NEUROSCIENCE

1. A 62-year-old female with a chronic psychiatric disorder claims that the comments of a well-known news anchorman have a special meaning that only she understands. She is convinced that when he reports on local events he is really trying to persuade her to start a "sinful relationship." 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

1. The answer is d. (DSM-IV [see under American Psychiatric Association in Bibliography], p 765; Sadock, 7/e, p 682.) A delusion of reference refers to events, objects, or persons in one's environment that are believed to have particular personal significance. A persecutory delusion refers to the belief that other people or malevolent entities intend to harm the individual. As in all delusions, the beliefs are unshakable. Hallucinations and illusions are perceptual disturbances, the former lacking any real basis, the latter being misinterpretations of actual stimuli. Concrete thinking refers to a cognitive style of processing that utilizes only information related to actual objects and events and is devoid of abstractions.

10. An adult whose IQ score falls in the moderate range of mental retardation (IQ level 35-40 to 50-55) is expected to function at a. Seventh to ninth grade level b. Third to sixth grade level c. Preschool to second grade level d. 1 to 3-years-old level e. 18-months-old level

10. The answer is c. (Yudofsky, 3/e, p 916.) Adults whose IQ scores fall in the range of 35-55 are considered to exhibit moderate mental retardation. These individuals can learn to manage some aspects of daily living such as the basics of self-care or making small change. They usually require life-long custodial supervision.

100. After being struck on the head by a four-by-four, a previously serious and dependable construction worker starts making inappropriate sexual remarks to his coworkers, is easily distracted, and loses his temper over minor provocations. What part of his brain has been damaged? a. Occipital lobes b. Temporal lobes c. Limbic system d. Basal ganglia e. Frontal lobes

100. The answer is e. (Kaufman, 4/e, pp 123-124; Yudofsky, 3/e, p 100.) The frontal lobes are associated with the regulation of emotions, the manifestation of behavioral traits usually connected to the personality of an individual, and executive functions (the ability to make appropriate judgments and decisions and to form concepts). They also contain the inhibitory systems for behaviors such as bladder and bowel release. Damage of the frontal lobes causes impairment of these functions but it is not, strictly speaking, a form of dementia, because memory, language, calculation ability, praxis, and IQ are often preserved. Personality changes, disinhibited behavior, and poor judgment are usually seen with lesions of the dorsolateral regions of the frontal lobes. Lesions of the mesial region, which is involved in the regulation of the initiation of movements and emotional responses, cause slowing of motor functions, speech, and emotional reactions. In the most severe cases, patients are mute and akinetic. Lesions of the orbitofrontal area are accompanied by abnormal social behaviors, an excessively good opinion of oneself, jocularity, sexual disinhibition, and lack of concern for others

11. An 18-year-old woman, previously in good health, seeks help at an emergency room for lightheadedness, headaches, and nausea. She appears anxious and is tremulous, sweating, and breathing heavily. These symptoms appeared suddenly 20 minutes before her arrival at the ER. While waiting to see a physician, she begins to complain of tingling around her mouth and in her fingertips. The physician should first a. Ask her to breathe into a paper bag b. Order immediate intravenous infusion of 50 ml of 50% glucose solution c. Arrange for a brain scan d. Conduct an amobarbital interview e. Draw a blood sample to evaluate blood alcohol concentration

11. The answer is a. (Hales, 3/e, p 573.) The symptoms experienced by the woman described in the vignette are classical symptoms of hyperventilation, which commonly is associated with panic disorder and other anxiety states. Hyperventilation causes a drop in blood CO2 and alkalosis, which in turn causes a decrease of the ionized fraction of the serum's calcium and constriction of the cerebral vessels. Dizziness, light-headedness, and feelings of derealization follow the cerebral hypoxia. The lower ionized calcium level causes signs of tetany, such as painful muscle spasms in the hands, perioral tingling, and paresthesias. Breathing into a paper bag reverses the symptoms because the recycled air has a higher concentration of carbon dioxide than does normal air.

13. This patient diagnosis is likely to be a. Dysthymia b. Conversion disorder c. Communication disorder d. Passive-aggressive personality disorder e. Schizophrenia

12-13. The answers are 12-b, 13-e. (Sadock, 7/e, p 680.) Patients who present 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 25-year-old man's teaching career has been abruptly terminated by a psychiatric illness. During a psychiatric evaluation he is asked the meaning of the proverb "People in glass houses should not throw stones." The patient replies, "They will break the windows." 12. This response is an example of a. Idiosyncratic thinking b. Concrete thinking c. Formal operation d. Loose associations e. Autistic thinking

12-13. The answers are 12-b, 13-e. (Sadock, 7/e, p 680.) Patients who present 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.

14. A 69-year-old man is suspected of having an acute onset of multiple small cerebral infarcts. The finding on a mental status examination that would be most supportive of this diagnosis is a. A decline in cognitive functioning b. Bizarre and idiosyncratic proverb interpretation c. An elated affect d. Loose associations e. Catatonic posturing

14. The answer is a. (Yudofsky, 3/e, pp 842-843.) Multiple cerebral infarcts cause a progressive dementia, focal neurological signs, and, often, neuropsychiatric symptoms, such as depression, mood lability (but not usually elated mood), and delusions. Loose associations, catatonic posturing, and bizarre proverb interpretations are typical symptoms of schizophrenia.

15. A 75-year-old African American male becomes profoundly depressed after his son dies in a car crash and he tells his doctor that he wants to "join Steve in Heaven." Choose the correct statement about suicide: a. People who talk about their death wishes rarely kill themselves b. Widowers have a higher incidence of suicide than divorced people c. Whites are more likely to kill themselves than African Americans d. Women have a higher risk for completed suicide than males e. Elderly patients rarely commit suicide due to their stronger religious beliefs

15. The answer is c. (Hales, 3/e, p 1384.) Males have a higher risk for completed suicide than females and people over 45 are at higher risk than younger people. Among the ethnic groups, Caucasians have the highest risk, followed by Native Americans, African Americans, Hispanics, and Asians. People who live with others or are married are less at risk of committing suicide than people who live alone. Divorced people have a higher risk than widows and widowers and singles. Good health lowers the risk for suicide and poor health increases it. People who commit suicide usually talk about their intent with others before going ahead with their plans.

16. A therapist considers administering the Minnesota Multiphasic Personality Inventory (MMPI) to a chronically depressed patient who does not seem to respond to treatment as well as expected. The MMPI is commonly used to a. Explore the patient's unconscious thoughts and emotions b. Measure the patient's intelligence c. Monitor severity of depressive symptoms d. Arrive at a definite diagnosis in ambiguous cases e. Better understand the patient's beliefs, expectations, and emotional status

16. The answer is e. (Sadock, 7/e, pp 689-732.) Three instruments are used to assess patients' functioning: psychological tests, rating scales, and structured interviews. Psychological tests use questions or statements the patients have to agree or disagree with, or similar sampling methods, to obtain more information about individuals' cognitive functions, emotional status, expectations, beliefs, and many other areas that are significant in psychiatry. Answers are standardized to assure reliability. Psychological tests are helpful tools, because they can provide understanding of personality traits, symptoms, and cognitive deficits not readily accessible during an unstructured evaluation, but a diagnosis should not be made only on the basis of test results. Commonly used psychological tests are the Wechsler Adult Intelligence Scale (WAIS), the Minnesota Multiphasic Personality Inventory (MMPI), and projective tests such as the Rorschach Inkblot Test. Rating scales are standardized devices which allow an observer to rate the patient's behavior in specific areas. An example is the Child Behavioral Checklist (CBCL), usually filled by parents and teachers. In semistructured interviews, questions are predetermined and responses are formulated in a way that permits standardization (Yes/No, Not at all/Sometimes/Always, and so on).The Minnesota Multiphasic Personality Inventory (MMPI) and the MMPI-2 (a revised version) are among the most used psychological tests. They are called personality tests because they provide information about the patient's characterological traits in addition to information concerning the patient's symptoms. The MMPI consists of a 566-item checklist in a true/false format, to be completed by the patient usually in one to two hours' time. The questions are worded so that a person with an elementary education would not have difficulties understanding them and are constructed to explore the presence or absence of emotions, experiences, and thoughts. The items are divided in groups, each intended to provide information in one of nine clinical scales: hypochondriasis, depression, hysteria, psychopathic deviance, masculinity-femininity, paranoia, psychoasthenia, schizophrenia, and mania. The patient's responses are computer scored and the patient's "profile" (personality) depends on the score in each scale. For example, a patient with a high score in the schizophrenia scale will typically emerge as distrustful, keeping people at a distance, using projection as a main defense, and so on.

17. During a psychoeducational evaluation, a school psychologist shows a child a series of ambiguous pictures and asks her to make up stories about them. This projective test is called a. Children Depression Inventory (CDI) b. Rorschach Inkblot Test c. Thematic Apperception Test (TAT) d. Personality Inventory for Children (PIC) e. Wechsler Intelligence Scale for Children III (WISC-III)

17. The answer is c. (Sadock, 7/e, pp 708-712.) Projective psychological tests are used to obtain information about feelings, interpersonal dynamics, intrapsychic dynamics, and other items that are outside of the patient's conscious awareness. In these tests, the patient "projects" his or her inner world into the stimulus provided (pictures, inkblots, or incomplete sentences, depending on the specific test). The Thematic Apperception Test (TAT) is a projective psychological test used to assess the patient's self-concept in relation to other. It consists of a series of 30 pictures depicting one or more individuals with ambiguous expressions or poses. The patient is asked to make up a story about each picture. The patient's feelings, desires, and impulses are usually reflected by the feelings, desires, and impulses attributed to the picture's main character. In the Rorschach Inkblot Test, another projective test, the patient is asked to describe what he or she sees in the inkblots. The Children Depression Inventory is a self-report measure used to assess symptoms of depression in children between 7 and 17 years of age. The Personality Inventory for Children is the equivalent of the MMPI for adults. It differs from the adult test insofar as questions are answered by parents and teachers for young children. The WISC is used to measure the child IQ.

19. This symptom is usually seen in patients with a. Schizophrenia b. Parkinson's disease c. Delirium d. Neuroleptic malignant syndrome e. Huntington's disease

18-19. The answers are 18-d, 19-a. (Sadock, 7/e, pp 680, 819.) The voluntary assumption of an inappropriate or bizarre posture for long periods of time is called catatonic posturing and it is usually seen in schizophrenia, especially of the catatonic type. In catatonic posturing, patients actively resist attempts to make them change position. A similar symptom, waxy flexibility, refers to patients that maintain the body position into which they are placed. Apraxia refers to the inability to perform voluntary motor activity in the absence of motor or sensory deficits. Dystonia refers to the protracted contraction of a group of muscles. In synesthesia, the stimulation of one sensory modality produces a sensation belonging to another sensory modality (a color is perceived as a smell). Trance is a sleeplike condition characterized by a reduced state of consciousness. Parkinson's disease, neuroleptic malignant syndrome, and Huntington's disease are characterized by different motor disturbances.

Items 18-19 A patient has been standing, immobile, for several hours. One of his arms is stretched upward, the other is wrapped around the patient's neck. The patient does not appear aware of his surroundings and actively resists any attempt to make him change position. 18. This is an example of a. Apraxia b. Dystonia c. Synesthesia d. Catatonia e. Trance

18-19. The answers are 18-d, 19-a. (Sadock, 7/e, pp 680, 819.) The voluntary assumption of an inappropriate or bizarre posture for long periods of time is called catatonic posturing and it is usually seen in schizophrenia, especially of the catatonic type. In catatonic posturing, patients actively resist attempts to make them change position. A similar symptom, waxy flexibility, refers to patients that maintain the body position into which they are placed. Apraxia refers to the inability to perform voluntary motor activity in the absence of motor or sensory deficits. Dystonia refers to the protracted contraction of a group of muscles. In synesthesia, the stimulation of one sensory modality produces a sensation belonging to another sensory modality (a color is perceived as a smell). Trance is a sleeplike condition characterized by a reduced state of consciousness. Parkinson's disease, neuroleptic malignant syndrome, and Huntington's disease are characterized by different motor disturbances.

2. A medical student finds it hard to follow a patient's train of thought because he gives very long, complicated explanations and many unnecessary details before finally answering the original questions. In his report, the medical student writes that the patient displayed a. Loose associations b. Circumstantiality c. Goal-oriented thought processes d. Perseveration e. Flight of ideas

2. The answer is b. (Sadock, 7/e, p 680.) Circumstantial thought processes are 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 lesser degrees of loss of the logical progression of thoughts. Flight of ideas in particular is manifested by a rapid succession of unrelated or fragmentary thoughts. Perseveration involves the persistent repetition of words or ideas.

20. A psychiatrist finds himself annoyed with a quarrelsome patient for no apparent reason. Later on he realizes that the patient reminds him of his disliked sibling. This is an example of a. Reaction formation b. Projection c. Countertransference d. Identification with the aggressor e. Illusion

20. The answer is c. (Hales, 2/e, p 1162.) Countertransference is the name given to the analyst's or psychotherapist's transference response to the patient. As with patients' transference, the particular form the countertransference takes depends on the therapist's past experiences, relationships, and unresolved conflicts. As with transference, countertransference is not limited to the patient-therapist relationship, but may be present in any relationship. By analyzing his countertransference toward the patient, the therapist may acquire useful insight into the patient's dynamics and his own. Consequently, even negative countertransference feelings can be helpful tools in the psychotherapy process. Reaction formation, projection, and identification with the aggressor are unconscious defense mechanisms. An illusion is a perceptual misinterpretation of a real stimulus.

21. A person is sitting alone and behaving as if listening intently, then suddenly begins to nod and mutter aloud. This person most likely is experiencing a. A delusion b. A depersonalization episode c. An hallucination d. An idea of reference e. Flight of ideas

21. The answer is c. (Sadock, 7/e, p 810.) An hallucination is the perception of a stimulus when, in fact, no sensory stimulus is present. Hallucinations can be auditory, visual, tactile, gustatory, olfactory, or kinesthetic (body movements). Auditory hallucinations are most commonly associated with psychotic illness, whereas visual, tactile, gustatory, and olfactory hallucinations often are associated with neurologic disorders. A delusion is an erroneous unshakable belief, and an idea of reference is a form of delusion.

22. The capacity to formulate concepts and generalize them is called a. Concrete thinking b. Abstract thinking c. Delusional thinking d. Intellectualization e. Rationalization

22. The answer is b. (Hales, 3/e, pp 219-220.) The capacity to generalize and to formulate concepts is called abstract thinking. The inability to abstract is called concreteness and is seen in organic disorders and sometimes in schizophrenia. Abstract thinking is commonly assessed by testing similarities, differences, and the meaning of proverbs. Intellectualization and rationalization are unconscious defenses, while delusional thinking refers to fixed beliefs with no basis in reality.

23. A 28-year-old man is brought to the ER of a local hospital by the police, who found him wandering without a coat in subzero weather, muttering about being persecuted by a secret organization. During the evaluation he is disorganized, distractible, and from time to time dozes off in the middle of a sentence. Family members deny previous psychiatric or substance abuse history, but they add that lately the patient had complained of fatigue and increased thirst. The toxic screen is negative and glucose level is 450 mg/dL. Choose the most likely diagnosis: a. Delirium b. Psychotic depression c. Brief psychotic episode d. Paranoid schizophrenia e. Dementia

23. The answer is a. (Yudofsky, 3/e, pp 455-459.) The patient's persecutory delusions and disorganized thinking could suggest a psychotic disorder such as schizophrenia or brief reactive psychosis, but fluctuations in consciousness 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 in the vignette; intoxications with drugs and poisons; withdrawal syndromes; head trauma; epilepsy; neoplasms; vascular disorders; allergic reactions and injuries caused by physical agents (heat, cold, radiation).

