Practice

Short recognise-and-discriminate exercises built on the phenomena, syndromes, and defences catalogued elsewhere in this app.

Recognise Questions

• After a minor disagreement with a colleague, a man remains intensely angry and preoccupied with the incident for several days, an ordinary feeling of anger but clearly out of proportion to the minor trigger, though he can still readily identify what set it off. What is this?
• A patient who is clearly deeply upset by a recent loss nonetheless deliberately maintains a composed, matter-of-fact manner in front of others, later admitting, when asked, that she is consciously suppressing any outward sign of how she feels. What is this?
• Two days after starting an antipsychotic medication, a patient suddenly develops a frightening, sustained spasm that forcibly twists his neck to one side. What is this?
• Throughout a lengthy interview covering both distressing and positive topics, a man's facial expression, vocal tone, and gestures remain noticeably reduced and flat across every subject discussed. He does not appear to notice or comment on this himself. What is this?
• Across a long conversation covering many different topics, a patient displays only a narrow range of emotional reactions, though the few emotions she does show, such as brief irritation or mild amusement, register with roughly normal intensity each time. What is this?
• A patient suddenly breaks into intense, uncontrollable crying triggered by a minor comment, with almost no ability to hold it back and little matching inner sadness behind the display. What is this?
• A patient with normal vision and normal hearing can describe the individual letter-shapes on a page perfectly well, but cannot make any sense of written words as language; his spoken language comprehension and production are entirely normal. What is this?
• A man started an antipsychotic ten days ago and now cannot sit still during the consultation, repeatedly shifting his weight from foot to foot and pacing when he is asked to wait. He describes an intense inner restlessness and unease that is, if anything, more distressing to him than the visible movement itself. What is this?
• A patient with a lesion affecting the third ventricle lies still with eyes open, giving a superficial appearance of alertness, but is unresponsive, uncooperative, and shows only slight reactivity to painful stimuli. On recovery, he has total amnesia for the entire episode. What is this?
• Asked to shake hands, a patient makes a series of tentative, incomplete movements toward the examiner's hand, repeatedly starting and stopping without ever actually completing the handshake, appearing genuinely caught in conflict about whether to carry out the action. What is this?
• Following a head injury, a patient is simply unable to recall anything from the several hours immediately surrounding the accident. She does not offer any account, false or otherwise, of that period — she is straightforwardly aware that the memory is missing. What is this?
• A patient following prolonged heavy alcohol use and poor nutrition cannot recall anything told to her five minutes ago and cannot recall events from the past several weeks, yet she can hold a fluent conversation, recall her childhood clearly, and immediately repeat a phone number just given to her. What is this?
• A man insists on a fixed daily schedule that has not varied in years, becomes visibly distressed by any last-minute change of plan, and has caused repeated friction at work by requiring colleagues to follow his own precise standards for filing paperwork, to the point of damaging his working relationships. What does this represent?
• A 39-year-old man who has played guitar for pleasure most evenings for twenty years continues to pick it up out of habit, but reports that it now feels like going through empty motions, with none of the satisfaction or enjoyment it used to bring him, no matter how long he plays. What is this?
• A 66-year-old woman with a dense left-sided paralysis is asked to raise both arms. She lifts only her right arm, insists she has raised both, and when the doctor points out that her left arm never moved, she calmly says it "must just be a bit tired today" and changes the subject, showing no concern at all. What is this?
• Following a head injury, a woman is alert and able to hold ordinary conversations, but the following day has no memory at all of anything from the several hours immediately after regaining consciousness, despite having behaved and responded appropriately throughout that period. What is this?
• A patient started on antipsychotic medication two weeks ago describes an inner urge to keep moving that he finds hard to resist, though on observation he only occasionally shifts his weight from foot to foot. What is the general category this presentation belongs to?
• A patient describes weeks of persistent apprehension and unease, not tied to any particular object or situation, accompanied by a racing heart, muscle tension, and a churning stomach that come and go but never fully settle. What is this?
• A patient with longstanding generalised anxiety describes gradually worsening forgetfulness over several months, closely tracking her worsening worry and poor concentration, which improves noticeably on the days her anxiety feels more settled. What is this?
• For several weeks, a woman has carried a persistent sense that something bad or catastrophic is about to happen, though she cannot say what, or to whom, or when — it is not tied to any particular object, situation, or event, just a sustained, uneasy sense of dread hanging over everything. What is this?
• A man describes a lifelong, keenly felt wish for close friendships, but says shyness, tension, and a fear of embarrassment have left him isolated and lonely despite that genuine desire for acceptance. He has found some comfort in solitary hobbies, and has managed to form a few close relationships, but only with people he experiences as completely uncritical of him. What is this?
• A patient shows a pervasive lack of interest and motivation across every area of his life — work, relationships, hobbies he once enjoyed — appearing outwardly indifferent even to matters of real significance to his own circumstances, without describing any particular sadness or distress about this state. What is this?
• Following a confirmed left-hemisphere stroke, a patient has marked difficulty understanding spoken instructions and producing meaningful speech, while other aspects of his thinking and behaviour remain relatively coherent and organised. What general category of disturbance is this?
• A man reports hearing a voice, with no one else present, that has the same perceptual quality and force as an actual person speaking aloud in the room, apparently coming from outside his head, saying critical things about him. He makes no effort to produce this and cannot stop it. What is this?
• Without any preceding perception, thought, or event that might explain it, a patient suddenly and completely finds himself convinced, fully formed and with total conviction, that he is secretly a member of the royal family, with no gradual development to the idea at all. What is this?
• A patient complies with every verbal instruction given during an examination, including one that produces an uncomfortable sensation, and continues to comply with further instructions in the same way immediately afterward, without any adjustment in response to that unpleasant experience. What is this?
