A 62-year-old female with achronic psychiatric disorder claimsthat the comments of a well-knownnews anchorman have a specialmeaning that only she understands.She is convinced that when he reportson local events he is really tryingto persuade her to start a “sinfulrelationship.” This is an example of
a. A visual hallucination
b. An illusion
c. A delusion of persecution
d. A delusion of reference
e. Concrete thinking
The answer is d. (DSM-IV [see under American Psychiatric Association inBibliography], p 765; Sadock, 7/e, p 682.) A delusion of reference refers toevents, objects, or persons in one’s environment that are believed to haveparticular personal significance. A persecutory delusion refers to the beliefthat other people or malevolent entities intend to harm the individual. Asin all delusions, the beliefs are unshakable. Hallucinations and illusions areperceptual disturbances, the former lacking any real basis, the latter beingmisinterpretations of actual stimuli. Concrete thinking refers to a cognitivestyle of processing that utilizes only information related to actual objectsand events and is devoid of abstractions.
A delusion of reference refers to
events, objects, or persons in one’s environment that are believed to haveparticular personal significance
A persecutory delusion refers to
the belief that other people or malevolent entities intend to harm the individual
Concrete thinking refers to
a cognitivestyle of processing that utilizes only information related to actual objectsand events and is devoid of abstractions
A medical student finds it hardto follow a patient’s train of thoughtbecause he gives very long, complicatedexplanations and many unnecessarydetails before finally answeringthe original questions. Inhis report, the medical studentwrites that the patient displayed
a. Loose associations
b. Circumstantiality
c. Goal-oriented thought processes
d. Perseveration
e. Flight of ideas
The answer is b. (Sadock, 7/e, p 680.) Circumstantial thought processesare characterized by the communication of unnecessary details before finally arriving at the central idea. Goal-oriented thought processes communicatethe central idea in a clear, concise, logical manner. Flight of ideas is oneform of loosening of associations, each of which involves greater or lesserdegrees of loss of the logical progression of thoughts. Flight of ideas in particularis manifested by a rapid succession of unrelated or fragmentary thoughts. Perseveration involves the persistent repetition of words or ideas.
Circumstantial thought processesare characterized byCircumstantial thought processesare characterized by
the communication of unnecessary details before finally arriving at the central idea
Goal-oriented thought processes
communicate the central idea in a clear, concise, logical manner
Flight of ideas is
one form of loosening of associations, each of which involves greater or lesserdegrees of loss of the logical progression of thoughts. Flight of ideas in particularis manifested by a rapid succession of unrelated or fragmentary thoughts
A delusion can best be defined as
a. A false belief that meets specific psychological needs
b. A perceptual misrepresentation of asensory image
c. A perceptual representation of asound or an image not actually present
d. A viewpoint able to be changedwhen convincing evidence to thecontrary is presented
e. A dissociative reaction
The answer is a. (Sadock, 7/e, p 681.) A delusion is a false belief that isnot supported by fact and cannot be challenged successfully by logic or reason.A false belief is not considered a delusion if it is shared by other membersof the person’s own cultural or social group. False beliefs that canchange in the face of strong evidence are called overvalued ideas.
A 7-year-old girl hospitalized fortonsillectomy awakens in the middleof the night and cries out that a“big bear” is in her room. She is relievedwhen a nurse turns on thelight revealing that the bear was anarmchair covered with a coat. Thisexperience is an example of
a. A delusion
b. A hallucination
c. An illusion
d. A projection
e. A dissociative reaction
The answer is c. (Hales, 3/e, p 218.) An illusion is a misinterpretationof a real sensory stimulus. Illusions are common even in individuals free ofpsychiatric disorders and their content often is affected by the person’s stateof mind, wishes, and fears. For example, the child described in the vignetteprobably took the armchair for a bear because she was frightened to be inthe hospital. Systemic diseases associated with confusion (certain types ofpoisoning, for instance) also can produce misperceptions of sensory imagesby interfering with proper functioning of the brain.
A consult is requested for a 75-year-old female who underwent hiprepair two days earlier, because thenurses noted that from time to timethe patient “was not making anysense.” The psychiatric resident conductingthe evaluation observes thatthe patient believes she is a younggirl, still living at home with her parents.She believes the resident is herdeceased father. These statementsare manifestations of impaired
a. Concentration
b. Memory
c. Thought associations
d. Orientation
e. Level of consciousness
The answer is d. (Sadock, 7/e, p 685.) Orientation refers to the state ofawareness of the individual as to the time and place, and to the awareness ofthe identity of oneself and others in the environment. The waxing and waningof the patient’s orientation, a hallmark of organic mental disturbances, isalso evident in the nursing report that led to the consultation request.
