Review of Psychiatry Praveen Tripathi
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BasicsChapter 1

Psychiatry is the branch of medicine which deals with morbid psychological processes. To establish diagnosis of a psychiatric disorder both history and clinical examination are required. The clinical examination in psychiatry, wherein the clinician records the psychiatric signs and symptoms, is known as Mental Status Examination (MSE)Q.
 
 
Mental Status Examination
In mental status examination, following areas of mental functioning are assessed:
  1. General appearance and behavior: The appearance of the patient is described along with any gross abnormalities (such as abnormalities of dressing etc).
  2. Speech: Various aspects of speech such as rate, tone, volume, spontaneity of speech are described.
  3. Mood and affect: The terms “affect” and “mood” are both used to describe the emotions or emotional state. “Affect”Q is the cross sectional emotional state whereas “mood” is the sustained or longitudinal emotional state. For example, if an individual who was extremely sad for last one month, gets extremely and unusually happy for a moment; it can be said that his affect is happy (euphoric), whereas his mood is depressed. The term affect and mood are at times used interchangeably. Affect and mood are further described under the following three subheads:
    • Quality: It refers to the predominant affective (or mood) state. There can be various disturbances in the quality of mood, common ones include:
      1. Euphoric mood (elevation of mood): Euphoria refers to a state of excessive happiness, without any reason. It is usually seen in mania or hypomania.
      2. Depressed mood: Excessive sadness of mood, which is usually seen in depression.
    • Fluctuations: It refers to the changes in mood/affect. The common disturbances of fluctuations are as follows:
      1. Labile mood: Excessive variations in mood without any apparent reason. It is also known as emotional labilityQ. For example, a man starts crying and then starts laughing without any apparent reason. It is usually seen in mania.
      2. Affective flattening: Absence of changes in mood irrespective of the situation. In this condition, patient doesn't experience any emotions hence his affect remains the same. For example, a schizophrenic patient would not look happy during festivals and did not appear sad when his mother died. His mood remained the same irrespective of the situation.
    • Appropriateness and congruency: Appropriateness of affect is described in relation to the social situation. For example, in a funeral, the expected emotional state is sadness. Hence, being sad in a funeral is an appropriate affect. If a man starts laughing and looks extremely happy in a funeral, it would be diagnosed as inappropriate affect. Congruency of mood is described in relation to the thought content of the person. Congruency describes whether the emotional state of person is in sync with his thought/speech or not. For example, if a man is thinking about or talking about the events which led to his mother's death, he is expected to be sad. Hence, appearing sad while talking about mother's death is a congruent affect. If a person, looks very happy and smiles while describing his mothers 2death, it would be considered as incongruent mood. It must be stressed that while “appropriateness” of affect is described after comparing the current affect with the expected affect in the given social situation, the congruence is described after comparing the current affect with the expected affect in the context of the patients thoughts.
    Few other important disturbances of emotions include:
    1. Alexithymia: It refers to the inability to understand emotions of others and inability to express emotions of self. Although alexithymia is closely related to affective flattening, alexithymiaQ is “lack of words to describe emotions” rather than absence of emotions.
    2. Anhedonia: It refers to the loss of capacity to experience pleasure. The patient is unable to enjoy anything in the life.
    Neuroanatomical substrate of emotions: Limbic systemQ (which includes hippocampus, amygdala, hypothalamus, cingulate gyrus and related thalamic and cortical areas) is the neural substrate for the emotional experiences. The regulation of emotions is a function of frontal lobeQ.
  4. Perception: Perception is the receiving of information using one of the sensory modalities (i.e. auditory, visual, tactile, olfactory and gustatory). Two most important disturbances of perception are:
    • IllusionsQ: Illusion is false perception of a real object. For example, a man mistakes a rope for snake in night.
    • Hallucinations: Hallucination is a false perception in the absence of any object or stimulus. For example, a patient of delirium reported seeing snakes on the ground of his room, when in reality there was nothing there. Hallucinations have the following properties and all these properties must be present to diagnose a perception as hallucination.
      1. Hallucinations occur in the absence of any sensory or perceptual stimulus.
      2. Hallucinations are as vivid (clear or detailed) as true perceptions. It means that the person who experiences hallucinations is able to give a detailed description of what he is experiencing.