• A man describes, with some alarm, having briefly seen a visual double of himself standing a few feet away, mirroring his own posture and movements. Throughout the experience his own sense of viewpoint stayed exactly where his real body was — he was looking at the double, not looking out from it. What is this experience?
• A woman presents with a sudden inability to move her left arm, fully consistent with a functional neurological symptom. She describes the paralysis clearly and in detail when asked, but does so with a calm, faintly cheerful manner that seems strikingly out of keeping with the apparent severity of losing the use of a limb. What is this attitude called?
• A patient reports that her left arm feels as though it has become enormous and grotesquely swollen, though there is no actual physical change and she does not deny that the arm belongs to her. What is this?
• A 26-year-old woman describes a new colleague as "the only person who has ever really understood her" within days of meeting them, then, after the colleague cancels a coffee catch-up due to a scheduling conflict, calls them "selfish and uncaring" and says she never wants to see them again. She describes a longstanding pattern like this across many relationships, alongside a persistent feeling of emptiness and an intense fear that people will eventually leave her. What is this presentation most consistent with?
• A woman with schizophrenia insists, with complete conviction, that her husband has been replaced by an identical-looking impostor, acknowledging he looks exactly like her real husband but maintaining he is "not really him." She becomes hostile toward him as a result. What is this?
• An examiner lifts a patient's arm, as if taking a pulse, and then releases it. Rather than falling back down, the arm stays exactly where it was placed for well over a minute before slowly sinking back toward a resting position. What is this?
• A patient is unable to recall a single, specific, deeply painful event from several years ago, while her general autobiographical memory, sense of personal identity, and everyday functioning all remain completely intact and unaffected. What is this?
• A patient speaks with a strange, stilted delivery and an unusual falsetto intonation, sounding almost unfamiliar with his own native language, despite using entirely fluent vocabulary and correct grammar. What is this?
• A patient with schizophrenia lies rigid and mute. Her face is entirely deadpan even as her care team discusses a distressing recent family event in front of her, though her eyes track their movements around the room. She is later found to have been passing urine without any apparent awareness of doing so. What is this presentation?
• A patient's spontaneous speech shows faulty grammar and sentence structure along with word-substitution errors, and he also has clear difficulty understanding what is said to him, with both his speaking and his writing impaired. What is this?
• A patient reports that everything he looks at appears washed in an abnormal yellow tinge, though he still correctly recognises every object and its shape; the tinge resolves once his medication is adjusted. What is this?
• Asked a simple question about when his symptoms began, a man gives a long, detailed, meandering account full of unnecessary tangents, and each time you try to redirect him he briefly returns to the point before digressing again. Eventually, several minutes later, he does answer the original question. What is this?
• A patient feels driven to check that the front door is locked exactly seven times before he can leave the house, recognising the behaviour as excessive and unreasonable, but experiencing significant anxiety if he tries to resist it, anxiety that is relieved once he completes the checking. What is this?
• A 61-year-old man with a long history of heavy alcohol use is asked what he did yesterday. He answers immediately and confidently that he watched his grandson's football match and had lunch with his sister. His grandson does not play football, and his sister lives abroad and has not visited in over a year. He shows no hesitation and becomes mildly irritated when the discrepancy is gently pointed out, insisting his account is accurate. What is this?
• A writer produces a passage that closely matches, almost word for word, a paragraph she read years earlier in someone else's book, sincerely believing the passage to be entirely her own original creation, with no awareness that she is reproducing something she previously encountered. What is this?
• While chatting with a new colleague for the first time, a 31-year-old man is suddenly gripped by an intense, specific certainty that this exact conversation has happened before, word for word. The feeling lasts only a few seconds before fading, leaving him slightly unsettled but otherwise unbothered, and he knows perfectly well it cannot actually have happened before. What is this?
• A patient states, with complete and unshakeable conviction, that he is the reincarnation of an ancient king, offering no coherent account of how he arrived at this belief and showing no interest in any evidence that might challenge it, despite this being entirely out of keeping with his cultural background. What is this?
• A 58-year-old man with severe depressive illness insists that he is "the most wicked man who has ever lived," that he personally caused a distant relative's illness through some unspecified moral failing years ago, and that he deserves to be imprisoned for it. He cannot be reassured by evidence that he did nothing wrong. What is this?
• A patient is convinced her bowels have "rotted away inside her" and that she is dying of an incurable disease, despite entirely normal investigations and repeated reassurance from several doctors. She cannot be persuaded otherwise even when shown her own normal test results. What is this?
• A man with a long history of alcohol dependence becomes convinced his wife is having an affair, searching her clothing daily for "evidence" and reinterpreting entirely ordinary events (a late bus, a changed hairstyle) as confirmation. No amount of reassurance changes his conviction. What is this best described as?
• A woman with no prior relationship with a well-known local celebrity becomes utterly convinced he is secretly in love with her and has been sending her coded signals through his public appearances. When he makes no contact, she concludes his letters must be being intercepted. What is this?
• A patient is fixedly convinced, with no realistic basis, that a specific government agency is monitoring his every move and plotting to harm him, a belief that has been present and unshaken for months despite no supporting evidence whatsoever. What is this?
• A retired teacher with severe depressive illness, who in reality has a comfortable pension and substantial savings, becomes utterly convinced she and her family are about to be made destitute, refusing to spend money even on basic food and remaining unmoved when shown her own bank statements. What is this?
• A patient describes several days of a vague but powerful sense that something important is happening around him and that it concerns him personally, though he cannot say what it actually is, accompanied by marked unease, before this feeling resolves into a specific, crystallised belief. What is this?
