Intro and Paraphilias CAM III
CLINICAL PSYCHIATRY · PARAPHILIAS & SEXUAL FUNCTION
50-Question Clinical Application Practice Exam
CAM III Psychiatry Module · Jamison Daniels PA-C · Class of 2027
Select the single best answer for each item. Content covers Lecture 1 (Introduction and Approach to Clinical Psychiatry): epidemiology, defining mental illness, rapport and transference, the psychiatric history, the full mental status examination, the Folstein MMSE, physical examination and diagnostic studies, and interviewing techniques including special populations — plus the Paraphilic Disorders and Disorders of Sexual Function lecture. Criteria, percentages, and thresholds follow the lecture slides. Answer key with clinical rationales follows.
BLOCK 1 — Epidemiology & Defining Mental Illness
1. A PA student is asked about the annual prevalence of mental illness among U.S. adults. Which figure is correct, and which disorder category is most common?
A. 1 in 10 adults; substance use disorders most common
B. 1 in 3 adults; psychotic disorders most common
C. 1 in 5 adults (~20-22%); anxiety disorders most common, followed by major depressive disorder
D. 1 in 20 adults; personality disorders most common
2. Which age group has the HIGHEST prevalence of mental illness but the LOWEST treatment utilization?
A. Ages 12-17
B. Ages 18-25
C. Ages 26-49
D. Ages 50 and older
3. Which three elements define a mental disorder according to the DSM-5-TR?
A. Clinically significant disturbance in cognition/emotion regulation/behavior, dysfunction in psychological/biological/developmental processes, and distress or impairment in functioning
B. Genetic predisposition, environmental trigger, and chronicity
C. Abnormal laboratory findings, imaging abnormalities, and symptom duration
D. Family history, medication response, and hospitalization history
4. Which statement correctly compares the DSM-5-TR and the ICD-11?
A. The ICD-11 is the primary U.S. classification system and provides diagnostic criteria
B. The DSM-5-TR is the primary U.S. system providing standardized criteria; the ICD-11 is also used for billing and global classification and includes some diagnoses not in the DSM, such as Complex PTSD
C. They are identical in content and use
D. The DSM-5-TR is used only for billing purposes
5. A patient meets DSM-5-TR criteria for a mild anxiety disorder but reports minimal functional impairment. Which statement is correct?
A. A psychiatric diagnosis always mandates pharmacologic treatment
B. A diagnosis guides prognosis and treatment but does not always require treatment; decisions are individualized based on symptom severity, functional impairment, and the risks and benefits of available treatments
C. Treatment should be withheld until symptoms become severe
D. Diagnosis and treatment decisions are the same process
BLOCK 2 — Rapport, Transference & Countertransference
6. A 42-year-old woman with a history of childhood abuse becomes hostile and accusatory toward her new PA during the first visit, stating she is sure he will hurt her. Which phenomenon does this illustrate?
A. Countertransference
B. Projection by the provider
C. Transference
D. Confrontation
7. A PA finds herself unusually impatient with a patient who reminds her of a difficult family member. Which phenomenon is occurring, and what is the appropriate response?
A. Transference; the patient should be reassigned immediately
B. Countertransference; maintain self-awareness and emotional regulation, aiming to understand the patient's behavior rather than react to it
C. Confrontation; point out the patient's behavior directly
D. Interpretation; explain the pattern to the patient
8. A PA feels uncomfortable taking a sexual history and rushes through the questions. What is the likely consequence?
A. Patient inhibition or reduced disclosure
B. The patient will appreciate the brevity
C. Improved rapport through efficiency
D. No effect on the interview
9. Which four elements are described as the components of establishing rapport?
A. Documentation, efficiency, diagnosis, and treatment
B. Confrontation, interpretation, silence, and transition
C. Putting the patient at ease, active listening, displaying empathy and compassion, and displaying confidence
D. Medication selection, dosing, monitoring, and follow-up
BLOCK 3 — Components of the Psychiatric History
10. A patient presenting for psychiatric evaluation states, 'The CIA is watching my house.' How should this be documented in the chief complaint?
A. Paraphrased as 'patient reports paranoid ideation'
B. Written exactly as stated by the patient, in quotation marks
C. Omitted because it is delusional content
D. Summarized as 'persecutory delusion'
11. Which statement about the psychiatric history is correct?
A. Laboratory testing is the single most important tool in establishing a psychiatric diagnosis
B. The patient's history is THE single most important tool in establishing a diagnosis
C. Imaging is the single most important tool
D. The mental status exam replaces the need for a history
12. Which set of questions belongs in the history of present illness for a psychiatric evaluation?
A. Onset of the current episode, precipitating events or triggers, life circumstances at symptom onset, and — if chronic — what prompted the patient to seek care now