A 47-year-old secretary has losther job because, due to her perfectionismand excessive attention totrivial details, she could never finishan assignment on time. She writesinnumerable lists of things to bedone and follows rules scrupulously.She consistently annoys friendsand family members with her lackof flexibility and her pedantic remarks.Her diagnosis is likely to be
a. Obsessive-compulsive disorder
b. Paranoid personality disorder
c. Obsessive-compulsive personality disorder
d. Narcissistic personality disorder
e. Passive-aggressive personality disorder
The answer is c. (DSM IV, pp 669–673.) The essential feature of obsessivepersonality disorder is a preoccupation with perfection, orderliness,and control. Individuals with this disorder lose the main point of an activityand miss deadlines because they pay too much attention to rules and detailsand are not satisfied with anything less than “perfection.” As in otherpersonality disorders, symptoms are ego-syntonic and create considerableinterpersonal, social, and occupational difficulties. Obsessive-compulsivedisorder is differentiated from obsessive-compulsive personality disorder bythe presence of obsessions and compulsions. Paranoid personality disorderis characterized by suspiciousness and distrust of others. Individuals withnarcissistic personality disorder are preoccupied with perfection, but usuallythey are convinced of having already reached it. Individuals with obsessive-compulsive personality disorder, instead, are rarely satisfied withthemselves. Passive-aggressive personality disorder is characterized by apassive resistance to perform in occupational and social settings, manifestedby forgetfulness, procrastination, and intentional lack of efficiency.
A 25-year-old man’s teachingcareer has been abruptly terminatedby a psychiatric illness. During apsychiatric evaluation he is askedthe meaning of the proverb “Peoplein glass houses should not throwstones.” The patient replies, “Theywill break the windows.”
This response is an example of
C. Patients whopresent with concrete thinking have lost the ability to form abstract concepts,such as metaphors, and focus instead on actual things and facts. Concrete thinking is the norm in children and is seen in cognitive disorders(mental retardation, dementia) and schizophrenia.
A 69-year-old man is suspectedof having an acute onset of multiplesmall cerebral infarcts. The findingon a mental status examination thatwould be most supportive of thisdiagnosis is
a. A decline in cognitive functioning
b. Bizarre and idiosyncratic proverbinterpretation
c. An elated affect
d. Loose associations
e. Catatonic posturing
The answer is a. (Yudofsky, 3/e, pp 842–843.) Multiple cerebral infarctscause a progressive dementia, focal neurological signs, and, often, neuropsychiatricsymptoms, such as depression, mood lability (but not usuallyelated mood), and delusions. Loose associations, catatonic posturing, andbizarre proverb interpretations are typical symptoms of schizophrenia
A 75-year-old African Americanmale becomes profoundly depressedafter his son dies in a car crash andhe tells his doctor that he wants to“join Steve in Heaven.” Choose thecorrect statement about suicide:
a. People who talk about their deathwishes rarely kill themselves
b. Widowers have a higher incidenceof suicide than divorced people
c. Whites are more likely to kill themselves than African Americans
d. Women have a higher risk for completedsuicide than males
e. Elderly patients rarely commit suicide due to their stronger religiousbeliefs
The answer is c. (Hales, 3/e, p 1384.) Males have a higher risk forcompleted suicide than females and people over 45 are at higher risk thanyounger people. Among the ethnic groups, Caucasians have the highestrisk, followed by Native Americans, African Americans, Hispanics, andAsians. People who live with others or are married are less at risk of committingsuicide than people who live alone. Divorced people have a higherrisk than widows and widowers and singles. Good health lowers the risk forsuicide and poor health increases it. People who commit suicide usually talkabout their intent with others before going ahead with their plans.
A patient has been standing,immobile, for several hours. One ofhis arms is stretched upward, theother is wrapped around thepatient’s neck. The patient does notappear aware of his surroundingsand actively resists any attempt tomake him change position.