• A man recalls that while waiting at a bus stop, a stranger across the road tied her shoelace — and at that exact moment he became completely and instantly certain that he had been chosen to expose corruption in the local council. He cannot explain any logical link between the shoelace and this conclusion, only that the certainty was total and arrived at once. What is this experience?
• A man with a chronic, painful joint condition describes feeling discouraged and unable to cope with his situation, but he still enjoys visiting his grandchildren, still looks forward to his favourite television programme, and his low feeling is clearly and understandably tied to his ongoing physical struggle. What is this?
• Told of a serious cancer diagnosis, a patient accepts the practical facts on the surface but continues making long-term plans exactly as before, behaving as though the emotional reality of the diagnosis has simply not registered. What is this?
• A 33-year-old man says he cannot decide what to order at a restaurant without his wife choosing for him first, has never lived alone, and describes feeling "lost" and anxious whenever she is away for more than a day, going to great lengths to keep her from leaving even briefly. He is quiet and self-effacing, and describes himself as needing someone else to take charge of most areas of his life. What is this most consistent with?
• A 22-year-old university student says that for the past few days it has felt like she is watching herself walk around campus instead of actually being there. She is clear that she still knows it is her and that she has not stopped existing — it just doesn't feel like it. What is this experience?
• For several weeks, a patient has experienced low mood present for most of the day, most days, loss of interest and pleasure in activities he previously enjoyed, disturbed early-morning waking, poor concentration, reduced energy, and feelings of worthlessness, all extending pervasively across every area of his life. What is this?
• A 74-year-old man is referred for suspected dementia after his family notices he can no longer manage his bills or recall recent conversations. On assessment he is profoundly low in mood and tearfully aware of and distressed by his own decline. After eight weeks of antidepressant treatment, his cognitive performance returns almost entirely to baseline. What is this presentation?
• A profoundly depressed patient becomes almost completely withdrawn and unresponsive, with a facial expression that remains recognisably sad and worsens noticeably when family matters are mentioned, normal muscle tone throughout, and no catalepsy, stereotypies, or incontinence. What is this?
• After several nights of very little sleep during a stressful exam period, a 20-year-old student says that walking across campus started to feel like walking through a film set, with the buildings and people around him oddly flat and distant. He is clear throughout that nothing has really changed and that the strangeness is happening in his own perception. What is this?
• A patient's speech remains grammatically correct throughout, but is repeatedly interrupted by sudden, unconnected ideas forcing their way in, each one coherent on its own but disrupting the intended flow of thought. What is this?
• A patient with severe depression sits with a permanently sad expression, makes almost no spontaneous hand gestures, and moves slowly and stiffly even when trying to express how she feels. What is this?
• An elderly man admitted to hospital cannot say what day or month it is, but can correctly identify that he is in a hospital and can correctly name his wife when she visits. What is the underlying finding, and what does the pattern tell you about its severity?
• A man has a long history of exploiting others for personal gain, shows no genuine remorse when confronted with the harm he has caused, offers only superficial apologies before repeating the same behaviour, and describes a childhood marked by conduct disorder and cruelty to animals. He is capable of superficial charm but this drops abruptly once it no longer serves him. What is this pattern?
• A patient describes a serious road traffic accident she was involved in, in a calm, matter-of-fact tone with no visible distress, while her emotional responses to other, unrelated topics discussed in the same interview remain entirely normal and appropriately expressed. What is this?
• Following a violent assault, a woman is found wandering in an unfamiliar town, unable to recall her name, address, or any personal history, yet she has navigated public transport and interacted appropriately with several strangers along the way. What is this?
• A patient confidently describes a detailed childhood memory of an event that, family members confirm, never actually happened — the content of the memory itself has been invented, though she experiences it with the same felt sense of familiarity as her genuine memories. What is this?
• A man briefly, on entering an entirely new office building for the first time, has a strong and striking sense that he has been in this exact place before, though he immediately recognises this can't actually be true, and the feeling passes within moments. What category of disturbance is this?
• During an interview, a patient's attention is repeatedly pulled away by every small sound or movement in the room, and he takes far longer than expected to stop reacting each time a background noise recurs. What is this?
• A previously sharply-dressed, punctual bank manager is found unshaven, disoriented to the day and date, and unable to give a coherent account of the last few hours, following a high fever. His usual social presentation and occupation make this level of disorganisation clearly out of keeping with his known baseline. What does this represent?
• A patient describes a persistent, distressing feeling that her own thoughts and actions no longer feel like they belong to her, though she recognises this as a strange change in how things feel rather than believing she has ceased to exist. What is this?
• A patient describes a frightening conviction that his own thoughts are somehow reaching outward and directly controlling events happening to other people, as though the ordinary boundary between his mind and the outside world has broken down. What is this?
• Following a severe illness, a patient describes feeling profoundly changed, as though she is no longer the same person she was before, with a strong sense that her old self is gone and someone new has taken her place, though she recognises this describes a change over time rather than feeling like two people right now. What is this?
• A woman describes moments where she feels as though she is two people acting at the same time, one part of her speaking automatically as if driven by another part of herself. She is clear, though, that this is only how it feels — she does not actually believe she is literally two separate people. What is this?
• Recovering from a severe chest infection, a 79-year-old man becomes convinced that small rodents are scurrying across his hospital bedsheets at night, reacting with genuine terror and swatting at them repeatedly. During the day he is calmer, though still unable to say what day it is, and he recognises his wife immediately whenever she visits. What is this presentation?
• Attempting to explain a single, complex idea, a patient produces all the right individual pieces of the thought, but they emerge jumbled and disorganised, so that the overall meaning becomes obscured, while the patient herself seems uneasily aware that something about her explanation isn't right. What is this?
• A patient looks at a real chair across the room and reports that it appears tiny, as though seen from a great distance, though she knows perfectly well it is an ordinary-sized chair nearby. What is this?
