, CONTENT
Chapter 1: Examination and Diagnosis of the Psychiatric Patient
Chapter 2: Neurodevelopmental Disorders and Other Childhood Disorders
Chapter 3: Neurocognitive Disorders
Chapter 4: Substance Use and Addictive Disorders
Chapter 5: Schizophrenia Spectrum and Other Psychotic Disorders
Chapter 6: Bipolar Disorders
Chapter 7: Depressive Disorders
Chapter 8: Anxiety Disorders
Chapter 9: Obsessive-Compulsive and Related Disorders
Chapter 10: Trauma- and Stressor-Related Disorders
Chapter 11: Dissociative Disorders
Chapter 12: Somatic Symptom and Related Disorders
Chapter 13: Feeding and Eating Disorders
Chapter 14: Elimination Disorders
Chapter 15: Sleep–Wake Disorders
Chapter 16: Human Sexuality and Sexual Dysfunctions
Chapter 17: Gender Dysphoria, Gender Identity, and Related Conditions
Chapter 18: Disruptive, Impulse-Control, and Conduct Disorders
Chapter 19: Personality Disorders
Chapter 20: Other Conditions That May Be a Focus of Clinical Attention
Chapter 21: Psychopharmacology
Chapter 22: Other Somatic Therapies
Chapter 23: Psychotherapy
Chapter 24: Psychiatric Rehabilitation and Other Interventions
Chapter 25: Consultation to Other Disciplines
Chapter 26: Level of Care
Chapter 27: Ethics and Professionalism
Chapter 28: Forensic and Legal Issues
Chapter 29: End-of-Life Issues and Palliative Care
Chapter 30: Community Psychiatry
Chapter 31: Global and Cultural Issues in Psychiatry
,CHAPTER 1 — Examination and Diagnosis of
the Psychiatric Patient
Focus: Foundations of psychiatric practice — interview techniques, MSE,
diagnostic formulation, mood/thought/cognition/perception/judgment/insight
assessment, diagnostic tools & rating scales, risk assessment, differential diagnosis,
biopsychosocial integration.
1
A 32-year-old man presents with 3 weeks of low mood, anergia, and insomnia after
losing his job. In the interview he repeatedly states “I am worthless” and that life is
“hopeless.” You notice psychomotor retardation and poor eye contact. Which
element of the MSE is most important to assess immediately to guide acute
management?
A. Insight into the cause of his symptoms
B. Presence of psychotic symptoms (command hallucinations)
C. Immediate suicide risk (intent, plan, means)
D. Cognitive impairment (orientation and memory)
Answer: C
Rationale: In a patient with depressed mood and statements of
worthlessness/hopelessness plus psychomotor retardation (a sign of severe
depression), immediate assessment of suicide risk (intent, plan, access to means,
prior attempts) takes clinical priority because it dictates safety planning and level-
of-care decisions. While psychosis, insight, and cognition are important, they are
secondary to assessing imminent risk. The correct triage decision (outpatient vs.
inpatient) is founded on suicide-risk assessment.
Key words: suicide risk, hopelessness, psychomotor retardation, safety, triage
2
During a psychiatric interview the patient alternates between vivid recollection of
traumatic events and appearing detached, describing events “like watching a
,movie.” Which MSE finding does this best illustrate?
A. Derealization
B. Depersonalization
C. Dissociative fugue
D. Thought blocking
Answer: A
Rationale: Derealization refers to a subjective sense that the external world feels
unreal or like a movie; depersonalization refers to feeling detached from oneself.
The stem describes the environment/events feeling like a movie — derealization.
Dissociative fugue involves travel/identity disturbance; thought blocking is
interruption of thought flow. Differentiating derealization vs depersonalization is
an important phenomenological skill in MSE.
Key words: derealization, depersonalization, dissociation, MSE phenomenology
3
A 67-year-old retired teacher shows progressive memory decline over 18 months
and scores 24/30 on the MMSE. Family reports sundowning and fluctuating
attention. Which assessment approach best differentiates delirium from a
neurocognitive disorder?
A. Repeat MMSE monthly to track decline
B. Obtain polysomnography to evaluate sleep fragmentation
C. Perform serial cognitive examinations over hours to days and check CAM
(Confusion Assessment Method) criteria
D. Order MRI brain to identify structural causes
Answer: C
Rationale: Delirium is characterized by an acute change in attention and cognition
with fluctuating course over hours to days. Serial cognitive exams and the
Confusion Assessment Method are designed to detect acute fluctuating
attention/awareness. MMSE trends monthly won't capture the acute fluctuation;
MRI and polysomnography may be helpful later but do not distinguish acute
delirium from progressive neurocognitive disorder in the short term.