25. A 55-year-old female, through her tears, complains of having no energy and no desire for anything. Her hair is unkempt, her clothes mismatched. She has lost 20 pounds in the past two months and she wakes up every morning at 3 A.M. Her daughter reports that her mother was functioning well three months earlier.

24-27. The answers are 24-e, 25-d, 26-g, 27-a. (Hales, 3/e, pp 345, 346, 512, 346.) Huntington's disease is a progressive neurodegenerative disorder, inherited as an autosomal dominant trait, which usually manifests between 35 and 40 years of age. Affected individuals present with a progressive dementia, choreoathetoid movements, and, often, psychiatric symptoms. Computed tomography (CT) scan and nuclear magnetic resonance imaging (MRI) demonstrate gross atrophy of the putamen and the caudate. The Dexamethasone Suppression Test (DST) can be part of the diagnostic workup of depression. In this test, 1 mg of dexamethasone is given in the afternoon of the first day of the test and cortisol levels are drawn the next day. Normally, due to the suppressive effect of the dexamethasone on the pituitary, the cortisol levels decrease to 5 micrograms/dL or less. In depression, due to a disregulation of the pituitary-adrenocortical axis, this cortisol level drop does not happen. Nonsuppression is found in 40 to 50% of depression cases, and values are even higher in severe psychotic depression (80 to 90%). The patient described in the third vignette has an HIV-associated dementia, a disorder caused by the direct toxic effect of the HIV virus on the brain. A CD4 count below 200 is usually associated with HIV dementia, since this disorder occurs usually in the more advanced stages of AIDS. More rarely, cognitive impairments may be the first manifestation of the HIV infection. The woman in the vignette has nonepileptic seizures, a form of conversion disorder. Although nonepileptic seizures can often be differentiated from epileptic episodes by the presence of unusual and wild movements and vocalizations, a lack of postictal confusion, and an association with a psychosocial stressor, sometimes the diagnosis can be made only by documenting that the behavioral manifestations of the seizure are not accompanied by epileptic activity on the EEG.

26. A 23-year-old male is hospitalized for a fever of unknown origin and persistent cough. During the past two months he has been increasingly forgetful and "disorganized." He stated having difficulties in balancing his checkbook and driving without getting lost. During the physical exam, the medical resident notices track marks on his arm.

24-27. The answers are 24-e, 25-d, 26-g, 27-a. (Hales, 3/e, pp 345, 346, 512, 346.) Huntington's disease is a progressive neurodegenerative disorder, inherited as an autosomal dominant trait, which usually manifests between 35 and 40 years of age. Affected individuals present with a progressive dementia, choreoathetoid movements, and, often, psychiatric symptoms. Computed tomography (CT) scan and nuclear magnetic resonance imaging (MRI) demonstrate gross atrophy of the putamen and the caudate. The Dexamethasone Suppression Test (DST) can be part of the diagnostic workup of depression. In this test, 1 mg of dexamethasone is given in the afternoon of the first day of the test and cortisol levels are drawn the next day. Normally, due to the suppressive effect of the dexamethasone on the pituitary, the cortisol levels decrease to 5 micrograms/dL or less. In depression, due to a disregulation of the pituitary-adrenocortical axis, this cortisol level drop does not happen. Nonsuppression is found in 40 to 50% of depression cases, and values are even higher in severe psychotic depression (80 to 90%). The patient described in the third vignette has an HIV-associated dementia, a disorder caused by the direct toxic effect of the HIV virus on the brain. A CD4 count below 200 is usually associated with HIV dementia, since this disorder occurs usually in the more advanced stages of AIDS. More rarely, cognitive impairments may be the first manifestation of the HIV infection. The woman in the vignette has nonepileptic seizures, a form of conversion disorder. Although nonepileptic seizures can often be differentiated from epileptic episodes by the presence of unusual and wild movements and vocalizations, a lack of postictal confusion, and an association with a psychosocial stressor, sometimes the diagnosis can be made only by documenting that the behavioral manifestations of the seizure are not accompanied by epileptic activity on the EEG.

27. During a period of severe marital discord, a young woman starts having episodes characterized by an altered state of consciousness, falling, rhythmic muscle contractions, and vocalizations (moaning, cries). These episodes last from 5 to 20 minutes and always take place in her husband's presence, often in the middle of or after an argument. At the end of the episodes the patient is fully alert and oriented.

24-27. The answers are 24-e, 25-d, 26-g, 27-a. (Hales, 3/e, pp 345, 346, 512, 346.) Huntington's disease is a progressive neurodegenerative disorder, inherited as an autosomal dominant trait, which usually manifests between 35 and 40 years of age. Affected individuals present with a progressive dementia, choreoathetoid movements, and, often, psychiatric symptoms. Computed tomography (CT) scan and nuclear magnetic resonance imaging (MRI) demonstrate gross atrophy of the putamen and the caudate. The Dexamethasone Suppression Test (DST) can be part of the diagnostic workup of depression. In this test, 1 mg of dexamethasone is given in the afternoon of the first day of the test and cortisol levels are drawn the next day. Normally, due to the suppressive effect of the dexamethasone on the pituitary, the cortisol levels decrease to 5 micrograms/dL or less. In depression, due to a disregulation of the pituitary-adrenocortical axis, this cortisol level drop does not happen. Nonsuppression is found in 40 to 50% of depression cases, and values are even higher in severe psychotic depression (80 to 90%). The patient described in the third vignette has an HIV-associated dementia, a disorder caused by the direct toxic effect of the HIV virus on the brain. A CD4 count below 200 is usually associated with HIV dementia, since this disorder occurs usually in the more advanced stages of AIDS. More rarely, cognitive impairments may be the first manifestation of the HIV infection. The woman in the vignette has nonepileptic seizures, a form of conversion disorder. Although nonepileptic seizures can often be differentiated from epileptic episodes by the presence of unusual and wild movements and vocalizations, a lack of postictal confusion, and an association with a psychosocial stressor, sometimes the diagnosis can be made only by documenting that the behavioral manifestations of the seizure are not accompanied by epileptic activity on the EEG.

Items 24-27 Match the following vignettes with the most useful diagnostic test. a. EEG b. ECG c. Liver function tests d. Dexamethasone Suppression Test (DST) e. MRI f. Serum amylase g. CD4 count 24. A 35-year-old postal worker has been getting lost in familiar places he has known for years. He has been moody and irritable and "irrational." His family members have noticed that he "makes bad decisions." His 42-year-old sister is in a hospice, due to a chronic neurodegenerative disorder. His father died 10 years earlier, due to the same condition.

24-27. The answers are 24-e, 25-d, 26-g, 27-a. (Hales, 3/e, pp 345, 346, 512, 346.) Huntington's disease is a progressive neurodegenerative disorder, inherited as an autosomal dominant trait, which usually manifests between 35 and 40 years of age. Affected individuals present with a progressive dementia, choreoathetoid movements, and, often, psychiatric symptoms. Computed tomography (CT) scan and nuclear magnetic resonance imaging (MRI) demonstrate gross atrophy of the putamen and the caudate. The Dexamethasone Suppression Test (DST) can be part of the diagnostic workup of depression. In this test, 1 mg of dexamethasone is given in the afternoon of the first day of the test and cortisol levels are drawn the next day. Normally, due to the suppressive effect of the dexamethasone on the pituitary, the cortisol levels decrease to 5 micrograms/dL or less. In depression, due to a disregulation of the pituitary-adrenocortical axis, this cortisol level drop does not happen. Nonsuppression is found in 40 to 50% of depression cases, and values are even higher in severe psychotic depression (80 to 90%). The patient described in the third vignette has an HIV-associated dementia, a disorder caused by the direct toxic effect of the HIV virus on the brain. A CD4 count below 200 is usually associated with HIV dementia, since this disorder occurs usually in the more advanced stages of AIDS. More rarely, cognitive impairments may be the first manifestation of the HIV infection. The woman in the vignette has nonepileptic seizures, a form of conversion disorder. Although nonepileptic seizures can often be differentiated from epileptic episodes by the presence of unusual and wild movements and vocalizations, a lack of postictal confusion, and an association with a psychosocial stressor, sometimes the diagnosis can be made only by documenting that the behavioral manifestations of the seizure are not accompanied by epileptic activity on the EEG.

29. A young housewife is convinced that her mild acne is disfiguring. She has spent hundreds of dollars on skin products and dermatological consultations. She also underwent three dermo-abrasions but she still believes she looks like "a monster."

28-32. The answers are 28-g, 29-e, 30-h, 31-b, 32-a. (Sadock, 7/e, pp 1746, 1527-1529, 1544, 1480-1482, 1509-1512.) Individuals with borderline personality disorder characteristically form intense but very unstable relationships. Since they tend to perceive themselves and others as either totally bad or perfectly good, borderline individuals either idealize or devalue any person who occupies a significant place in their lives. Usually these perceptions do not last, and the person idealized one day can be seen as completely negative the next day. An extreme feeling of dislike for a part of the body in spite of a normal or near-normal appearance is the main characteristic of body dysmorphic disorder. The fear of being ugly or repulsive is not decreased by reassurance and compliments and has almost a delusional quality. The social, academic, and occupational lives of individuals with this disorder are greatly affected, due to avoidance of social interactions for fear of embarrassment, the time spent in checking mirrors and seeking surgical treatment or cosmetic remedies, and the chronic emotional distress that accompanies the disorder. Dissociative amnesia is characterized by the inability to remember important autobiographical information, usually of a traumatic or disturbing nature. The period of amnesia may last from hours to years. Occasionally the amnesia is limited to specific events, for example, memories involving an abusive individual. Often patients with dissociative amnesia are not aware of their memory loss, but come to treatment complaining of anxiety, depression, poor concentration, and blank spells. 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 experience severe anxiety that can reach the level of panic attack. Characteristically, phobic patients go to great lengths to avoid whatever they fear and this phobic avoidance can greatly interfere with functioning. Conversion disorder is characterized by the sudden appearance of often dramatic neurological symptoms that are not associated with the usual diagnostic signs and test results. Conversion disorder occurs in the context of a psychosocial stressor or an insoluble interpersonal or intrapsychic conflict. The psychological distress is not consciously acknowledged but it is expressed through a metaphorical body dysfunction. In the vignette example, the young woman who was torn between leaving home and becoming independent, found a temporary solution in her paralysis, which prevented her from leaving her home without having to consciously acknowledge her conflict.

30. A 50-year-old woman is trapped for hours in an elevator during a blackout. She has no memory of the hours she spent in the elevator.

28-32. The answers are 28-g, 29-e, 30-h, 31-b, 32-a. (Sadock, 7/e, pp 1746, 1527-1529, 1544, 1480-1482, 1509-1512.) Individuals with borderline personality disorder characteristically form intense but very unstable relationships. Since they tend to perceive themselves and others as either totally bad or perfectly good, borderline individuals either idealize or devalue any person who occupies a significant place in their lives. Usually these perceptions do not last, and the person idealized one day can be seen as completely negative the next day. An extreme feeling of dislike for a part of the body in spite of a normal or near-normal appearance is the main characteristic of body dysmorphic disorder. The fear of being ugly or repulsive is not decreased by reassurance and compliments and has almost a delusional quality. The social, academic, and occupational lives of individuals with this disorder are greatly affected, due to avoidance of social interactions for fear of embarrassment, the time spent in checking mirrors and seeking surgical treatment or cosmetic remedies, and the chronic emotional distress that accompanies the disorder. Dissociative amnesia is characterized by the inability to remember important autobiographical information, usually of a traumatic or disturbing nature. The period of amnesia may last from hours to years. Occasionally the amnesia is limited to specific events, for example, memories involving an abusive individual. Often patients with dissociative amnesia are not aware of their memory loss, but come to treatment complaining of anxiety, depression, poor concentration, and blank spells. 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 experience severe anxiety that can reach the level of panic attack. Characteristically, phobic patients go to great lengths to avoid whatever they fear and this phobic avoidance can greatly interfere with functioning. Conversion disorder is characterized by the sudden appearance of often dramatic neurological symptoms that are not associated with the usual diagnostic signs and test results. Conversion disorder occurs in the context of a psychosocial stressor or an insoluble interpersonal or intrapsychic conflict. The psychological distress is not consciously acknowledged but it is expressed through a metaphorical body dysfunction. In the vignette example, the young woman who was torn between leaving home and becoming independent, found a temporary solution in her paralysis, which prevented her from leaving her home without having to consciously acknowledge her conflict.

31. The career of a young executive who needs to travel often for his business is much impaired because, due to his overwhelming fear of flying, he refuses all the jobs that require traveling by plane.

28-32. The answers are 28-g, 29-e, 30-h, 31-b, 32-a. (Sadock, 7/e, pp 1746, 1527-1529, 1544, 1480-1482, 1509-1512.) Individuals with borderline personality disorder characteristically form intense but very unstable relationships. Since they tend to perceive themselves and others as either totally bad or perfectly good, borderline individuals either idealize or devalue any person who occupies a significant place in their lives. Usually these perceptions do not last, and the person idealized one day can be seen as completely negative the next day. An extreme feeling of dislike for a part of the body in spite of a normal or near-normal appearance is the main characteristic of body dysmorphic disorder. The fear of being ugly or repulsive is not decreased by reassurance and compliments and has almost a delusional quality. The social, academic, and occupational lives of individuals with this disorder are greatly affected, due to avoidance of social interactions for fear of embarrassment, the time spent in checking mirrors and seeking surgical treatment or cosmetic remedies, and the chronic emotional distress that accompanies the disorder. Dissociative amnesia is characterized by the inability to remember important autobiographical information, usually of a traumatic or disturbing nature. The period of amnesia may last from hours to years. Occasionally the amnesia is limited to specific events, for example, memories involving an abusive individual. Often patients with dissociative amnesia are not aware of their memory loss, but come to treatment complaining of anxiety, depression, poor concentration, and blank spells. 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 experience severe anxiety that can reach the level of panic attack. Characteristically, phobic patients go to great lengths to avoid whatever they fear and this phobic avoidance can greatly interfere with functioning. Conversion disorder is characterized by the sudden appearance of often dramatic neurological symptoms that are not associated with the usual diagnostic signs and test results. Conversion disorder occurs in the context of a psychosocial stressor or an insoluble interpersonal or intrapsychic conflict. The psychological distress is not consciously acknowledged but it is expressed through a metaphorical body dysfunction. In the vignette example, the young woman who was torn between leaving home and becoming independent, found a temporary solution in her paralysis, which prevented her from leaving her home without having to consciously acknowledge her conflict.

32. A young woman who has ambivalent feelings about separating from her family wakes up paralyzed on the morning she is scheduled to go back to college.