This is an example of
a. Apraxia
b. Dystonia
c. Synesthesia
d. Catatonia
e. Trance
The voluntary assumption of an inappropriate or bizarre posture for long periods14 Psychiatryof time is called catatonic posturing and it is usually seen in schizophrenia,especially of the catatonic type. In catatonic posturing, patients actively resistattempts to make them change position. A similar symptom, waxy flexibility,refers to patients that maintain the body position into which they areplaced. Apraxia refers to the inability to perform voluntary motor activityin the absence of motor or sensory deficits. Dystonia refers to the protractedcontraction of a group of muscles. In synesthesia, the stimulation of onesensory modality produces a sensation belonging to another sensory modality(a color is perceived as a smell). Trance is a sleeplike condition characterizedby a reduced state of consciousness. Parkinson’s disease, neurolepticmalignant syndrome, and Huntington’s disease are characterized by differentmotor disturbances.
A psychiatrist finds himself annoyedwith a quarrelsome patientfor no apparent reason. Later on herealizes that the patient remindshim of his disliked sibling. This is an example of
a. Reaction formation
b. Projection
c. Counter transference
d. Identification with the aggressor
e. Illusion
The answer is c. (Hales, 2/e, p 1162.) Countertransference is the namegiven to the analyst’s or psychotherapist’s transference response to the patient.As with patients’ transference, the particular form the countertransferencetakes depends on the therapist’s past experiences, relationships, andunresolved conflicts. As with transference, countertransference is not limitedto the patient-therapist relationship, but may be present in any relationship.By analyzing his countertransference toward the patient, the therapistmay acquire useful insight into the patient’s dynamics and his own.Consequently, even negative countertransference feelings can be helpfultools in the psychotherapy process. Reaction formation, projection, andidentification with the aggressor are unconscious defense mechanisms. Anillusion is a perceptual misinterpretation of a real stimulus.
A person is sitting alone andbehaving as if listening intently,then suddenly begins to nod andmutter aloud. This person mostlikely is experiencing
a. A delusion
b. A depersonalization episode
c. An hallucination
d. An idea of reference
e. Flight of ideas
The answer is c. (Sadock, 7/e, p 810.) An hallucination is the perceptionof a stimulus when, in fact, no sensory stimulus is present. Hallucinationscan be auditory, visual, tactile, gustatory, olfactory, or kinesthetic(body movements). Auditory hallucinations are most commonly associatedwith psychotic illness, whereas visual, tactile, gustatory, andolfactory hallucinations often are associated with neurologic disorders. Adelusion is an erroneous unshakable belief, and an idea of reference is aform of delusion.
The capacity to formulate conceptsand generalize them is called
a. Concrete thinking
b. Abstract thinking
c. Delusional thinking
d. Intellectualization
e. Rationalization
The answer is b. (Hales, 3/e, pp 219–220.) The capacity to generalizeand to formulate concepts is called abstract thinking. The inability to abstractis called concreteness and is seen in organic disorders and sometimesEvaluation,Assessment, and Diagnosis Answers 15in schizophrenia. Abstract thinking is commonly assessed by testing similarities,differences, and the meaning of proverbs. Intellectualization and rationalizationare unconscious defenses, while delusional thinking refers tofixed beliefs with no basis in reality.
A 28-year-old man is brought tothe ER of a local hospital by the police,who found him wandering withouta coat in subzero weather, mutteringabout being persecuted by asecret organization. During the evaluationhe is disorganized, distractible,and from time to time dozesoff in the middle of a sentence. Family members deny previous psychiatricor substance abuse history, but they add that lately the patient hadcomplained of fatigue and increased thirst. The toxic screen is negativeand glucose level is 4.5.Choose the most likely diagnosis:
a. Delirium
b. Psychotic depression
c. Brief psychotic episode
d. Paranoid schizophrenia
e. Dementia
The answer is a. (Yudofsky, 3/e, pp 455–459.) The patient’s persecutorydelusions and disorganized thinking could suggest a psychotic disordersuch as schizophrenia or brief reactive psychosis, but fluctuations inconsciousness and disorientation are typically found in delirium. Memory,language, and sleep-wake cycle disturbances are also typical of delirium.Delusions, hallucinations, illusions, and misperceptions are also common.The causes of delirium are many and include metabolic encephalopathies,such as the hyperglycemic encephalopathy experienced by the patient inthe vignette; intoxications with drugs and poisons; withdrawal syndromes;head trauma; epilepsy; neoplasms; vascular disorders; allergic reactions andinjuries caused by physical agents (heat, cold, radiation).
