CLINICAL VIGNETTES AND LEARNING OBJECTIVES FOR DISCUSSION:

PSYCHIATRY, BEHAVIORAL SCIENCE, BIOSTATISTICS & MEDICAL ETHICS

Case 1:

A 6-year-old boy has been toilet-trained since the age of 2 and has not wet his bed at
night since the age of 3. However, he started having nocturnal enuresis one month ago.
His parents state that the boy also reverted to thumb-sucking while watching television
around the same time. The boys mother had delivered a baby boy one month ago. The
boys change in behavioral pattern is a defense against increased anxiety about the
arrival of a new baby in the family.

Questions & learning objectives for discussion:

1. What is the term used for the defense mechanism exhibited by the boy in this case?
Illustrate with another example.

2. Describe the following defense mechanisms and give one example of each:
Suppression, Altruism, Sublimation, Humor, Acting out, Denial, Displacement,
Identification, Projection, Passive-aggression, Rationalization, Regression and Splitting.

3. Describe the developmental milestones during different ages starting from infancy to
school age. Identify both motor and cognitive/social milestones.

4. Define intellectual disability (ID), formerly known as mental retardation, according to

the level of support needed to address impaired adaptive functioning in one or more
settings (e.g., school, home, work). Describe the characteristic impairments in ID that
affect one or more adaptive domains (conceptual, social, or practical) and categorize
the levels of severities of ID into mild, moderate, severe and profound using the DSM-5
criteria.

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Case 2:

A 29-year-old woman and her husband were on vacation in Belize. The evening before
they were to return home, the woman suffered sudden onset of palpitations, shortness
of breath, sweating, abdominal discomfort and general weakness. These symptoms
were at their peak within 10 minutes. Her husband rushed her to a hospital, where no
one spoke English, and the patient went into a state of helplessness and dread. She
feared she was going to die. However, the symptoms subsided without any treatment
and she was fine in the next 20 minutes. She and her husband returned home and
resumed their work. One evening after a long day, the patient had another episode, like
the one in Belize, again experiencing palpitations, weakness, shortness of breath, fear,
and dread. As time went on, she began to suffer these episodes more frequently. She
was not originally a high anxiety person, but became increasingly more anxious
because of fear of these attacks.

Questions & learning objectives for discussion:

1. What is the most likely diagnosis in the above patient? Justify your answer.

2. Describe the diagnostic criteria for panic disorder. Identify the signs/symptoms of a
panic attack and relate them to different organs/systems involved.

3. Define the following anxiety disorders: Agoraphobia, Generalized anxiety disorder,

Specific phobia and Social anxiety disorder. Illustrate each with one example.

4. Define obsessions and compulsions. List the criteria for the diagnosis of
obsessive-compulsive disorder (OCD) and illustrate with an example.

5. Explain the characteristic symptoms (include: re-experiencing the event,

avoidance/numbing symptoms, negative alternations in cognitions and mood, and
persistent symptoms of increased arousal) and diagnostic criteria of posttraumatic
stress disorder. Illustrate each symptom with an example.

6. Compare and contrast (include clinical features and diagnostic criteria) the following
disorders: Major depressive disorder, Persistent depressive disorder (Dysthymia),
Bipolar I disorder, Bipolar II disorder and Cyclothymic disorder.

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Case 3:

A 32-year-old male has become progressively more isolated for the past 12 months. He
has lost contact with his friends, and he has interacted minimally with his family. He eats
alone in his bedroom and maintains poor personal hygiene. He is reported to have been
outgoing and to have had a lot of friends during his college years. Over the past year,
he has attempted several jobs, including manual labor and factory work. However,
despite an initial good impression, he was dismissed from each position often after a
very short period. Reasons for dismissal included an inability to conform to safety
regulations, tardiness and chaotic behavior. For the past 7 months, he has experienced
episodes of hallucinations and delusions. During these episodes, he hears
conversations between several voices. Some of the voices command him to behave in
ways that are uncomfortable for him. Physical examination and laboratory studies are
negative.

Questions & learning objectives for discussion:

1. What is the most likely diagnosis in this patient?

2. Describe the etiology, pathogenesis, dopamine hypothesis, anatomical and functional

brain areas involved, genetics, signs and symptoms, DSM-V diagnostic criteria and
phases (prodromal, active and residual) of schizophrenia.

3. Define the term, describe the general properties and diagnostic criteria of the
following somatic symptom-related disorders and illustrate each with an example:
Somatic symptom disorder, Illness anxiety disorder, Conversion disorder (Functional
neurological symptom disorder) and Factitious disorder. Compare and contrast
Factitious disorder (Munchausens syndrome) with Malingering.

4. Define each of the following terms and illustrate each with an example: Hallucination,
Illusion, Delusion and Loose association. Identify specific type of hallucination observed
in a patient with migraines, schizophrenia, delirium tremens and psychomotor epilepsy.

5. Classify personality disorders into cluster A, B and C. Describe each of the following
personalities and give an example: Paranoid, Schizoid, Schizotypal, Borderline,
Histrionic, Antisocial, Narcissistic, Avoidant, Dependent and Obsessive-compulsive.

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Case 4:

A new blood test is devised for the detection of osteoarthritis. It is applied to a sample of
2000 elderly males between the ages of 65-75 years. Before the test is administered,
200 out of the 2000 were found to actually have osteoarthritis by the accepted gold
standard. The new blood test gives a positive result for 130 cases. Eighty of these are
positive by the gold standard.

The 2x2 table is given below:

Health status
Test status Positive (Diseased) Negative (Healthy) Total
Positive test 80 50 130
Negative test 120 1750 1870
Total 200 1800 2000

Questions & learning objectives for discussion:

1. Describe a 2x2 table comparing test results and true disease status (gold standard).
Define and identify each of the following terms from the table: True positives, False
negatives, False positives, True negatives, Total population tested. Show them in the
above example.

2. Define sensitivity, specificity, positive predictive value (PPV) and negative predictive
value (NPV). State the formula for calculating them. Calculate in percentage sensitivity,
specificity, positive predictive value (PPV) and negative predictive value (NPV) in the
above example and give meaning to each of them.

3. Define the terms incidence and prevalence of a disease and their relationship.

4. Explain the design of following types of studies: Case-control study, Cohort study and
Cross-sectional study.

5. Explain the following terms that describe statistical distributions: Normal distribution
(Gaussian curve), Bimodal, Positive skew and Negative skew.

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Case 5

A 39-year-old bank executive is brought to the ER after being involved in a motor

vehicle accident. He is confused and his vital signs are pulse 124/min., blood pressure
90/50 mmHg, temperature 36oC and respiration 26/min. He has bluish discoloration of
the flanks and abdominal examination reveals tenderness over the lower left ribs. CT
abdomen shows fracture of the left 10th to 12th ribs along the anterior axillary line with
splenic laceration and significant hemoperitoneum. He was planned for emergency
laparotomy. On him was found a card stating unequivocally that he is opposed to
transfusion of blood or blood products under any circumstance because of his religious
belief and that his friend is his surrogate decision maker. His friend upholds his belief
but his family is opposed to it.

Questions & learning objectives for discussion:

1. What is the best ethical decision for the management of this patient?

2. Explain with relevant examples the following terms: decision making capacity,
surrogate decision maker, Best interest standard, advance directive, living will and Do
Not Resuscitate (DNR) order.

3. Define informed consent and patients confidentiality and explain with specific
examples exemptions for informed consent and confidentiality.