28-32. The answers are 28-g, 29-e, 30-h, 31-b, 32-a. (Sadock, 7/e, pp 1746, 1527-1529, 1544, 1480-1482, 1509-1512.) Individuals with borderline personality disorder characteristically form intense but very unstable relationships. Since they tend to perceive themselves and others as either totally bad or perfectly good, borderline individuals either idealize or devalue any person who occupies a significant place in their lives. Usually these perceptions do not last, and the person idealized one day can be seen as completely negative the next day. An extreme feeling of dislike for a part of the body in spite of a normal or near-normal appearance is the main characteristic of body dysmorphic disorder. The fear of being ugly or repulsive is not decreased by reassurance and compliments and has almost a delusional quality. The social, academic, and occupational lives of individuals with this disorder are greatly affected, due to avoidance of social interactions for fear of embarrassment, the time spent in checking mirrors and seeking surgical treatment or cosmetic remedies, and the chronic emotional distress that accompanies the disorder. Dissociative amnesia is characterized by the inability to remember important autobiographical information, usually of a traumatic or disturbing nature. The period of amnesia may last from hours to years. Occasionally the amnesia is limited to specific events, for example, memories involving an abusive individual. Often patients with dissociative amnesia are not aware of their memory loss, but come to treatment complaining of anxiety, depression, poor concentration, and blank spells. 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 experience severe anxiety that can reach the level of panic attack. Characteristically, phobic patients go to great lengths to avoid whatever they fear and this phobic avoidance can greatly interfere with functioning. Conversion disorder is characterized by the sudden appearance of often dramatic neurological symptoms that are not associated with the usual diagnostic signs and test results. Conversion disorder occurs in the context of a psychosocial stressor or an insoluble interpersonal or intrapsychic conflict. The psychological distress is not consciously acknowledged but it is expressed through a metaphorical body dysfunction. In the vignette example, the young woman who was torn between leaving home and becoming independent, found a temporary solution in her paralysis, which prevented her from leaving her home without having to consciously acknowledge her conflict.

Match the symptoms with the most appropriate diagnosis. 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 28. A young woman presents to the emergency room for the third time in two months with multiple self-inflicted cuts on her arms and legs. 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 her way out, the patient tells the resident that he is the best doctor she has ever met and the only one who really understands her pain.

28-32. The answers are 28-g, 29-e, 30-h, 31-b, 32-a. (Sadock, 7/e, pp 1746, 1527-1529, 1544, 1480-1482, 1509-1512.) Individuals with borderline personality disorder characteristically form intense but very unstable relationships. Since they tend to perceive themselves and others as either totally bad or perfectly good, borderline individuals either idealize or devalue any person who occupies a significant place in their lives. Usually these perceptions do not last, and the person idealized one day can be seen as completely negative the next day. An extreme feeling of dislike for a part of the body in spite of a normal or near-normal appearance is the main characteristic of body dysmorphic disorder. The fear of being ugly or repulsive is not decreased by reassurance and compliments and has almost a delusional quality. The social, academic, and occupational lives of individuals with this disorder are greatly affected, due to avoidance of social interactions for fear of embarrassment, the time spent in checking mirrors and seeking surgical treatment or cosmetic remedies, and the chronic emotional distress that accompanies the disorder. Dissociative amnesia is characterized by the inability to remember important autobiographical information, usually of a traumatic or disturbing nature. The period of amnesia may last from hours to years. Occasionally the amnesia is limited to specific events, for example, memories involving an abusive individual. Often patients with dissociative amnesia are not aware of their memory loss, but come to treatment complaining of anxiety, depression, poor concentration, and blank spells. 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 experience severe anxiety that can reach the level of panic attack. Characteristically, phobic patients go to great lengths to avoid whatever they fear and this phobic avoidance can greatly interfere with functioning. Conversion disorder is characterized by the sudden appearance of often dramatic neurological symptoms that are not associated with the usual diagnostic signs and test results. Conversion disorder occurs in the context of a psychosocial stressor or an insoluble interpersonal or intrapsychic conflict. The psychological distress is not consciously acknowledged but it is expressed through a metaphorical body dysfunction. In the vignette example, the young woman who was torn between leaving home and becoming independent, found a temporary solution in her paralysis, which prevented her from leaving her home without having to consciously acknowledge her conflict.

3. A delusion can best be defined as a. A false belief that meets specific psychological needs b. A perceptual misrepresentation of a sensory image c. A perceptual representation of a sound or an image not actually present d. A viewpoint able to be changed when convincing evidence to the contrary is presented e. A dissociative reaction

3. The answer is a. (Sadock, 7/e, p 681.) A delusion is a false belief that is not 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 members of the person's own cultural or social group. False beliefs that can change in the face of strong evidence are called overvalued ideas.

34. The proportion of a population affected by a disorder at a given time

33-36. The answers are 33-e, 34-a, 35-b, 36-d. (Sadock, 7/e, pp 507, 2957.) All the terms listed are particularly significant for psychiatric epidemiology. The goal of secondary prevention is to address problems at an early stage to avoid future more severe problems. Prevalence refers to the portion of the population who has a specific disorder at a specific point in time, regardless of when the disorder started. The point in time may be a date (point prevalence), six months, or the entire life of an individual (life prevalence). The incidence of a disease refers to a rate that includes only those people who develop the disease during a specific period of time, usually one year. Primary prevention focuses on preventing a disorder from happening in the future and targets normal individuals at risk. Validity refers to the accuracy and verifiability of a study. It is usually demonstrated by agreement between two attempts to measure the same issue by different methods. Tertiary prevention defines those interventions aimed at reducing the disability or the duration of a disorder.

35. The proportion of a population that becomes affected by a disorder for the first time in a given period of time

33-36. The answers are 33-e, 34-a, 35-b, 36-d. (Sadock, 7/e, pp 507, 2957.) All the terms listed are particularly significant for psychiatric epidemiology. The goal of secondary prevention is to address problems at an early stage to avoid future more severe problems. Prevalence refers to the portion of the population who has a specific disorder at a specific point in time, regardless of when the disorder started. The point in time may be a date (point prevalence), six months, or the entire life of an individual (life prevalence). The incidence of a disease refers to a rate that includes only those people who develop the disease during a specific period of time, usually one year. Primary prevention focuses on preventing a disorder from happening in the future and targets normal individuals at risk. Validity refers to the accuracy and verifiability of a study. It is usually demonstrated by agreement between two attempts to measure the same issue by different methods. Tertiary prevention defines those interventions aimed at reducing the disability or the duration of a disorder.

36. Attempting to discover and eliminate the causes of mental illness

33-36. The answers are 33-e, 34-a, 35-b, 36-d. (Sadock, 7/e, pp 507, 2957.) All the terms listed are particularly significant for psychiatric epidemiology. The goal of secondary prevention is to address problems at an early stage to avoid future more severe problems. Prevalence refers to the portion of the population who has a specific disorder at a specific point in time, regardless of when the disorder started. The point in time may be a date (point prevalence), six months, or the entire life of an individual (life prevalence). The incidence of a disease refers to a rate that includes only those people who develop the disease during a specific period of time, usually one year. Primary prevention focuses on preventing a disorder from happening in the future and targets normal individuals at risk. Validity refers to the accuracy and verifiability of a study. It is usually demonstrated by agreement between two attempts to measure the same issue by different methods. Tertiary prevention defines those interventions aimed at reducing the disability or the duration of a disorder.

Items 33-36 Match each definition with the correct term. a. Prevalence b. Incidence c. Validity d. Primary prevention e. Secondary prevention f. Tertiary prevention 33. Early case finding and treatment to minimize duration of illness and to prevent permanent disability

33-36. The answers are 33-e, 34-a, 35-b, 36-d. (Sadock, 7/e, pp 507, 2957.) All the terms listed are particularly significant for psychiatric epidemiology. The goal of secondary prevention is to address problems at an early stage to avoid future more severe problems. Prevalence refers to the portion of the population who has a specific disorder at a specific point in time, regardless of when the disorder started. The point in time may be a date (point prevalence), six months, or the entire life of an individual (life prevalence). The incidence of a disease refers to a rate that includes only those people who develop the disease during a specific period of time, usually one year. Primary prevention focuses on preventing a disorder from happening in the future and targets normal individuals at risk. Validity refers to the accuracy and verifiability of a study. It is usually demonstrated by agreement between two attempts to measure the same issue by different methods. Tertiary prevention defines those interventions aimed at reducing the disability or the duration of a disorder.

38. An adolescent patient responds to the examiner's question with the same response he has given to a variety of previous questions.

37-40. The answers are 37-b, 38-f, 39-d, 40-g. (Sadock, 7/e, pp 678-688.) All the choices are elements of the mental status examination, an essential part of the psychiatric evaluation. Mood refers to the sustained feeling tone experienced internally by the patient. The patient may describe it, or the clinician may infer it from the patient's verbal and nonverbal behavior. In reporting their moods, patients may describe themselves as depressed, happy, angry, euphoric, or anxious. Affect is the feeling tone that accompanies the patient's verbalizations or immediate behaviors. The interviewer's observations of the patient's affect during the whole evaluation represent an important part of the mental status evaluation. In schizophrenia, affect is often inappropriate or flat. Blunting of affect is also common in brain disorders. Tangentiality, circumstantiality, and perseveration are forms of thought disorder. Tangentiality is present when the patient wanders and digresses to unnecessary details and the substance of the idea is not communicated. Circumstantiality is a disturbance in which the patient digresses into unnecessary details before communicating the central idea. In perseveration, the patient displays an inability to change the topic or gives the same response to different questions. In blocking, the patient suddenly stops talking, usually in the middle of a sentence, and cannot complete his or her thoughts. Disorientation is an impairment of awareness of time, place, or person. A disoriented patient usually does not know the date or where he or she is. Very rarely, a person is disoriented about his or her own identity, and, when this symptom is present, malingering may be suspected. Disorientation is a typical finding in cognitive disorders such as delirium and dementia but it is not usually found in primary psychotic disorders such as schizophrenia.

39. A 75-year-old man is asked a question and gives a long answer that incorporates a great deal of tedious and unnecessary details.

37-40. The answers are 37-b, 38-f, 39-d, 40-g. (Sadock, 7/e, pp 678-688.) All the choices are elements of the mental status examination, an essential part of the psychiatric evaluation. Mood refers to the sustained feeling tone experienced internally by the patient. The patient may describe it, or the clinician may infer it from the patient's verbal and nonverbal behavior. In reporting their moods, patients may describe themselves as depressed, happy, angry, euphoric, or anxious. Affect is the feeling tone that accompanies the patient's verbalizations or immediate behaviors. The interviewer's observations of the patient's affect during the whole evaluation represent an important part of the mental status evaluation. In schizophrenia, affect is often inappropriate or flat. Blunting of affect is also common in brain disorders. Tangentiality, circumstantiality, and perseveration are forms of thought disorder. Tangentiality is present when the patient wanders and digresses to unnecessary details and the substance of the idea is not communicated. Circumstantiality is a disturbance in which the patient digresses into unnecessary details before communicating the central idea. In perseveration, the patient displays an inability to change the topic or gives the same response to different questions. In blocking, the patient suddenly stops talking, usually in the middle of a sentence, and cannot complete his or her thoughts. Disorientation is an impairment of awareness of time, place, or person. A disoriented patient usually does not know the date or where he or she is. Very rarely, a person is disoriented about his or her own identity, and, when this symptom is present, malingering may be suspected. Disorientation is a typical finding in cognitive disorders such as delirium and dementia but it is not usually found in primary psychotic disorders such as schizophrenia.

40. A 45-year-old male with a chronic psychiatric disorder suddenly seems to forget what he wants to say, in the middle of a sentence.

37-40. The answers are 37-b, 38-f, 39-d, 40-g. (Sadock, 7/e, pp 678-688.) All the choices are elements of the mental status examination, an essential part of the psychiatric evaluation. Mood refers to the sustained feeling tone experienced internally by the patient. The patient may describe it, or the clinician may infer it from the patient's verbal and nonverbal behavior. In reporting their moods, patients may describe themselves as depressed, happy, angry, euphoric, or anxious. Affect is the feeling tone that accompanies the patient's verbalizations or immediate behaviors. The interviewer's observations of the patient's affect during the whole evaluation represent an important part of the mental status evaluation. In schizophrenia, affect is often inappropriate or flat. Blunting of affect is also common in brain disorders. Tangentiality, circumstantiality, and perseveration are forms of thought disorder. Tangentiality is present when the patient wanders and digresses to unnecessary details and the substance of the idea is not communicated. Circumstantiality is a disturbance in which the patient digresses into unnecessary details before communicating the central idea. In perseveration, the patient displays an inability to change the topic or gives the same response to different questions. In blocking, the patient suddenly stops talking, usually in the middle of a sentence, and cannot complete his or her thoughts. Disorientation is an impairment of awareness of time, place, or person. A disoriented patient usually does not know the date or where he or she is. Very rarely, a person is disoriented about his or her own identity, and, when this symptom is present, malingering may be suspected. Disorientation is a typical finding in cognitive disorders such as delirium and dementia but it is not usually found in primary psychotic disorders such as schizophrenia.

Items 37-40 Match each patient with the correct symptom. a. Mood disturbance b. Affect disturbance c. Disorientation d. Circumstantiality e. Tangentiality f. Perseveration g. Blocking 37. A 29-year-old patient describes witnessing a terrible plane crash that involved many victims and smiles and chuckles while telling the story.

37-40. The answers are 37-b, 38-f, 39-d, 40-g. (Sadock, 7/e, pp 678-688.) All the choices are elements of the mental status examination, an essential part of the psychiatric evaluation. Mood refers to the sustained feeling tone experienced internally by the patient. The patient may describe it, or the clinician may infer it from the patient's verbal and nonverbal behavior. In reporting their moods, patients may describe themselves as depressed, happy, angry, euphoric, or anxious. Affect is the feeling tone that accompanies the patient's verbalizations or immediate behaviors. The interviewer's observations of the patient's affect during the whole evaluation represent an important part of the mental status evaluation. In schizophrenia, affect is often inappropriate or flat. Blunting of affect is also common in brain disorders. Tangentiality, circumstantiality, and perseveration are forms of thought disorder. Tangentiality is present when the patient wanders and digresses to unnecessary details and the substance of the idea is not communicated. Circumstantiality is a disturbance in which the patient digresses into unnecessary details before communicating the central idea. In perseveration, the patient displays an inability to change the topic or gives the same response to different questions. In blocking, the patient suddenly stops talking, usually in the middle of a sentence, and cannot complete his or her thoughts. Disorientation is an impairment of awareness of time, place, or person. A disoriented patient usually does not know the date or where he or she is. Very rarely, a person is disoriented about his or her own identity, and, when this symptom is present, malingering may be suspected. Disorientation is a typical finding in cognitive disorders such as delirium and dementia but it is not usually found in primary psychotic disorders such as schizophrenia.

4. In psychiatry, the electroencephalogram (EEG) can be helpful in the diagnosis of a. Intermittent explosive disorder b. Panic disorder c. Bipolar disorder d. Social phobia e. Frotteurism

4. The answer is a. (Hales, 3/e, pp 292-293, 776, 1416.) Intermittent explosive disorder is characterized by discrete episodes of aggression and destructiveness that are out of proportion with the precipitant stressor. EEG may help to clarify the diagnosis, since 55% of patients have EEG abnor-malities as well as learning disabilities, a history of attention deficit hyperactivity disorder (ADHD), and abnormal neuropsychological test results. EEG may also be helpful in diagnosing the rare cases of violence that occur during or after a complex partial seizure and specific types of delirium and dementing disorders (for example, Creutzfeldt-Jakob dementia and delirium induced by hepatic encephalopathy are both associated with very specific EEG patterns). Frotteurism (a paraphilia), panic disorder, social phobia, and bipolar disorder are not associated with EEG changes.