Key words: delirium, fluctuating attention, CAM, serial exams, acute change
,4
A 24-year-old woman presents with excessive fear of vomiting and avoids social
situations where food is present. Which diagnostic tool or approach most directly
quantifies severity and tracks treatment response for phobic avoidance?
A. Beck Depression Inventory (BDI)
B. Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
C. Specific phobia severity scale or behavioral avoidance test (BAT)
D. Mini International Neuropsychiatric Interview (MINI)
Answer: C
Rationale: For phobic avoidance, a disorder-specific tool such as a behavioral
avoidance test (BAT) or a phobia severity scale directly quantifies avoidance and
physiological fear responses and can track treatment response to exposure-based
therapy. BDI measures depression, Y-BOCS is for OCD, and MINI is a structured
diagnostic interview (useful for diagnosis but not sensitive for quantifying phobic
avoidance severity over time).
Key words: phobia, behavioral avoidance test, disorder-specific scale, treatment
monitoring
5
A patient displays tangential thinking and loose associations during the interview
but remains oriented and can follow simple commands. Which domain of the MSE
is primarily affected, and what differential diagnosis is most likely?
A. Perception domain; substance-induced hallucinosis
B. Thought process domain; formal thought disorder associated with schizophrenia
spectrum disorder
C. Affect domain; major depressive disorder with psychotic features
D. Cognition domain; mild neurocognitive disorder
Answer: B
Rationale: Tangentiality and loose associations are disturbances of thought
process (formal thought disorder). These are classically associated with
,schizophrenia spectrum disorders, though they can occur in mania and severe
psychosis as well. Orientation and basic cognition being intact argue against a
primary cognitive disorder. Perception refers to hallucinations; affect denotes
mood; cognition refers to memory, attention — none best explain formal thought
disorder.
Key words: thought process, tangentiality, loose associations, formal thought
disorder, schizophrenia
6
A 45-year-old with chronic alcoholism scores 18/30 on the MoCA and shows
impaired attention, visuospatial deficits, and recent memory problems. Which next
step best distinguishes Wernicke encephalopathy from alcohol-related
neurocognitive disorder?
A. Trial of thiamine replacement and reassessment of mental status
B. Start memantine for cognitive symptoms immediately
C. Order a urine drug screen for benzodiazepines
D. Schedule outpatient neuropsychological testing in 6 months
Answer: A
Rationale: Wernicke encephalopathy from thiamine deficiency is an acute,
potentially reversible condition in chronic alcoholics; immediate thiamine
replacement is a medical emergency and diagnostic/therapeutic step. Reassessment
after thiamine can show improvement. Memantine is not indicated acutely; urine
drug screen or delayed neuropsych testing are less urgent compared to prompt
thiamine replacement.
Key words: Wernicke, thiamine, reversible, alcohol, acute management
7
A 19-year-old college student reports “voices commenting” and visual
hallucinations for 2 days after heavy cannabis use. He is disoriented and has
fluctuating consciousness. What is the most appropriate immediate diagnostic
formulation?
, A. Primary psychotic disorder (schizophrenia)
B. Substance/medication-induced psychotic disorder with delirium
C. Brief psychotic disorder unrelated to substances
D. Schizoaffective disorder
Answer: B
Rationale: The temporal association with heavy cannabis use, acute onset,
disorientation, and fluctuating consciousness point toward a substance/medication-
induced psychosis with features of delirium. Primary psychotic disorders typically
have a different course (not acutely disoriented and substance temporality). Brief
psychotic disorder could be considered but the substance link and altered
consciousness favor substance-induced delirium/psychosis.
Key words: substance-induced psychosis, delirium, temporal relation, cannabis
8
A patient denies suicidal ideation verbally but gives ambiguous replies and has
previously attempted overdose three years ago. Which assessment technique
reduces risk of underestimating suicidality?
A. Rely only on self-report and mental status examination
B. Use collateral history from family and review past records, and directly ask
about intent, plan, and access to means
C. Assume no risk because current denial is present
D. Administer a global depression scale and defer suicide questions to the
psychiatrist on call
Answer: B
Rationale: To avoid underestimating suicide risk, clinicians should gather
collateral information, review past records, and ask direct questions about intent,
plan, timing, and access to means — especially when there is a history of past
attempts and ambiguous answers. Reliance on single self-report or deferring
without assessment is unsafe. Using a validated suicide assessment instrument plus
collateral is best practice.
