Psychopathology + Classification Flashcards
A 79-year-old woman with a diagnosis of Alzheimer’s disease is causing concern
as she is constantly getting lost on the way back from the local shop to her home,
which is only a short walk and one that she has done nearly every day for 20 years.
What sort of memory disturbance does this represent?
A. Autobiographical memory
B. Episodic memory
C. Procedural memory
D. Semantic memory
E. Topographical memory
E. Topographical memory
As the name suggests, the inability to orientate oneself represents a
failure of topographical memory (E) which is fairly common in dementia.
Autobiographical memory (A) refers to specific events and issues related
to oneself such as one’s 60th birthday or the birth of one’s grandchild.
Episodic memory (B) is essentially analagous to autobiographical
memory. Procedural memory (C) is also known as ‘implicit memory’
(whereas autobiographical would be ‘explicit’) and refers to the memory
or knowledge of ‘how to do things’. These are accessed unconsciously –
motor skills (such as driving) would fall into this category for example.
Semantic memory (D) refers to our ‘knowledge base’ and is unrelated to
specific experiences or events – for example, knowing your nine times
table or what the capital of Australia is.
A 72-year-old woman who suffers from Alzheimer’s disease is asked who the
Prime Minister was during the Second World War, to which she replies ‘Winston
Churchill’. She is then asked where she lived during the war, to which she answers
‘Winston Churchill’. What phenomenon is being described here?
A. Confabulation
B. Déjà vu
C. Ganser’s syndrome
D. Jamais vu
E. Perseveration
E. Perseveration
Perseveration (E) is seen almost exclusively in organic brain disease,
for example dementia. It involves giving an appropriate response to a
stimulus the first time but then giving the same response (incorrectly) to
a different second stimulus. Note, it is not limited to verbal statements,
but may also occur with, for example, motor activity. Confabulation (A)
is the phenomenon whereby false memories occur and results in incorrect
answers being given. It is a complex concept, may result from the sufferer
trying to ‘cover up’ not knowing the real answer and may be confused
with deliberate attempts to deceive, or as is often seen in organic brain
disease, the sufferer inventing ‘fantastical’ answers, which may be
difficult to separate from delusions. Déjà vu (B) refers to the phenomenon
whereby the person feels the sense of familiarity of having encountered
an event before, even though it is a new experience for them. It may be
a feature of temporal lobe epilepsy but is seen in non-pathological states
and does not always indicate organic disease. Ganser’s syndrome (C) is
an unusual phenomenon whereby people give ‘approximate’ answers,
among other symptoms, such as, ‘How many legs does a cow have?’
‘Five’. It has caused considerable debate as to whether it represents an
organic psychotic disorder or a dissociative disorder. Jamais vu (D) refers
to the sensation that a familiar event or place has never been encountered
before.
A young woman wakes from a nightmare and sees her dressing gown hanging
from the door, which she mistakes as an assailant. What is being described here?
A. Affect illusion
B. Completion illusion
C. Pareidolic illusion
D. Tactile hallucination
E. Visual hallucination
A. Affect illusion
An illusion is a misinterpretation of a perception, as opposed to a
hallucination, in which a new perception is experienced in the absence of a stimulus. Illusions are not usually pathological. An affect illusion (A) is
one in which a perception is altered depending on the mood state; in this
case a frightened woman wakes suddenly and misinterprets a hanging
piece of clothing for an attacker. A completion illusion (B) occurs when
there is a lack of attention, and a perception is ‘incorrectly’ interpreted,
for example skipping over a misprint in a book because we are tired.
Pareidolic illusions (C) consist of shapes being seen in other objects – the
classic example being seeing images such as animals in cloud formations.
In contrast to other illusions, pareidolic illusions become more vivid
with concentration. A tactile hallucination (D) refers to a tactile (‘touch’)
sensation in the absence of a stimulus. This scenario does not represent
a visual hallucination (E) as the stimulus is real (the dressing gown),
but it has been misinterpreted. Had there been no dressing gown and
the woman had still seen an assailant, this may then have represented a
visual hallucination.
A young man with schizophrenia describes how he can hear the secret service
in their base in Finland discussing their plans to assassinate him. What is this
phenomenon known as?