42. A patient in a state hospital is convinced that she has caused the earthquake that flattened her hometown because she was wishing for a reason not to go visit her parents.

41-44. The answers are 41-c, 42-a, 43-b, 44-g. (Sadock, 7/e, pp 678-688.) Looseness of associations refers to a string of thoughts that are disconnected in content and are illogical in their sequence. Severe cases are referred to as "word salad." This kind of thought disorder is seen in schizophrenia and acute mania. Magical thinking is normal in young children and is present in people affected by a variety of psychiatric conditions. Magical thinking is the belief that specific thoughts, words, or gestures can directly lead to the fulfillment of wishes. Such thinking is due to an unrealistic understanding of the relationship between cause and effect. Obsessions are recurrent thoughts, ideas, or impulses that cannot be eliminated from consciousness by reasoning or desire to stop them. Obsessions are characteristic symptoms of obsessive-compulsive disorder and are usually ego-dystonic. Nihilism refers to a delusional belief that oneself, or part of oneself, has ceased to exist. Echolalia refers to the parrotlike repeating of the words of another person. Depersonalization is the sense of being outside one's own body, observing oneself as an actor engaged in a role. A similar symptom, derealization, is the feelings that the person's surroundings are not real. These symptoms represent the main disturbance in depersonalization disorders and are seen in several other psychiatric disorders including schizophrenia, personality disorders, anxiety disorders, and temporal lobe epilepsy. A compulsion is a repetitive behavior or a ritual that is performed to avoid future unpleasant events. Compulsions have an urgent quality and resisting them generates anxiety.

43. A 24-year-old man confides to his physician that for several weeks he has not been able to stop worrying about germs. As much as he tries, he cannot avoid the thought that everything he touches is contaminated.

41-44. The answers are 41-c, 42-a, 43-b, 44-g. (Sadock, 7/e, pp 678-688.) Looseness of associations refers to a string of thoughts that are disconnected in content and are illogical in their sequence. Severe cases are referred to as "word salad." This kind of thought disorder is seen in schizophrenia and acute mania. Magical thinking is normal in young children and is present in people affected by a variety of psychiatric conditions. Magical thinking is the belief that specific thoughts, words, or gestures can directly lead to the fulfillment of wishes. Such thinking is due to an unrealistic understanding of the relationship between cause and effect. Obsessions are recurrent thoughts, ideas, or impulses that cannot be eliminated from consciousness by reasoning or desire to stop them. Obsessions are characteristic symptoms of obsessive-compulsive disorder and are usually ego-dystonic. Nihilism refers to a delusional belief that oneself, or part of oneself, has ceased to exist. Echolalia refers to the parrotlike repeating of the words of another person. Depersonalization is the sense of being outside one's own body, observing oneself as an actor engaged in a role. A similar symptom, derealization, is the feelings that the person's surroundings are not real. These symptoms represent the main disturbance in depersonalization disorders and are seen in several other psychiatric disorders including schizophrenia, personality disorders, anxiety disorders, and temporal lobe epilepsy. A compulsion is a repetitive behavior or a ritual that is performed to avoid future unpleasant events. Compulsions have an urgent quality and resisting them generates anxiety.

44. A patient insists that the whole world has ceased to exist.

41-44. The answers are 41-c, 42-a, 43-b, 44-g. (Sadock, 7/e, pp 678-688.) Looseness of associations refers to a string of thoughts that are disconnected in content and are illogical in their sequence. Severe cases are referred to as "word salad." This kind of thought disorder is seen in schizophrenia and acute mania. Magical thinking is normal in young children and is present in people affected by a variety of psychiatric conditions. Magical thinking is the belief that specific thoughts, words, or gestures can directly lead to the fulfillment of wishes. Such thinking is due to an unrealistic understanding of the relationship between cause and effect. Obsessions are recurrent thoughts, ideas, or impulses that cannot be eliminated from consciousness by reasoning or desire to stop them. Obsessions are characteristic symptoms of obsessive-compulsive disorder and are usually ego-dystonic. Nihilism refers to a delusional belief that oneself, or part of oneself, has ceased to exist. Echolalia refers to the parrotlike repeating of the words of another person. Depersonalization is the sense of being outside one's own body, observing oneself as an actor engaged in a role. A similar symptom, derealization, is the feelings that the person's surroundings are not real. These symptoms represent the main disturbance in depersonalization disorders and are seen in several other psychiatric disorders including schizophrenia, personality disorders, anxiety disorders, and temporal lobe epilepsy. A compulsion is a repetitive behavior or a ritual that is performed to avoid future unpleasant events. Compulsions have an urgent quality and resisting them generates anxiety.

Items 41-44 Match each definition with the correct term. a. Magical thinking b. Obsession c. Looseness of associations d. Echolalia e. Depersonalization f. Compulsion g. Nihilism h. Derealization 41. When asked where he lives, a patient replies with, "House, mouse, you will pay for that! I know who you are. . . . Come, come to me, little bird, little flower. . . . Stop it right now!"

41-44. The answers are 41-c, 42-a, 43-b, 44-g. (Sadock, 7/e, pp 678-688.) Looseness of associations refers to a string of thoughts that are disconnected in content and are illogical in their sequence. Severe cases are referred to as "word salad." This kind of thought disorder is seen in schizophrenia and acute mania. Magical thinking is normal in young children and is present in people affected by a variety of psychiatric conditions. Magical thinking is the belief that specific thoughts, words, or gestures can directly lead to the fulfillment of wishes. Such thinking is due to an unrealistic understanding of the relationship between cause and effect. Obsessions are recurrent thoughts, ideas, or impulses that cannot be eliminated from consciousness by reasoning or desire to stop them. Obsessions are characteristic symptoms of obsessive-compulsive disorder and are usually ego-dystonic. Nihilism refers to a delusional belief that oneself, or part of oneself, has ceased to exist. Echolalia refers to the parrotlike repeating of the words of another person. Depersonalization is the sense of being outside one's own body, observing oneself as an actor engaged in a role. A similar symptom, derealization, is the feelings that the person's surroundings are not real. These symptoms represent the main disturbance in depersonalization disorders and are seen in several other psychiatric disorders including schizophrenia, personality disorders, anxiety disorders, and temporal lobe epilepsy. A compulsion is a repetitive behavior or a ritual that is performed to avoid future unpleasant events. Compulsions have an urgent quality and resisting them generates anxiety.

46. A 40-year-old unmarried accountant who just underwent surgery has managed to irritate the whole medical team because he is suspicious and untrusting. He interprets every physical discomfort as the proof that "something went wrong and nobody is telling me." He has threatened multiple times to sue the hospital. His sister tells the resident who is conducting the evaluation that "My brother has been like that all his life."

45-47. The answers are 45-c, 46-b, 47-e. (DSM-IV, pp 25-31.) Medical disorders etiologically related to mental disorders or symptoms are coded on Axis III. In this case, pheochromocytoma is recorded on Axis III because the episodic changes in the patient's mental status are a direct result of abnormally high levels of circulating catecholamines. Personality disorders are coded on Axis II. The lifelong nature of the patient's symptoms and the fact that they are based on actual events and perceptions that are then misinterpreted are evidence arguing in favor of a diagnosis of personality disorder, more specifically, paranoid personality disorder. On Axis V, the interviewer records his or her impression of the patient's general level of functioning and whether this represents a change from baseline. The depressed man in the vignette clearly was functioning at a much lower level than baseline. Axis IV is used to code the nature and the severity of events that preceded and precipitated the individual's mental disorders or symptom. Axis I is used to record all psychiatric disorders and conditions except for personality disorders which are recorded on Axis II.

47. The change in level of function of a 46-year-old college professor, who, during the past six weeks, has not been able to go to work and spends his days in front of the TV, unwashed and unshaven, due to severe depression.

45-47. The answers are 45-c, 46-b, 47-e. (DSM-IV, pp 25-31.) Medical disorders etiologically related to mental disorders or symptoms are coded on Axis III. In this case, pheochromocytoma is recorded on Axis III because the episodic changes in the patient's mental status are a direct result of abnormally high levels of circulating catecholamines. Personality disorders are coded on Axis II. The lifelong nature of the patient's symptoms and the fact that they are based on actual events and perceptions that are then misinterpreted are evidence arguing in favor of a diagnosis of personality disorder, more specifically, paranoid personality disorder. On Axis V, the interviewer records his or her impression of the patient's general level of functioning and whether this represents a change from baseline. The depressed man in the vignette clearly was functioning at a much lower level than baseline. Axis IV is used to code the nature and the severity of events that preceded and precipitated the individual's mental disorders or symptom. Axis I is used to record all psychiatric disorders and conditions except for personality disorders which are recorded on Axis II.

Items 45-47 Match each pertinent clinical information with the axis where it should be recorded. a. I b. II c. III d. IV e. V 45. A patient suddenly develops episodes of acute, intense anxiety, accompanied by increased blood pressure, palpitations, and sweating. Three months later he is discovered to have a pheochromocytoma. On which axis is the pheochromocytoma recorded?

45-47. The answers are 45-c, 46-b, 47-e. (DSM-IV, pp 25-31.) Medical disorders etiologically related to mental disorders or symptoms are coded on Axis III. In this case, pheochromocytoma is recorded on Axis III because the episodic changes in the patient's mental status are a direct result of abnormally high levels of circulating catecholamines. Personality disorders are coded on Axis II. The lifelong nature of the patient's symptoms and the fact that they are based on actual events and perceptions that are then misinterpreted are evidence arguing in favor of a diagnosis of personality disorder, more specifically, paranoid personality disorder. On Axis V, the interviewer records his or her impression of the patient's general level of functioning and whether this represents a change from baseline. The depressed man in the vignette clearly was functioning at a much lower level than baseline. Axis IV is used to code the nature and the severity of events that preceded and precipitated the individual's mental disorders or symptom. Axis I is used to record all psychiatric disorders and conditions except for personality disorders which are recorded on Axis II.

48. A mother promptly responds to her infant's distress cries. Well attuned to his cues, she has no difficulty identifying the cause of the distress and she promptly attends to it. Shortly after, the infant smiles contentedly and the mother smiles back at him. Later in the day, the child spends two hours with a babysitter while the mother goes shopping. On his mother's return, he greets her with great displays of pleasure and outstretched arms. According to Bowlby's theory, this child's behavior is characteristic of a. Insecure attachment b. Oral phase c. Secure attachment d. Infantile neurosis e. Easy temperament

48. The answer is c. (Lewis, 2/e, pp 126-128.) John Bowlby, a psychiatrist who published most of his work between 1970 and 1990, is known for his work on infant attachment. He theorized that infants are predisposed from birth to form attachments with their primary caregivers and that the quality of the attachment depends on their caregivers' response to them. When the caregiver is attentive and responsive to the infant's physical and emotional needs, secure attachment is the norm. Insecure attachment occurs when the caregiver is unresponsive, neglectful, or inconsistent. The quality of attachment has been empirically studied through the "Strange Situation Procedure," which focuses on the infant's reaction when he or she is reunited with the parent after a brief separation. Children with secure attachment greet their parents with relatively unequivocal pleasure (like the child in the vignette). Children with insecure attachment manifest a variety of deviant behaviors, stemming from their lack of confidence that the parent will be helpful and available. Behaviors associated with insecure attachment include avoiding and ignoring the parent, anger and aggression, extreme passivity, clingy, whiny behavior, or a combination of all these. Basic trust also describes a stage of development characterized by the security that caregivers will be helpful and available, on the basis of the quality of the child's previous interactions. This phase is the first of Erickson's eight psychosocial developmental stages and does not belong to Bowlby's theories. The oral phase is the first of the five psychosexual developmental stages theorized by Freud. The term infantile neurosis describes, in Freudian psychoanalytic theory of development, the appearance of regressive behaviors and fears during the oedipal period as an attempt to withdraw from the conflicts caused by the intensity of the oedipal longing for the parent of the opposite sex. Temperament refers to an inherited set of personality traits such as adaptability, intensity of reaction, threshold of re-sponsiveness, and so forth. A difficult temperament may affect attachment, because it makes parenting more frustrating and can interfere with the parent's ability to relate to the child positively.

49. A 10-year-old child is very interested in school and is proud of his athletic achievements. Peers are very important to him but he also gets along with his parents. Under stress he tends to become overfocused on details and slightly obsessive. At what stage is he, according to Sigmund Freud's theory of psychosexual development? a. Concrete operational b. Latency c. Industry versus inferiority d. Object constancy e. Separation-individuation

49. The answer is b. (Sadock, 7/e, pp 574-579; Lewis, 2/e, pp 162-163.) According to Freud's psychosexual developmental theory, children between the age of 5 and 12 or 13 enter into a stage where sexual drives become secondary (hence the term latency) while other developmental tasks, such as peer relations and school achievements, become more important. Children at this stage have a strong sense of "right and wrong" and like to play "by the rules." Usually there is a tendency toward orderliness, attention to details, and collecting things. Under stress, these traits may become exaggerated. The stormy parent-child relationship that characterizes adolescence is yet to come. The other stages of Freud's psychosexual development theory are discussed in detail in the answers to questions 88-90. Industry versus inferiority and concrete operational stage apply to the same age period, respectively, in Erickson's psychosocial developmental theory and Piaget's theory of cognitive development. Separation and individuation and object constancy refer totwo stages of infant development according to Margaret Mahler's theory

5. A 7-year-old girl hospitalized for tonsillectomy awakens in the middle of the night and cries out that a "big bear" is in her room. She is relieved when a nurse turns on the light revealing that the bear was an armchair covered with a coat. This experience is an example of a. A delusion b. A hallucination c. An illusion d. A projection e. A dissociative reaction

5. The answer is c. (Hales, 3/e, p 218.) An illusion is a misinterpretation of a real sensory stimulus. Illusions are common even in individuals free of psychiatric disorders and their content often is affected by the person's state of mind, wishes, and fears. For example, the child described in the vignette probably took the armchair for a bear because she was frightened to be in the hospital. Systemic diseases associated with confusion (certain types of poisoning, for instance) also can produce misperceptions of sensory images by interfering with proper functioning of the brain.