      3. Hallucinations are experienced in outer objective spaceQ. It means that patients experiences that the source of hallucinations is in the outer world. For example, a patient who is having auditory hallucinations will report that the voices are coming from the wall or from outside the house. (PseudohallucinationsQ are experienced in the inner subjective space, or originating from within the mind. For example, a patient with auditory pseudohallucinations will report that the voices are originating within his mind and not from outside).
      4. Hallucinations are not under the willful controlQ of the patient. It means that the patient can neither start the hallucinations nor can he stop them.
      Hallucinations can occur in any modality. The most common hallucinations in psychiatric disorders are auditory hallucinationsQ. The most common hallucinations in organic psychiatric disorders (such as delirium) are visual hallucinationsQ. In patients with temporal lobe epilepsyQ all kinds of hallucinations can be present including olfactory and tactile hallucinations. Tactile hallucinations are also a typical feature of cocaine intoxication.
      Few specific hallucinations:
    1. Hypnagogic hallucinationsQ: These hallucinations occur while falling asleep or while going to sleep. Since hypnagogic has the word “go” in it, hence its easy to remember that they occur while “going” to sleep. Hypnagogic hallucinations are seen in narcolepsy.
    2. Hypnopompic hallucinationsQ: These hallucinations occur while getting up from the sleep.
    3. Reflex hallucinations (SynesthesiaQ): In reflex hallucinations, stimulus in one sensory modality produces hallucinations in another sensory modality. For example, a patient reports that whenever he sees a white bulb (stimulus in visual modality), he starts hearing voices of god (hallucination in auditory modality). Reflex hallucinations are a feature of cannabis and LSDQ (and other hallucinogens) intoxication.
    4. Functional hallucination: Here, stimulus in one sensory modality, produces hallucinations in the same sensory modality. For example, a patient reported that whenever he heard the sound of a ticking clock (stimulus in auditory modality), he would also start hearing voices of god (hallucinations in auditory modality).
  5. Thought (Cognition): The terms “thought” and “cognition”Q are at times used interchangeably, however in a stricter sense cognition is the mental process of acquiring knowledge which includes thoughts but 3also experiences and sensations. The thought disturbances are primary in many psychiatric disorders like schizophrenia. Thought and its disturbances can be described under the following subheads.
    • Stream (Flow of thought): It refers to the speed with which thoughts follow each other. The disturbances of stream includes:
      1. Flight of ideasQ: Here, the thoughts follow each other very rapidly, and connection between different thoughts appears to be due to chance factors or rhyming. It is usually seen in mania. For example, a manic patient when asked about his hometown said “I live in Delhi…my cat has a big belly…..i like to eat Jelly…..lilly lilly lilly”. Some authors describe “flight of ideas” as an abnormality of form of thought.
      2. Inhibition of thinking: Here thoughts come in mind very slowly and thought progresses with a slow rate.
    • Form of thought: The form refers to the “organization” of thought or the “association” between the consecutive thoughts. Normally, the thoughts are well organized and there is a connection between various components of a single thought and between the consecutive thoughts. In formal thought disorders, there are disturbance in the organization, associations and connections of the thoughts. The important formal thought disorders include:
      1. Derailment: In derailment, the association between two successive thoughts is disturbed. For example, a patient said Jawahar Lal Nehru was the first prime minister of India and he was a congress leader. Sachin Tendulkar scored 100 international hundreds”. In this example, there is no link between the first thought about Nehru and second thought about Tendulkar.
      2. Loosening of associationQ: Here, the connection is lost between components of a single thought. For example, a patient says “I thought that it will rain today, Modi is the current prime minister of India”. In this example the phrase before the comma is totally disconnected from the phrase after the comma and hence this represents loosening of association.
      3. Incoherence: It is the total lack of organization so that the thought is incomprehensible and does not make any sense. For example, a patient says “India me churchgate pulses cricket computer”.
      4. CircumstantialityQ: It is a pattern of speech which progresses with inclusion of lots of unnecessary details and goes round and round before reaching the final goal. For example, a medical student was asked about his preferred branch in postgraduation and he replied by saying “Sir, in the first year i was very interested in physiology, however in the second year i started liking pathology. In the third year, i started liking ophthalmology however in the final year i realized that i have a lot of liking for orthopedics too and i liked putting casts and working with POP. I also think that after MBBS one should get married as soon as possible and that noone should have more than two kids…Well..you see i like pediatrics as a subject and want to do my postgraduation in the pediatrics”. In this example the thought process progressed with inclusion of lots of irrelevant details however in the end, the goal was reached as student said that he wants to become a pediatrician.