A. Extracampine hallucination
B. Functional hallucination
C. Hypnagogic hallucination
D. Hypnopompic hallucination
E. Reflex hallucination
A. Extracampine hallucination
An extracampine hallucination (A) is one which occurs beyond the usual
range of sensation, in this case, beyond the limits of audibility – there
is no possibility that the patient would be able to hear anyone speaking
from Finland. These are definite hallucinations as the patient is hearing
them, rather than them constituting delusional beliefs. A functional
hallucination (B) occurs when a hallucination is experienced only when
an external stimulus is present in the same modality. An example may
be a patient hearing voices only when he hears classical music. Note that
although the stimulus and the hallucination are in the same modality,
they do not have to take the same form, e.g. in the example just given the
stimulus is music, while the hallucination is voices. Hypnagogic (C) and
hypnopompic (D) hallucinations refer to those that occur on falling asleep
and waking respectively, and may occur in non-pathological states. An
example would be the feeling of falling off a cliff when falling asleep.
Reflex hallucinations (E) are similar to functional hallucinations but
the stimulus is in a different modality to the hallucination, for example,
a woman with schizophrenia hearing voices every time her child looks
at her.
A 28-year-old man is diagnosed with schizophrenia, with the belief that he has
been targeted for extermination by a religious cult who have implanted tiny
electrical ‘ants’ into his fingernails. When asked when he knew this, he said he had
seen a magazine story 3 months ago on ‘retiring to the country’ and immediately
felt this was a covert message from the cult that he should be ‘retired’. There was
no evidence of delusions prior to this. What is being described here?
A. Autochthonous (primary) delusion
B. Autoscopy
C. Delusional atmosphere
D. Delusional memory
E. Delusional perception
E. Delusional perception
A delusional perception (E) occurs when a normal perception (e.g. seeing
a magazine cover) is invested with a delusional meaning (a cult is trying
to kill me). The perception is given a whole new false, and usually bizarre,
meaning that is specific to the patient and nearly always of monumentous
importance. An autochthonous delusion (A) is one that arises out of the
blue (and unlike delusional perception is not attached to a real stimulus).
It should be distinguished from secondary delusions in which the beliefs
are understandable in the context of the sufferer’s mood or history (e.g. a
mood-congruent depressive delusion). A primary delusion is by definition
un-understandable in any context. Autoscopy (B) refers to the sensation
of seeing oneself, although its aetiology and precise psychopathology is
controversial. Delusional atmosphere (C), also known as delusional mood,
refers to the state of perplexity or bewilderment in which sufferers feel
that something is ‘going on’ but without being able to state exactly what.
It often occurs prior to a delusion forming and the sufferer will often
describe feeling odd and that everything around them has new ‘meanings’
and significance to them in particular. Delusional memory (D) is when a
patient recalls an event from the past and interprets it with a delusional
meaning. Although this may seem similar to the answer ‘E’, the difference
is that the event at the time will not have been invested with a delusional
interpretation; it is only afterwards that this occurs.
A 48-year-old man with poorly controlled schizophrenia is admitted to the ward.
He appears confused and he is difficult to interview. On asking him why he is in
hospital, he replies, ‘Jealousy, the Collaborative, collaborate and dissipate. What’s
in my fridge? It isn’t my time’. How would you describe this type of thinking?
A. Circumstantial
B. Derailment
C. Flight of ideas
D. Pressure of speech
E. Thought blocking
B. Derailment
Derailment (B) is a type of formal thought disorder in which there are
disjointed thoughts with no meaningful connections. It is commonly
seen in schizophrenia, but also presents sometimes in other disorders.
Circumstantial thinking (A) is somewhat difficult to describe but occurs
when the person talks around a subject exhaustively with only loosely
relevant associations. They will usually return to the point but only
after many detours of almost irrelevant (or certainly over-inclusive)
information. Flight of ideas (C) occurs when thinking is accelerated –
associations between ideas are logical to an extent, but the ‘goal’ of
thinking changes rapidly, usually because of poor attention as a result
of a manic state. Pressure of speech (D) is the ‘verbal’ description of
this acceleration (whereas flight of ideas refers to the speed of thoughts
as opposed to speech). Thought blocking (E) occurs most commonly in
schizophrenia and manifests as the patient suddenly stopping in midsentence
without them being able to explain why. It is not the same as
thought withdrawal, in which the patient believes an external agency is
removing thoughts from their head.
