A 12 year old boy of 7th class from rural Tarija was brought to psychiatry outpatient clinic of
General Hospital of Asunción, Paraguay, with symptoms of sleep disturbances, running away
from school, increased talkativeness and talks of big things for the past 20 days. He would
refuse to go to school or to do school homework. He would run away from school or would not
listen to teachers and even make fun of other students. He would talk more and keep roaming
in the house as well as outside. Sometimes he would even go out without informing anyone at
home. He would not be able to sit at one place and keep shifting positions or moving things of
house from here to there. He started saying that he has been given special powers by God
through which he can do anything. He would say “I am a rich man, I have lots of money”. Only
when family members contradicted him he would get aggressive and abusive and even hit
them. He would specially get angry towards his family members saying they did not believe in
what he was saying. He would order family members to bring new clothes and eatables for
him. He would get angry on trivial things when spoken to but otherwise he would keep talking
about his grandiose powers and his ability. He would sleep for two to three hours at night and
would keep roaming or waking everyone rest of the night. Throughout the illness patient’s
mood used to remain irritable. He did not manifest hallucinations or thought alienation, thought
broadcasting, passivity or depersonalization. He had no inappropriate or precocious sexual
behaviour. There was no history of delinquent behaviour, bed-wetting, sleep talking, seizure,
substance abuse and head trauma. Birth and development were normal with no significant past
history. Significant family history was reported as patient’s mother as well as grandfather was
reported to have bipolar affective disorder. Prior to the onset of illness, he was a quiet boy, shy,
responsible and would listen to family members. He would go to his school regularly and was
average in studies. General physical examination was within normal limits. Mental state
examination revealed an average built boy, uncooperative, increased psychomotor activity with
decrease reaction time, easily distractible as he was not able to sit at one place and all through
the interview he kept on changing postures or trying to go from the room and when made to sit
he would get angry, spontaneous speech, inflated selfesteem and delusion of grandiosity. He
was found to be irritable throughout the interview. The neurological examination, routine
laboratory test, thyroid, visual examination and CT scan head were normal. He was submitted
for psychometric investigation with the BinetKamat test of mental ability, the Wechsler
Intelligence Scale for Children, and the Rorschach inkblot test. There were no schizophrenic
indicators in the inkblot test. His IQ was 92, with average intelligence.
Which of the following is the most likely diagnosis in this case?
Seleccione una:
a. Intermittent Explosive Disorder
b. Bipolar Disorder, Manic Episode
c. Oppositional defiant disorder
d. Conduct Disorder
A 15-year-old girl is brought to a psychiatrist by her parents because they are concerned that
she might be depressed. The parents had no complaints until 2 or 3 years ago. The patient’s
grades have fallen because she cuts classes. She gets into fights, and her parents claim that
she hangs out with the “wrong crowd”; some nights she does not come home until well past her
curfew. The patient says that there is “nothing wrong” with her and that she wants her parents
to “butt out of her life.” She claims that she is sleeping and eating well. She says she skips
school to hang out with her friends and admits that they frequently steal food from a
convenience store and spend time watching movies at one of their homes. She claims that she
fights only to prove that she is as tough as her friends but admits that she often picks on
younger students. She is not concerned about her grades and just wants her parents to “lay
off” and let her enjoy her youth. She denies the use of drugs or alcohol other than occasionally
at parties. Her blood alcohol level is zero, and the results of a urinalysis are negative for drugs
of abuse.
Which of the following is the most likely diagnosis in this case?
Seleccione una:
a. Intermittent Explosive Disorder
b. Conduct Disorder
c. Oppositional Defiant Disorder
d. Kleptomania
Kyle is a 16 year old who was psychiatrically evaluated while he was serving a 3-year sentence
in a juvenile correctional facility for property destruction and arson. He reported becoming
angry with his father over a limit being set while he was mowing the family lawn. To retaliate
against his father, he flipped a lit cigarette into his father’s car that was parked in the driveway.