      5. TangentialityQ: In tangentiality, the answer is related to the question in some distant way and the goal of thought is never reached. For example, a patient was asked about his favorite bollywood actor and he replied “Well, you see the hindi movies are mostly hero centric and usually deal with the relationship issues whereas the hollywood movies have lots of action and science fiction. I think the Hindi Film Industry is growing rapidly and its a good medium for entertainment of masses”. In this example, the patients answer was distantly related to question, however the exact answer was never given.
      6. Neologism: A neologismQ is coining of a new word, whose derivation cannot be understood. For example, a patient would use the word “tintintapa” for a pen. Neologism is highly suggestive of schizophrenia.
      7. Word approximations (metonyms): Here, old words are used in a new or unconventional way. The meaning will be easily evident, though the word in itself might appear strange. For example, a patient would us the world “time vessel” for watch, and use the word “handshoes” for gloves.
      8. Perseveration: It is repetition of the same response, beyond the point of relevance. For 4example, a patient was asked the following questions. Q: What is your name. Ans. Mahesh kumar….Q: Where do you live. Ans: Mahesh Kumar…..Q: How many children do you have… A: Mahesh Kumar.
        It must be noted that the perseveration is in response to a question and is not spontaneous.
    • Content of thought: It refers to what person is actually thinking about. Delusion is a disorder of content of thought. It is defined as a false, unshakeable belief that cannot be explained on the basis of persons social and cultural background. The following are the types of delusion:
      1. Delusion of persecution: It is the most common type of delusion. The patient believes that someone wants to harm him. For example, a patient claimed that Indian police along with CBI is hatching a conspiracy to kill him.
      2. Delusion of reference: The patient believes that events happening around him are somehow related to him. For example, a patient claimed that the tube light of his apartment was flickering as there was a camera fitted inside through which his movements are being recorded.
      3. Delusion of grandeur or grandiosity: The patient believes that he has some exceptional identity or power. For example, a patient claimed that he is the reincarnation of Lord Hanuman and that he can carry the mountains on his shoulders.
      4. Delusion of love (erotomaniaQ, fantasy lover syndrome): Patient may have false belief that someone is in love with them. It is also known as de Clerambault syndrome. For example, a rickshaw puller claimed that Katrina Kaif is in love with him though he admitted that he has never met her.
      5. Nihilistic delusion (delusion of negation, Cotard's syndromeQ): Here, the patient may deny existence of their body, their mind, or the world in general. They may claim that everybody is dead, the world has stopped, etc. The basic theme of delusion is the “end of existence”.
      6. Delusion of infidelity (delusion of jealousy): The patient has a false belief that his partner/spouse is having an affair. It is also known as morbid jealousy or Othello syndromeQ.
      7. Delusion of guilt: Here, the patient may develop a delusion that they are bad or evil person and may claim that they have committed unpardonable sins. It is usually seen in severe depression.
        Bizarre Vs Nonbizarre Delusions
        Bizarre delusions: The term bizarre is used for delusions which are scientifically impossible and culturally implausible (ununderstandable). For example, if a patient says that aliens have stolen his heart, it would be an example of bizarre delusion.
        Nonbizarre delusions: These are delusions which are false but are possible, i.e. they can happen. For example, if a patient develops a delusion that his family members wants to take away his property, it would be an example of nonbizarre delusion, since it is not impossible for a family member to take away property of another family member.
    • Possession of thought: Normally one experiences that their thoughts belong to themselves and no one else can influence their thinking process, also there is a sense of control over one's thought. In disturbances of possession of thought either the patients experiences that others are tampering with their thoughts or that they have lost control over their thoughts. The disorders of possession include the following:
      1. ObsessionsQ: Here, a thought comes repeatedly into the mind of patient against his will. The patient recognizes the thought as his own, however is distressed by the repetitive and intrusive nature of the thought. The patient feels that he has lost control over his thoughts.
