DSM-5 EXAM: Neurocognitive Disorders

The essential feature of the DSM-5 diagnosis of delirium is a disturbance in at- tention/awareness and in cognition that develops over a short period of time, represents a change from baseline, and tends to fluctuate in severity during the course of a day. Which of the following additional conditions must apply?

A. There must be laboratory evidence of an evolving dementia.

B. The disturbance must be associated with a disruption of the sleep-wake cycle.

C. The disturbance must not occur in the context of a severely reduced level of

arousal, such as coma.

D. The disturbance must be a direct physiological consequence of a substance

use disorder.

E. The disturbance must not be superimposed on a preexisting neurocognitive disorder.

Correct Answer: C.

P.601

Both major and mild neurocognitive disorders can increase the risk of delirium

and complicate its course. Traditionally, delirium is distinguished from dementia on the basis of the key features of acute onset, impairment in attention,

and which of the following?

A. Fluctuating course.

B. Steady course.

C. Presence of mania.

D. Presence of depression.

E. Cogwheeling movements.

Correct Answer: A. Fluctuating course.

(Page 407).

A 79-year-old woman with a history of depression is being evaluated at a nursing home for a suspected urinary tract infection. She is easily distracted, perseverates on answers to questions, asks the same question repeatedly, is unable

to focus, and cannot answer questions regarding orientation. The mental status

changes evolved over a single day. Her family reports that they thought she

"wasn't herself" when they saw her the previous evening, but the nursing report this morning indicates that the patient was cordial and appropriate. Whatis the most likely diagnosis?

A. Major depressive disorder, recurrent episode.

B. Depressive disorder due to another medical condition.

C. Delirium.

D. Major depressive disorder, with anxious distress.

E. Obsessive-compulsive disorder.

Correct Answer: C. Delirium.

(Page 407).

The diagnostic criteria for major or mild neurocognitive disorder with Lewy

bodies (NCDLB) include fulfillment of criteria for major or mild neurocognitive disorder and presence of "a combination of core diagnostic features and

suggested diagnostic features for either probable or possible neurocognitive

disorder with Lewy bodies." Another feature necessary for the diagnosis is

that "the disturbance is not better explained by cerebrovascular disease, another neurodegenerative disease, the effects of a substance, or another mental,

neurological, or systemic disorder." Which of the following completes the list

of features necessary for the diagnosis?

A. An acute onset and rapid progression.

B. An insidious onset and gradual progression.

C. An insidious onset and rapid progression.

D. A waxing and waning presentation.

E. A characteristic finding on ultrasound of the neck.

Correct Answer: B. An insidious onset and gradual progression.

(Page 408).

Which of the following is not a diagnostic criterion, feature, or marker of major

or mild neurocognitive disorder with Lewy bodies (NCDLB)?

A. Concurrent symptoms of rapid eye movement (REM) sleep behavior disorder.

B. High striatal dopamine transporter uptake in basal ganglia demonstrated

by single-photon emission computed tomography (SPECT) or positron

emission tomography (PET) imaging.

C. Low striatal dopamine transporter uptake in basal ganglia demonstrated

by SPECT or PET imaging.

D. Severe neuroleptic sensitivity.

E. Insidious onset and gradual progression.

Correct Answer: B. High striatal dopamine transporter uptake in basal ganglia demonstrated by SPECT or PET imaging.

(Page 409).

The diagnostic criteria for neurocognitive disorder (NCD) due to HIV infection

include fulfillment of criteria for major or mild NCD and documented infection with human immunodeficiency virus (as confirmed by established laboratory methods). Which of the following is a prominent feature of NCD due to

HIV infection?

A. Impairment in executive functioning.

B. Conspicuous aphasia.

C. Significant delusions and hallucinations at onset of the disorder.

D. Marked difficulty with recall of learned information.

E. Rapid progression to profound neurocognitive impairment.

Correct Answer: A. Impairment in executive functioning.