51. Margaret Mahler is best known for her theories on a. Psychosocial development b. Psychosexual maturation c. Cognitive development d. Moral development e. Separation-individuation

50-51. The answers are 50-d, 51-e. (Sadock, 7/e, p 593.) Margaret Mahler made her contributions to the psychoanalytic movement called ego psychology through her theories on early infantile development. On the basis of her observations of normal and pathological mother-child interactions, Margaret Mahler identified three developmental phases of infant development. The "autistic phase" occurs during the first two months of life, when the child spends a good part of his or her day asleep and has little interest in interpersonal relationships. From 2 to 6 months, the child enters "symbiosis," a stage characterized by psychological fusion or lack of differentiation between mother and child. Margaret Mahler is best known, though, for her research on the third phase, called "separation-individuation." This phase occurs between 6 and 36 months during which the child develops a concept of him- or herself as different and separated from the mother. During the same period, the infant gradually develops an internal, stable representation (introjection) of the mother, which includes both her positive and negative aspects. The separation-individuation phase is subdivided into four subphases: "differentiation," between 6 and 10 months, refers to the child's ini-tial awareness that the mother is a separate person; "practicing," between 10 and 16 months, is characterized by the child's enthusiastic exploration of the environment, thanks to his or her newly acquired mobility; "rapprochement," between 16 and 24 months, refers to a period characterized by a need to know where the mother is and frequent "refueling," triggered by the child's new awareness that independence also makes him or her vulnerable; the fourth subphase, "object constancy," takes place during the third year of life and refers to the integration of the good and bad aspects of both the internalized images of the mother and the child's self. According to ego psychology theory, object constancy is necessary for the later development of stable and mature interpersonal relationships. The "depressive position" refers, in Melanie Klein's theory of infantile psychological development, to the period during which the infant realizes that the "bad mother" who frustrates the child's wishes and the "good mother" who nurtures him or her are the same person and the child worries that rage at the "bad mother" may also destroy the good. Autonomy versus shame and doubt is one of the eight stages of psychosocial development described by Erikson and corresponds, in age, to the period of Mahler's separation-individuation.

Items 50-51 A 20-month-old boy loves running around and exploring the environment but every few minutes keeps returning to his mother, to "check on her" and solicit a quick hug. 50. Margaret Mahler calls this normal stage of early childhood development a. Depressive position b. Secure attachment c. Insecure attachment d. Rapprochement e. Autonomy versus shame and doubt

50-51. The answers are 50-d, 51-e. (Sadock, 7/e, p 593.) Margaret Mahler made her contributions to the psychoanalytic movement called ego psychology through her theories on early infantile development. On the basis of her observations of normal and pathological mother-child interactions, Margaret Mahler identified three developmental phases of infant development. The "autistic phase" occurs during the first two months of life, when the child spends a good part of his or her day asleep and has little interest in interpersonal relationships. From 2 to 6 months, the child enters "symbiosis," a stage characterized by psychological fusion or lack of differentiation between mother and child. Margaret Mahler is best known, though, for her research on the third phase, called "separation-individuation." This phase occurs between 6 and 36 months during which the child develops a concept of him- or herself as different and separated from the mother. During the same period, the infant gradually develops an internal, stable representation (introjection) of the mother, which includes both her positive and negative aspects. The separation-individuation phase is subdivided into four subphases: "differentiation," between 6 and 10 months, refers to the child's ini-tial awareness that the mother is a separate person; "practicing," between 10 and 16 months, is characterized by the child's enthusiastic exploration of the environment, thanks to his or her newly acquired mobility; "rapprochement," between 16 and 24 months, refers to a period characterized by a need to know where the mother is and frequent "refueling," triggered by the child's new awareness that independence also makes him or her vulnerable; the fourth subphase, "object constancy," takes place during the third year of life and refers to the integration of the good and bad aspects of both the internalized images of the mother and the child's self. According to ego psychology theory, object constancy is necessary for the later development of stable and mature interpersonal relationships. The "depressive position" refers, in Melanie Klein's theory of infantile psychological development, to the period during which the infant realizes that the "bad mother" who frustrates the child's wishes and the "good mother" who nurtures him or her are the same person and the child worries that rage at the "bad mother" may also destroy the good. Autonomy versus shame and doubt is one of the eight stages of psychosocial development described by Erikson and corresponds, in age, to the period of Mahler's separation-individuation.

52. Which of the following theorists primarily focused on the importance of early interpersonal experiences in the development of a cohesive and stable sense of self? a. Piaget b. Erikson c. Freud d. Klein e. Kohut

52. The answer is e. (Sadock, 7/e, pp 593-594.) Heinz Kohut is one of the founders of one of the three modern psychoanalytic schools, Self-Psychology. He theorized that in order to develop a coherent, stable, and resilient sense of self, the child needs positive, empathic, and consistent responses from his or her caretakers. The need for positive and validating responses from the environment is not limited to infancy or childhood, since even adults need a certain amount of positive feedback from others to maintain positive selfesteem. Individuals whose sense of self remains fragile and unstable due to faulty early parenting need constant and excessive reassurance from others and become emotionally and behaviorally dysfunctional under stress. Freud's theories relate to the child's psychosexual development and to the part unconscious conflicts play in psychopathology. Erik Erikson is known for his theory of psychosocial development throughout the life cycle. Melanie Klein is an proponent of the object relations school of psychoanalysis and wrote extensively on early stages of infant-mother interaction. Piaget is known for his work on cognitive development.

53. Piaget is best known for his theories and investigations of a. Cognitive development b. Psychosexual development c. Psychosocial development d. Interpersonal development e. Attachment theories

53. The answer is a. (Lewis, 2/e, pp 135-138.) Jean Piaget, a Swiss psychologist, made extensive empirical observations of the way children rea-son and make sense of their environment at various ages. His theory of the development of cognitive thinking in children encompasses four stages: sensorimotor (18-24 months), pre-operational (2 to 5-7 years), concrete operational (6-11 years), and formal operational (11 years to adulthood). Each stage is characterized by specific ways of approaching and processing information.

55. This concept was introduced by a. Piaget b. Klein c. Kohut d. Anna Freud e. Winnicott

54-55. The answers are 54-c, 55-e. (Sadock, 7/e, pp 389-390.) D. W. Winnicott, a British pediatrician with a keen interest in psychoanalysis, focused his attention on the early mother-child relationship. In his view, the child is able to develop a separate and stable identity only if the child's needs are met by his or her mother's empathic anticipation. Winnicott calls the positive environment so created by the mother the "holding environment." According to Winnicott, mothers do not have to be perfect in order to fulfill their roles, but they have to be "good enough" to provide the infant with a sufficient amount of comfort and constancy. Winnicott also coined the term "transitional object," usually a toy or a blanket, that represents a comforting substitute for the primary caregiver. Thanks to a transitional object, the child can tolerate separation from the mother without excessive anxiety.

tems 54-55 A 2-year-old child carries around an old, tattered blanket wherever he goes. When he is sad or upset, he calms himself down by hugging and stroking his blanket. He also needs it to settle down before sleep. 54. For this child, the old blanket is a. A fetish b. An obsession c. A transitional object d. A phallic substitute e. An imaginary friend

54-55. The answers are 54-c, 55-e. (Sadock, 7/e, pp 389-390.) D. W. Winnicott, a British pediatrician with a keen interest in psychoanalysis, focused his attention on the early mother-child relationship. In his view, the child is able to develop a separate and stable identity only if the child's needs are met by his or her mother's empathic anticipation. Winnicott calls the positive environment so created by the mother the "holding environment." According to Winnicott, mothers do not have to be perfect in order to fulfill their roles, but they have to be "good enough" to provide the infant with a sufficient amount of comfort and constancy. Winnicott also coined the term "transitional object," usually a toy or a blanket, that represents a comforting substitute for the primary caregiver. Thanks to a transitional object, the child can tolerate separation from the mother without excessive anxiety.

57. This concept is encountered in theories of a. Psychosexual development b. Moral development c. Cognitive development d. Social development e. Autism

56-57. The answers are 56-c, 57-c. (Lewis, 2/e, pp 136-137.) Egocentrism refers to young children's inability to see things from another point of view. Egocentrism is described by Jean Piaget as part of the pre-operational stage of cognitive development, which occurs between 2 and 5-7 years of age

Items 56-57 A 3-year-old boy stands on one side of a large sculpture and is asked to describe what he sees. When he is asked to describe what a person on the other side of the sculpture sees, the child answers that the other person sees just what he does. 56. This kind of logic, normal in early childhood, is called a. Autistic thinking b. Concrete thinking c. Egocentrism d. Primary process e. Object constancy

56-57. The answers are 56-c, 57-c. (Lewis, 2/e, pp 136-137.) Egocentrism refers to young children's inability to see things from another point of view. Egocentrism is described by Jean Piaget as part of the pre-operational stage of cognitive development, which occurs between 2 and 5-7 years of age

58. A 70-year-old woman has had three face-lifts and never leaves the house without makeup. She forbids her grandchildren to address her as "grandmother" and lies about her age. Which stage of development, according to Erikson, is she having difficulty mastering? a. Integrity versus despair stage b. Egocentric stage c. Generative versus stagnation stage d. Narcissistic stage e. Pragmatic development stage

58. The answer is a. (Sadock, 7/e, pp 610-612.) Erik Erikson's theory of psychosocial development centers around eight stages of ego development that take place during the life cycle. Each stage represent a turning point in which physical, cognitive, social, and emotional changes trigger an internal crisis, whose resolution results either in psychological growth or regression. Integrity versus despair is the last of the Eriksonian stages and takes place between age 60 and death. If this stage is successfully mastered, the individual arrives at a peaceful acceptance of his or her mortality without losing interest in life. The woman in the vignette, with her futile attempts to deny the passage of time, clearly has difficulties in this developmental stage. The other developmental stages in Erikson's theory are (1) trust versus mistrust, which occurs between birth and 18 months of age. During this period, if the infant's needs are promptly and empathically met, the infant learns to see the world as a benign and nurturing place; (2) autonomy versus shame and doubt, which occurs between 18 months and 3 years and corresponds to Freud's anal stage and Mahler's separation-individuation stage. During this period, if allowed to experiment with his or her new motility and curiosity about the environment, and at the same time he or she is provided enough nurturance, the child acquires a healthy self-esteem and sense of autonomy; (3) initiative versus guilt, which occurs between 3 and 5 years of age, when the child expands his or her explorations of the outside world and has omnipotent fantasies about his or her own powers. During this stage, in a good psychosocial environment, the child develops a capacity of self-reflection, manifested by feeling guilty when rules are broken, without losing enthusiasm for independent exploration; (4) industry versus inferiority, which occurs between 5 and 13 years of age, is equivalent to Freud's latency. The child's psychological growth depends on his or her opportunity to learn new skills and to take pride in accomplishments; (5) identity versus role confusion occurs during adolescence, approximately between 13 and 21 years. If this stage is mastered successfully, the young individual enters adulthood with a solid sense of identity, knowing his or her role in society; (6) intimacy versus isolation refers to the adult developmental task of learning to make and honor commitments to other people and to ideas; (7) generativity versus stagnation, which occurs between 40 and 60 years of age. According to Erikson, the focus of the individual starts shifting from personal accomplishments and needs to a concern for the rest of society and the nurturing of the next generation; (8) integrity versus despair, which occurs from approximately age 60 to the time of death. The main developmental task is accepting life as it is, without desire to change the past or change others. When this stage is mastered, the individual acquires the wisdom necessary to face the inevitability of death with equanimity and without dread.

59. An 18-month-old girl predictably takes a nap every afternoon, is easily soothed if she is ill or she hurts herself, and always smiles at strangers. This is an example of a child with an "easy temperament." Choose the most appropriate statement: a. Temperament is biologically determined b. Temperamental traits are unchangeable throughout life c. Poor parenting is always the cause of difficult temperament d. Slow-to-warm-up children cannot be taught to become less fearful of changes e. Temperament is a synonym for personality

59. The answer is a. (Lewis, 2/e, pp 170-180.) Temperament refers to an inherited set of traits that are present at birth and are rather stable during the first years of life, although they can often be modified by interpersonal and other experiences later on. Three temperamental styles are described, on the basis of variations in several categories such as rhythmicity, adaptability, intensity of reaction, quality of mood, attention span, and so forth. Children with an easy temperament, approximately 40% of the population, are adaptable to changes, have regular feeding and sleeping rhythms, have a predominantly pleasant mood, and have responses of mild or mod-erate intensity. Children with a difficult temperament, on the contrary, adapt slowly to change, have irregular biological rhythms, and have frequent high-intensity negative emotional displays. Children with a slowto- warm-up temperament, usually labeled as "shy," tend to withdraw from new experiences and have negative emotional responses with low intensity. Although quality of parenting does not cause a specific temperament, temperament can affect parenting styles. For example, children with difficult temperaments are more likely to elicit negative responses and, in extreme cases, abusive behaviors from caregivers.

3-year-old girl is clumsy and poorly coordinated. Her language is impaired and she wrings her hands constantly. Her head is small in comparison with the rest of her body. 6. The most likely diagnosis is a. Asperger's disorder b. Down syndrome c. Congenital rubella d. Rett's disorder e. Childhood disintegrative disorder

6-7. The answers are 6-d, 7-a. (DSM IV, p 71.) Patients diagnosed with Rett's disorder have normal prenatal and postnatal development but, between ages 5 to 30 months, they begin to lose previously acquired purposeful hand skills and develop stereotyped hand movements (hand wringing or hand washing) and poorly coordinated gait or trunk movements. These patients have severe to profound mental retardation and have severe receptive and expressive language deficits. They also lose all the interest they had in social interaction. Characteristically, head circumference is normal at birth, but between 5 months and 4 years of age the rate of the head growth decelerates rapidly. Rett's disorder has been described only in females and is very rare. Rett's disorder is one of the pervasive developmental disorders, with autistic disorder, Asperger's disorder, and childhood disintegrative disorder (a catastrophic deterioration of cognitive functions, social awareness, and adaptive behavior that starts after two years of normal development).

7. In the DSM-IV this disorder is listed under a. Pervasive developmental disorders b. Mental retardation c. Psychotic disorders d. Communication disorders e. Learning disorders

6-7. The answers are 6-d, 7-a. (DSM IV, p 71.) Patients diagnosed with Rett's disorder have normal prenatal and postnatal development but, between ages 5 to 30 months, they begin to lose previously acquired purposeful hand skills and develop stereotyped hand movements (hand wringing or hand washing) and poorly coordinated gait or trunk movements. These patients have severe to profound mental retardation and have severe receptive and expressive language deficits. They also lose all the interest they had in social interaction. Characteristically, head circumference is normal at birth, but between 5 months and 4 years of age the rate of the head growth decelerates rapidly. Rett's disorder has been described only in females and is very rare. Rett's disorder is one of the pervasive developmental disorders, with autistic disorder, Asperger's disorder, and childhood disintegrative disorder (a catastrophic deterioration of cognitive functions, social awareness, and adaptive behavior that starts after two years of normal development).

60. A young woman with a history of childhood neglect feels suddenly worthless and devastated when her supervisor makes a mildly negative comment about her work performance. According to Heinz Kohut's theory, her hypersensitivity to criticism is due to a. An unresolved oedipal complex due to her parents' divorce when the patient was 4 years old b. An inability to make stable commitment to others c. A punitive superego due to harsh and critical parents d. A fragmented sense of self due to an empathic failure from her parents e. Autistic traits

60. The answer is d. (Sadock, 7/e, pp 593-594.) According to Kohut, emphatic validation from caregivers is essential for the development of an integrated sense of self. People who have been neglected or abused or have received suboptimal parenting grow up with a very fragile sense of self and an easily shaken self-esteem. These individuals, like the woman in the vignette, when exposed to criticism or rejection, cannot maintain a positive image of themselves and experience a devastating sense of worthlessness and fragmentation.

