This week, we are sharing another USMLE® Step 1-style practice question to test your knowledge of medical topics. Today’s case focuses on a 35-year-old who reported “No one seems good enough for me. I’ve tried and tried with all the people in my life, but they all seem the same. I picked a fight with one last night and almost stabbed them in the eye with a toothpick.” Blood alcohol level is undetectable, and the urine drug screen is negative. Blood levetiracetam level is currently therapeutic. Which of the following is the strongest risk factor predisposing this patient to this clinical condition? Can you figure it out?
A 35-year-old person presents to the psychiatrist for evaluation of emotional instability. The patient reports, “No one seems good enough for me. I’ve tried and tried with all the people in my life, but they all seem the same. I picked a fight with one last night and almost stabbed them in the eye with a toothpick.” Shortly thereafter, the patient pivots and assumes a different tone of voice when stating that a friend of theirs wouldn’t have so many problems with dating if the friend simply stopped drinking and exercised more, adding, “As I say, a sound mind makes a sound body and vice-versa.” The patient has a history of polysubstance use, somatic symptom disorder, and epilepsy for which they take levetiracetam. The patient was sexually abused by their parent as a child into their teenage years and coped by using marijuana heavily. Vital signs are within normal limits. Physical exam reveals a disheveled person in no acute distress. Several healed scars are noted on the forearms bilaterally. Blood alcohol level is undetectable, and the urine drug screen is negative. Blood levetiracetam level is currently therapeutic. Which of the following is the strongest risk factor predisposing this patient to this clinical condition?
A. History of sexual abuse
B. Heavy marijuana use as a teenagerC. Chronic alcohol use
D. History of somatic symptom disorderE. History of epilepsy
Scroll down to find the answer!
The correct answer to today’s USMLE® Step 1 Question is…
A. History of sexual abuse
Before we get to the Main Explanation, let’s look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!
Incorrect answer explanations
The incorrect answers to today’s USMLE® Step 1 Question are…
B. Heavy marijuana use as a teenager
Incorrect: Heavy marinjuana use as a teenager portends a poorer prognosis for patients with underlying schizophrenia. This patient’s presentation is consistent with dissociative identity disorder, which is strongly correlated with a history of severe, chronic childhood trauma.
C. Chronic alcohol use
Incorrect: Chronic alcohol use and substance misuse are risk factors for the development of dissociative identity disorder; however, it is not the strongest risk factor in this patient.
D. History of somatic symptom disorder
Incorrect: Somatic symptom disorder is a risk factor for the development of dissociative identity disorder; however, it is not the strongest risk factor.
E. History of epilepsy
Incorrect: Underlying toxic or metabolic central nervous system diseases should be ruled out before declaring a diagnosis of dissociative identity disorder. However, this patient’s levetiracetam level is therapeutic.
Main Explanation
This patient presents with multiple risk factors for the development of dissociative identity disorder (DID), which is defined as ≥2 distinct personality states. The strongest predisposing risk factor for the development of this condition is a history of physical or sexual abuse.
DID, previously referred to as multiple personality disorder, is a disruption of identity in which patients take on multiple personalities. In addition to a history of physical or sexual abuse, risk factors include female sex, substance misuse, and associated psychiatric conditions (e.g., major depressive disorder, posttraumatic stress disorder, borderline personality disorder, somatic symptom disorder). In addition to multiple personality states, clinical clues include gaps in autobiographical memory and evidence of self mutilation or risky behavior. Diagnostic criteria are listed in the table below.
Major Takeaway
Dissociative identity disorder, previously called multiple personality disorder, is defined as ≥2 distinct personality states. The strongest predisposing risk factor for the development of this condition is a history of chronic physical or sexual abuse as a child.
References
Spiegel D, Loewenstein RJ, Lewis-Fernández R, et al. Dissociative disorders in DSM-5. Depress Anxiety 2011; 28:824.
Ross CA. Epidemiology of multiple personality disorder and dissociation. Psychiatr Clin North Am 1991; 14:503. _________________________
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