(Page 410).

A 72-year-old man with no history of alcohol or other substance use disorders

and no psychiatric history is brought to the emergency department (ED) because of transient episodes of unexplained loss of consciousness. His wife reports that he has experienced repeated falls and syncope over the past year, as well as auditory and visual hallucinations. A thorough workup for cardiac disease has found no evidence of structural heart disease or arrhythmias. In the ED, he is found to have severe autonomic dysfunction, including orthostatic hypotension and urinary incontinence. What is the best provisional diagnosis for this patient?

A. New-onset schizophrenia.

B. New-onset schizoaffective disorder.

C. Possible major or mild neurocognitive disorder with Lewy bodies.

D. Possible major or mild neurocognitive disorder due to Alzheimer's disease.

E. New-onset seizure disorder.

Correct Answer: C. Possible major or mild neurocognitive disorder with

Lewy bodies.

(Page 410).

In addition to documented infection with HIV and fulfillment of criteria for

major or mild neurocognitive disorder (NCD), what other requirement must

be met to qualify for a diagnosis of major or mild NCD due to HIV infection?

A. Presence of HIV in the cerebrospinal fluid.

B. A pattern of cognitive impairment characterized by early predominance of

aphasia and impaired memory for previously learned information.

C. Presence of progressive multifocal leukoencephalopathy.

D. Inability to attribute the NCD to non-HIV conditions (including secondary

brain diseases), another medical condition, or a mental disorder.

E. Presence of Kayser-Fleisher rings.

Correct Answer: D. Inability to attribute the NCD to non-HIV conditions (including secondary brain diseases), another medical condition, or a mental

disorder.

(Page 411).

Which of the following features characterizes alcohol-induced major or mild

neurocognitive disorder, amnestic-confabulatory type?

A. Amnesia for new information and confabulation.

B. Seizures.

C. Amnesia for previously learned information and downward gaze paralysis.

D. Aphasia.

E. Anosognosia and apraxia.

Correct Answer: A. Amnesia for new information and confabulation.

(Page 412).

17.15 Major and mild neurocognitive disorders (NCDs) exist on a spectrum of cognitive and functional impairment. Which of the following constitutes an important threshold differentiating the two diagnoses?

A. Whether or not the individual is concerned about the decline in cognitive

function.

B. Whether or not there is impairment in cognitive performance as measured

by standardized testing or clinical assessment.

C. Whether or not the cognitive impairment is sufficient to interfere with independent completion of activities of daily living.

D. Whether or not the cognitive deficits occur exclusively in the context of a

delirium.

E. Whether or not the cognitive deficits are better explained by another mental

disorder.

Correct Answer: C. Whether or not the cognitive impairment is sufficient to

interfere with independent completion of activities of daily living.

(Page 415).

Which of the following statements about the diagnosis of neurocognitive disorder due to Huntington's disease (NCDHD) is true?

A. NCDHD is a laboratory-based diagnosis/disorder.

B. NCDHD is a disorder that requires positive neuroimaging for diagnosis.

C. NCDHD is a clinical diagnosis based on abnormal physical findings and

family history/genetic findings.

D. NCDHD is a diagnosis that is best defined as patients who have a pillrolling tremor.

E. NCDHD is a diagnosis mostly based on radiological examination.

Correct Answer: C. NCDHD is a clinical diagnosis based

(Page 412).

Depression, irritability, anxiety, obsessive-compulsive symptoms, and apathy

are frequently associated with Huntington's disease and often precede the onset of motor symptoms. Psychosis more rarely precedes the onset of motor

symptoms. Which of the following is a core feature of major or mild neurocognitive disorder due to Huntington's disease?

A. Progressive cognitive impairment with early changes in executive function.

B. Prominent early memory impairment, mostly affecting short-term memory.

C. Psychosis in the early stages, with marked olfactory hallucinations.

D. Voluntary jerking movements.

E. Diminished hearing and smell.

Correct Answer: A. Progressive

(Page 413).