Key words: suicide assessment, collateral, past attempt, intent/plan, safety
Chapter 1: Examination and Diagnosis of the Psychiatric Patient
Chapter 2: Neurodevelopmental Disorders and Other Childhood Disorders
Chapter 3: Neurocognitive Disorders
Chapter 4: Substance Use and Addictive Disorders
Chapter 5: Schizophrenia Spectrum and Other Psychotic Disorders
Chapter 6: Bipolar Disorders
Chapter 7: Depressive Disorders
Chapter 8: Anxiety Disorders
Chapter 9: Obsessive-Compulsive and Related Disorders
Chapter 10: Trauma- and Stressor-Related Disorders
Chapter 11: Dissociative Disorders
Chapter 12: Somatic Symptom and Related Disorders
Chapter 13: Feeding and Eating Disorders
Chapter 14: Elimination Disorders
Chapter 15: Sleep–Wake Disorders
Chapter 16: Human Sexuality and Sexual Dysfunctions
Chapter 17: Gender Dysphoria, Gender Identity, and Related Conditions
Chapter 18: Disruptive, Impulse-Control, and Conduct Disorders
Chapter 19: Personality Disorders
Chapter 20: Other Conditions That May Be a Focus of Clinical Attention
Chapter 21: Psychopharmacology
Chapter 22: Other Somatic Therapies
Chapter 23: Psychotherapy
Chapter 24: Psychiatric Rehabilitation and Other Interventions
Chapter 25: Consultation to Other Disciplines
Chapter 26: Level of Care
Chapter 27: Ethics and Professionalism
Chapter 28: Forensic and Legal Issues
Chapter 29: End-of-Life Issues and Palliative Care
Chapter 30: Community Psychiatry
Chapter 31: Global and Cultural Issues in Psychiatry
,CHAPTER 1 — Examination and Diagnosis of
the Psychiatric Patient
Focus: Foundations of psychiatric practice — interview techniques, MSE,
diagnostic formulation, mood/thought/cognition/perception/judgment/insight
assessment, diagnostic tools & rating scales, risk assessment, differential diagnosis,
biopsychosocial integration.
1
A 32-year-old man presents with 3 weeks of low mood, anergia, and insomnia after
losing his job. In the interview he repeatedly states “I am worthless” and that life is
“hopeless.” You notice psychomotor retardation and poor eye contact. Which
element of the MSE is most important to assess immediately to guide acute
management?
A. Insight into the cause of his symptoms
B. Presence of psychotic symptoms (command hallucinations)
C. Immediate suicide risk (intent, plan, means)
D. Cognitive impairment (orientation and memory)
Answer: C
Rationale: In a patient with depressed mood and statements of
worthlessness/hopelessness plus psychomotor retardation (a sign of severe
depression), immediate assessment of suicide risk (intent, plan, access to means,
prior attempts) takes clinical priority because it dictates safety planning and level-
of-care decisions. While psychosis, insight, and cognition are important, they are
secondary to assessing imminent risk. The correct triage decision (outpatient vs.
inpatient) is founded on suicide-risk assessment.
Key words: suicide risk, hopelessness, psychomotor retardation, safety, triage
2
During a psychiatric interview the patient alternates between vivid recollection of
traumatic events and appearing detached, describing events “like watching a
,movie.” Which MSE finding does this best illustrate?
A. Derealization
B. Depersonalization
C. Dissociative fugue
D. Thought blocking
Answer: A
Rationale: Derealization refers to a subjective sense that the external world feels
unreal or like a movie; depersonalization refers to feeling detached from oneself.
The stem describes the environment/events feeling like a movie — derealization.
Dissociative fugue involves travel/identity disturbance; thought blocking is
interruption of thought flow. Differentiating derealization vs depersonalization is
an important phenomenological skill in MSE.
Key words: derealization, depersonalization, dissociation, MSE phenomenology
3
A 67-year-old retired teacher shows progressive memory decline over 18 months
and scores 24/30 on the MMSE. Family reports sundowning and fluctuating
attention. Which assessment approach best differentiates delirium from a
neurocognitive disorder?
A. Repeat MMSE monthly to track decline
B. Obtain polysomnography to evaluate sleep fragmentation
C. Perform serial cognitive examinations over hours to days and check CAM
(Confusion Assessment Method) criteria
D. Order MRI brain to identify structural causes
Answer: C
Rationale: Delirium is characterized by an acute change in attention and cognition
with fluctuating course over hours to days. Serial cognitive exams and the
Confusion Assessment Method are designed to detect acute fluctuating
attention/awareness. MMSE trends monthly won't capture the acute fluctuation;
MRI and polysomnography may be helpful later but do not distinguish acute
delirium from progressive neurocognitive disorder in the short term.
