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Evaluation, Assessment, and Diagnosis

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A 42-year-old woman is seen in the emergency room after she was brought in for starting a fight in a bar. During the interview, she answers questions with a nearly continuous flow of accelerated speech that jumps from topic to topic. For example, one run-on sentence began, “I am fine, are you fine?...does the sun shine?...it is nice outside today…the today show is a very interesting place to be, I will have to run it.” Which of the following psychiatric findings best describes this style of train of thought?

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a. Loose association

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b. Circumstantiality

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c. Neologism

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d. Perseveration

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e. Flight of ideas

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The answer is e. (Kaplan and Sadock, p 202.) Flight of ideas is a disorder of thinking in which the patient expresses thoughts very rapidly, with constant shifting from one idea to another, though the ideas are often connected. In loose associations, the thought process has also lost its goal-directedness; however, the patient never gets back to the original point and there is no clear connection between sentences. Circumstantiality indicates the loss of a goal-directed thought process: the patient brings in many irrelevant details and comments, but eventually will get back to the point. A neologism is a fabricated word made up by the patient, which is usually a combination of existing words. Perseveration, often associated with cognitive disorders, refers to a response that persists even after a new stimulus has been introduced—for example, a patient asked to repeat the phrase “no ifs, and, or buts” responds by saying, “no ifs, ifs, ifs, ifs.”

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A 23-year-old man comes to the psychiatrist with a chief complaint of a depressed mood. He is very anxious and obviously uncomfortable in the physician's office. Which of the following actions should be used to help develop rapport with this patient?

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a. Inform the patient that his problem is simple and easily fixed.

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b. Express compassion with the difficult position the patient is in.

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c. Tell the patient that you, too, are nervous when seeing new patients.

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d. Ask the patient why he is so unusually anxious about seeing a psychiatrist.

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e. Get right to the patient's complaint, so that the patient can leave as soon as possible.

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The answer is b. (Kaplan and Sadock, p 193.) A patient in this situation needs empathy above all else if a successful rapport is to be developed. Informing the patient that his problem is ...

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