B. Only current medications and allergies
C. Only family psychiatric history
D. Only the results of prior diagnostic studies
13. Which medical history elements are singled out as especially important in the psychiatric evaluation?
A. Orthopedic surgeries and dermatologic conditions
B. Dental history and vision correction
C. Craniocerebral trauma, neurological disorders, seizure disorders, and cancer
D. Allergies to environmental agents only
14. Which elements should be included in the identifying data section of a psychiatric evaluation?
A. Only name and age
B. Name, age, sex, marital status, occupation, language, ethnicity, religion, current living situation, source of information and reliability, and location of interview
C. Only chief complaint and HPI
D. Only insurance information and referring provider
BLOCK 4 — MSE: Appearance, Motor, Speech & Affect
15. Which statement about the mental status examination is correct?
A. It is a fixed checklist of questions asked in a specific order
B. Most of it is gathered through observation during the interview, and it can change during the interview unlike the patient's history
C. It is a head-to-toe physical examination
D. It should be completed before the history is obtained
16. A 58-year-old man with severe depression speaks in a slow, quiet voice with long pauses, moves deliberately, and has difficulty buttoning his shirt. Which term describes this finding?
A. Psychomotor agitation
B. Akathisia
C. Catatonia
D. Psychomotor retardation
17. A patient shows virtually no emotional expression, with a monotone voice and immobile face. Which term applies?
A. Constricted affect
B. Blunted affect
C. Flat affect
D. Labile affect
18. Which statement correctly distinguishes mood from affect?
A. Mood is the provider's observation; affect is what the patient reports
B. Mood is the patient's subjective emotional state stated in their own words; affect is the observed emotional expression and responsiveness
C. They are interchangeable terms
D. Mood is assessed only in depression; affect only in mania
19. Which characteristics belong to the SPEECH portion of the mental status exam?
A. Content of thought and presence of delusions
B. Orientation and memory
C. Insight and judgment
D. Rate, volume, rhythm, amount, and articulation
BLOCK 5 — MSE: Thought Process
20. A patient asked about his medications gives a long account including what he ate for breakfast and the weather, but eventually answers the question. Which thought process is this?
A. Tangential
B. Loose associations
C. Circumstantial
D. Flight of ideas
21. A patient's responses shift between ideas that have little or no relationship to one another, and he appears unaware of the lack of coherence. Which term applies?
A. Circumstantiality
B. Thought blocking
C. Perseveration
D. Loose associations
22. A patient responds to a question by saying, 'I'm feeling fine, wine, dine, nine, sign.' Which thought process abnormality is this?
A. Neologism
B. Flight of ideas
C. Clang associations
D. Word salad
23. A 26-year-old man in a manic episode speaks rapidly and shifts from topic to topic, with links between ideas that are understandable but superficial. Which term describes this, and in what condition is it commonly seen?
A. Word salad; schizophrenia
B. Thought blocking; depression
C. Flight of ideas; mania, as in bipolar disorder
D. Perseveration; dementia
24. A patient's speech is goal-directed with clear cause-and-effect reasoning, but the conclusions he reaches are false and fixed. How is this best characterized?
A. Word salad
B. Thought process may appear linear but illogical, suggesting delusional thinking
C. Circumstantiality
D. Normal thought process with no abnormality
BLOCK 6 — MSE: Thought Content, Perception, Insight & Judgment
25. An elated patient believes she is the Virgin Mary. A second elated patient believes he has a brain tumor. How are these classified?
A. Both are mood-congruent delusions
B. Neither represents a delusion
C. Both are mood-incongruent delusions
D. The first is mood-congruent, the second is mood-incongruent
26. A patient reports that the television news anchor is speaking directly to him and sending him personal messages. Which delusion type is this?
A. Delusion of grandeur
B. Delusion of persecution
C. Delusion of control
D. Delusion of reference
27. A patient hears creaking sounds in his house at night and interprets them as footsteps. Which term applies?
A. Auditory hallucination
B. Delusion of persecution
C. Illusion
D. Depersonalization
28. A patient acknowledges he has been unwell but insists it is entirely due to his neighbors poisoning his water. How is his insight characterized?
A. Partial insight
B. No insight
C. Good insight
D. Insight cannot be assessed
29. A patient endorses suicidal ideation. Which components must be assessed?
A. Plan (specific method), intent (likelihood of acting), and means or access
B. Only whether they have a plan
C. Only prior attempts
D. Only family history
BLOCK 7 — The Folstein Mini-Mental State Exam
30. A 79-year-old woman scores 21 on the Folstein MMSE. How is this interpreted?
A. No cognitive impairment
B. The score is invalid
C. Severe impairment
D. Mild impairment
31. Which statement about the Folstein MMSE is correct?
A. It is sufficient on its own to diagnose dementia
B. It cannot be used to track cognitive change
C. It is a screening tool for cognitive impairment used to screen for dementia and delirium and track change over time, but is NOT sufficient alone to diagnose dementia
