pattern. D. “Married” marital status. E. Less severe depressive episodes. 3.14 The course of bipolar II disorder would likely be worse for individuals who have an onset of the disorder at which of the following ages? A. Age 10 years. B. Age 20 years. C. Age 40 years. D. Age 70 years. E. None of the above; there is no association between onset age and course. 3.15 Which of the following statements about postpartum hypomania is true? A. It tends to occur in the late postpartum period. B. It occurs in less than 1% of postpartum women. C. It is a risk factor for postpartum depression. D. It is easily distinguished from the normal adjustments to childbirth. E. It is more common in multiparous women. Bipolar and Related Disorders—QUESTIONS | 37 3.16 For an adolescent who presents with distractibility, which of the following ad- ditional features would suggest an association with bipolar II disorder rather than attention-deficit/hyperactivity disorder (ADHD)? A. Rapid speech noted on examination. B. A report of less need for sleep. C. Complaints of racing thoughts. D. Evidence that the symptoms are episodic. E. Evidence that the symptoms represent the individual’s baseline behavior. 3.17 A 50-year-old man with a history of a prior depressive episode is given an an- tidepressant by his family doctor to help with his depressive symptoms. Two weeks later, his doctor contacts you for a consultation because the patient now is euphoric, has increased energy, racing thoughts, psychomotor agitation,

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