Flammable objects placed on the seat quickly caught fire and destroyed the car. When asked
about his judgment in doing this, Kyle replied, “How was I supposed to know there was stuff in
the front seat that would burn?” This was his third arrest and second term in a correctional
facility. His first arrest occurred at age 14 years for possession of drugs with intent to sell and
his second arrest at age 16 for disorderly conduct. His family functioning was characterized by
conflict between his parents and between his father and himself. His mother had a history of
depression and his father a history of alcoholism and a poor work record with frequent periods
of unemployment. Early-onset difficulties were noted when Kyle began to attend school and a
diagnosis of ADHD was made when he was 6 years old. Several trials of stimulants were
prescribed but discontinued because of parental fears that they would predispose him to later
substance abuse. Problems with school performance, especially poor reading skills, were
noted beginning in the third grade. By grade six, Kyle was frequently skipping school and he
dropped out of school permanently in the ninth grade. He reported that he “liked prison”
because “the other kids here are just like me.”
Which of the following is the most likely diagnosis in this case?
Seleccione una:
a. Attention Deficit Hyperactivity Disorder
b. Conduct Disorder
c. Intermittent Explosive Disorder
d. Oppositional Defiant Disorder
W, 5 years old, male, was a full term baby born by cesarean delivery due to abnormal position,
which caused the membrane to break. In addition, the umbilical cord was tangled. W slept very
little during his early years. He always wanted to be rocked and held. His developmental
milestones were accomplished in a normal time frame. His difficult behavior patterns started to
concern his mom when he was asked to leave his second preschool because of his behavior.
W was a strong willed child who easily refused to do anything that was asked of him. His
selfcare skills were still developing. He was not potty trained and would not sleep by himself at
night. He has average intelligence and his behavior was quite purposeful. His hyperactive
aspects surface during oppositional phases. He has refused to pick up toys that he’d pull off
shelves. He did not listen and would do what he wanted and when he wanted to.
W was frequently openly uncooperative and hostile. His ongoing pattern of defiant and hostile
behavior toward authority seriously interfered with his day-to-day functioning. W had frequent
temper tantrums and refused to comply with adult requests and rules. M was easily annoyed
by others and often blamed others for his mistakes or misbehavior. He made deliberate
attempts to annoy or upset others. M was clearly spiteful and vindictive and often angry and
resentful. W had much difficulty staying focused on activities within the classroom. His short
attention span made him easily distractible, especially by noise. Throughout the day, W would
need repetition and clarification more than other children his age. He most definitely has
difficulty establishing his personal space and physical boundaries. He often runs into others
and bumps them roughly.
Which of the following is the most likely diagnosis in this case?
Seleccione una:
a. Conduct Disorder
b. Oppositional defiant disorder
c. Intermittent Explosive Disorder
d. Bipolar Disorder
A 20-year-old homeless white male (JO) was informally admitted to a psychiatric unit after
reports of fire-setting behavior (eg, laughing while setting individuals on fire with lighter fluid).
As a child, he had set fire to a hillside barn, which would have had significant consequences for
a village further up the hill had it not been extinguished. When admitted to the unit he was
found to be grossly cognitively impaired. However, collateral information indicated that
previously he was an average student, completing 10 years of education. He did not exhibit
behavioral problems during the last several years of his education. The patient had brief
periods of manual labor employment, the longest lasting 3 months. He denied having had any
long-term relationships. He has had limited contact with his mother. The patient’s father was a
heavy drinker and committed suicide two years previously, several months after losing his
business. Police databases did not show a formal forensic history for the patient.
On admission to the ward, JO was noted to have low mood associated with anhedonia,
reduced motivation, and cognitive depressive symptoms. He also had persecutory delusional
ideas; thinking that others talked about him and mocked him. He admitted to fleeting visual and
auditory hallucinations. These consisted of hearing “breathing” in his bedroom and seeing
blood on the wall. In addition, he stated that he had seen “ghost-like people that looked like
water”. During a diagnostic interview the patient indicated that he had problems with memory,
including difficulty remembering names, phone numbers, appointments, directions, and recent
events.