      2. Thought alienation: Here, the patient feels that their thoughts are under control of an outside agency or that others are interfering with their thought process. Thought alienation phenomenon is of following types:
        • Thought insertion: Patient feels that some external agency is inserting foreign thoughts into their mind.
        • Thought withdrawal: Patient experiences that his thoughts are being withdrawn from their mind by an external agency.
        • Thought broadcast: Patient experiences that thoughts are escaping from their minds and other people are able to access them.
  6. Higher mental functions: In this component of MSE, various higher mental functions like attention, concentration, memory, judgement, abstract thinking and insight are assessed.
5
 
CLASSIFICATION
At present, there are two major classificatory systems in psychiatry.
  1. ICD-10 (International classification of diseases, 10th edition): It is published by WHO and provides classification for all medical disorders (including psychiatric disorders). The psychiatric disorders have been classified in the chapter-V (F)Q of ICD-10.
  2. DSM-5 (Diagnostic and statistical manual of mental disorders): It is published by American Psychiatric Association. The fifth edition of DSM was published in 2013.
Psychiatric disorders have been classified in multiple ways. The most important classifications includes organic vs functional psychiatric disorders and psychosis vs neurosis.
Organic vs Functional (Nonorganic) mental disorders: This was the first major classification of psychiatric/mental disorders.
  1. Organic mental disorders: These disorders are caused by demonstrable disturbances of brain (primary brain disturbances or systemic disturbances which are known to affect brain parenchyma) For example, delirium, dementia.
  2. Functional (Nonorganic) mental disorders: These disorders do not have any demonstrable disturbance of brain parenchyma. For example, schizophrenia, mania, etc.
This classification is at best arbitrary, since with the advent of science its possible to demonstrate brain parenchyma disturbances even in so called “functional” mental disorders.
Psychoses vs neuroses: The functional disorders can be further classified into psychotic disorders (psychoses) and neurotic disorders (neuroses).
  1. Psychoses: Psychotic disorders are characterized by lack of awareness of illness (also known as lack of insight)Q and impaired reality testing (i.e. the patients loses contact with reality and start living in a fantasy world created by their ill minds). For example, schizophrenia, bipolar disorder. Delusions and hallucinations are the prototype psychotic symptoms.
  2. Neuroses: Neurotic disorders are characterized by awareness of the illness (insight is present) and reality contact is also intact. For example, anxiety disorders, depression.
 
QUESTIONS AND ANSWERS
 
QUESTIONS
1. Which of the following are sections of Mental State Examination?
(DNB NEET 2014-15)
  1. Mood and affect
  2. Speech and language
  3. Cognition
  4. All of the above
 
Affect and Mood
2. A 25-year-old woman complaints of intense depressed mood for last 6 months. She also reports inability to enjoy previously pleasurable activities. This symptom is known as:
(AIIMS Nov 2005)
  1. Anhedonia
  2. Avolition
  3. Apathy
  4. Amotivation
3. Alexithymia is:
(Kerala 2000, DNB 2004)
  1. A feeling of intense rapture
  2. Pathological sadness
  3. Affective flattening
  4. Inability to recognize and describe feelings
  5. Inappropriate mood
4. A person who laughs at one minute and cries the next minute without any clear stimulus is said to have:
(AIIMS Nov 2005)
  1. Incongruent affect
  2. Euphoria
  3. Labile affect
  4. Split personality
5. Emotion is controlled by:
(PGI 1997)
  1. Limbic system
  2. Frontal lobe
  3. Temporal lobe
  4. Occipital lobe
 
Perception
6. Phantom limb is an example of disorder of:
(DNB NEET 2104-15)
  1. Thought
  2. Perception
  3. Cognition
  4. None of the above6
7. A patient wanting to scratch for itching in his amputated limb is an example of:
(DNB NEET 2014-15)
  1. Illusion
  2. Pseudohallucination
  3. Phantom limb hallucination
  4. Autoscopic hallucination
8. A patient sees a rope and gets afraid that it is a snake. This sign is known as:
(DNB NEET 2014-15, PGI 2002)
  1. Illusion
  2. Hallucination
  3. Delusion
  4. Depersonalization
  5. Derealization
9. A 8-year-old child after a tonsillectomy sees a bear in her room. She screams in fright. A nurse who rushes on switching the light, finds a rug wrapped on an armchair. What child experiences is best described as?