• Asked 'How are you feeling today?', a patient replies 'How are you feeling today?' rather than answering, and this pattern repeats for several subsequent questions regardless of their content, with no evidence the patient understands what is being repeated. What is this?
• During a ward assessment, a 26-year-old man with catatonia claps his hands and snaps his fingers each time the assessing nurse does so, apparently without noticing he is doing it, continuing until she deliberately stops moving her hands. What is this?
• For a brief period, a patient experiences an overwhelming, transcendent state of rapture, describing a profound sense of unity with the universe and access to ultimate truth, an intensity of feeling well beyond ordinary happiness, before the episode passes. What is this?
• A patient with a history of hallucinogenic drug use describes recalling a scene from months earlier with an unusually vivid, almost picture-like clarity, but is entirely clear that this is a memory of something she genuinely saw at the time, not a current perception of something happening now. What is this?
• In one major classification system, a clinician describes a patient's presentation as falling under a broader diagnostic umbrella that groups together two related but distinguishable patterns of poor emotional and behavioural control, one centred on explosive outbursts and one on unstable relationships and self-image. What is the umbrella term being used here?
• A previously outgoing, trusting man develops, in the three years since surviving a violent hostage situation, a lasting and pervasive change in character: he has become socially withdrawn, hostile and mistrustful of others, and describes a constant, chronic sense of being under threat, with no personality difficulties of any kind documented before the event. What is this?
• A patient in a manic episode is restless, cheerful, and interfering, talking rapidly with flight of ideas and occasionally rushing about and shouting, with the overall picture one of markedly increased motor activity throughout. What is this?
• A patient understands everything said to him and clearly knows what he wants to say, but can only produce a handful of expletives and fixed phrases, delivered with different intonation each time to try to convey different meanings, visibly frustrated by his inability to say more. What is this?
• A mother with severe, delusional depressive illness, believing she has passed an incurable inherited curse on to her children that guarantees them a life of suffering, kills both her children and then attempts to take her own life, describing this afterward, within her belief system, as an act of protecting them. What is this pattern called?
• A patient reports seeing a figure standing directly behind his own head, a location entirely outside the physical range his eyes could actually perceive, describing the image with the same full conviction and sensory quality as anything he might see in front of him. What is this?
• A man confidently and in vivid detail describes attending a family event that, according to every other family member present and all available records, simply never took place. He is not lying — he genuinely believes it happened and experiences the memory with full conviction. What is this?
• A patient in an acute confusional state repeatedly greets several strangers on the ward as though they were old friends, while also occasionally insisting that his own genuinely familiar nurse is actually a stranger he has never met. What is this?
• A war veteran describes sudden, unbidden moments where he is abruptly plunged back into the sights and sounds of combat, feeling for those moments as though it is happening again right now, complete with the original fear and physical tension. What is this?
• Many years after a major national tragedy, a woman can describe in vivid, precise detail exactly where she was standing, what she was wearing, and who she was with when she first heard the news, and she is completely confident this memory is accurate down to the smallest detail — though she has never had it independently verified. What is this?
• Asked how she has been sleeping, a 34-year-old woman in an elated mood replies, "Sleeping, sheep, I counted sheep, sheep go to the meadow, meadow like the perfume my mother wore, my mother's coming to visit, visit, a visit to the seaside would be lovely wouldn't it," continuing in this vein for several minutes without ever returning to the original question, though each individual link is easy enough to follow. What is this?
• A patient is explicitly told not to shake the examiner's hand on future occasions, yet continues to shake it every single time it is offered, despite the instruction being repeated before each attempt. What is this?
• During an unstructured conversation, a patient's speech drifts between ideas with connections that are difficult or impossible to follow, blending unrelated concepts together and occasionally using ordinary words in oddly literal ways, making the overall structure of what she is saying hard to grasp even though individual sentences are grammatically intact. What is this?
• A 40-year-old woman notices that every time she runs the kitchen tap, she hears a voice muttering indistinctly beneath the sound of the water. She can hear the water perfectly normally the whole time, and the voice stops the instant she turns the tap off. What is this?
• A man in custody gives consistently approximate answers to simple questions, while also appearing disoriented, with clouded consciousness and occasional visual hallucinations, and later has no memory of the episode at all. What is this?
• On examination, gentle attempts to passively move a patient's arm meet almost no resistance, but when the examiner applies firmer pressure, the patient's arm resists with a force that closely matches whatever force is being applied, so the limb seems to actively oppose being moved. What is this?
• A man with elevated mood, reduced need for sleep, and pressured speech becomes convinced he has been chosen to negotiate world peace personally, describing detailed plans to meet with heads of state who he says are "already expecting him." He cannot be persuaded this is unrealistic. What is this?
• A patient reports a persistent, unpleasant metallic taste in her mouth despite having eaten or drunk nothing, occurring alongside a smell of something burning that nobody else can detect. What is the taste symptom, specifically?
• In a quiet, empty room with no external sound source present, a patient clearly and repeatedly hears a voice commenting on his actions, experienced with the same sense of reality as an ordinary sound, while he otherwise perceives the room around him accurately. What is this?
• A 55-year-old man with a decades-long history of heavy drinking describes hearing threatening voices discussing him for the past several days. Throughout the assessment he is fully oriented to time, place, and person, answers every question coherently, and describes his recent history in clear, accurate detail, despite the ongoing voices. What is this presentation?
• Following a right parietal lesion, a man simply fails to mention or attend to his left arm at all — when asked directly, he does not actively claim it belongs to someone else, he just seems to have lost the felt sense that it is part of him and rarely refers to it. What is this?
• Following a right parietal stroke, a patient consistently fails to notice food on the left side of her plate, does not respond to people or objects approaching from her left, and only draws the right half of a clock face when asked, despite intact vision and movement on that side. What is this?