61. A young woman, who during childhood was severely punished for showing anger, never loses her temper, even when anger would be completely appropriate. According to Jung, for this person, anger is part of her a. Shadow b. Archetype c. Unconscious d. Aggressive drive e. Animus

61. The answer is a. (Sadock, 7/e, p 622.) Carl Jung, a contemporary and disciple of Freud, who later moved away from classical Freudian psychoanalytic theory, defined the "shadow" as a part of the unconscious personality that contains all the traits and qualities that are unacceptable to an individual. For example, for a generous person, avarice is a shadow quality. On the contrary, a person that takes pride in frugality, generosity is part of the shadow. Archetypes, also part of Jungian psychology, are universal, symbolic images that recur in dreams and are part of the "collective unconscious." The animus, according to Jung, contains the masculine elements of a woman's personality, while the anima represents the female traits of a man's personality.

62. A 23-year-old woman constantly goes to great lengths to avoid being criticized, even when this requires going against her own beliefs and wishes. Although she is good looking and successful, she is tormented by doubts about her abilities and her physical appearance. According to Kohut's theories, her difficulties are most likely due to a. An overly harsh toilet training when she was 21⁄2 b. Overindulgent parents who freely dispensed praise c. A lack of self-esteem, which causes a constant need for validation d. An overly punitive superego e. A shy temperament

62. The answer is d. (Sadock, 7/e, pp 603-604.) According to Kohut's theories, individuals who require other people's constant validation to maintain a marginal self-esteem have suffered a "narcissistic injury" during childhood due to parental neglect or lack of empathy.

63. A 5-year-old boy is presented with two stories and asked which character has committed the worse infraction and should receive the more severe consequence. In the first story, a little boy breaks one cup when he climbs over the counter to reach a cake placed on top of the refrigerator. In the second story, a little girl breaks five cups and one plate by accident when she trips over the cat while she is helping her mother in the kitchen. The boy's answer would probably be a. The little boy, because he broke the cup while he was trying to steal the cake, a forbidden act b. The little girl, because she did more damage c. The boy and the girl are equally guilty because both of them broke something and breaking things is wrong d. The boy and the girl have done nothing wrong, because they did not intend to break anything e. The boy has committed the worse infraction, but only if he is found out

63. The answer is b. (Sadock, 7/e, pp 2547-2549.) According to the theories of moral development of Piaget and Kohlberg, for children between 4 Human Behavior:Theories of Personality and Development Answers 35 and 7 years of age, the consequence of an action determines its intrinsic moral value independently from the intention and circumstances. At this age, children see rules as permanent and unchangeable, and punishment is dispensed by figures of authority without a possibility of appeal. Older children (7 to 14) make moral judgments taking into account the intent of the doer and the situational circumstances.

64. In psychoanalytic theory, the superego a. Is totally unconscious b. Is a defense mechanism c. Functions to reduce guilt and shame d. Contains the sexual and aggressive drives e. Contains the ego ideal

64. The answer is e. (Sadock, 7/e, pp 583-586.) In his structural theory of the mind, Freud divided the psychic apparatus into three agencies: the id, which contains the instinctual drives; the ego, whose function is to find an equilibrium between gratification of the instinctual drives and the rules of society (and the demands of the superego); and the superego, the agency that contains the internalized parental and societal rules and dictates to the ego what is not to be done. The ego ideal, a component of the superego, is the internal standard of what one should be to be approved all the time by society and internalized parental figures. Shame is a consequence of not living up to one's ego ideal while guilt is the consequence of transgressing the superego's prohibitions. The superego, as well as the ego, have both conscious and unconscious components.

66. The effects of emotional deprivation on infants were extensively investigated by a. Melanie Klein b. Erik Erikson c. Otto Kernberg d. Anna Freud e. Renée Spitz

65-66. The answers are 65-a, 66-e. (Lewis, 2/e, pp 579-580; Sadock, 7/e, p 2741.) Although the relationships between emotional deprivation and failure to thrive are complex, the fact that children who are emotionally deprived do not grow well even when an adequate amount of food is available is well proved. Renée Spitz studied institutionalized children and demonstrated that, due to lack of adequate nurturing, they become apathetic, withdrawn, and less interested in feeding, which in turn causes failure to thrive and, in extreme cases, death. Spitz called this syndrome "analytic depression." Schizophrenia and autism have not been associated with emotional deprivation in infancy.

Items 65-66 A 20-month-old girl is admitted to a pediatric ward because she weighs only 15 pounds but an extensive medical workup does not reveal any organic cause for the child's failure to thrive. The child is listless, apathetic, and does not smile. The parents rarely come to visit, and, when they do, they do not pick the child up and do not play or interact with her. 65. This scenario proves the established notion that a. Lack of adequate emotional nurturance causes depression and failure to thrive in infants b. Neglected infants fail to thrive but do not have the intrapsychic structures necessary for experiencing depression c. Infants reared in institutions are likely to become autistic d. Neglected infants are at higher risk for developing schizophrenia e. Environmental variables have little impact on the health of infants as long as enough food is provided

65-66. The answers are 65-a, 66-e. (Lewis, 2/e, pp 579-580; Sadock, 7/e, p 2741.) Although the relationships between emotional deprivation and failure to thrive are complex, the fact that children who are emotionally deprived do not grow well even when an adequate amount of food is available is well proved. Renée Spitz studied institutionalized children and demonstrated that, due to lack of adequate nurturing, they become apathetic, withdrawn, and less interested in feeding, which in turn causes failure to thrive and, in extreme cases, death. Spitz called this syndrome "analytic depression." Schizophrenia and autism have not been associated with emotional deprivation in infancy.

68. This behavior is a. Common in normal infants b. Always a symptom of insecure attachment c. Only present in children who will develop anxiety disorders later in life d. Likely to persist, if not appropriately treated e. A symptom of a pervasive developmental disorder

67-68. The answers are 67-e, 68-a. (Lewis, 2/e, p 259.) The term "stranger anxiety" refers to manifestations of discomfort and distress on the part of the infant when he or she is approached by a stranger. Although it does not necessarily appear every time the child meets a stranger and although some children seem to be more prone than others to such reactions, stranger anxiety is considered a normal, transient phenomenon. It manifests at about 8 months of age, when the child starts differentiating between familiar and unfamiliar adults.

Items 67-68 A healthy 9-month-old girl, previously very friendly with everyone, now bursts into tears when she is approached by an unfamiliar adult. 67. Her behavior is most likely due to a. Separation anxiety b. Insecure attachment c. Simple phobia d. Depressive position e. Stranger anxiety

67-68. The answers are 67-e, 68-a. (Lewis, 2/e, p 259.) The term "stranger anxiety" refers to manifestations of discomfort and distress on the part of the infant when he or she is approached by a stranger. Although it does not necessarily appear every time the child meets a stranger and although some children seem to be more prone than others to such reactions, stranger anxiety is considered a normal, transient phenomenon. It manifests at about 8 months of age, when the child starts differentiating between familiar and unfamiliar adults.

69. A 29-month-old boy plays with a ball, which rolls under a couch. The boy promptly crawls under the couch to retrieve the ball. According to Piaget's theories of cognitive development, this behavior is characteristic of a thinking process called a. Object permanence b. Basic trust c. Initiative versus guilt d. Object constancy e. Sensory-motor stage

69. The answer is a. (Lewis, 2/e, p 136.) According to Piaget, object permanence is the recognition that an object continues to exist even if it cannot be perceived. Object permanency is reached during the preoperational stage of cognitive development, which extends from 2 to 6 years of age. The child in the vignette understands that, even if he cannot see the ball anymore, the toy still exists under the couch. A younger child, who has not yet reached the stage of object permanence, would consider the ball as lost forever. Object permanence is often confused with object constancy, a psychoanalytic concept referring to children's ability to maintain stable, realistic internalized constructs of their caretakers and themselves. Object constancy is a fundamental concept in ego psychology and self-psychology.

70. According to Sigmund Freud, primary processes are a. Typically conscious b. Nonlogical and primitive c. Absent during dreaming d. Characteristic of the neuroses e. Rational and well organized

70. The answer is b. (Sadock, 7/e, pp 571, 580-581.) Primary process thinking is primitive, nonlogical, and timeless. Primary processes characterize the operational style of the id and are manifested in dreams. Condensation, displacement, and symbolic representation are, according to Freud's theory, forms of primary processes.

71. Harry Stack Sullivan's theory of personality development was characterized by an emphasis on a. Psychosexual development b. Genetic determinism c. Infant-mother interaction d. Interpersonal relations e. Object relations

71. The answer is d. (Sadock, 7/e, pp 632-625.) Harry Stack Sullivan's theory of personality development emphasized the central importance of interpersonal relationships. He believed that the interpersonal relationships of the first five years of life were crucial, although not immutable, in shaping personality. He thought that personality continues to develop and change throughout adolescence and into adulthood and that, in therapy, the opportunity for change derived from an active interaction between patient and therapist.

72. Erikson's developmental theories differ from Freud's in that Erikson placed greater emphasis on a. Cultural factors in development b. Instinctual drives c. Interpersonal relations d. Psychosexual development e. Object relations

72. The answer is a. (Sadock, 7/e, pp 610-611.) Erikson's work concentrated on the effects of social, cultural, and psychological factors in development. Although Erikson acknowledged the important role of sexuality, it was less central to his theory. The concepts of instinctual drives and psychosexual development are essential parts of Freud's theories. Object relations, which refers not to interpersonal relationships but to the interactions of internalized constructs of external relationships, is the central idea in object relation psychology

74. A teacher does not like one of her students, although she believes that she should be completely impartial. She makes exaggerated efforts to be helpful and uncritical toward the student.

73-77. The answers are 73-d, 74-h, 75-c, 76-e, 77-a. (Sadock, 7/e, pp 584-585, 2149.) In Freudian psychoanalytic theory, defense mechanisms Human Behavior:Theories of Personality and Development Answers 37 represent the ego's attempts to mediate between the pressure of the instinctual drives, emerging from the id, and the restrictions imposed by societal rules through the superego. Freud classified defense mechanisms as narcissistic (or primitive, including denial, projection, and distortion), immature (acting out, introjection, passive-aggressive behavior, somatization, and several others), neurotic (displacement, externalization, intellectualization, rationalization, inhibition, reaction formation, and repression), and mature (sublimation, altruism, asceticism, anticipation, suppression, and humor). Primitive and immature defenses are the norm during childhood and infancy and persist in pathological states. Mature defenses are considered more adaptive than immature and neurotic defenses. Identification refers to the incorporation of another person's qualities into one's ego system. In the particular case illustrated in the vignette of question 73, the boy, by identifying with his violent father (the aggressor), acquires a sense of control over an otherwise very distressing situation. In reaction formation, an unacceptable, unconscious impulse is transformed into its opposite. Through sublimation, satisfaction of an objectionable impulse is obtained by using socially acceptable means. In the vignette of question 75, the writer derives a vicarious satisfaction of his antisocial impulses through the criminal activities of the characters of his stories. Acting out implies the expression of an impulse through action to avoid experiencing the accompanying effect at a conscious level. Rationalization refers to offering a rational explanation to justify actions or impulses that would otherwise be regarded as unacceptable.

75. A writer of mystery novels who has never had legal problems jokes about his "dark side" and his hidden fantasies about leading an exciting life of crime.

73-77. The answers are 73-d, 74-h, 75-c, 76-e, 77-a. (Sadock, 7/e, pp 584-585, 2149.) In Freudian psychoanalytic theory, defense mechanisms Human Behavior:Theories of Personality and Development Answers 37 represent the ego's attempts to mediate between the pressure of the instinctual drives, emerging from the id, and the restrictions imposed by societal rules through the superego. Freud classified defense mechanisms as narcissistic (or primitive, including denial, projection, and distortion), immature (acting out, introjection, passive-aggressive behavior, somatization, and several others), neurotic (displacement, externalization, intellectualization, rationalization, inhibition, reaction formation, and repression), and mature (sublimation, altruism, asceticism, anticipation, suppression, and humor). Primitive and immature defenses are the norm during childhood and infancy and persist in pathological states. Mature defenses are considered more adaptive than immature and neurotic defenses. Identification refers to the incorporation of another person's qualities into one's ego system. In the particular case illustrated in the vignette of question 73, the boy, by identifying with his violent father (the aggressor), acquires a sense of control over an otherwise very distressing situation. In reaction formation, an unacceptable, unconscious impulse is transformed into its opposite. Through sublimation, satisfaction of an objectionable impulse is obtained by using socially acceptable means. In the vignette of question 75, the writer derives a vicarious satisfaction of his antisocial impulses through the criminal activities of the characters of his stories. Acting out implies the expression of an impulse through action to avoid experiencing the accompanying effect at a conscious level. Rationalization refers to offering a rational explanation to justify actions or impulses that would otherwise be regarded as unacceptable.

76. A psychotherapist is irritated with one of his patients, who consistently tries to put him down. Contrary to his usual punctuality, the therapist seems unable to start this patient's sessions on time.

73-77. The answers are 73-d, 74-h, 75-c, 76-e, 77-a. (Sadock, 7/e, pp 584-585, 2149.) In Freudian psychoanalytic theory, defense mechanisms Human Behavior:Theories of Personality and Development Answers 37 represent the ego's attempts to mediate between the pressure of the instinctual drives, emerging from the id, and the restrictions imposed by societal rules through the superego. Freud classified defense mechanisms as narcissistic (or primitive, including denial, projection, and distortion), immature (acting out, introjection, passive-aggressive behavior, somatization, and several others), neurotic (displacement, externalization, intellectualization, rationalization, inhibition, reaction formation, and repression), and mature (sublimation, altruism, asceticism, anticipation, suppression, and humor). Primitive and immature defenses are the norm during childhood and infancy and persist in pathological states. Mature defenses are considered more adaptive than immature and neurotic defenses. Identification refers to the incorporation of another person's qualities into one's ego system. In the particular case illustrated in the vignette of question 73, the boy, by identifying with his violent father (the aggressor), acquires a sense of control over an otherwise very distressing situation. In reaction formation, an unacceptable, unconscious impulse is transformed into its opposite. Through sublimation, satisfaction of an objectionable impulse is obtained by using socially acceptable means. In the vignette of question 75, the writer derives a vicarious satisfaction of his antisocial impulses through the criminal activities of the characters of his stories. Acting out implies the expression of an impulse through action to avoid experiencing the accompanying effect at a conscious level. Rationalization refers to offering a rational explanation to justify actions or impulses that would otherwise be regarded as unacceptable.

77. A man cheats on his tax returns and justifies himself with the thought that the government wastes most of the tax money anyway.

73-77. The answers are 73-d, 74-h, 75-c, 76-e, 77-a. (Sadock, 7/e, pp 584-585, 2149.) In Freudian psychoanalytic theory, defense mechanisms Human Behavior:Theories of Personality and Development Answers 37 represent the ego's attempts to mediate between the pressure of the instinctual drives, emerging from the id, and the restrictions imposed by societal rules through the superego. Freud classified defense mechanisms as narcissistic (or primitive, including denial, projection, and distortion), immature (acting out, introjection, passive-aggressive behavior, somatization, and several others), neurotic (displacement, externalization, intellectualization, rationalization, inhibition, reaction formation, and repression), and mature (sublimation, altruism, asceticism, anticipation, suppression, and humor). Primitive and immature defenses are the norm during childhood and infancy and persist in pathological states. Mature defenses are considered more adaptive than immature and neurotic defenses. Identification refers to the incorporation of another person's qualities into one's ego system. In the particular case illustrated in the vignette of question 73, the boy, by identifying with his violent father (the aggressor), acquires a sense of control over an otherwise very distressing situation. In reaction formation, an unacceptable, unconscious impulse is transformed into its opposite. Through sublimation, satisfaction of an objectionable impulse is obtained by using socially acceptable means. In the vignette of question 75, the writer derives a vicarious satisfaction of his antisocial impulses through the criminal activities of the characters of his stories. Acting out implies the expression of an impulse through action to avoid experiencing the accompanying effect at a conscious level. Rationalization refers to offering a rational explanation to justify actions or impulses that would otherwise be regarded as unacceptable.