Routine cognitive examination revealed difficulty with word finding and reading retention.
Manual motor tasks were adequate. He was casually dressed, but dishevelled and had a
blunted affect, paucity of facial expression, and poverty of speech. Significantly, he scored in
the impaired range (18 correct of 30 items) on the Mini Mental Status Examination (MMSE),
doing poorly on measures of short-term memory, concentration, and orientation in time. He
seemed to be making a genuine effort to complete the tests, and he appeared perplexed at his
inability to answer questions. From the diagnostic interview it was apparent that fire setting did
not occur as an accident during a confusional state such as alcoholism or drug intoxication.
Moreover, fire setting did not occur during an acute manic episode or psychotic episode in
specific response to a delusional idea or commands from hallucinated voices. The patient did
not meet the criteria for conduct disorder, as most of his behavioral problems were limited to
verbal outbursts. As a child he did not make the association between fire setting and the
potential harm it might present to others.
His characteristic ward behavior was described as being withdrawn with poverty of speech.
However, during an interview, a rapid change in affect occurred when questioned about what
he did for entertainment. The patient began to laugh and smile indicating that he “enjoyed
putting lighter fluid on people and setting them on fire”. The patient continued to be animated
while discussing violent topics (eg, what it would be like to drop objects from motorway bridges
to cause an accident). He was also at times sexually inappropriate toward female staff and
talked of his wish to travel to a foreign country for “loads of sex”. On another occasion, he
asked a female mental health worker if she could arrange for prostitutes dressed as nurses to
visit the inpatient ward.
Previously, JO had experienced two episodes of collapse for which he was admitted to
hospital. On both occasions he had normal CT scans and a normal EEG. These collapses
were attributed to illicit drug use, probably opiates. He had experimented with other drugs
including marijuana but did not evidence signs of dependence. During the current admission,
however, nursing staff observed 2 generalized tonic-clonic seizures. Routine bloods were
normal as were lumbar puncture (including testing for new variant Creutzfeldt-Jakob disease
[nvCJD]), HIV screening, and EEG. Testing for nvCJD was undertaken due to the severity of
JO’s cognitive impairments. An MRI examination demonstrated evidence of generalized
cerebral atrophy. JO was initially treated with an anticonvulsant sodium valproate (300 mg bd,
increased to 800 mg bd; serum levels confirmed dose in therapeutic range). No further
seizures were observed. Olanzapine was commenced 5 days after sodium valproate.
Neuropsychological tests were administered on admission and were repeated 5-months later.
Olanzapine 10 mg was started after baseline testing and maintained throughout the 5-month
psychiatric hospitalization. Perceptual abnormalities and paranoia resolved following the
introduction of olanzapine. While behavioral disturbance gradually abated, cognitive function
gradually improved.
Which of the following is the most likely diagnosis in this case?
Seleccione una:
a. Pyromania + Delusional Disorder
b. Bipolar Disorder + Personality Disorder
c. Pyromania + Schizophrenia
d. Pyromania + Antisocial Personality Disorder
You are working at a child psychiatry clinic, helping with urgent assessments. A GP phones
you about 9-year-old Miguel under her care. He has been suspended from schools on two
previous occasions – once for fighting and latterly for stealing. His parents have been keeping
him under ‘house arrest’ for the past 3 months. The current crisis began when he was
suspended from school for cruelty to the classroom pets.
Although he had normal milestones, Miguel has become a ‘difficult middle child’ according to
his mother. His father wishes he could disown him for the hurt he has caused. He is an army
officer, frequently assigned overseas, whose job has resulted in family relocation twice in the
past 3 years. Miguel’s 16-year-old sister lives alternate weeks with her natural father. Miguel’s
mother has spent much time recently on hospital visits with her 2-year-old son who has
bilateral hip dislocations.
You find out that Miguel’s current school have been concerned about his failure to settle in
there, even before the incident with the pets. He has had an assessment by an educational
psychologist.
His parents receive the report from the educational psychologist at the same time you do. His
IQ is 71. They are upset that he has scored so poorly. They ask you whether this the cause of
Miguel’s problems and if any intervention can make his life better?