• A 34-year-old woman describes an ordinary work disagreement in highly theatrical, hyperbolic terms, dressed strikingly for the appointment, and repeatedly steers the conversation back toward whether you find her impressive. On closer contact her initial charm proves mixed with flirtatiousness and a degree of manipulativeness, and she becomes visibly upset when you glance at your notes rather than at her. What personality pattern is this?
• A patient recalls the day of a serious accident in extraordinarily vivid, almost hallucinatory detail, describing sounds, smells, and images with striking intensity; on checking, her account matches the documented facts closely. What is this?
• As a healthy young woman with no psychiatric history is falling asleep one night, she briefly and vividly hears her name being called, lasting only a few seconds before it passes and does not recur once she is either fully asleep or awake again. What is this?
• Following a severe, unresolved argument with her family, a woman is found wandering many miles from home, with only a hazy awareness of recent events and, when asked, unable to say who she is. No organic cause is found on investigation, and the episode arose in the context of clear, severe psychological conflict. What is this presentation called?
• Walking through a dimly lit garden at dusk, a man briefly perceives a coat hanging on a hook as a person standing still — but on looking more closely, he immediately recognises it correctly as a coat. What is this?
• Without any warning or apparent reason, a catatonic patient suddenly strikes a fellow patient, and afterward is unable to give any explanation for why he did it. What is this?
• A man describes a lifelong pattern, since his teenage years, of explosive outbursts triggered by minor provocations, with little thought of consequences beforehand and genuine remorse afterward once the anger passes. What is this?
• Describing the recent death of her father, a 26-year-old woman giggles intermittently throughout the account. When her clinician gently notes the mismatch, she appears genuinely puzzled rather than embarrassed or self-conscious about it. What is this?
• A depressed patient describes his thoughts as coming slowly and with effort, complaining of a mental fog that makes it hard to concentrate or make even small decisions, a pace that has gradually worsened over weeks. What is this?
• A patient's aphasic language disturbance is difficult to place cleanly into either a purely receptive or purely expressive category; assessment reveals a specific, more circumscribed pattern rather than a global disturbance, though exactly which of two recognised specific sub-types best fits requires further, more detailed testing to establish. What broader category does this fall under?
• A patient with a family history of Huntington's disease develops abrupt, coarse, dance-like jerking movements affecting his limbs and face, worsened whenever he becomes anxious. What is this?
• Over recent weeks, a patient has become persistently quick to anger at minor, everyday provocations that would not normally trouble him, a change clearly noticed by his family as being unlike his usual, easy-going temperament, though he retains full control over his reactions. What is this?
• During a single ten-minute conversation, a man moves abruptly from tearfulness to laughter to irritability and back again, each shift more pronounced than anything in the conversation seems to warrant. What is this pattern called?
• A person briefly cannot recall the name of a familiar acquaintance during a conversation, experiencing a strong sense that the name is known and almost within reach, before it resolves on its own moments later with no lasting difficulty. What is this?
• A depressed man describes, with visible distress, that when his children greet him he feels absolutely nothing — no warmth, no connection — despite still outwardly smiling and responding to them appropriately. To an observer he seems to react normally, but subjectively he feels a troubling inner absence. What is this?
• Two weeks after a stroke, an 80-year-old woman appears profoundly slowed and apathetic, giving only brief, unclear answers and occasionally repeating the same word. She has no hallucinations, illusions, or agitation, prompting concern about severe dementia. Six weeks later she has regained much of her clarity, left with only a mild residual word-finding difficulty. What was this presentation most likely to have been?
• A 30-year-old man with schizophrenia has a distinctive, exaggerated flourish every time he signs his name, sweeping his hand in a wide unnecessary arc before setting pen to paper. His family confirms this habit has been present, unchanged, for several years, and he cannot explain it when asked. What is this?
• Despite being explicitly instructed to resist, a patient's arm can be moved into any position with no resistance at all, and immediately returns to its original resting position as soon as the examiner lets go. What is this?
• A patient describes a pervasive, sustained state of anxiety present most of the time for months, persisting regardless of what is actually happening in her life, and significantly impairing her ability to work or socialise. What is this?
• A patient has experienced a low, hopeless mood every day for the past four months that has not lifted regardless of positive events, alongside sleep disturbance and loss of interest in previously enjoyed activities; her facial expressions and manner of showing emotion remain entirely normal throughout. What level of disturbed emotion does this represent?
• A man with bipolar affective disorder has, for the past two weeks, been persistently and infectiously cheerful and optimistic, convinced everything in his life is going brilliantly despite recently losing his job, and has begun making a series of large, risky financial commitments as a result. What is this?
• A patient's face has become noticeably flat and his voice monotone over recent months, changes his wife brought to the clinician's attention; when asked directly, the patient insists nothing about how he shows his feelings has changed at all. What is this?
• Following a frontal lobe injury, a man persistently makes jokes and puns regardless of the seriousness of the conversation, seemingly unable to engage with a topic for long without lapsing into facetious remarks that feel shallow and hollow rather than genuinely witty or warm. What is this?
• After being asked to put her tongue out and told "thank you, that's enough," a patient continues moving her tongue in and out for several more seconds before stopping, seemingly unable to move straight on to the next instruction. What is this?
• A patient describes, and appears genuinely to experience, having several entirely distinct personalities, each with its own name, manner, and way of relating to the world, rather than simply feeling like a changed or different version of herself. What is this?
• A man has presented to more than a dozen hospitals across the country, each time with a dramatic, well-rehearsed account of a medical emergency, and bears multiple surgical scars from procedures sought under false pretences. What is this?
