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NBME 20 Answers

nbme20/Block 1/Question#15 (48.9 difficulty score)
A 30-year-old man who completed a successful ...
Adjustment disorder with anxietyπŸ”

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submitted by hayayah(1076),
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ieofnintDi of taeutdmnjs drisedro:

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If yspmtoms irepsts gt;& 6 ntsmoh rtefa esotsrrs de,ns ti is GDA.

hello  Yep, and I think what we are supposed to take from this Q is: The only info. we have for this patient is that he ended chemo 2 months ago and has been calling the doctor a lot -- this is supposed to mean he has been calling a lot since ending chemo 2 months ago. His frequent calls starting after ending chemo and within 3 months of the stressor fits with the above-stated definition of "adjustment disorder" with anxiety. I stressor in this case could possibly be either the actual illness or the ending of chemo/treatment. It probably does not matter much in this case. +4  
charcot_bouchard  I think doing uw done me wrong here. Adjustment disorder isnt diagnosed when symptom match another disorder --- it was like never a right answer. But ofc its right answer in nbme +5  
maxillarythirdmolar  Just to add to that, the tingling in his fingers may seem like a distraction/it probably is. Likely has some relation to his Chemo. +3  
j44n  shit I thought this poor guy had OCD with all the repetitive behaviors. +1  

submitted by johnthurtjr(144),
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heiWl I anc egt no bdora tihw utsjmendAt sre,iDdor I notd' see how siht wrnsae is nya ttbere athn tcmioSa tymmpSo .ierdsorD omrF AF:

Vrtiaye fo ylbiod omiatcpnsl listnag nhtosm to rsyea daiceosats thiw evixsce,es retinstpes htuosthg and iyxnaet uaotb pmtsms.oy Mya aarp-ocep ithw lse.nsil

SDS sgnbole in a pgruo fo dirdsrseo eaecdtrazhicr by slhyacip omsmtyps gunaisc agnsficniti disstsre nda i.pemtnarim

savdaddy  I think part of it stems from the fact that this patients symptoms are occurring within the time-frame for adjustment disorder while SSD seems to have a longer timeline. Aside from that I find it difficult to see why SSD wasn't a possible answer. +4  
chillqd  To add to that, I inferred that the obsession with checking temp and with the tingling sensation were signs provided to him by the physicians of recurrence. He is anxious over his cancer recurring, and they are more specific than a variety of body complaints +1  
hello  In somatic symptom disorder, the motivation is unconscious. I think for the patient in this Q-stem, his motivation is conscious -- he wants to make sure that recurrence of cancer is not going "undetected". +14  
cienfuegos  I also had issues differentiating these two and ultimately went with SSD, but upon further review it seems that a key differentiating feature was the timeline. His somatic symptoms would have had to have been present for at least 6 months per the DSM criteria +3  
almondbreeze  @chillqd Same! Why not OCD? He's fearful that something bad might happen (=cancer relapse; obsession) and calling his doc (=compulsion) +  
kevin  great reasoning @hello, this was confusing me but that makes perfect sense +  

submitted by arkanaftus(12),

The best answer would be Illness Anxiety Disorder, however it is not an option here, therefore it can't be right... so NBME...

j123  Both somatic sx disorder and illness anxiety disorder must be persistent for >6 months. Since this pt has only been acting excessively worried for 2 months, then it would have to be Adjustment disorder with Anxiety. (PS I got this question wrong since I at first thought Somatic Sx disorder) +2  

submitted by foodi(0),

why can't this be OCD? fits the time frame, his obsessions are checking his temp and he relieves these with calling the physician (compulsions)...

hiroshimi  According to DSM-5, with OCD, the disturbance is not better explained by the symptoms of another mental disorder such as preoccupation with having an illness, as in illness anxiety disorder. In his case, he was previously dx with cancer, treated, then develop these anxieties that he may have missed some sign is more fitted with illness anxiety disorder. Moreover, OCD is characterized by ego-dystonic, which is "thoughts, impulses, and behaviors that are felt to be repugnant, distressing, unacceptable or inconsistent with one's self-concept", which clearly doesn't apply to the pt case, as checking the temperature is actually meaningful and goal-directed. +