(DNB 2006, Kerala 1997)
  1. Illusion
  2. Hallucination
  3. Delusion
  4. Depersonalization
10. Which statement is not true about hallucinations?
(AIIMS 2009)
  1. It is as vivid as a real perception
  2. It occurs in inner subjective space
  3. It is independent of will of observer
  4. It occurs in the absence of any perceptual stimulus
11. All of the following are features of hallucinations, except:
(AI 2003)
  1. It is independent of will of observer
  2. Sensory organs are not involved
  3. It is as vivid as a real perception
  4. It occurs in the absence of any perceptual stimulus
12. Formed visual hallucinations are seen in lesions of:
(PGI 2006, 2000)
  1. Frontal lobe
  2. Temporal lobe
  3. Occipital lobe
  4. Parietal lobe
13. The following is suggestive of an organic cause of behavioral symptoms:
(AI 2002)
  1. Formal thought disorder
  2. Auditory hallucinations
  3. Delusion of guilt
  4. Prominent visual hallucinations
14. When is hypnopompic phenomenon experienced?
(Bihar 2006, DNB 2002)
  1. At the beginning of the sleep
  2. At the end of sleep, while getting up
  3. After head trauma
  4. After convulsions
15. Hallucinations which occur at the “start” of sleep are known as:
(JIPMER 2002, DNB 2005)
  1. Hypnagogic hallucinations
  2. Hypnopompic hallucinations
  3. Jactatio capitis nocturna
  4. Extracampine hallucinations
16. Hallucinations are seen in all except:
(MP 1999, DNB 2001)
  1. Schizophrenia
  2. Seizures due to intracerebral space occupying lesions
  3. Lysergic acid diethyl amide intoxication (LSD intoxication)
  4. Anxiety
17. Olfactory hallucinations are seen in:
(PGI May 2011)
  1. Schizophrenia
  2. Alzheimer's disease
  3. Mesial temporal sclerosis
  4. Body dysmorphic disorder
  5. Temporal lobe epilepsy
18. Visual hallucinations are seen in:
(PGI Jun 2009)
  1. Hebephrenic schizophrenia
  2. Residual schizophrenia
  3. Simple schizophrenia
  4. Delirium
  5. Temporal lobe epilepsy
19. Reflex hallucinations is a morbid variety of:
(AIIMS May 2009, 2011)
  1. Kinesthesia
  2. Paresthesia
  3. Hyperesthesia
  4. Synesthesia
 
Thought
20. The term “cognition” is used to imply about:
(AI 1997, Jharkhand 2003, DNB 1998)
  1. Affect
  2. Perception
  3. Thought
  4. Speech
21. True about thought is all except:
(PGI Feb 2007)
  1. Perseveration is out of context repetition
  2. Circumstantiality is over inclusion of irrelevant details while eventually getting back to the original point
  3. 7Verbigeration is senseless repetition
  4. Vorbeireden is skirting around the end point but never reaching it
  5. Loosening of association is logically connected thoughts with loss of goal.
22. Perseveration is:
(AI 2005)
  1. Persistent and inappropriate repetition of the same thoughts
  2. Feeling of distress in a patient with schizophrenia
  3. Characteristic of schizophrenia
  4. Characteristic of obsessive compulsive disorder
23. In schizophrenia, characteristic feature is:
(PGI 1997)
  1. Formal thought disorder
  2. Delusion
  3. Hallucination
  4. Apathy
24. Loosening of association is an example of:
(AI 2006)
  1. Formal thought disorder
  2. Schneider's first rank symptoms
  3. Perseveration
  4. Concrete thinking
25. Not a disorder of form of thought is:
(AIIMS May 2012)