• A patient produces no spoken speech at all over several days of observation, despite being otherwise physically capable of speaking, and communicates instead only through gesture and occasional handwritten notes. What is this?
• A 45-year-old executive describes his recent promotion as "the company finally recognising what everyone already knew," becomes coldly dismissive toward a colleague after a project's success is credited to the whole team rather than to him alone, and redirects a conversation about his partner's difficult week back to his own achievements within moments. What is this presentation most consistent with?
• A patient resists every attempt to move his arm, and when asked to open his eyes he instead screws them shut more tightly, and when asked to shake hands he pulls his hand away — always doing the precise opposite of what is requested, apparently for no discernible reason. What is this?
• A patient with a longstanding psychotic illness repeatedly uses the word 'plimtosis' to describe a private, hard-to-put-into-words inner experience, using it consistently across several conversations. When asked, he offers an explanation of what he means by it, though the word itself is not a real one. What is this?
• A severely depressed patient states, with complete and unshakeable conviction, that his bowels have rotted away and no longer exist, holding this as literal fact despite obvious evidence to the contrary, and shows no insight that this could be a subjective feeling rather than a genuine physical absence. What is this?
• A patient speaks in grammatically correct, fluent sentences but repeatedly cannot find the name of common objects shown to him, instead describing what each one is used for; his comprehension and grammar are otherwise entirely intact. What is this?
• A man is troubled by repeated, unwanted images of harming his own child, which he finds horrifying and completely contrary to how he actually feels. He recognises the thoughts as arising from his own mind, tries hard to resist them, and is acutely aware that they are excessive and irrational, which itself causes him great distress and guilt. What is this?
• A patient begins to reach for a cup, stops abruptly partway through the movement for no apparent reason, and then completes the action with no difficulty a few moments later, this pattern occurring unpredictably across several different actions during the interview. What is this?
• A confused, disoriented patient in hospital, a retired carpenter, is observed repeatedly making sawing and hammering motions in the air with his hands, actions his family immediately recognise from his decades of trade work, though he is not actually holding any tools. What is this?
• A patient repeatedly reports smelling burning rubber, on and off over several days, though no one else in the room notices anything and no source can be found on careful checking of the environment. What is this?
• Following a significant head injury with confirmed structural brain damage, a patient has a persisting, severe difficulty forming new memories, while her sense of who she is and her social behaviour remain essentially intact and recognisable to those who know her. What is this?
• A patient who lost his left arm in an accident several years ago describes ongoing, sometimes painful sensations that feel as though they are coming from the missing limb. What is this?
• For several years, a man has held a single, dominating belief that he was wrongly dismissed from a job, a belief with a plausible basis in reality, held with strong conviction, though he is somewhat more willing than most to discuss and consider other perspectives on it than a typical fixed false belief would allow. What is this?
• While sitting quietly at home with nothing in particular happening, a woman is suddenly overwhelmed by intense fear, her heart pounding, chest tight, and short of breath, convinced for several minutes that she might be dying, before the whole episode subsides within half an hour. What is this?
• A patient's memory of a past holiday is present and can be recounted in detail, but on closer examination is found to be altered, with an incorrect sense of unfamiliarity about parts of it that genuinely happened. Nothing is simply missing — the memory exists, just distorted. What general category of memory disturbance is this?
• A woman has for many years been quick to take offence, consistently assumes colleagues and even her own husband are acting against her interests without good evidence, and has become increasingly isolated as friends have drifted away from her persistent suspicion, though she remains able, if pressed, to consider that she might be wrong. What does this represent?
• Following a confirmed stroke affecting a specific language area, a patient repeatedly says "the spoon" when trying to name a fork, alongside other clear signs of word-finding difficulty and disturbed grammar, but with no evidence of psychotic thought content. What is this?
• A patient insists that her left arm now has an extra joint partway along the forearm, and describes feeling as though a small, unreal extra structure is attached to it, while recognising this cannot really be true. What is this?
• A man states, with complete conviction, that his own arm movements are not made by him but are directly controlled by a device implanted by a government agency, and that the fear he feels is likewise put into him by the same device rather than being his own feeling. What is this?
• After drinking a single small glass of wine, a man with no history of violence becomes suddenly and senselessly violent toward those around him for about an hour, shows none of the usual unsteadiness or slurred speech of drunkenness, and afterward has no memory whatsoever of the episode. What is this?
• A patient in the early stages of an acute psychotic episode appears outwardly bewildered and hesitant, repeatedly saying she cannot make sense of what is happening around her or of her own thoughts, though she remains fully alert and correctly oriented to time, place, and person. What is this?
• Asked to name the current prime minister, a patient with known brain disease answers correctly. Asked next what day of the week it is, he repeats the prime minister's name instead. He seems to notice something is wrong and tries again, with limited success. What is this?
• An examiner passively moves a patient's arm into an unusual, uncomfortable raised position; there is no resistance felt during the movement itself, but when the examiner releases the arm, the patient's muscles can be felt to contract and actively hold the arm in that position for several minutes. What is this?
• A woman has shown a consistent, deeply ingrained pattern of certain emotional and behavioural traits since her teenage years, continuing unchanged into her forties, and these traits have caused persistent, significant difficulty in her relationships throughout that time, independent of any distinct episode of illness. What general category does this represent?
• A patient experiences intense fear only when near dogs, consistently and specifically, recognises that her reaction is excessive given that the dogs in question are calm and on leads, and has begun taking long detours to avoid streets where she might encounter one. What is this?
• A man suddenly becomes convinced, with no preceding change in mood, no hallucination, and no prior belief it could plausibly have grown from, that he is the reincarnation of a historical king. The conviction simply appears, fully formed, as something entirely new in his mental life. What kind of delusion is this?
