MENTAL STATUS EXAMINATION

Loosening of associations is an example of formal thought disorder, which is a disturbance in the form of thought rather than content of thought. It is a characteristic feature of schizophrenia.

Loosening of association refers to lack of connection between the ideas expressed by the patient. The links between ideas may be illogical or they wander from the original theme. In its extreme form, loosening of association leads to totally incoherent thought and speech (word salad).

Ref: Psychiatry By John Geddes, 4th edition page 248; Kaplan & Sadock’s Comprehensive Textbook of Psychiatry, 9th edition page 924; Psychopathology: History, Diagnosis, and Empirical Foundations By W. Edward Craighead, 2nd edition page 406.

Thought disorders can be of 2 types:

a) Disorders of thought form or stream e.g. Thought block, formal thought disorder in Schizophrenia, disorganised thinking, derailment in thinking etc
b) Disorders of thought content e.g. Delusions, obsessions and compulsions etc

Hallucinations are not thought disorders. They are perceptual abnormalities. Hallucinations can however lead to secondary delusions. 

Ans:C-Delusion of infedility

• Othello Syndrome or Delusional jealousy is a psychiatric disorder in which a person holds a strong delusional belief that their spouse or sexual partner is being unfaithful without having any, very little, or insignificant proof to back up their claim.
• People who suffer from this disorder have a strong association with stalking, cyberstalking, sabotage, or even violence.
• It can be found in the context of schizophrenia and delusional disorder, such as bipolar disorder, but is also associated with alcoholism and sexual dysfunction and after neurological illness.

Ans:D-Inability to recognize & describe feelings 

Alexithymia is inability or disability in describing or being aware of one’s emotions or mood.

It is seen in elaboration of fantasies associated with depression, substance abuse, and post traumatic stress disorder.

Signs and symptoms of alexithymia include:

• difficulties identifying feelings and emotions
• problems distinguishing between emotions and bodily sensations that relate to those emotions
• limited ability to communicate feelings to others
• difficulties recognizing and responding to emotions in others, including tone of voice and facial expressions
• a lack of fantasies and imagination
• a logical and rigid thinking style that does not account for emotions
• poor coping skills when it comes to dealing with stress
• behaving less altruistically than others
• appearing distant, rigid, and humorless
• poor life satisfaction

Ans:A. i.e. Hypnagogic hallucinations

• Hypnagogic hallucinations are imagined sensations that seem very real.
• They occur as a person is falling asleep, and are also referred to as sleep hallucinations.
• The term hypnopompic describes the period when a person wakes up. 
• Hypnagogic defines the period when a person falls asleep

Ans:B. i.e. Delusion

Obsessive compulsive disorder,Schizophrenia & Loosening of association are formal thought disorders.

Whereas delusion is a disorder of content of thought

Ans:C-Verbigeration is senseless repetition in response to stimulus

• Verbigeration is obsessive repetition of random words.
• It is similar to perseveration, in which a person repeats words in response to a stimulus.
• However, verbigeration occurs when a person repeats words without a stimulus.

Ans:C i.e. Thought Block

• Formal thought disorder typically refer to marked abnormalities in the form & flow of or connectivity of thought; some clinicians use the term broadly to include any psychotic cognitive sign or symptoms. So broadly speaking all can be included in formal thought disorder but in tangentiality, loosening of association and derailment the form of thought is more disordered than thought block. (Kaplan’s & CDTP)

• In formal thought disorder, the structure or form of thought is disordered. It includes perseveration, flight of ideas (clang association, puns, rhymes), loosening of associations, derailment, vorbeireden, verbigeration (word salad) (Oxford); tangentiality, transitory thinking, substitution, omission, drivelling, desultory thinking, neologism, poverty of speech and poverty of content (Fish). Whereas thought block is mainly a disorder of flow/stream of thought.

D i.e. Foul odour

B i.e. Othello syndrome

It is characterized by nonbizzare delusion of atleast one month duration with overall well preserved personality (except in the area of delusion) and absence of significant hallucinations. 

D i.e. Delirium

Ans. B i.e. Delusion

Delusion is a disorder of thought content (NOT a formal thought disorder/disorder of thought process)

Delusion

• Disorder of thought;
• False unshaken belief not amenable to reasoning

Schizophrenia- Formal thought disorder

Loosening of association-Formal thought disorder-Loss of connection between components of same thought

Clanging-Form of thought disorder-Words are associated with each other,as they sound similar & there may be lack of meaningful connection

Ans. C: Abnormal perception by a sensory misinterpretation of actual stimulus

Illusion is an abnormal perception caused by a sensory misinterpretation of actual stimulus, sometimes precipitated by strong emotion, e.g. fear provoking a person to imagine they have seen an intruder in the shadows.

Ans. Misinterpretation of real objects

Ans:C-Nihilistic delusions

Nihilistic delusions:- False belief that oneself, others or the world is non-existent or about to end. There are pessimistic ideas that the patient’s career is finished, he is about to die, world is doomed. These occur in severe depression. If nihilistic delusions are accompanied by ideas concerning bodily function failure, e.g., putrefaction of intestines, etc., the syndrome is called COTARD’s SYNDROME.

Ans. is ‘b’ i.e., Obsession

Obsessive compulsive disorder (OCD)

* OCD is an anxiety disorder which is characterized by recurrent, unwanted thoughts (Obsessions) and repettive behaviors (compulsions).

* An obsession has following characteristic : –

  – An idea, impulse or image which intrudes into the conscious awareness repeatedly.

  – It is recognized as one’s own ideas, impulse or image but is perceived as egoalien (foreign to one’s personality).

  – It is recognized as irrational and absurd (insight is present –4 Patient knows about disorder).

  – Patient tries to resist against it but is unable to do so which leads to marked distress or anxiety.

A compulsion has following characteristics :-

* It is repetitive, purposeful form of behavior is carried out because of strong feeling of compulsion to do so.

* It usually follows an obsession.

* ts goal is to prevent or reduce the anxiety or stress caused by obsession however it do not always succeed in doing so.

* It is irrational or excessive and not realistic.

* Insight is present.

  – A patient with OCD may have an obsession, a compulsion or both (mostly patients have both).

  – A patient with OCD realizes the irrationality of the obsession and experiences both the obsession and the compulsion as ego-dystonic (unwanted behavior).

  – The person is preoccupied with details rules, list order, organisation or schedules to the extent that the major point of activity is lost.

  – The person shows perfectionism that interfers with task completion (e.g., unable to complete project because his own overtly strict standard are not met).

Ans. D. Schizophrenia

Neologisms:

• Refers to a new word or condensed combination of several words that are not a true word & is not readily understandable, although sometimes the intended meaning or partial meaning may be apparent.
• Feature of schizophrenia(thought & speech disorder)