  1. Tangentiality
  2. Derailment
  3. Thought block
  4. Loosening of association
26. Which of the following is/are thought disorder?
(DNB NEET 2014-15)
  1. Circumstantiality
  2. Tangentiality
  3. Prolixity
  4. All of the above
27. Schizophrenia and depression both have the following features except:
(PGI 2002)
  1. Formal thought disorder
  2. Social withdrawal
  3. Poor personal care
  4. Decreased interest in sex
  5. Suicidal tendency
28. Delusion is a disorder of:
(DNB NEET 2014-15, AIIMS Nov 2006, AI 2007)
  1. Perception
  2. Thought
  3. Insight
  4. Affect
29. A false belief which is unexplained by reality and is shared by a number of people is:
(AIIMS 2003, 2004 Jipmer 1998)
  1. Illusion
  2. Delusion
  3. Obsession
  4. Superstition
30. The primary delusions are disorder of:
(AI 1999)
  1. Flow of thought
  2. Form of thought
  3. Content of thought
  4. Possession of thought
31. Delusions are not likely to be seen in:
(AI 2012)
  1. Dementia
  2. Depression
  3. Schizophrenia
  4. Conversion disorder
32. Delusions can be seen in all of the following except:
(SGPGI 2002, DNB 2001)
  1. OCD
  2. Depression
  3. Mania
  4. Schizophrenia
33. Delusion of persecution can be seen in:
(PGI Jun 2009)
  1. Schizophrenia
  2. Delusional disorder
  3. Manic episode
  4. Melancholic depression
34. Delusion of grandiosity can be seen in: PGI Nov 2010, May 2011)
  1. Hypomania
  2. Paranoid schizophrenia
  3. Schizoaffective disorder
  4. Kleptomania/Pyromania
  5. Cyclothymia
35. Nihilistic ideas are seen in:
(PGI Dec 2008)
  1. Simple schizophrenia
  2. Paranoid schizophrenia
  3. Cotard's syndrome
  4. Depression
  5. Body dysmorphic disorder
36. A 25-year-old university student had a fight with the neighbouring boy. On the next day while out, he started feeling that two men in police uniform were observing his movements. When he reached home in the evening he was frightened and told his family members that police was after him and would arrest him. Despite reassurances by family members, he remained afraid that he is about to 8be arrested. The history is suggestive of which psychiatric sign/symptom:
(AIIMS Nov 2003)
  1. Delusion of persecution
  2. Delusion of reference
  3. Somatic passivity
  4. Thought insertion
37. A man had a fight with his neighbor. The next day he started feeling that police is following him and his brain is being controlled by radio waves by his neighbor. The history is suggestive of which psychiatric sign/symptom:
(AIIMS 1999)
  1. Thought insertion
  2. Somatic passivity
  3. Delusion of persecution
  4. Obsession
38. Healthy thinking includes all of the following except:
(AIIMS 2011)
  1. Continuity
  2. Constancy
  3. Organization
  4. Clarity
 
Insight
39. The awareness regarding the disease in mental status examination is known as:
(AIIMS Nov 2012, May 2013)
  1. Insight
  2. Orientation
  3. Judgment
  4. Rapport
40. Impaired insight is found in:
(PGI 1997)
  1. Acute psychosis
  2. Schizophrenia
  3. Anxiety disorder
  4. Obsessive compulsive disorder
41. If a person is asked, “what will he do if he sees a house on fire”? Then what is being tested in that person?
(DNB NEET 2014-15)
  1. Social Judgment
  2. Test Judgment
  3. Response Judgment
  4. None
 
ANSWERS
1. D. All of the above
2. A. Anhedonia. Anhedonia is seen in both depression as well as schizophrenia.
3. D. Inability to recognize and describe feelings.
4. C. Labile affect.
5. B. Frontal lobe. The neuroanatomical substrate for generation of emotions is limbic system however the regulation/control of emotions is a function of frontal lobe.
6. B. Perception. In phantom limb, the patient feels sensations in the amputated limb. Hence, its a disorder of perception.
7. C. Phantom limb hallucination. Since, patient experiences sensation in the absence of any stimulus, it is a hallucination. In autoscopic hallucination, patient sees himself in the mirror and feels that “he” is the “image” i.e. what he is seeing is not only an image but him.
8. A. Illusion.
9. A. Illusion.
Illusion is false perception of a real object.
10. B. It occurs in inner subjective space. Hallucinations occur in outer and objective space; pseudohallucinations occur in inner and subjective space.
11. None > B.
All the statements are correct. However, if one has to chose, the best answer would be B (sensory organs are not involved) as rest three options form the criterion of hallucinations.
12. B. Temporal lobe. The lesions of temporal lobe can cause all types of hallucinations and formed visual hallucinations (elaborate visual hallucinations) should raise a strong doubt of an organic cause, specifically a temporal lobe pathology.