Items 73-77 Match the following vignettes with the appropriate defense mechanism. a. Rationalization b. Anticipation c. Sublimation d. Identification with the aggressor e. Acting out f. Introjection g. Distortion h. Reaction formation i. Externalization 73. A child is hit by his father for breaking a valuable vase. One hour later he slaps his little sister for dropping his toy train.

73-77. The answers are 73-d, 74-h, 75-c, 76-e, 77-a. (Sadock, 7/e, pp 584-585, 2149.) In Freudian psychoanalytic theory, defense mechanisms Human Behavior:Theories of Personality and Development Answers 37 represent the ego's attempts to mediate between the pressure of the instinctual drives, emerging from the id, and the restrictions imposed by societal rules through the superego. Freud classified defense mechanisms as narcissistic (or primitive, including denial, projection, and distortion), immature (acting out, introjection, passive-aggressive behavior, somatization, and several others), neurotic (displacement, externalization, intellectualization, rationalization, inhibition, reaction formation, and repression), and mature (sublimation, altruism, asceticism, anticipation, suppression, and humor). Primitive and immature defenses are the norm during childhood and infancy and persist in pathological states. Mature defenses are considered more adaptive than immature and neurotic defenses. Identification refers to the incorporation of another person's qualities into one's ego system. In the particular case illustrated in the vignette of question 73, the boy, by identifying with his violent father (the aggressor), acquires a sense of control over an otherwise very distressing situation. In reaction formation, an unacceptable, unconscious impulse is transformed into its opposite. Through sublimation, satisfaction of an objectionable impulse is obtained by using socially acceptable means. In the vignette of question 75, the writer derives a vicarious satisfaction of his antisocial impulses through the criminal activities of the characters of his stories. Acting out implies the expression of an impulse through action to avoid experiencing the accompanying effect at a conscious level. Rationalization refers to offering a rational explanation to justify actions or impulses that would otherwise be regarded as unacceptable.

79. A 14-year-old girl spends a great deal of time putting on makeup and styling her hair. She babysits after school and she likes to cook. She considers heavy yard work a job more suited to her brother.

78-80. The answers are 78-c, 79-b, 80-d. (Hales, 3/e, pp 739-740.) Gender identity, a deep-rooted awareness of being either male or female, seems to depend in great part on the way the individual is reared, as a boy or a girl. Once established, usually by age 2 or 3, it is extremely resistant to change. In gender identity disorders, the individuals identify strongly with the opposite sex and dislike their own sexual characteristics. Gender role refers to the many behaviors, such as wearing dresses and makeup versus wearing pants and neckties, that identify an individual as male or female. It is not as unchangeable as gender identity and usually tends to fluctuate during the life course due to changes in beliefs, attitudes, and social mores (for example, smoking was considered a behavior unfit for women, but this has changed in recent years). Sexual identity refers to a subjective experience of an individual's sexual orientation and includes the awareness of what the individual considers sexually desirable.

80. A 23-year-old man enjoys the company of girls and is sexually aroused by them.

78-80. The answers are 78-c, 79-b, 80-d. (Hales, 3/e, pp 739-740.) Gender identity, a deep-rooted awareness of being either male or female, seems to depend in great part on the way the individual is reared, as a boy or a girl. Once established, usually by age 2 or 3, it is extremely resistant to change. In gender identity disorders, the individuals identify strongly with the opposite sex and dislike their own sexual characteristics. Gender role refers to the many behaviors, such as wearing dresses and makeup versus wearing pants and neckties, that identify an individual as male or female. It is not as unchangeable as gender identity and usually tends to fluctuate during the life course due to changes in beliefs, attitudes, and social mores (for example, smoking was considered a behavior unfit for women, but this has changed in recent years). Sexual identity refers to a subjective experience of an individual's sexual orientation and includes the awareness of what the individual considers sexually desirable.

Items 78-80 Match the following vignettes with the correct concept. a. Core identity b. Gender role c. Gender identity d. Sexual identity e. Sexual drive 78. A 3-year-old boy knows that he is a male "like Daddy" and becomes upset if someone mistakes

78-80. The answers are 78-c, 79-b, 80-d. (Hales, 3/e, pp 739-740.) Gender identity, a deep-rooted awareness of being either male or female, seems to depend in great part on the way the individual is reared, as a boy or a girl. Once established, usually by age 2 or 3, it is extremely resistant to change. In gender identity disorders, the individuals identify strongly with the opposite sex and dislike their own sexual characteristics. Gender role refers to the many behaviors, such as wearing dresses and makeup versus wearing pants and neckties, that identify an individual as male or female. It is not as unchangeable as gender identity and usually tends to fluctuate during the life course due to changes in beliefs, attitudes, and social mores (for example, smoking was considered a behavior unfit for women, but this has changed in recent years). Sexual identity refers to a subjective experience of an individual's sexual orientation and includes the awareness of what the individual considers sexually desirable.

8. A consult is requested for a 75- year-old female who underwent hip repair two days earlier, because the nurses noted that from time to time the patient "was not making any sense." The psychiatric resident conducting the evaluation observes that the patient believes she is a young girl, still living at home with her parents. She believes the resident is her deceased father. These statements are manifestations of impaired a. Concentration b. Memory c. Thought associations d. Orientation e. Level of consciousness

8. The answer is d. (Sadock, 7/e, p 685.) Orientation refers to the state of awareness of the individual as to the time and place, and to the awareness of the identity of oneself and others in the environment. The waxing and waning of the patient's orientation, a hallmark of organic mental disturbances, is also evident in the nursing report that led to the consultation request.

81. The concept that a symptom may have a number of different origins and meanings

81-83. The answers are 81-e, 82-a, 83-d. (Hales, 3/e, pp 148-155, 681.) Each of the terms listed in the question describes a concept important to Freudian psychoanalytic theory. Freud's theory of psychic determinism refers to his belief that all mental events are in some way connected. Overdetermination describes the concept that mental phenomena, such as neurotic symptoms and dreams, have multiple causes and multiple meanings. Primary gain refers to the relief of tension and conflict produced by the development of symptoms. In addition to the internal reduction of distress, the symptoms may gratify wishes or impulses (secondary gain). Examples of secondary gain include an increase in attention and sympathy, relief from burdensome obligations, and monetary compensation. Wish fulfillment is the term used by Freud to describe one of the goals of dreams.

82. The concept that all mental events are causally linked to others in an associative network

81-83. The answers are 81-e, 82-a, 83-d. (Hales, 3/e, pp 148-155, 681.) Each of the terms listed in the question describes a concept important to Freudian psychoanalytic theory. Freud's theory of psychic determinism refers to his belief that all mental events are in some way connected. Overdetermination describes the concept that mental phenomena, such as neurotic symptoms and dreams, have multiple causes and multiple meanings. Primary gain refers to the relief of tension and conflict produced by the development of symptoms. In addition to the internal reduction of distress, the symptoms may gratify wishes or impulses (secondary gain). Examples of secondary gain include an increase in attention and sympathy, relief from burdensome obligations, and monetary compensation. Wish fulfillment is the term used by Freud to describe one of the goals of dreams.

83. The benefit derived as the result of a neurotic illness

81-83. The answers are 81-e, 82-a, 83-d. (Hales, 3/e, pp 148-155, 681.) Each of the terms listed in the question describes a concept important to Freudian psychoanalytic theory. Freud's theory of psychic determinism refers to his belief that all mental events are in some way connected. Overdetermination describes the concept that mental phenomena, such as neurotic symptoms and dreams, have multiple causes and multiple meanings. Primary gain refers to the relief of tension and conflict produced by the development of symptoms. In addition to the internal reduction of distress, the symptoms may gratify wishes or impulses (secondary gain). Examples of secondary gain include an increase in attention and sympathy, relief from burdensome obligations, and monetary compensation. Wish fulfillment is the term used by Freud to describe one of the goals of dreams.

85. Relationship problems as result of early empathic failure and developmental arrest

84-87. The answers are 84-a, 85-f, 86-c, 87-e. (Sadock, 7/e, pp 580, 593-595.) In Freudian psychoanalytic theory, signal anxiety represents an autonomous function of the ego that activates unconscious defenses when impulses unacceptable to the superego threaten to emerge into consciousness. Heinz Kohut's theories hold that empathic, validating, and consistent responses from the parents or other primary caregivers are essential in the development of a cohesive and resilient self-concept. Developmental intrapsychic deficits caused by early empathic failures are, in Kohut's theories, involved in the development of personality disorders and manifest themselves through a multitude of emotional and behavioral dysfunctions, including anxiety. John Bowlby's work, as discussed in more detail in the explanation of question 48, focused on infant attachment. In Bowlby's view, anxiety follows an insecure attachment, caused by inconsistent or neglectful parenting. According to Carl Jung, when a characteristic of a child meets with the persistent disapproval of his or her parents, that characteristic is disowned and "forgotten." The unwanted and unrecognized traits are collected into the person's "shadow." Mental health, according to Jung, requires that individuals recognize and accept their shadow parts.

86. Anxiety caused by disruption of attachment to parents in infancy

84-87. The answers are 84-a, 85-f, 86-c, 87-e. (Sadock, 7/e, pp 580, 593-595.) In Freudian psychoanalytic theory, signal anxiety represents an autonomous function of the ego that activates unconscious defenses when impulses unacceptable to the superego threaten to emerge into consciousness. Heinz Kohut's theories hold that empathic, validating, and consistent responses from the parents or other primary caregivers are essential in the development of a cohesive and resilient self-concept. Developmental intrapsychic deficits caused by early empathic failures are, in Kohut's theories, involved in the development of personality disorders and manifest themselves through a multitude of emotional and behavioral dysfunctions, including anxiety. John Bowlby's work, as discussed in more detail in the explanation of question 48, focused on infant attachment. In Bowlby's view, anxiety follows an insecure attachment, caused by inconsistent or neglectful parenting. According to Carl Jung, when a characteristic of a child meets with the persistent disapproval of his or her parents, that characteristic is disowned and "forgotten." The unwanted and unrecognized traits are collected into the person's "shadow." Mental health, according to Jung, requires that individuals recognize and accept their shadow parts.

87. Symptoms as consequence of disowned parts of the personality

84-87. The answers are 84-a, 85-f, 86-c, 87-e. (Sadock, 7/e, pp 580, 593-595.) In Freudian psychoanalytic theory, signal anxiety represents an autonomous function of the ego that activates unconscious defenses when impulses unacceptable to the superego threaten to emerge into consciousness. Heinz Kohut's theories hold that empathic, validating, and consistent responses from the parents or other primary caregivers are essential in the development of a cohesive and resilient self-concept. Developmental intrapsychic deficits caused by early empathic failures are, in Kohut's theories, involved in the development of personality disorders and manifest themselves through a multitude of emotional and behavioral dysfunctions, including anxiety. John Bowlby's work, as discussed in more detail in the explanation of question 48, focused on infant attachment. In Bowlby's view, anxiety follows an insecure attachment, caused by inconsistent or neglectful parenting. According to Carl Jung, when a characteristic of a child meets with the persistent disapproval of his or her parents, that characteristic is disowned and "forgotten." The unwanted and unrecognized traits are collected into the person's "shadow." Mental health, according to Jung, requires that individuals recognize and accept their shadow parts.

Items 84-87 For each phenomenon or experience listed below, select the psychoanalytic theorist with whom it is most commonly associated. a. Sigmund Freud b. Harry Stack Sullivan c. John Bowlby d. Melanie Klein e. Carl Jung f. Heinz Kohut g. Erich Fromm 84. Signal anxiety as result of conflicts between id, ego, and superego

84-87. The answers are 84-a, 85-f, 86-c, 87-e. (Sadock, 7/e, pp 580, 593-595.) In Freudian psychoanalytic theory, signal anxiety represents an autonomous function of the ego that activates unconscious defenses when impulses unacceptable to the superego threaten to emerge into consciousness. Heinz Kohut's theories hold that empathic, validating, and consistent responses from the parents or other primary caregivers are essential in the development of a cohesive and resilient self-concept. Developmental intrapsychic deficits caused by early empathic failures are, in Kohut's theories, involved in the development of personality disorders and manifest themselves through a multitude of emotional and behavioral dysfunctions, including anxiety. John Bowlby's work, as discussed in more detail in the explanation of question 48, focused on infant attachment. In Bowlby's view, anxiety follows an insecure attachment, caused by inconsistent or neglectful parenting. According to Carl Jung, when a characteristic of a child meets with the persistent disapproval of his or her parents, that characteristic is disowned and "forgotten." The unwanted and unrecognized traits are collected into the person's "shadow." Mental health, according to Jung, requires that individuals recognize and accept their shadow parts.

89. A 4-year-old girl loves her father's attention and tells him she will marry him when she grows up.

88-90. The answers are 88-b, 89-d, 90-a. (Sadock, 7/e, pp 577-579.) According to Freud's theory of psychosexual development, the child goes through six stages between birth and adolescence: oral, anal, phallic, oedipal, latency, and genital. In each stage, pleasure (not necessarily sexual) is derived from specific areas of the body. Each stage is associated with specific drives, conflicts, and defenses. Human Behavior:Theories of Personality and Development Answers 39 In the first 18 months of life, infants go through the oral stage, during which oral sensations (feeding, sucking, biting, etc.) represent the main gratification. According to Freud, excessive gratification or deprivation during this stage can cause an "oral fixation." Individuals with an oral character are dependent and require that others fulfill their needs. In the anal stage, between 18 and 36 months of age, the child is much more independent and active than during the previous stage. Erotic stimulation of the anal mucosa through the excretion or retention of feces is the main source of pleasure. Battles over toilet training are common in the attempts to achieve autonomy from the parents. If toilet training is too harsh or inconsistent, "anal traits" may persist as personality traits later in life. Stubbornness, obstinacy, and frugality are common traits of the "anal individual," usually seen in obsessive-compulsive personalities. The phallic stage, which starts at age 3, is characterized by a concentration of erotic pleasure in the penis and the clitoris areas. During the phallic stage, the child starts looking outside himself or herself for an erotic object, thus heralding the advent of the oedipal stage. Freud theorized that between the ages of 3 and 5, the male child, as Oedipus in Greek mythology, falls in love with the mother and perceives the father as a murderous rival. Resolution of the oedipal stage leads to the boy's identification with the father and the abandonment of the erotic wishes for the mother, which are later transferred to other women. During the oedipal stage, girls experience an equivalent attraction for their fathers and perceive their mothers as rivals. How girls resolve their oedipal conflicts and come to identify with their mothers is less clearly explained. During latency, between 5 and 11 to 13 years of age, the sexual drive is relatively quiescent and the child becomes focused on learning new skills and social interactions with peers. The genital stage begins with puberty and ends with young adulthood and is characterized by a reintensification of sexual drives. The key developmental tasks associated with this stage are mastery over instinctual drives, separation from parents, and the establishment of a genital sexuality with an appropriate partner.