D. It is the only cognitive screening tool available
BLOCK 8 — Physical Exam & Diagnostic Studies
32. Which statement about laboratory testing in psychiatry is correct?
A. No laboratory test can confirm or rule out primary psychiatric disorders; labs are used to rule out underlying medical causes and to monitor treatment
B. Laboratory tests can confirm the diagnosis of schizophrenia and bipolar I disorder
C. Laboratory testing is never indicated in psychiatric evaluation
D. Laboratory tests replace the need for a history
33. Which set constitutes the basic screening laboratory tests in an initial psychiatric evaluation?
A. Only a urine drug screen
B. Only a TSH
C. CBC, CMP, TSH, and UA, with UPT, UDS, and CT brain as needed
D. CBC and blood cultures
34. Which is an indication for CT of the brain in a psychiatric patient?
A. Chronic stable schizophrenia with no change in symptoms
B. Established diagnosis of generalized anxiety disorder
C. Routine screening before starting any antidepressant
D. Sudden onset of new psychiatric symptoms such as new-onset psychosis, acute mental status change, neurologic deficits, or neurologic symptoms with fever
35. In which psychiatric scenario is an EEG most appropriate?
A. Suspected pseudoseizures or a sudden unexplained change in mental status
B. Routine baseline before starting an SSRI
C. Monitoring lithium levels
D. Assessing insight and judgment
36. Which patients should have an ECG considered before starting a psychotropic medication?
A. All patients without exception
B. Patients with cardiac history, electrolyte abnormalities, or concurrent use of multiple QT-prolonging medications
C. Only patients under 18
D. Only patients starting an SSRI
BLOCK 9 — Interviewing Techniques & Special Populations
37. A patient describes a difficult experience and the PA responds, 'It sounds like you felt abandoned when that happened.' Which technique is this?
A. Reflection
B. Confrontation
C. Interpretation
D. Facilitation
38. A PA gently points out to a patient that he has said he does not drink but also described drinking daily. Which technique is being used, and what is the caution?
A. Confrontation; must be used carefully as it can disrupt the therapeutic alliance, especially with delusional thinking or poor insight
B. Interpretation; requires no established rapport
C. Summation; may confuse the patient
D. Reassurance; may be false
39. Which statement about reassurance as an interviewing technique is correct?
A. All reassurance strengthens the therapeutic relationship
B. Truthful reassurance enhances trust, support, and adherence; false reassurance is misleading, undermines trust, and may reduce compliance
C. Reassurance should never be used in psychiatry
D. Reassurance is synonymous with positive reinforcement
40. A patient with paranoid personality traits is guarded, suspicious, and critical during the interview. Which approach is most appropriate?
A. Warm, highly familiar, and personally disclosing
B. Respectful, professional, and somewhat formal, since excessive warmth may increase suspicion and defensiveness
C. Confrontational, to challenge the mistrust directly
D. Silent, allowing the patient to lead entirely
41. A severely depressed patient has difficulty concentrating and speaking spontaneously. Which interviewing adjustment is appropriate?
A. Use long silences to allow the patient to gather thoughts
B. Limit the interview to closed-ended questions only
C. Long silences are often NOT helpful; the provider may need to guide and structure the interview
D. Defer the interview until the patient improves
42. A patient in the emergency department is becoming increasingly agitated with pacing and restlessness. Which safety measures apply?
A. Position yourself between the patient and the door to prevent elopement
B. Place a hand on the patient's shoulder to calm them
C. Maintain prolonged direct eye contact to establish dominance
D. Ensure no physical barrier to exiting the room, avoid standing over the patient or staring, and terminate the interview immediately if agitation escalates
BLOCK 10 — Paraphilic Disorders
43. What duration criterion is common to all paraphilic disorders under DSM-5?
A. At least 6 months
B. At least 3 months
C. At least 1 month
D. At least 12 months
44. Which paraphilic disorder has the highest reported incidence among males?
A. Voyeuristic disorder at approximately 12%
B. Exhibitionistic disorder at approximately 2-4%
C. Pedophilic disorder at approximately 1%
D. Sexual sadism disorder at less than 1%
45. A 34-year-old man presents with distress over recurrent urges involving nonliving objects that have been present for over a year. His mental status examination is normal. Which disorder is this, and what is the expected MSE finding?
A. Exhibitionistic disorder; anxious and defensive
B. Pedophilic disorder; guarded or evasive
C. Voyeuristic disorder; anxious or secretive
D. Fetishistic disorder; usually normal
46. Which treatment approach is common across the paraphilic disorders discussed?
A. Antipsychotics as monotherapy
B. Electroconvulsive therapy
C. Benzodiazepines as first line
D. CBT, aversion therapy, and SSRIs, with anti-androgens for selected disorders
47. Which statement about sexual sadism disorder is correct?
A. Diagnosis requires either acting on urges with a non-consenting person OR that the urges cause clinically significant distress or impairment
B. Diagnosis requires distress only, never behavior toward others
C. Prevalence is highest in the general population
D. It is more common than sexual masochism disorder
BLOCK 11 — Disorders of Sexual Function
48. A 44-year-old woman reports 8 months of markedly reduced sexual interest and arousal causing significant personal distress. Which FDA-approved medication is specified for this condition, and what is its mechanism?