13. D. Prominent visual hallucinations. The presence of prominent visual hallucinations is a strong pointer towards an organic cause (i.e. a disturbance of brain parenchyma such as tumors).
14. B. At the end of sleep. While getting up.
15. A. Hypnagogic hallucinations. These occur while “going” to sleep. Jactatio capitis nocturna, or rhythmic movement disorder is a neurological disorder characterized by involuntary movements, usually of head and neck, before and during the sleep.
16. D. Anxiety.
17. A, B, C, E.
Olfactory hallucinations can be seen in temporal lobe epi-lepsy, medial temporal sclerosis (which is a common cause of epilepsy). Though rare, olfactory hallucinations can also be present in schizophrenia and Alzheimer's disease.
18. A, D, E.
Visual hallucinations are the most common type of hallucinations in delirium. Temporal lobe epilepsy can present with all types of hallucinations including visual hallucinations. In hebephrenic schizophrenia, the primary symptom is 9disorganized behavior and formal though disorders however hallucinations can also be seen.
19. D. Synesthesia.
20. C. Thought.
21. E. Loosening of association is logically connected thoughts with loss of goal. In loosening of association, the connec- tions between the thought is lost. The rest of the statements are true. Verbigeration is a senseless repetition of one or several sentences or phrases. For example, a patient continued to repeat the following sentences for hours “Life is great. The lord is great. Summer will come soon” Its an example of verbigeration. Vorbeireden or vorbeigehen is seen in Ganser's syndrome (described in later chapters) and is another name for approximate answers in which patient reaches close to the right answer, but never gives the right answer.
22. A. Persistent and inappropriate repetition of the same thoughts.
23. A. Formal thought disorders are characteristic abnormalities in schizophrenia. In schizophrenia, the abnormalities of affect, perception, motor system as well as thought are present, however the characteristic abnormality in schizophrenia is that of thought, and more specifically the form of thought (known as formal thought disorder).
24. A. Formal thought disorder.
25. C. Thought block.
26. D. All of the above. Prolixity is a milder form of “flight of ideas”. As mentioned in the text, flight of ideas can be considered as both a disorder of stream of thought and form of thought.
27. A. Formal thought disorder is seen only in schizophrenia and not in depression. Rest all options can be present in either of the illnesses.
28. B. Thought. Delusion is a disorder of content of thought.
29. D. Superstition. There are many beliefs which are false and are shared by whole communities e.g. black magic, witches etc. These beliefs are considered as superstitions. In comparison, delusions are not shared by members of the same sociocultural background. For example, if a villager starts claiming that he is lord hanuman, no one in his village will share his belief.
30. C. Content of thought.
31. D. Conversion disorder. Conversion disorder is a neurotic disorder (described in later chapters). Delusion is not a feature of conversion disorder.
32. None > A.
Delusion can be seen in schizophrenia, mania, depression as well as OCD. However the best answer here would be OCD, as delusions are rarely seen in OCD.
33. A, B, C, D.
Delusions can be seen in all these disorders. Melancholic depression is usually seen in elderlies.
34. B, C.
Delusion of grandiosity can be seen in paranoid schizophrenia and schizoaffective disorders. Delusion of grandiosity can be seen in mania but not in hypomania.
35. B, C, D.
Nihilistic delusions can be seen in paranoid schizophrenia, Cotard's syndrome and depression.
36. A. Delusion of persecution.
37. C. Delusion of persecution. Here, in the question the history for delusion of persecution (i.e police is following) is clear. The second half where patient feels that his mind is being controlled by radio waves is suggestive of possible though alienation phenomenon but we have not been provided with any further details.
38. D. Clarity. Healthy thinking has three characteristics (1) Continuity (2) Organization and (3) Constancy.
39. A. Insight
40. A, B.
Only first two options are psychotic illnesses in which insight is impaired.
41. B. Test Judgment. In mental status examination, the judgment of the patient is also described. Patient is given hypothetical scenarios such as “you see that a house is on fire” or “you find a letter lying on the road” and is asked “what will you do”. This is called “test judgment” as patient's judgment is being tested in a hypothetical scenario. There are other forms of judgment like “social judgment” which describes whether a person is able to interact socially in an appropriate manner. Finally, in “personal judgment”, patient is asked about his future plans and it is assessed whether he has a logical plan for his future or not.