90. A 6-month-old puts everything in her mouth and can fall asleep only if she sucks on her pacifier.

88-90. The answers are 88-b, 89-d, 90-a. (Sadock, 7/e, pp 577-579.) According to Freud's theory of psychosexual development, the child goes through six stages between birth and adolescence: oral, anal, phallic, oedipal, latency, and genital. In each stage, pleasure (not necessarily sexual) is derived from specific areas of the body. Each stage is associated with specific drives, conflicts, and defenses. Human Behavior:Theories of Personality and Development Answers 39 In the first 18 months of life, infants go through the oral stage, during which oral sensations (feeding, sucking, biting, etc.) represent the main gratification. According to Freud, excessive gratification or deprivation during this stage can cause an "oral fixation." Individuals with an oral character are dependent and require that others fulfill their needs. In the anal stage, between 18 and 36 months of age, the child is much more independent and active than during the previous stage. Erotic stimulation of the anal mucosa through the excretion or retention of feces is the main source of pleasure. Battles over toilet training are common in the attempts to achieve autonomy from the parents. If toilet training is too harsh or inconsistent, "anal traits" may persist as personality traits later in life. Stubbornness, obstinacy, and frugality are common traits of the "anal individual," usually seen in obsessive-compulsive personalities. The phallic stage, which starts at age 3, is characterized by a concentration of erotic pleasure in the penis and the clitoris areas. During the phallic stage, the child starts looking outside himself or herself for an erotic object, thus heralding the advent of the oedipal stage. Freud theorized that between the ages of 3 and 5, the male child, as Oedipus in Greek mythology, falls in love with the mother and perceives the father as a murderous rival. Resolution of the oedipal stage leads to the boy's identification with the father and the abandonment of the erotic wishes for the mother, which are later transferred to other women. During the oedipal stage, girls experience an equivalent attraction for their fathers and perceive their mothers as rivals. How girls resolve their oedipal conflicts and come to identify with their mothers is less clearly explained. During latency, between 5 and 11 to 13 years of age, the sexual drive is relatively quiescent and the child becomes focused on learning new skills and social interactions with peers. The genital stage begins with puberty and ends with young adulthood and is characterized by a reintensification of sexual drives. The key developmental tasks associated with this stage are mastery over instinctual drives, separation from parents, and the establishment of a genital sexuality with an appropriate partner.

tems 88-90 Match each example with the appropriate developmental stage according to Freudian theory. a. Oral b. Anal c. Phallic d. Oedipal e. Latency 88. Two young parents are worried because their once happy-go-lucky infant has become oppositional and obstinate since he turned 2. Their psychologically oriented pediatrician assures them that the child's behavior is age appropriate.

88-90. The answers are 88-b, 89-d, 90-a. (Sadock, 7/e, pp 577-579.) According to Freud's theory of psychosexual development, the child goes through six stages between birth and adolescence: oral, anal, phallic, oedipal, latency, and genital. In each stage, pleasure (not necessarily sexual) is derived from specific areas of the body. Each stage is associated with specific drives, conflicts, and defenses. Human Behavior:Theories of Personality and Development Answers 39 In the first 18 months of life, infants go through the oral stage, during which oral sensations (feeding, sucking, biting, etc.) represent the main gratification. According to Freud, excessive gratification or deprivation during this stage can cause an "oral fixation." Individuals with an oral character are dependent and require that others fulfill their needs. In the anal stage, between 18 and 36 months of age, the child is much more independent and active than during the previous stage. Erotic stimulation of the anal mucosa through the excretion or retention of feces is the main source of pleasure. Battles over toilet training are common in the attempts to achieve autonomy from the parents. If toilet training is too harsh or inconsistent, "anal traits" may persist as personality traits later in life. Stubbornness, obstinacy, and frugality are common traits of the "anal individual," usually seen in obsessive-compulsive personalities. The phallic stage, which starts at age 3, is characterized by a concentration of erotic pleasure in the penis and the clitoris areas. During the phallic stage, the child starts looking outside himself or herself for an erotic object, thus heralding the advent of the oedipal stage. Freud theorized that between the ages of 3 and 5, the male child, as Oedipus in Greek mythology, falls in love with the mother and perceives the father as a murderous rival. Resolution of the oedipal stage leads to the boy's identification with the father and the abandonment of the erotic wishes for the mother, which are later transferred to other women. During the oedipal stage, girls experience an equivalent attraction for their fathers and perceive their mothers as rivals. How girls resolve their oedipal conflicts and come to identify with their mothers is less clearly explained. During latency, between 5 and 11 to 13 years of age, the sexual drive is relatively quiescent and the child becomes focused on learning new skills and social interactions with peers. The genital stage begins with puberty and ends with young adulthood and is characterized by a reintensification of sexual drives. The key developmental tasks associated with this stage are mastery over instinctual drives, separation from parents, and the establishment of a genital sexuality with an appropriate partner.

9. A 47-year-old secretary has lost her job because, due to her perfectionism and excessive attention to trivial details, she could never finish an assignment on time. She writes innumerable lists of things to be done and follows rules scrupulously. She consistently annoys friends and family members with her lack of 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

9. The answer is c. (DSM IV, pp 669-673.) The essential feature of obsessive personality disorder is a preoccupation with perfection, orderliness, and control. Individuals with this disorder lose the main point of an activity and miss deadlines because they pay too much attention to rules and details and are not satisfied with anything less than "perfection." As in other personality disorders, symptoms are ego-syntonic and create considerable interpersonal, social, and occupational difficulties. Obsessive-compulsive disorder is differentiated from obsessive-compulsive personality disorder by the presence of obsessions and compulsions. Paranoid personality disorder is characterized by suspiciousness and distrust of others. Individuals with narcissistic personality disorder are preoccupied with perfection, but usually they are convinced of having already reached it. Individuals with obsessive- compulsive personality disorder, instead, are rarely satisfied with themselves. Passive-aggressive personality disorder is characterized by a passive resistance to perform in occupational and social settings, manifested by forgetfulness, procrastination, and intentional lack of efficiency.

92. The process that transforms the raw unconscious wishes and impulses of the dreamer into images more acceptable to his superego is called a. Sublimation b. Return of the repressed c. Rationalization d. Dream work e. Wish fulfillment

91-93. The answers are 91-b, 92-d, 93-d. (Sadock, 7/e, pp 370-372.) One of Freud's main accomplishments was his observation that dreams are meaningful and that they provide valuable information about the dreamer's unconscious, although their meaning was often hidden or disguised. According to Freud's theory, each dream has a manifest content, which refers to images and sensations recalled by the dreamer, and a hid- 40 Psychiatry den latent content, represented by impulses, ideas, and feelings unacceptable to the conscious mind. Dream work is the process through which the latent content of the dream is transformed into the more acceptable manifest content. To disguise the latent content, the mind combines different concepts or feelings into one single image (condensation), uses neutral or innocent images to represent highly charged ideas or impulses (symbolic representation), and diverts the feeling or the energy associated with one object to another more acceptable to the dreamer's superego (displacement). Condensation, displacement, and symbolic representation are primary processes and can make the manifest content of the dream quite bizarre. Secondary revision, a process guided by the ego, intervenes at the end of the dream work to make the manifest content more rational and acceptable to the dreamer.

93. The appearance in a dream of a composite character with the characteristics of more than one person in the dreamer's life is due to a process called a. Displacement b. Overdetermination c. Identification d. Condensation e. Secondary revision

91-93. The answers are 91-b, 92-d, 93-d. (Sadock, 7/e, pp 370-372.) One of Freud's main accomplishments was his observation that dreams are meaningful and that they provide valuable information about the dreamer's unconscious, although their meaning was often hidden or disguised. According to Freud's theory, each dream has a manifest content, which refers to images and sensations recalled by the dreamer, and a hid- 40 Psychiatry den latent content, represented by impulses, ideas, and feelings unacceptable to the conscious mind. Dream work is the process through which the latent content of the dream is transformed into the more acceptable manifest content. To disguise the latent content, the mind combines different concepts or feelings into one single image (condensation), uses neutral or innocent images to represent highly charged ideas or impulses (symbolic representation), and diverts the feeling or the energy associated with one object to another more acceptable to the dreamer's superego (displacement). Condensation, displacement, and symbolic representation are primary processes and can make the manifest content of the dream quite bizarre. Secondary revision, a process guided by the ego, intervenes at the end of the dream work to make the manifest content more rational and acceptable to the dreamer.

Items 91-93 A young man who is in a conflicted relationship with a woman who reminds him of his domineering mother dreams that he is having tea with a woman who has his fiancée's features but his mother's eyes and hair color. In the dream, the young man realizes, with horror, that he is paralyzed from the waist down. He tries to communicate his distress to his fiancée but she is oblivious and continues talking about buying new furniture. With an enormous effort, the young man manages to stand up and at that moment the woman in his dreams starts floating in the air as a balloon and presently she disappears. 91. According to Freud's theories, the dream may represent an insight into the fact that his fiancée has emotionally paralyzed the dreamer, as his mother had done before her. This insight represents a. The manifest content of the dream b. The latent content of the dream c. Dream work d. A punishment dream e. A defense mechanism

91-93. The answers are 91-b, 92-d, 93-d. (Sadock, 7/e, pp 370-372.) One of Freud's main accomplishments was his observation that dreams are meaningful and that they provide valuable information about the dreamer's unconscious, although their meaning was often hidden or disguised. According to Freud's theory, each dream has a manifest content, which refers to images and sensations recalled by the dreamer, and a hid- 40 Psychiatry den latent content, represented by impulses, ideas, and feelings unacceptable to the conscious mind. Dream work is the process through which the latent content of the dream is transformed into the more acceptable manifest content. To disguise the latent content, the mind combines different concepts or feelings into one single image (condensation), uses neutral or innocent images to represent highly charged ideas or impulses (symbolic representation), and diverts the feeling or the energy associated with one object to another more acceptable to the dreamer's superego (displacement). Condensation, displacement, and symbolic representation are primary processes and can make the manifest content of the dream quite bizarre. Secondary revision, a process guided by the ego, intervenes at the end of the dream work to make the manifest content more rational and acceptable to the dreamer.

94. A Vietnam veteran with PTSD (post-traumatic stress disorder) startles if someone approaches him from behind and experiences panic, palpitation, and sweating when he hears a loud popping sound. These hyperarousal symptoms are thought to be due to a stress-induced, chronic hyperactivity of the a. Nucleus basalis of Meynert b. Locus ceruleus c. Substantia nigra d. Raphe nuclei e. Vagus

94. The answer is b. (Sadock, 7/e, pp 1450-1451, 1454.) The locus ceruleus is located on the floor of the fourth ventricle in the anterior pons. It is the main noradrenergic nucleus of the brain and, through its widespread projections to many areas of the brain and the spinal cord, it regulates arousal, attention, and autonomic tone. The locus ceruleus, due to its connection with the amygdala, is stimulated by exposure to threats. Its firing causes adaptive responses that prepare the individual for fight or flight, such as increased vigilance, heart rate, and pupil dilation. Since severe stress causes a chronic state of hyperactivity of the nucleus ceruleus, individuals with post-traumatic stress disorder experience fight or flight symptoms such as increased startle reflex, autonomic hyperarousal, and increased level of vigilance in response to nonthreatening stimuli that trigger memories of the original stressful event. The nucleus basalis of Meynert is connected to cognitive functions and memory. This nucleus degenerates in Alzheimer's dementia. Degeneration of the neurons in the substantia nigra is connected to Parkinson's disease. The raphe nuclei are the main source of serotonin in the central nervous system and they are connected with the regulation of mood, pain, and aggression

95. A young man is often the object of his friends' jokes because he drops on the floor whenever he is having a good laugh. This young man suffers from a. Cataplexy b. Narcolepsy c. Hysteria d. Drop seizures e. Histrionic personality

95. The answer is a. (Sadock, 7/e, p 1647.) Cataplexy refers to a sudden loss of muscle tone, ranging in severity from weakness in the knee to a total loss of tone, triggered by strong emotions, that takes place during full wakefulness. Cataplexy is thought to be due to an abnormal intrusion of REM sleep phenomena in periods of wakefulness. It is usually treated with medications that reduce REM sleep, such as antidepressants. Cataplexy may be a symptom of narcolepsy, another dyssomnia characterized by the irresistible urge to fall asleep regardless of the situation.

96. A young woman with a history of severe childhood abuse cuts or burns herself when she feels angry or anxious. She claims that hurting herself calms her and causes no pain. Self-injury can have this effect because it triggers the release of a. ACTH b. Endorphins c. Serotonin d. Substance P e. Arachidonic acid

96. The answer is b. (Hales, 3/e, p 614.) When animals are exposed to prolonged and inescapable stress, they develop analgesia through the release of endogenous opiates such as endorphins. Equally, patients who have experienced severe trauma readily release opiates in response to any stimulus that is reminiscent of the original trauma. This release, in turn, causes psychic numbing, a subjective feeling of calm and analgesia. This response can be suppressed by opiate antagonists and explains why traumatized people use self-injury as a way to calm themselves.

97. Benzodiazepines, barbiturates, and many anticonvulsants exert their influence through which of the following types of receptors? a. Muscarinic b. Dopamine c. Glutamate d. Adrenergic e. Gamma-aminobutyric acid (GABA)

97. The answer is e. (Hales, 3/e, p 22.) Gamma-aminobutyric acid (GABA) receptors represent the most important inhibitory system in the central nervous system (CNS) and are found in almost every area the brain. Benzodiazepines, barbiturates, and many anticonvulsants act through activation of the GABA receptors. This explains the cross-tolerance that occurs between these substances.

98. Seasonal circadian rhythm has been implicated in the etiology of a. Depression b. Sociopathy c. Capgras syndrome d. Panic disorder e. OCD

98. The answer is a. (Sadock, 7/e, pp 140-141.) Seasonal circadian rhythm has been implicated in the etiology of seasonal depressive disorder, which is characterized by recurrent depression that starts in November and resolves in March. Winter's short days cause a change in the pattern of secretion of nocturnal melatonin, which is inhibited by light. In animals this causes a decrease in activity level, reproduction-related behaviors, and aggressive behavior. The same mechanism is postulated to be effective in seasonal depression, which, in fact, responds to light therapy.

99. The subject of a sleep study has been asleep for 90 minutes. When he enters his first REM period, his eyes start moving rapidly, his heart rate changes, and his muscles are flaccid. Another event associated with this sleep cycle is a. Night terrors b. Sleepwalking c. Dreaming d. Restless legs e. Sleep paralysis

99. The answer is c. (Kaufman, 4/e, pp 390-391; Hales, 3/e, pp 958, 966.) Dreaming is the main characteristic of REM (rapid eye movement) sleep. The active eye movements are attributed to the individual's "watching" his or her dreams. The lack of muscle tone prevents the individual from acting out his or her dreams. REM sleep is also characterized by increased heart rate and blood pressure and, in men, nocturnal erections. In sleep paralysis, the individual is unable to move on awakening due to an abnormal intrusion of an REM sleep-related atonia into wakefulness. Sleepwalking and night terrors take place during transition from deep sleep to REM sleep. Restless legs syndrome is classified as a "parasomnia not otherwise specified." It consists of an inability to fall asleep due to paresthesia of the calf muscles that promotes an intense urge to keep the legs in motion.