A. Sildenafil; PDE5 inhibitor
B. Bupropion; NDRI
C. Testosterone; androgen replacement
D. Flibanserin (Addyi); selective serotonin receptor agonist and antagonist
49. What is the reported incidence of male hypoactive sexual desire disorder?
A. Up to 5% of men
B. Up to 50% of men
C. Up to 30% of men
D. Up to 15% of men
50. A 39-year-old man reports low sexual desire causing relationship strain. He was started on an SSRI four months ago. Which management consideration is most relevant?
A. Assess mood and cognition, and consider medication adjustment as part of treatment
B. Immediately start testosterone replacement
C. Refer directly for surgical evaluation
D. Reassure him that medications do not affect sexual desire
ANSWER KEY & CLINICAL RATIONALES
Intro to Clinical Psychiatry & Paraphilic Disorders · 50 Questions
BLOCK 1 — Epidemiology & Defining Mental Illness
1. C. 1 in 5 adults (~20-22%); anxiety disorders most common, followed by major depressive disorder
Approximately 1 in 5 U.S. adults have a mental illness annually (about 20-22%), and roughly 50% of individuals will meet criteria for a mental disorder in their lifetime. ANXIETY DISORDERS are most common, followed by major depressive disorder. Only about 50% of adults with mental illness receive treatment each year. Females are affected more than males, especially for anxiety and depressive disorders.
2. B. Ages 18-25
Ages 18-25 have the highest prevalence of mental illness and the lowest treatment utilization — a combination that makes this group a particular clinical concern. Adolescents have an annual prevalence of about 20-25%, and suicide is the second leading cause of death in ages 10-14.
3. A. Clinically significant disturbance in cognition/emotion regulation/behavior, dysfunction in psychological/biological/developmental processes, and distress or impairment in functioning
The DSM-5-TR defines a mental disorder as a clinically significant DISTURBANCE in cognition, emotion regulation, or behavior; reflecting DYSFUNCTION in psychological, biological, or developmental processes; usually associated with DISTRESS or IMPAIRMENT in functioning (social, occupational, or other important areas). The high-yield shorthand is disturbance + dysfunction + distress/impairment.
4. B. The DSM-5-TR is the primary U.S. system providing standardized criteria; the ICD-11 is also used for billing and global classification and includes some diagnoses not in the DSM, such as Complex PTSD
Psychiatric disorders in the U.S. are primarily classified using the DSM-5-TR (Text Revision, 2022), which provides standardized diagnostic criteria. The ICD-11 is also used for billing and global classification and includes some diagnoses not in the DSM, such as Complex PTSD. Note that exams such as the PANCE are based on DSM criteria and may not immediately reflect recent revisions.
5. B. A diagnosis guides prognosis and treatment but does not always require treatment; decisions are individualized based on symptom severity, functional impairment, and the risks and benefits of available treatments
A psychiatric diagnosis helps guide prognosis and treatment, but does NOT always require treatment. Treatment decisions are individualized and based on symptom severity, degree of functional impairment, and the risks and benefits of available treatments.
BLOCK 2 — Rapport, Transference & Countertransference
6. C. Transference
TRANSFERENCE is the patient's expectations, beliefs, and emotional responses brought into the provider relationship, shaped by past experiences and personality. It often reflects PAST RELATIONSHIPS rather than the actual provider and may be positive or negative. Examples: basic trust leading to over-idealization of the provider, and basic mistrust leading to expectation of harm or abuse. It is primarily patient-driven but can be influenced by clinician behavior.
7. B. Countertransference; maintain self-awareness and emotional regulation, aiming to understand the patient's behavior rather than react to it
COUNTERTRANSFERENCE is the provider's emotional reactions and attitudes toward the patient, often influenced by the provider's own experiences, beliefs, and biases. It can lead to perceptions such as 'ideal patient' versus 'difficult patient.' Management requires SELF-AWARENESS and EMOTIONAL REGULATION, aiming to UNDERSTAND the patient's behavior (hostility, resistance) rather than react to it, using reflection and empathy to de-escalate tension and maintain the therapeutic alliance.
8. A. Patient inhibition or reduced disclosure
Discussing sexual history can be challenging due to provider discomfort or anxiety, and this can lead to PATIENT INHIBITION OR REDUCED DISCLOSURE. Emotional reactions on either side may limit open communication. This requires a NONJUDGMENTAL, COMFORTABLE clinical approach.