• A 58-year-old widow says, "About a month after my husband died, I'd see him sitting in his armchair in the evenings. I always knew it wasn't really him — it was more like seeing a very clear picture in my head that happened to be laid over the chair." She has no other symptoms and is coping well with her grief. What is this experience?
• Facing upcoming legal proceedings, a man with no evidence of any brain disease begins telling elaborate, fluent, and increasingly grandiose stories about a secret career as a decorated intelligence officer, seeming genuinely caught up in these accounts, but eventually admits the truth when confronted with clear documentary proof that none of it happened. What is this?
• A 60-year-old man with severe depressive illness takes noticeably long pauses before answering even simple questions, moves slowly and with little spontaneous gesture, and describes feeling as though he is "moving through treacle." What is this?
• A patient can hear that people are speaking and recognises other environmental sounds normally, but cannot understand a single spoken word said to him, though his reading and writing remain completely unaffected. What is this?
• A patient is entirely unable to speak, spontaneously or on request, yet writes fluent, grammatically correct, and entirely appropriate answers to every question asked of him in writing. What is this?
• A catatonic patient shows a general, stiff unresponsiveness, failing to flinch at a sudden loud noise or turn toward unexpected movement nearby, without any sense that she is deliberately resisting or refusing anything in particular. What is this?
• A patient's mood brightens noticeably within minutes of a friend visiting with good news, only to drop sharply again when a minor inconvenience occurs shortly afterward, with this pattern of marked responsiveness to circumstances recurring throughout the day. What is this?
• A patient speaks fluently and without apparent effort, but the words he produces are often unrelated to any question asked, and he shows no sign of understanding spoken or written instructions given to him. What is this?
• Every time a patient hears a car door slam nearby, she reliably and reproducibly experiences a full, vivid visual hallucination of a figure in the corner of the room, distressing and unbidden each time. What is this?
• A patient appears only slightly bemused, with awareness narrowed to a small number of preoccupying ideas, disoriented for time and place, yet still able to wander about the ward in a relatively well-ordered way despite being unable to look after herself. What is this?
• A 26-year-old man is brought to hospital after a motorcycle accident with a brief loss of consciousness. Once he is alert again, he can lay down new memories normally, but he cannot recall anything from the twenty minutes immediately before the crash, and over the following days that gap gradually shrinks to only the last minute or two before impact. What is this?
• A patient with a well-documented two-year history of a persecutory delusion insists, despite clear evidence of a recent onset, that people have "always" been plotting against her, reshaping her account of her entire childhood to fit this belief. What is this?
• A patient in a depressed mood recalls an entire period of her life as an unbroken run of failure, having genuinely forgotten or downplayed the real successes that were also part of that time. What is this?
• Over several years of progressive brain disease, a patient gradually loses track of what happened even a week ago, while continuing to describe events from his childhood in vivid, accurate detail, with the gap between recent and remote memory widening steadily as the illness advances. What is this?
• A man reports hearing two voices, speaking to each other about him in the third person, describing his actions as he performs them in real time: 'he's picking up the cup now... he's putting it down again.' What is this?
• A patient reports that her right leg suddenly feels enormous, several times its actual size, though she knows objectively that it looks and measures the same as always. What is this?
• A man describes a lifelong pattern of emotional coolness and detachment from others, with little genuine wish for close relationships, taking real enjoyment instead from solitary intellectual pursuits, and appearing entirely content with this way of life rather than distressed by it. What is this?
• A patient with chronic schizophrenia produces speech so profoundly confused and disorganised that it is largely impossible to follow, yet she is still able to carry out simple practical tasks around the ward competently, with no history of stroke or other focal neurological event. What is this?
• A longstanding pattern of social oddness is described in a patient who has a small number of relationships he does genuinely value, but who experiences fluctuating episodes of feeling detached from the world, holds several odd beliefs that fall short of true delusions, and shows unusual, eccentric ways of communicating with others. What is this?
• A woman recalls a childhood memory of being comforted by her mother after a fall, but careful, gradual exploration later establishes that while the fall genuinely happened, it was in fact her father, not her mother, who was present and whose role in the memory has been substituted, apparently protecting her from a more painful truth about that day. What is this kind of memory called?
• A man with profound, established depressive illness comes to believe, arising directly out of his overwhelming sense of worthlessness, that he has committed unforgivable sins and deserves severe punishment — a belief that developed gradually and can be clearly traced back to, and understood in light of, his underlying depressed mood. What kind of delusion is this?
• Following the death of her husband, a woman describes a clear, specific feeling that someone is standing just behind her — she cannot say she has seen, heard, or felt anything in particular, only that she is certain someone is there. What is this experience?
• During a period of high anxiety, a patient reports that ordinary background sounds have started to feel painfully loud, though he can correctly identify every sound and knows exactly what is producing it. What is this?
• A man maintains a sociable, cheerful manner throughout a consultation, explaining he does not want to burden his family, yet on careful, direct questioning discloses profound hopelessness, loss of interest in everything, and significant suicidal thinking that his outward presentation gave no hint of. What is this?
• A patient with depressive illness repeatedly presents to her doctor with persistent fatigue, vague abdominal pain, and headaches, insisting these physical symptoms are her only concern; only on specific, direct questioning about her mood does significant sadness and loss of interest become apparent. What is this?
• Following a right hemisphere stroke, a woman has left-sided paralysis and sensory loss. She acknowledges that the arm lying beside her cannot move, but insists with complete conviction that it is not her own arm — she says it belongs to the nurse and was left there by mistake. What is this?
• Under significant stress, a man's speech becomes broken by pauses and by repetition of parts of words, accompanied by visible grimacing, a difficulty he had as a child but which had resolved years ago. What is this?
