NCE Diagnosis and Psychopathology 2 — Questions and Answers
Question 1: A client presents with a 3-month history of recurrent episodes of intense fear lasting 10-20 minutes, including palpitations, sweating, trembling, shortness of breath, and fear of dying. Between episodes, they worry constantly about having another episode. What is the MOST likely diagnosis?
- Generalized Anxiety Disorder
- Specific Phobia
- Panic Disorder (Correct answer)
- Agoraphobia
Correct answer: Panic Disorder
Recurrent unexpected panic attacks plus persistent anticipatory anxiety about future attacks is the hallmark of Panic Disorder. The panic attacks include multiple somatic and cognitive symptoms peaking within minutes.
DSM-5 Panic Disorder: Recurrent unexpected panic attacks + at least 1 month of (a) anticipatory anxiety about future attacks or their consequences, or (b) significant maladaptive behavioral changes. Panic attacks: abrupt surge of intense fear with 4+ of 13 symptoms (palpitations, sweating, trembling, shortness of breath, choking, chest pain, nausea, dizziness, derealization, fear of losing control, fear of dying, paresthesias, chills/hot flashes). Agoraphobia can co-occur but is now a separate diagnosis.
Question 2: The diagnostic criteria for Autism Spectrum Disorder (ASD) in the DSM-5 are organized around which two core domains?
- Restricted interests and intellectual disability
- Social communication deficits and restricted/repetitive behaviors (Correct answer)
- Language delays and sensory processing disorders
- Emotional dysregulation and executive function deficits
Correct answer: Social communication deficits and restricted/repetitive behaviors
DSM-5 ASD is defined by persistent deficits in social communication/interaction AND restricted, repetitive patterns of behavior, interests, or activities, present in the early developmental period.
DSM-5 merged Autistic Disorder, Asperger's Disorder, and PDD-NOS from DSM-IV into one ASD diagnosis with severity specifiers. Domain A (Social Communication): deficits in social-emotional reciprocity, nonverbal communication, and developing/maintaining relationships. Domain B (Restricted/Repetitive Behaviors): stereotyped movements/speech, insistence on sameness, highly restricted interests, hyper/hyporeactivity to sensory input. Severity levels (1-3) rated separately for each domain based on support needed.
Question 3: In the DSM-5, 'specifiers' are used to:
- Diagnose comorbid conditions on the same diagnostic line
- Provide additional detail about a diagnosis (onset, severity, features, course) (Correct answer)
- Indicate that a diagnosis is provisional and may change
- Replace the older multiaxial system's Axis II personality disorders
Correct answer: Provide additional detail about a diagnosis (onset, severity, features, course)
Specifiers add descriptive detail to a DSM-5 diagnosis, including onset (e.g., with peripartum onset), course (e.g., with seasonal pattern), severity (mild/moderate/severe), and specific features (e.g., with psychotic features).
The DSM-5 uses specifiers extensively to capture clinical heterogeneity within diagnoses. Examples: MDD with anxious distress specifier, with melancholic features (pervasive anhedonia, morning worsening, terminal insomnia), with atypical features (mood reactivity, hypersomnia, leaden paralysis, interpersonal rejection sensitivity). Specifiers inform treatment planning -- e.g., melancholic depression may respond better to TCAs or ECT; atypical depression responds to MAOIs.
Question 4: Which personality disorder is characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affect, along with marked impulsivity?
- Narcissistic Personality Disorder
- Histrionic Personality Disorder
- Borderline Personality Disorder (Correct answer)
- Antisocial Personality Disorder
Correct answer: Borderline Personality Disorder
Borderline Personality Disorder (BPD) is defined by instability across relationships, self-image, and emotion, plus impulsivity. Key features include fear of abandonment, splitting, self-harm, and identity diffusion.
DSM-5 BPD criteria (5 of 9): frantic efforts to avoid abandonment, unstable intense relationships (idealization/devaluation/splitting), identity disturbance, impulsivity in 2+ self-damaging areas, recurrent suicidal/self-harm behavior, affective instability, chronic emptiness, inappropriate intense anger, transient stress-related paranoia/dissociation. Evidence-based treatments: Dialectical Behavior Therapy (DBT, Linehan), Mentalization-Based Treatment (MBT), Transference-Focused Psychotherapy (TFP). DBT is considered the gold standard treatment.
Question 5: A client who lost their job three months ago presents with sadness, trouble sleeping, and decreased concentration that has significantly impaired daily functioning. No symptoms of a full major depressive episode are present. The MOST appropriate diagnosis is:
- Major Depressive Disorder
- Persistent Depressive Disorder
- Adjustment Disorder with Depressed Mood (Correct answer)
- Bereavement
Correct answer: Adjustment Disorder with Depressed Mood
Adjustment Disorder is characterized by emotional or behavioral symptoms in response to an identifiable stressor that are disproportionate or cause marked distress/impairment, occurring within 3 months of the stressor, without meeting full criteria for another disorder.
DSM-5 Adjustment Disorder subtypes: with Depressed Mood, with Anxiety, with Mixed Anxiety and Depressed Mood, with Disturbance of Conduct, with Mixed Disturbance of Emotions and Conduct, and Unspecified. Key features: response to an identifiable stressor within 3 months; symptoms are disproportionate or cause marked distress; symptoms do not meet criteria for another disorder; not bereavement. Adjustment Disorder is often called a 'transitional diagnosis' -- the prognosis is generally good with brief therapy.
Question 6: The 'diathesis-stress model' of mental illness proposes that:
- Stress alone is sufficient to cause all mental disorders
- Mental disorders result only from biological vulnerabilities, with stress as secondary
- Mental disorders arise from the interaction of a pre-existing vulnerability and environmental stressors (Correct answer)
- Stress inoculation is the best prevention for mental illness
Correct answer: Mental disorders arise from the interaction of a pre-existing vulnerability and environmental stressors
The diathesis-stress model holds that mental disorders result from an interaction between a pre-existing vulnerability (genetic, biological, or psychological) and environmental stressors that trigger the disorder.
The diathesis (vulnerability) can be genetic predisposition, neurobiological factors, early adverse experiences, or personality traits. The stress component includes life events, chronic adversity, or trauma. Neither alone is sufficient -- a person with high diathesis may remain well under low stress. This model has significant implications for counseling: reducing stress and building protective factors (resilience, social support, coping skills) can prevent disorder even in vulnerable individuals.
NCE Diagnosis and Psychopathology 2
A client presents with a 3-month history of recurrent episodes of intense fear lasting 10-20 minutes, including palpitations, sweating, trembling, shortness of breath, and fear of dying.
Between episodes, they worry constantly about having another episode.
What is the MOST likely diagnosis?