9. C. Putting the patient at ease, active listening, displaying empathy and compassion, and displaying confidence
Establishing rapport involves PUTTING THE PATIENT AT EASE, MASTERING ACTIVE LISTENING, DISPLAYING EMPATHY AND EXPRESSING COMPASSION, and DISPLAYING CONFIDENCE. Rapport is defined as a close, harmonious relationship with mutual understanding and effective communication, based on trust, empathy, and understanding, relying on open two-way communication. A strong therapeutic relationship is essential for accurate diagnosis and effective care.
BLOCK 3 — Components of the Psychiatric History
10. B. Written exactly as stated by the patient, in quotation marks
The chief complaint is written EXACTLY AS STATED BY THE PATIENT, IN QUOTATION MARKS, and should NOT be paraphrased regardless of content. Examples from the lecture include 'The CIA is watching my house,' 'God speaks to me through my right molar,' 'I've been having a lot of anxiety lately,' and 'I need help.'
11. B. The patient's history is THE single most important tool in establishing a diagnosis
The patient's HISTORY is THE single most important tool in establishing a psychiatric diagnosis. The psychiatric evaluation comprises elements of the psychiatric history, mental status examination, physical examination, diagnostic studies, and documentation.
12. A. Onset of the current episode, precipitating events or triggers, life circumstances at symptom onset, and — if chronic — what prompted the patient to seek care now
Helpful HPI questions are: when was the onset of the current episode, what were the precipitating events or triggers, what were the patient's life circumstances at symptom onset, and if symptoms are chronic what prompted the patient to seek care now. The HPI is a chronological description of events leading to the current interview, including the relationship between psychological stressors and symptom onset, and relevant psychiatric positives and negatives. TIMING AND ONSET are very important, as most psychiatric conditions have timing as part of diagnostic criteria.
13. C. Craniocerebral trauma, neurological disorders, seizure disorders, and cancer
The past medical and surgical history should include major medical and surgical illnesses and significant traumas, with CRANIOCEREBRAL TRAUMA, NEUROLOGICAL DISORDERS, SEIZURE DISORDERS, and CANCER especially important. Infectious diseases with neuropsychiatric relevance, such as HIV/AIDS and syphilis, should also be documented.
14. B. Name, age, sex, marital status, occupation, language, ethnicity, religion, current living situation, source of information and reliability, and location of interview
Identifying data is a concise demographic summary including name, age, sex, marital status, occupation, language, ethnicity, religion, current living situation, SOURCE OF INFORMATION AND RELIABILITY, and LOCATION OF INTERVIEW. The reliability of the informant and where the interview took place are frequently forgotten components.
BLOCK 4 — MSE: Appearance, Motor, Speech & Affect
15. B. Most of it is gathered through observation during the interview, and it can change during the interview unlike the patient's history
The MSE is the provider's OBSERVATIONS of the patient during the interview, providing a 'snapshot' of current functioning. It CAN CHANGE during the interview, unlike the patient's history. It is NOT a checklist of questions, information is NOT obtained in a fixed order, and it is NOT a head-to-toe physical exam. MOST of the MSE is gathered through OBSERVATION, requiring active listening, observation, and ongoing assessment.
16. D. Psychomotor retardation
PSYCHOMOTOR RETARDATION (psychomotor slowing) refers to slowed movements or decreased activity, involving both physical movements and mental processes, often seen in severe depression. Examples include speaking slowly and quietly with long pauses, moving slowly, difficulty with fine motor tasks, avoiding eye contact, reduced facial expression, and difficulty with memory and attention. PSYCHOMOTOR AGITATION is the opposite — restlessness, pacing, wringing hands, rocking.
17. C. Flat affect
The affect gradient runs: NORMAL RANGE (appropriate variation in facial expression, tone of voice, body movements), CONSTRICTED (reduced range and intensity), BLUNTED (markedly reduced expression), and FLAT (virtually no emotional expression — monotone voice, immobile face). LABILE affect is abrupt, rapid, and repeated shifts in emotion.
18. B. Mood is the patient's subjective emotional state stated in their own words; affect is the observed emotional expression and responsiveness
MOOD is the patient's SUBJECTIVE emotional state, stated IN THEIR OWN WORDS, and is useful for tracking change over time. AFFECT is the OBSERVED emotional expression and responsiveness during the interview. Appropriateness of affect assesses whether emotional expression matches the content being discussed; INAPPROPRIATE or INCONGRUENT affect is affect not consistent with what the patient is saying.
19. D. Rate, volume, rhythm, amount, and articulation
Speech in the MSE describes the PHYSICAL CHARACTERISTICS of the patient's speech: RATE (slow, hesitant, long pauses, rapid, pressured), VOLUME (soft, normal, loud), RHYTHM (monotone, stuttering), AMOUNT (verbose, minimal, mute), and ARTICULATION (clear, mumbling, slurred). Content of speech belongs under thought content, not speech.