You meet Miguel for the first time and have two further assessment sessions with him over the
next 2 weeks. You have opportunities to ask questions, interact with him and observe him
playing.
From repeated assessments, you have identified consistent signs of hyperactivity. His teachers
say he frequently fails to complete his homework, having followed instructions poorly. He
forgets to keep with him items he needs for this work and becomes upset when his mistakes
are identified.
The team have intervened over 3 months to support Miguel and his family in improving his
behaviour. A three-way meeting between the team, his teachers and his parents resolved the
issue of harming the school pets. The disruptive behaviours have stopped but he continues to
fail at school and this exacerbates his frustration. His mood appears normal and anxiety levels
are low, except where homework is involved. There is a team consensus to initiate a trial of
methylphenidate.
Three years later, Miguel attends for review. He has had a good response to medication and
this was discontinued without ill effect 2 months ago. He caught up at school and describes
several good friends he has made there. His home life has improved too; his father and his
siblings are spending much longer periods at home. He began to enjoy activities with his
father, but the last 2 weeks have been characterized by a loss of pleasure in his hobbies and
preoccupations about the future. In particular, he cannot imagine what his life will be like when
he leaves school at 18.
Which of the following is the most likely diagnosis in this case?
Seleccione una:
a. Trastorno de conducta + Depressive Disorder
b. Trastorno de conducta + Oppositional Defiant Disorder
c. Attention Deficit Hyperactivity Disorder + Conduct Disorder
d. Attention Deficit Hyperactivity Disorder + Oppositional Defiant Disorder
History: A 14-year-old boy presents to casualty with cuts on his hand that require stitches. It
transpires that the injury was sustained in a fight with a friend because he killed the hamster of
his friend’s younger sibling. He has shown no remorse and appears amused by the distress he
has caused. He rarely attends school usually preferring to play truant with peers. When he
does go to school, he often gets into trouble for threatening behaviour and for answering back.
His mother feels she has no control over her son and that his aggressive behaviour is
escalating. His mother also states that he runs around with a bad group who are probably
engaged in vandalism and theft. She states that her son can be very moody and has more
recently been erratic in his behaviour. She says she thinks he is often restless and cannot
sleep at night. She hears him wandering round the house but when she has tried to talk to him
he tells her to mind her own business. He has had no regular contact with his father who has
spent spells in prison.
Mental state examination: You are faced with a hostile sullen teenager who is verbally abusive
and makes poor eye contact. He is uncooperative and impatient, demanding his injury be dealt
with immediately so he can leave. He is also abusive towards his mother when she tries to
interject. He denies feeling low in mood and has not tried to harm himself. During your
interview there is no evidence that he is being bothered by hallucinations and does not come
across as thought disordered. He is orientated in time, place and person.
Which of the following is the most likely diagnosis in this case?
Seleccione una:
a. Trastorno explosivo intermitente
b. Bipolar Disorder, Manic Epsiode
c. Conduct Disorder
d. Trastorno oposicional desafiante
A 14-year-old girl’s family brings her to treatment against her wishes. The family reports she
has a very short temper, argues with them and teachers at school daily, often refuses requests
at both settings, and usually blames her teachers or her parents for the behaviors she is
showing. She denies being depressed, anxious, or any psychotic symptoms. With this
information, what might be the best diagnosis?
Seleccione una:
a. Oppositional Defiant Disorder
b. Borderline Personality Disorder
c. Antisocial Personality Disorder
d. Conduct Disorder
A 15-year-old boy is arrested for shooting the owner of the convenience store he tried to rob.
He has been in department of youth services custody several times for a variety of crimes
against property, possession of illegal substances, and assault and battery. He is cheerful and
unconcerned during the arrest, more worried about losing his leather jacket than about the fate
of the man he has injured.
Which of the following is the most likely diagnosis in this case?
Seleccione una:
a. Conduct disorder
b. Oppositional defiant disorder
c. Narcissistic personality disorder
d. Antisocial personality disorder