Which of the following is not a first-rank symptom of schizophrenia as described
by Schneider?
A. Delusional perception
B. Persecutory delusions
C. Running commentary
D. Somatic passivity
E. Thought alienation
B. Persecutory delusions
Persecutory delusions (B) are certainly seen in schizophrenia but they
do not form part of the core of ‘first-rank’ symptoms that Schneider
described as core to the diagnosis. It should be noted that these symptoms
are not pathognomonic of schizophrenia as they have also been observed
in other disorders (e.g. 20 per cent of those with biploar disorder). Not
everyone with schizophrenia has ‘first-rank’ symptoms. Delusional
perception (A) has been described above and is a first-rank symptom.
Running commentary (C) refers to third-person auditory hallucinations in
which one or more voices discuss in great detail what the person is doing
as they do it. Other types of auditory hallucination designated as firstrank
include audible thoughts, in which the patient’s thoughts are ‘spoken
out loud’, and voices heard arguing with each other. Somatic passivity (D)
is the symptom whereby patients feel that their body is being controlled
by an external source. While it may be present along with somatic or
tactile hallucinations, in itself it is a delusional belief, not a hallucination.
Other first-rank passivity phenomena include passivity of emotions or
impulses. Thought alienation (E) is similar to the above but involves the
patient’s thoughts rather than impulses or feelings. People may feel that
their thoughts are being planted (thought insertion), taken away (thought
withdrawal) or played out loud (thought broadcasting).
A 72-year-old man with Parkinson’s dementia is seen in clinic. He is asked how
he is feeling, to which he replies, ‘I feel fantastic…tic…tic…tic…tic…’. What is the
name for this type of speech abnormality?
A. Alogia
B. Dysarthria
C. Echolalia
D. Logoclonia
E. Neologism
D. Logoclonia
Logoclonia (D) describes the symptom of repeating the last syllable of a
word repeatedly and is often seen in Parkinson’s disease. It has a different
aetiology to stammering or the tics seen in Tourette’s syndrome. Alogia
(A) is the phenomenon of ‘not having any words’ and refers to extreme
poverty of speech. It is commonly seen in severe negative schizophrenia
or dementia. Dysarthria (B) refers to a difficulty in the manufacture of
speech, and is usually caused by structural lesions either in the vocal
cords or the brainstem. Echolalia (C) is the phenomenon whereby
words or sentences that the patient hears are repeated back, sometimes
continuously and incessantly. It often has an organic cause such as
dementia or brain injury but may also be seen in functional disorders
such as schizophrenia. Neologisms (E) are new words created by the
patient that have a specific meaning for them, usually involved with their
delusional beliefs. It is not the same as using a known word in a different
way (known as metonymy). For example, when describing the machine
used to trace his whereabouts, a man with schizophrenia referred to it as
a ‘Labulizer’.
A 26-year-old man is seen by his GP. For the last few months, he has become
increasingly concerned about a mole on his cheek, which he feels has got bigger
and people are noticing it more. Over the last week he has become convinced
that people are laughing at it when he passes them. He has a thought in his head
of ‘you’re so ugly, look at the size of that mole’. The patient does not feel he
knows where the thought comes from, but it does not seem to be his. He wonders
if someone has planted the thought there. The GP does not feel the mole is in
any way abnormally sized or has other unusual features. What is the most likely
aetiology of these symptoms?
A. Compulsion
B. Delusion
C. Hallucination
D. Rumination
E. Somatization
B. Delusion
This is a difficult question, but actually one that is seen with some
regularity by GPs and psychiatrists. The key features here that make this
most likely to be a delusion (B) is the thought that people are looking
at him excessively, coupled with the intrusive thought that is not his
own. In a rumination (D), the patient would recognize the thought as
being their own. It is not a hallucination (C) because the thought is not
spoken out loud. A compulsion (A) represents a repetitive act, driven
by obsessive anxiety. Somatization (E) refers to physical symptoms that
manifest as the result of intrapsychic anxiety with no adequate physical
explanation. Usually these patients end up having exhaustive negative
medical investigations and refuse to accept that there is nothing physical
to be found. The important point of this question is that it would be easy
to mistake this for obsessive–compulsive disorder or dysmorphophobia.