BLOCK 5 — MSE: Thought Process
20. C. Circumstantial
CIRCUMSTANTIAL thought process includes excessive, irrelevant detail but EVENTUALLY RETURNS TO THE POINT. TANGENTIAL thought process deviates from the topic and does NOT return to the original point. That single difference — whether the patient gets there in the end — is the discriminator.
21. D. Loose associations
LOOSE ASSOCIATIONS describe disrupted logical connections between ideas, where thoughts shift with little or no relationship between them and the patient is OFTEN UNAWARE of the lack of coherence. WORD SALAD is severely disorganized, incoherent speech with no meaningful connection between words, representing the EXTREME END of loose associations.
22. C. Clang associations
CLANG ASSOCIATIONS are speech driven by the SOUND of words — rhyming, puns — rather than meaning. NEOLOGISMS are newly created words formed by combining or altering existing words, with idiosyncratic meaning. Both are distinct from flight of ideas, which is about the RATE and shifting of topics rather than the basis of word selection.
23. C. Flight of ideas; mania, as in bipolar disorder
FLIGHT OF IDEAS is rapid, pressured speech with frequent shifts from topic to topic, where links between ideas MAY BE UNDERSTANDABLE OR SUPERFICIAL. It is commonly seen in MANIA, as in bipolar disorder. This contrasts with loose associations, where connections between ideas are absent rather than superficial.
24. B. Thought process may appear linear but illogical, suggesting delusional thinking
Thought process describes HOW the patient thinks and connects ideas. Logical and coherent means goal-directed, relevant responses with clear cause-and-effect reasoning. However, thought process MAY APPEAR LINEAR BUT ILLOGICAL, which SUGGESTS DELUSIONAL THINKING — the structure is intact but the premises are false.
BLOCK 6 — MSE: Thought Content, Perception, Insight & Judgment
25. D. The first is mood-congruent, the second is mood-incongruent
Delusions are fixed, false beliefs held with strong conviction despite evidence to the contrary, and the patient has NO INSIGHT OR DOUBT regarding the belief. They may be MOOD-CONGRUENT or MOOD-INCONGRUENT. The lecture's examples: an elated patient who believes she is the Virgin Mary is CONGRUENT with her elevated mood, while an elated patient who believes he has a brain tumor is INCONGRUENT.
26. D. Delusion of reference
DELUSIONS OF REFERENCE (ideas of reference) are the belief that external media — TV, radio, newspapers — are specifically referring to or communicating with the patient. DELUSIONS OF INFLUENCE/CONTROL involve an external force controlling thoughts, feelings, or behavior. DELUSIONS OF GRANDEUR involve exceptional power, importance, talent, or identity. DELUSIONS OF PERSECUTION (paranoid) involve being watched, targeted, or harmed.
27. C. Illusion
An ILLUSION is a MISINTERPRETATION OF A REAL EXTERNAL STIMULUS — the lecture's example is hearing footsteps from creaking sounds. A HALLUCINATION, by contrast, occurs WITHOUT an external stimulus and may be auditory, visual, tactile, or olfactory. Screening questions include 'Have you ever heard voices or sounds that others could not hear or when no one else was around?' and 'Have you ever seen things that others could not see?'
28. A. Partial insight
Insight is the degree to which the patient understands and is aware of their illness. NO INSIGHT is complete denial of illness. PARTIAL INSIGHT is awareness of illness but EXTERNALIZING THE CAUSE — blaming others or physical factors. GOOD INSIGHT recognizes the illness and understands implications and prognosis.
29. A. Plan (specific method), intent (likelihood of acting), and means or access
When suicidal or homicidal ideation is present it MUST be assessed for PLAN (specific method), INTENT (likelihood of acting), and MEANS/ACCESS. If homicidal ideation is present, identify the target(s) if applicable. A thorough suicide assessment also includes perceived consequences, history of prior attempts, and family history of suicide. Importantly, ASKING ABOUT SUICIDE DOES NOT INCREASE RISK.
BLOCK 7 — The Folstein Mini-Mental State Exam
30. D. Mild impairment
The Folstein MMSE scores range from 0-30: 24-30 indicates NO cognitive impairment, 19-23 indicates MILD impairment, and 0-18 indicates SEVERE impairment. A score of 21 falls in the mild range. Note these are the bands as taught in this lecture.
31. C. It is a screening tool for cognitive impairment used to screen for dementia and delirium and track change over time, but is NOT sufficient alone to diagnose dementia
The Folstein MMSE has historically been the most widely used screening tool for cognitive impairment, used to screen for DEMENTIA AND DELIRIUM and to track cognitive change over time. It is NOT SUFFICIENT ON ITS OWN TO DIAGNOSE DEMENTIA. It is introduced to the patient with a statement such as 'Now I'm going to ask you some questions to test your memory and concentration.' Note that it now incurs a licensing fee and is often discouraged for routine use by general practitioners in the U.S.