Key words: delirium, fluctuating attention, CAM, serial exams, acute change
,4
A 24-year-old woman presents with excessive fear of vomiting and avoids social
situations where food is present. Which diagnostic tool or approach most directly
quantifies severity and tracks treatment response for phobic avoidance?
A. Beck Depression Inventory (BDI)
B. Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
C. Specific phobia severity scale or behavioral avoidance test (BAT)
D. Mini International Neuropsychiatric Interview (MINI)
Answer: C
Rationale: For phobic avoidance, a disorder-specific tool such as a behavioral
avoidance test (BAT) or a phobia severity scale directly quantifies avoidance and
physiological fear responses and can track treatment response to exposure-based
therapy. BDI measures depression, Y-BOCS is for OCD, and MINI is a structured
diagnostic interview (useful for diagnosis but not sensitive for quantifying phobic
avoidance severity over time).
Key words: phobia, behavioral avoidance test, disorder-specific scale, treatment
monitoring
5
A patient displays tangential thinking and loose associations during the interview
but remains oriented and can follow simple commands. Which domain of the MSE
is primarily affected, and what differential diagnosis is most likely?
A. Perception domain; substance-induced hallucinosis
B. Thought process domain; formal thought disorder associated with schizophrenia
spectrum disorder
C. Affect domain; major depressive disorder with psychotic features
D. Cognition domain; mild neurocognitive disorder
Answer: B
Rationale: Tangentiality and loose associations are disturbances of thought
process (formal thought disorder). These are classically associated with
,schizophrenia spectrum disorders, though they can occur in mania and severe
psychosis as well. Orientation and basic cognition being intact argue against a
primary cognitive disorder. Perception refers to hallucinations; affect denotes
mood; cognition refers to memory, attention — none best explain formal thought
disorder.
Key words: thought process, tangentiality, loose associations, formal thought
disorder, schizophrenia
6
A 45-year-old with chronic alcoholism scores 18/30 on the MoCA and shows
impaired attention, visuospatial deficits, and recent memory problems. Which next
step best distinguishes Wernicke encephalopathy from alcohol-related
neurocognitive disorder?
A. Trial of thiamine replacement and reassessment of mental status
B. Start memantine for cognitive symptoms immediately
C. Order a urine drug screen for benzodiazepines
D. Schedule outpatient neuropsychological testing in 6 months
Answer: A
Rationale: Wernicke encephalopathy from thiamine deficiency is an acute,
potentially reversible condition in chronic alcoholics; immediate thiamine
replacement is a medical emergency and diagnostic/therapeutic step. Reassessment
after thiamine can show improvement. Memantine is not indicated acutely; urine
drug screen or delayed neuropsych testing are less urgent compared to prompt
thiamine replacement.
Key words: Wernicke, thiamine, reversible, alcohol, acute management
7
A 19-year-old college student reports “voices commenting” and visual
hallucinations for 2 days after heavy cannabis use. He is disoriented and has
fluctuating consciousness. What is the most appropriate immediate diagnostic
formulation?
, A. Primary psychotic disorder (schizophrenia)
B. Substance/medication-induced psychotic disorder with delirium
C. Brief psychotic disorder unrelated to substances
D. Schizoaffective disorder
Answer: B
Rationale: The temporal association with heavy cannabis use, acute onset,
disorientation, and fluctuating consciousness point toward a substance/medication-
induced psychosis with features of delirium. Primary psychotic disorders typically
have a different course (not acutely disoriented and substance temporality). Brief
psychotic disorder could be considered but the substance link and altered
consciousness favor substance-induced delirium/psychosis.
Key words: substance-induced psychosis, delirium, temporal relation, cannabis
8
A patient denies suicidal ideation verbally but gives ambiguous replies and has
previously attempted overdose three years ago. Which assessment technique
reduces risk of underestimating suicidality?
A. Rely only on self-report and mental status examination
B. Use collateral history from family and review past records, and directly ask
about intent, plan, and access to means
C. Assume no risk because current denial is present
D. Administer a global depression scale and defer suicide questions to the
psychiatrist on call
Answer: B
Rationale: To avoid underestimating suicide risk, clinicians should gather
collateral information, review past records, and ask direct questions about intent,
plan, timing, and access to means — especially when there is a history of past
attempts and ambiguous answers. Reliance on single self-report or deferring
without assessment is unsafe. Using a validated suicide assessment instrument plus
collateral is best practice.
Key words: suicide assessment, collateral, past attempt, intent/plan, safety