Genetic testing is the primary laboratory test for the determination of Huntington's disease. Which of the following best characterizes the genetic nature of

Huntington's disease?

A. X-linked recessive inheritance with incomplete penetrance.

B. Autosomal recessive inheritance with complete penetrance.

C. Autosomal dominant inheritance with complete penetrance.

D. Random mutation.

E. X-linked dominant inheritance.

Correct Answer: C. Autosomal dominant inheritance with complete penetrance.

(Page 414).

Major or mild neurocognitive disorder (NCD) due to prion disease encompasses NCDs associated with a group of subacute spongiform encephalopathies caused by transmissible agents known as prions. What is the most common prion disease?

A. Creutzfeldt-Jakob disease.

B. Wernicke-Korsakoff syndrome.

C. Bovine spongiform encephalopathy.

D. Huntington's disease.

E. Neurosyphilis.

Correct Answer: A. Creutzfeldt-Jakob disease.

(Page 414).

Prion disease has been reported to occur in individuals of all ages, from the

teenage years to late life. Which of the following best characterizes the time

frame of disease progression?

A. Over a few months.

B. Over several days.

C. Over several weeks.

D. Over 5 years.

E. Over 10 years.

Correct Answer: A. Over a few months.

(Page 415).

Expressed as a percentile, what is the typical performance on neuropsychological testing of individuals with major neurocognitive disorder (NCD)?

A. Sixtieth percentile or below.

B. Fiftieth percentile or below.

C. Twenty-fifth percentile or below.

D. Sixteenth percentile or below.

E. Third percentile or below.

Correct Answer: E. Third percentile or below.

(Page 416).

In major or mild frontotemporal neurocognitive disorder, which of the following is a diagnostic feature of the language variant?

A. Severe semantic memory impairment.

B. Severe deficits in perceptual-motor function.

C. Receptive aphasia.

D. Grammar, word-finding, or

word-generation difficulty.

E. Hyperorality.

Correct Answer: D. Grammar, word-finding, or word-generation difficulty.

(Page 419).

A 68-year-old semiretired cardiologist with responsibility for electrocardiogram (ECG) interpretation at his community hospital is referred by the hospital's Employee Assistance Program for clinical evaluation because of concerns

expressed by other clinicians that he has been making many mistakes in his

ECG interpretations over the past few months. The patient discloses symptoms

of persistent sadness since the death of his wife 6 months prior to the evaluation, with frequent thoughts of death, trouble sleeping, and escalating usage of

sedative-hypnotics and alcohol. He has some trouble concentrating, but he has

been able to maintain his household, pay his bills, shop, and prepare meals by

himself without difficulty. He scores 28/30 on the Mini-Mental State Examination (MMSE). Which of the following would be the primary consideration in

the differential diagnosis?

A. Major neurocognitive disorder (NCD).

B. Mild NCD.

C. Adjustment disorder.

D. Major depressive disorder.

E. No diagnosis.

Correct Answer: D. Major depressive disorder.

(Page 417).

A 69-year-old semiretired radiologist with responsibility for chest x-ray interpretation at his academic medical center has been referred by the hospital's

Employee Assistance Program for clinical evaluation because of concerns expressed by other clinicians that he has been making many mistakes in his x-ray

interpretations over the past few months. Evaluation discloses a remote history

of alcohol dependence with sobriety for the past 20 years, and a depressive episode following the death of his wife 9 years before the current problem, treated with cognitive-behavioral therapy with full resolution of symptoms after 6 months and no recurrence. He acknowledges some trouble concentrating

but no other symptoms, and he minimizes the alleged x-ray interpretation

problems. He cannot state the correct date or day of the week and cannot recall

the previous day's news events, but he can describe highlights of his long career in medicine in great detail. Collateral history from his children reveals that

on several occasions in the past year neighbors in his apartment building had

complained that he forgot to turn off his stove while cooking, resulting in a

smoke-filled apartment. He scores 21/30 on the Mini-Mental State Examination. What diagnosis best fits this clinical picture?