A young woman presents to the emergency room for the third time in two months with multiple self-inflicted cuts on her arms andlegs. The resident on call cleans and bandages her wounds and listens patiently while she bitterly complains about her therapist, her psychiatrist,and her family. On herway out, the patient tells the residentthat he is the best doctor she has ever met and the only one whoreally understands her pain.
a. Conversion disorder
b. Specific phobia
c. Agoraphobia
d. Narcissistic personality disorder
e. Body dysmorphic disorder
f. Schizophrenia
g. Borderline personality disorder
h. Dissociative amnesia
Individuals with borderlinepersonality disorder characteristically form intense but very unstablerelationships. Since they tend to perceive themselves and others as either totallybad or perfectly good, borderline individuals either idealize or devalueany person who occupies a significant place in their lives. Usually theseperceptions do not last, and the person idealized one day can be seen ascompletely negative the next day.Individuals with borderlinepersonality disorder characteristically form intense but very unstable relationships. Since they tend to perceive themselves and others as either totallybad or perfectly good, borderline individuals either idealize or devalueany person who occupies a significant place in their lives. Usually theseperceptions do not last, and the person idealized one day can be seen ascompletely negative the next day.
A young housewife is convincedthat her mild acne is disfiguring.She has spent hundreds ofdollars on skin products and dermatologicalconsultations. She alsounderwent three dermo-abrasionsbut she still believes she looks like“a monster.”
a. Conversion disorder
b. Specific phobia
c. Agoraphobia
d. Narcissistic personality disorder
e. Body dysmorphic disorder
f. Schizophrenia
g. Borderline personality disorder
h. Dissociative amnesia
An extreme feeling of dislike for a part of the body in spite of a normalor near-normal appearance is the main characteristic of body dysmorphicdisorder. The fear of being ugly or repulsive is not decreased by reassuranceand compliments and has almost a delusional quality. The social,academic, and occupational lives of individuals with this disorder aregreatly affected, due to avoidance of social interactions for fear of embarrassment,the time spent in checking mirrors and seeking surgical treatmentor cosmetic remedies, and the chronic emotional distress that accompaniesthe disorder.
A 50-year-old woman istrapped for hours in an elevatorduring a blackout. She has nomemory of the hours she spent inthe elevator.
a. Conversion disorder
b. Specific phobia
c. Agoraphobia
d. Narcissistic personality disorder
e. Body dysmorphic disorder
f. Schizophrenia
g. Borderline personality disorder
h. Dissociative amnesia
Dissociative amnesia is characterized by the inability to remember importantautobiographical information, usually of a traumatic or disturbingnature. The period of amnesia may last from hours to years. Occasionallythe amnesia is limited to specific events, for example, memories involvingan abusive individual. Often patients with dissociative amnesia are notaware of their memory loss, but come to treatment complaining of anxiety,depression, poor concentration, and blank spells.
The career of a young executivewho needs to travel often forhis business is much impaired because,due to his overwhelming fearof flying, he refuses all the jobs thatrequire traveling by plane.
a. Conversion disorder
b. Specific phobia
c. Agoraphobia
d. Narcissistic personality disorder
e. Body dysmorphic disorder
f. Schizophrenia
g. Borderline personality disorder
h. Dissociative amnesia
Fear of flying is one of the many presentations of specific phobias. Phobic individuals have an excessive or unreasonable fear of an object, an animal,or a situation. When exposed to the feared stimulus, they experiencesevere anxiety that can reach the level of panic attack patients go to great lengths to avoid whatever they fear and this phobic avoidance can greatly interfere with functioning.
A young woman who has ambivalentfeelings about separatingfrom her family wakes up paralyzedon the morning she is scheduled togo back to college.
a. Conversion disorder
b. Specific phobia
c. Agoraphobia
d. Narcissistic personality disorder
e. Body dysmorphic disorder
f. Schizophrenia
g. Borderline personality disorder
h. Dissociative amnesia
Conversion disorder is characterized by the sudden appearance ofoften dramatic neurological symptoms that are not associated with the usualdiagnostic signs and test results. Conversion disorder occurs in the contextof a psychosocial stressor or an insoluble interpersonal or intrapsychic conflict.The psychological distress is not consciously acknowledged but it isexpressed through a metaphorical body dysfunction. In the vignette example,the young woman who was torn between leaving home and becomingindependent, found a temporary solution in her paralysis, which preventedher from leaving her home without having to consciously acknowledgeher conflict.