BLOCK 8 — Physical Exam & Diagnostic Studies
32. A. No laboratory test can confirm or rule out primary psychiatric disorders; labs are used to rule out underlying medical causes and to monitor treatment
NO LABORATORY TEST CAN CONFIRM OR RULE OUT primary psychiatric disorders such as schizophrenia, bipolar I disorder, or major depressive disorder. Labs are primarily used to RULE OUT UNDERLYING MEDICAL CAUSES of psychiatric symptoms, and to monitor treatment and medication effects — including drug levels and lithium monitoring with electrolytes, thyroid function, and renal function.
33. C. CBC, CMP, TSH, and UA, with UPT, UDS, and CT brain as needed
Basic screening tests are CBC, CMP, TSH, and UA, with urine pregnancy test, urine drug screen, and CT brain as needed. These rule out medical causes and establish a baseline for monitoring. Thyroid and endocrine disorders can produce mood symptoms or psychosis, and infection, cancer, or connective tissue disease can produce psychiatric or acute mental status changes.
34. D. Sudden onset of new psychiatric symptoms such as new-onset psychosis, acute mental status change, neurologic deficits, or neurologic symptoms with fever
CT brain indications include SUDDEN ONSET of new psychiatric symptoms such as new-onset psychosis, ACUTE CHANGES IN MENTAL STATUS, NEUROLOGICAL DEFICITS on examination, and NEUROLOGICAL SYMPTOMS IN THE SETTING OF FEVER — in which case lumbar puncture should also be considered. X-rays may be used if foreign body ingestion is suspected.
35. A. Suspected pseudoseizures or a sudden unexplained change in mental status
EEG records the electrical activity of the brain and may be ordered in psychiatry for a SUDDEN, UNEXPLAINED CHANGE IN MENTAL STATUS or SUSPECTED PSEUDOSEIZURES (psychogenic nonepileptic seizures). A normal EEG can help support exclusion of certain neurologic conditions that may present with psychiatric or behavioral symptoms.
36. B. Patients with cardiac history, electrolyte abnormalities, or concurrent use of multiple QT-prolonging medications
An ECG is not universally required but should be CONSIDERED before starting psychotropic medications, assessing for QT prolongation and arrhythmia risk — especially with ANTIPSYCHOTICS, TCAs, and METHADONE. It is recommended in patients with cardiac history, electrolyte abnormalities, or concurrent use of multiple QT-prolonging medications, and is increasingly important in inpatient settings due to rapid titration and frequent PRN use.
BLOCK 9 — Interviewing Techniques & Special Populations
37. A. Reflection
REFLECTION is repeating or paraphrasing what the patient has said in a supportive manner. It confirms the provider has understood the patient correctly and communicates that they are being heard and understood. FACILITATION uses verbal and nonverbal cues encouraging the patient to continue — nodding, 'Yes, and then...?', 'Uh-huh, go on...'
38. A. Confrontation; must be used carefully as it can disrupt the therapeutic alliance, especially with delusional thinking or poor insight
CONFRONTATION gently points out inconsistencies, avoidance, or denial in what the patient is expressing, intended to help the patient recognize what is being missed or avoided in a direct but respectful manner. It MUST BE USED CAREFULLY as it can DISRUPT THE THERAPEUTIC ALLIANCE, especially in patients with delusional thinking or poor insight.
39. B. Truthful reassurance enhances trust, support, and adherence; false reassurance is misleading, undermines trust, and may reduce compliance
TRUTHFUL reassurance can enhance trust, support, and treatment adherence and conveys empathy. FALSE reassurance is misleading, undermines trust, and may reduce compliance. POSITIVE REINFORCEMENT is a separate technique — it helps patients feel comfortable sharing openly and communicates that the provider is not judgmental, for example 'I appreciate you telling me that.'
40. B. Respectful, professional, and somewhat formal, since excessive warmth may increase suspicion and defensiveness
Suspicious patients may have chronic, deeply ingrained mistrust that others intend harm — for example paranoid personality traits — and are often highly suspicious, guarded, and critical. Use a RESPECTFUL, PROFESSIONAL, AND SOMEWHAT FORMAL approach, because EXCESSIVE WARMTH OR FAMILIARITY MAY INCREASE SUSPICION AND DEFENSIVENESS.
41. C. Long silences are often NOT helpful; the provider may need to guide and structure the interview
Severely depressed patients may have difficulty concentrating, thinking clearly, and speaking spontaneously. LONG SILENCES ARE OFTEN NOT HELPFUL, and the provider may need to GUIDE AND STRUCTURE the interview. This contrasts with the general use of silence as a technique, where purposeful silence allows the patient to think, reflect, cry, or continue at their own pace.