A. Major neurocognitive disorder (NCD).

B. Mild NCD.

C. Adjustment disorder.

D. Major depressive disorder.

E. No diagnosis.

Correct Answer: A. Major NCD.

(Page 418).

In a patient with mild neurocognitive disorder (NCD), which of the following

would distinguish probable from possible Alzheimer's disease?

A. Evidence of a causative Alzheimer's disease genetic mutation from either

genetic testing or family history.

B. Clear evidence of decline in memory and learning.

C. Steadily progressive, gradual decline in cognition, without extended plateaus.

D. No evidence of mixed etiology.

E. Onset after age 80.

Correct Answer: A. Evidence of a causative Alzheimer's disease genetic mutation from either genetic testing or family history.

(Page 418).

A previously healthy 67-year-old man, who is experiencing an acute change in

mental status, is brought to the emergency department by his family. There is

no evidence in the initial history, physical examination, and laboratory studies

to indicate substance intoxication or withdrawal, or to suggest another medical

problem as the cause of his altered mental state. Over the course of 1 hour of

observation, his level of alertness varies from alert but distractible, with apparent auditory and visual hallucinations, to somnolent; he has difficulty sustaining attention to an examiner, and he cannot perform simple tasks such as serial

subtractions or spelling words backwards. What is the most appropriate diagnosis?

A. Delirium.

B. Delirium due to another medical condition.

C. Delirium due to substance intoxication.

D. Delirium due to multiple etiologies.

E. Unspecified delirium.

Correct Answer: E. Unspecified delirium.

(Page 421).

Which of the following neurocognitive disorders (NCDs) is especially characterized by deficits in domains such as speech production, word finding, object

naming, or word comprehension, whereas episodic memory, perceptual-motor

abilities, and executive function are relatively preserved?

A. Major or mild NCD due to Alzheimer's disease.

B. Major or mild NCD with Lewy bodies.

C. Major or mild vascular NCD.

D. Behavioral-variant major or mild frontotemporal NCD.

E. Language-variant major or mild frontotemporal NCD.

Correct Answer: E. Language-variant major or mild frontotemporal NCD.

(Page 419).

Which of the following is a core feature of major or mild neurocognitive disorder with Lewy bodies?

A. Fluctuating cognition with pronounced variations in attention and alertness.

B. Recurrent auditory hallucinations.

C. Spontaneous features of parkinsonism, with onset at least 1 year prior to development of cognitive decline.

D. Fulfillment of criteria for rapid eye movement (REM) sleep behavior disorder.

E. Evidence of low striatal dopamine transporter uptake in basal ganglia as

demonstrated by single photon emission computed tomography (SPECT)

or positron emission tomography (PET) imaging.

Correct Answer: A. Fluctuating cognition with pronounced variations in attention and alertness.

(Page 420).

A 35-year-old man brings his 60-year-old father for evaluation of cognitive and

functional decline, stating that he thinks his father has dementia; the son is also

worried about the possibility of a hereditary illness. The physician notes to herself that the patient has substantial cognitive impairment and features suggestive of the diagnosis of major neurocognitive disorder due to Huntington's disease, but she is not sure about the cause of the neurocognitive disorder. Shealso notes that the patient's son appears extremely anxious. She has a tight schedule and cannot provide a counseling session for the patient's son until the next day. What is the most appropriate diagnosis to record on the insurance claim form that the patient's son will submit on his father's behalf?

A. Unspecified central nervous system (CNS) disorder.

B. Unspecified neurocognitive disorder.

C. Unspecified mild neurocognitive disorder.

D. Huntington's disease.

E. Problem related to living alone (V code category reflecting other problems

related to the social environment).

Correct Answer: B. Unspecified neurocognitive disorder.

(Page 422).