Always assess for more ‘sinister’ symptoms such as psychosis as they can
sometimes be hidden beneath more obvious diagnoses.
Which of the following is not a core symptom of depression as defined by ICD-10?
A. Anergia
B. Anhedonia
C. Anorexia
D. Hyperphagia
E. Insomnia
D. Hyperphagia
Hyperphagia (D), or increased consumption of food, is not a core
symptom of depression according to ICD-10, although it certainly
can be seen in depressive disorders, and forms part of the criteria for
atypical depression. Anergia (A), or lack of energy, is a core symptom
of depression, although obviously is non-specific. Anhedonia (B), or
lack of enjoyment or inability to experience pleasure, is perhaps even
more common than anergia. Anorexia (C) as a symptom means lack of
appetite and most certainly does occur in depression – this should not be
confused with anorexia nervosa which is a specific condition. Insomnia
(E), particularly in the form of early morning wakening, is a common and
extremely distressing symptom of depression. Do not underestimate how
disabling lack of sleep can be for depression sufferers.
A 42-year-old man sees his GP after witnessing a horrific motorway pile-up. For
the last 6 weeks he has been experiencing recurrent and intrusive images of the
event where he relives what happened, both at night and during the day. At night
he is also having vivid nightmares about the crash which is now stopping him
from going to sleep. He has not driven his car since, although he himself was not
involved in the crash. Every time a car starts he jumps and becomes extremely
upset. His mood is low and he feels disconnected from his wife and children and he
has been thinking about killing himself. What symptom is not being described here?
A. Avoidance
B. Detachment
C. Insomnia
D. Increased arousal
E. Night terrors
E. Night terrors
Night terrors (E) are not the same as nightmares, and they do not occur in
rapid eye movement sleep – the sufferer (who is usually a child) does not
tend to remember any bad dreams, but will awake from sleep in a state
of abject terror and confusion, often shouting and sometimes lashing
out. Hypnopompic hallucinations are common on waking, particularly
seeing insects. Avoidance symptoms (A) are evident here in the form of
the patient not wanting to drive his car. Detachment (B) is also present in
feeling disconnected from his wife and children. A feeling of derealization
or depersonalization may also occur, in which the sufferer feels in some
way removed from the world around him or even from his own body.
Insomnia is present (C) as the patient is purposefully not sleeping from
fear of the nightmares. Note insomnia may be ‘induced’ by the patient in
this way, it does not necessarily mean the person is trying to sleep. There
is evidence of increased arousal (D) in terms of jumping at the sound of
car engines.
What is the most likely diagnosis in the case described in the previous question?
A. Acute stress reaction
B. Adjustment disorder
C. Depressive episode
D. Dissociative fugue
E. Post-traumatic stress disorder (PTSD)
E. Post-traumatic stress disorder (PTSD)
Note that the symptoms have been present for more than 1 month which
is required for a diagnosis of PTSD (E). The criteria for diagnosis include
exposure to a potentially life-threatening event, re-experiencing of the
event in various ways such as nightmares or flashbacks, avoidance of
stimuli that recall the event (e.g. driving) and increased arousal such
as hypervigilance, increased startle reaction, insomnia and sometimes
irritability and anger. Depressive symptoms (C) are also extremely common, but the diagnosis here is clearly one with a stressful precipitant.
An acute stress (A) reaction must subside within hours or days of a
stressful event and results in disorientation and confusion in response
to the stressor. Panic and other symptoms of anxiety commonly
occur. Adjustment disorders (B) occur in response to a significant and
stressful change in life circumstances or events, such as bereavement or
emigration. The main symptoms are those of depression or anxiety along
with an inability to cope with daily tasks. A dissociative fugue (D) is one
of the dissociative or conversion disorders, in which either the body or
mind in some way lose their normal integration. They usually resolve
after weeks or months and are manifestations of intrapsychic stress. They
were originally known as ‘hysterical’ disorders but the term is no longer
used because of its sexist overtones. In a dissociative fugue, the sufferer
will have a period of amnesia during which he or she will travel, often for
long distances, and certainly beyond their usual range of travel. Despite
this they often appear normal to passers-by.
A 49-year-old woman with schizophrenia is admitted to the psychiatric unit in a
mute state. She is staring blankly ahead and not responding to any commands.