42. D. Ensure no physical barrier to exiting the room, avoid standing over the patient or staring, and terminate the interview immediately if agitation escalates
The goal with potentially violent patients is to complete an assessment while ensuring safety. Unpremeditated violence is often preceded by a PRODROME OF INCREASING PSYCHOMOTOR AGITATION. Conduct the interview in a quiet, non-stimulating environment; ensure NO PHYSICAL BARRIER TO EXITING THE ROOM; AVOID behaviors perceived as threatening such as standing over the patient, staring, or inappropriate touch; TERMINATE the interview immediately if agitation escalates; and in severe cases involve security and consider physical or chemical restraints.
BLOCK 10 — Paraphilic Disorders
43. A. At least 6 months
All paraphilic disorders are manifested by fantasies, urges, or behaviors for AT LEAST 6 MONTHS. This shared duration threshold applies across exhibitionistic, voyeuristic, fetishistic, sexual masochism, sexual sadism, and pedophilic disorders, and also to the sexual dysfunction disorders covered in this lecture.
44. A. Voyeuristic disorder at approximately 12%
Reported incidences from the lecture: VOYEURISTIC disorder approximately 12% of males (rare in females) — the highest of those listed; EXHIBITIONISTIC disorder approximately 2-4% of males, rare in females; SEXUAL MASOCHISM approximately 2% in nonclinical males; PEDOPHILIC disorder approximately 1% of males, rare in females; SEXUAL SADISM less than 1%, with higher rates in forensic populations.
45. D. Fetishistic disorder; usually normal
FETISHISTIC DISORDER is sexual arousal from nonliving objects or non-genital body parts for at least 6 months, more common in males, with conditioning and psychodynamic etiologies. Its characteristic MSE finding is USUALLY NORMAL. Contrast the MSE findings across the disorders: exhibitionistic — anxious, defensive; voyeuristic — may be anxious or secretive; pedophilic — may appear guarded or evasive; masochism/sadism — normal cognition, may show preoccupation, guilt, or distress.
46. D. CBT, aversion therapy, and SSRIs, with anti-androgens for selected disorders
Treatment across the paraphilic disorders consistently includes CBT, AVERSION THERAPY, and SSRIs. ANTI-ANDROGENS are specified for sexual sadism/masochism and for pedophilic disorder. Referral indications include psychotherapy and legal or forensic support, and more broadly risk to self or others, legal issues, severe distress, or comorbidities.
47. A. Diagnosis requires either acting on urges with a non-consenting person OR that the urges cause clinically significant distress or impairment
SEXUAL SADISM DISORDER requires recurrent intense sexual arousal from the physical or psychological suffering of another person, present at least 6 months, and EITHER the individual has ACTED ON THESE URGES WITH A NON-CONSENTING PERSON, OR the urges/fantasies cause clinically significant distress or impairment. It is LESS common than sexual masochism (under 1% vs approximately 2%), with higher rates in forensic populations. Note that sexual masochism may include asphyxiophilia, sexual arousal from oxygen deprivation.
BLOCK 11 — Disorders of Sexual Function
48. D. Flibanserin (Addyi); selective serotonin receptor agonist and antagonist
FEMALE SEXUAL INTEREST/AROUSAL DISORDER is lack or reduced sexual interest/arousal for at least 6 months causing distress, with an incidence up to 30% of women. FLIBANSERIN (ADDYI) is the FDA-approved medication, described as a SELECTIVE SEROTONIN RECEPTOR AGONIST AND ANTAGONIST. Other treatment includes psychotherapy, hormone therapy, and couples counseling, with referral to a sexual health specialist or psychologist.
49. D. Up to 15% of men
MALE HYPOACTIVE SEXUAL DESIRE DISORDER is deficient sexual desire for at least 6 months causing distress, with an incidence UP TO 15% OF MEN. Compare with female sexual interest/arousal disorder at up to 30% of women. Etiology is hormonal, psychological, or medical; treatment includes psychotherapy, hormones, and MEDICATION ADJUSTMENTS.
50. A. Assess mood and cognition, and consider medication adjustment as part of treatment
For male hypoactive sexual desire disorder, the MSE component is to ASSESS MOOD AND COGNITION, and treatment includes psychotherapy, hormones, and MEDICATION ADJUSTMENTS. Etiology is hormonal, psychological, or medical — and given that SSRIs commonly cause sexual dysfunction, medication review is a central consideration. Recall from the depression lecture that bupropion and mirtazapine have minimal sexual side effects and are preferred when this is a concern.
QUICK-SCORE ANSWER GRID
1. C 2. B 3. A 4. B 5. B
6. C 7. B 8. A 9. C 10. B
11. B 12. A 13. C 14. B 15. B
16. D 17. C 18. B 19. D 20. C
21. D 22. C 23. C 24. B 25. D
26. D 27. C 28. A 29. A 30. D
31. C 32. A 33. C 34. D 35. A
36. B 37. A 38. A 39. B 40. B
41. C 42. D 43. A 44. A 45. D
46. D 47. A 48. D 49. D 50. A