She is not eating or drinking and looks dehydrated. Which of the following is the
least likely to be observed in catatonia?
A. Catalepsy
B. Clanging
C. Echolalia
D. Negativism
E. Stupor
B. Clanging
Clanging (B) is a form of thought disorder whereby words are used
based on their similar sounds or rhyming and the meaning becomes
unimportant. For example, ‘A cat pat on my hat sack, ate the bait and
skated’. It is seen in schizophrenia but would not be a typical feature of
catatonia. Catatonia is a state of either stupor in which a patient is entirely
unresponsive (E) or excited. It is associated with various conditions, not
just schizophrenia, and its exact cause is not known. It appears to be
less common than 50 years ago, but the reason for this is not clear.
Catatonia can be associated with various symptoms, including catalepsy
(A), in which the limbs become rigid. Sometimes patients’ limbs can be
moved into unusual positions and will remain in place even if extremely
uncomfortable. This is known as waxy flexibility. Catalepsy should not
be confused with cataplexy, in which there is sudden and transient loss
of muscle tone resulting in collapse. Echolalia (C) is the phenomenon
whereby sufferers repeat the words of those speaking to them. Remember
that not all catatonic patients are mute, and echolalia is often found in
these patients. Negativism (D) is the symptom whereby catatonic patients
will appear to automatically do the opposite of what they are asked to do.
This is not just resisting instructions or movement but actually attempting
to perform the opposite instruction or movement.
Which of the following statements regarding the two classification systems in
psychiatry (ICD-10 and DSM-IV) is false? Note this refers specifically to the section
in ICD-10 related to psychiatry and mental health.
A. Dementia cannot be classified in either of the two
systems
B. DSM-IV uses a multiaxial system
C. Homosexuality is no longer a diagnostic category in the two systems
D. ICD-10 was developed by the World Health Organization (WHO)
E. The first categories in ICD-10 are those related to organic disorders
A. Dementia cannot be classified in either of the two
systems
Dementia (A) can certainly be classified in both ICD-10 and DSM-IV,
although the various subtypes of dementia are not necessarily accurately
definable. For instance, Lewy body dementia is not represented in ICD
(or at least not in the section related to psychiatric disorders, it is
mentioned in the neurological disease section, but this is not usually used
in mental health settings). DSM-IV is a multiaxial system (B), in other
words a diagnosis will be made up of several different axes. These are:
Axis 1 – clinical disorders, Axis 2 – personality disorders and learning
disability, Axis 3 – acute medical conditions and physical disorders, Axis
4 – psychosocial and environmental factors contributing to the disorder,
and Axis 5 – global assessment of functioning. In this way it differs from
ICD-10 which uses only a single category per diagnosis. Homosexuality
was, to many people’s surprise, still included in the ICD (European) system
until 1990 and the DSM (American) system until 1986. It can still be found
vestigially as a category relating to ‘ego-dystonic sexual orientation’ in
ICD-10. ICD-10 (D) is a WHO system of coding diseases, symptoms, social
circumstances and injuries. The first categories in ICD-10 (E) are related
to organic disorders (F00–F09). There has been some attempt by ICD-10
to classify disorders ‘hierachically’, with organic disorders needing to be
excluded first and therefore placed first. This, however, is just one of the
many various controversies surrounding the classification systems used
currently in psychiatry, the scope of which is well beyond this book
Which of the following would be the best definition of the term ‘loosening of
associations’?
A. A decrease in the amount of words produced by a patient
B. An incompleteness of the development of ideas or thoughts, leading to
a lack of logical relationship between them
C. Difficulty in verbalizing names of objects, despite being able to describe
their function
D. Talking in a roundabout manner before finally answering a question
E. The creation of a new word with particular meaning to the patient
B. An incompleteness of the development of ideas or thoughts, leading to
a lack of logical relationship between them
Loosening of associations (B) is seen in schizophrenia. It has various
definitions but fundamentally describes a form of thought disorder in
which links between ideas become illogical. (A) describes alogia and is
seen in chronic schizophrenia among other disorders. (C) is a definition of
nominal dysphasia, seen in dementia, stroke and other organic disorders.
(D) refers to circumstantiality, often seen in hypomanic states. (E) is the
definition for a neologism, which is most usually seen in schizophrenia.