• A patient spontaneously adopts and rigidly holds his head a few inches above the pillow for hours at a time, with no prompting or passive manipulation by anyone else. What is this?
• Throughout a lengthy interview covering many different topics, a patient's expression remains fixed in an intense, suspicious wariness that never shifts, even when the conversation moves to neutral or pleasant subjects that would ordinarily change how someone looks. What is this?
• A patient lies motionless, gives no response to being spoken to or touched, and produces no speech at all beyond, on rare occasions, a brief, barely audible monosyllable. Consciousness, judged from other clinical evidence, appears essentially clear. What is this?
• Since childhood, a person has reliably experienced a distinct colour whenever hearing a particular musical note, this pairing being stable, automatic, and lifelong, occurring only when the actual sound is genuinely present, with no history of psychiatric illness. What is this?
• A patient describes a vivid, persistent sensation of insects crawling under the skin of both forearms, prompting frequent scratching, in the context of recent heavy stimulant use. No skin lesions or rash are found on examination. What is this?
• Asked the colour of grass, a patient answers "white." Asked the colour of snow, he answers "green." His answers are coherent, grammatically intact, and clearly related to each question, showing he has understood perfectly well. What is this?
• After several years of antipsychotic treatment, a patient develops repetitive, purposeless movements of the mouth, tongue, and face, with a gradual onset that developed slowly over time rather than suddenly. What is this?
• A man describes, across several different experiences, a general loss of the ordinary sense that his thoughts belong exclusively to him — sometimes they are placed into his mind, sometimes taken out, sometimes made accessible to others. What is the general term for this family of experiences?
• A 27-year-old man is mid-sentence describing his week when he suddenly stops, stares blankly for a few seconds, and says he has completely lost his train of thought and cannot recall what he was about to say. There was no obvious distraction. He says this has been happening several times a day for the past two weeks. What is this?
• A patient describes, with obvious distress, that as he thinks something, people around him somehow know exactly what he is thinking at that moment — as though his thoughts are no longer confined to his own head and are somehow accessible to others. He denies that anyone is putting thoughts into his mind or taking them away. What is this?
• A patient reports that, as soon as she thinks something, she hears her own thought spoken aloud by a voice, word for word, a moment later — she recognises the words as her own thought, but experiences the voice as external and real, not as her own inner speech. What is this?
• A man tells you, with complete conviction, that when certain thoughts appear in his mind they are not his own — someone else has put them there. He can describe the exact sensation of a thought being placed into his head, and insists these thoughts feel foreign from the moment they arrive, not merely unwelcome. What is this?
• A patient describes that, mid-thought, his thinking suddenly and completely vanishes, and he is certain this happened because an outside force actively took the thought out of his mind, rather than him simply losing his train of thought. What is this?
• During a period of severe low mood, a 47-year-old woman describes each afternoon feeling as though it lasts an entire day, remarking that she has repeatedly checked the clock certain that hours must have passed, only to find that mere minutes have gone by. When asked directly, she correctly states the date and time. What is this presentation?
• During a period of hallucinogenic drug intoxication, a patient watches a real hand moving smoothly across his field of view, but instead of seeing continuous motion, he perceives a series of separate, discontinuous images of the hand strung out behind it, though he correctly identifies it as a hand throughout. What is this?
• A patient's sentence begins clearly on the topic of his medication, but partway through, without any explanation or connecting logic, the sentence structure breaks down and finishes on an entirely unrelated topic, with grammar disrupted in the process. What is this?
• A man with epilepsy is witnessed to wander from his workplace, behaving in a relatively well-ordered way throughout, before returning to full awareness twenty minutes later with no memory of the episode at all — a clean break rather than a gradual return. What is this presentation called?
• A lonely teenager spends long stretches of time each day absorbed in an elaborate, private daydream in which she is a celebrated adventurer, readily acknowledging when asked that it is simply imagination and a welcome escape from a difficult home life, not something she believes is actually happening. What is this?
• Throughout a lengthy interview, a patient repeatedly says "the wheels are turning" — inserting the phrase after answers to entirely unrelated questions about his mood, his sleep, and his family, with no evident connection to any of them. What is this?
• For several minutes, unprompted, a patient continuously repeats the sentence "I want to go home now, I want to go home now" in a flat, monotonous tone, seemingly regardless of anything said to her in the meantime. What is this?
• A patient describes a persistent sensation that her stomach "has stopped working and is rotting inside her," with a sense of pulling and burning deep in her abdomen, in the absence of any positive findings on thorough medical investigation. What is this?
• A patient cannot read words aloud or recognise them visually, though he understands the same words perfectly well when they are read to him, and he is still able to copy the written words onto a fresh sheet of paper even though he cannot read what he has copied. What is this?
• A patient with a fluctuating level of alertness reports seeing small, fully detailed figures of people moving about in the corner of the room, describing them with the same conviction and sense of reality as any object actually present, alongside intermittent disorientation to time and place. What is this?
• An examiner gently raises a catatonic patient's arm into an unusual, awkward position; the arm moves with a smooth, even resistance throughout, similar to bending a soft wax rod, and then remains held in that exact position for several minutes without the patient appearing to actively resist. What is this?

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• A patient has felt persistently low in mood for several months, with the low mood present most days regardless of what is actually happening in her life, worsening steadily despite generally positive circumstances. Before revealing the answer: is this an abnormal emotional reaction?
• A man involved in a minor car accident becomes intensely distressed and remains so, out of all proportion to the event, for several weeks afterward, describing his own reaction as clearly excessive but unable to shift it; how he outwardly shows this distress is unremarkable. Before revealing the answer: is this an abnormal expression of emotion?
• A patient with a years-long history of catatonic schizophrenia, on no new or recently changed medication, is found holding a bizarrely twisted body position, unresponsive to attempts to move it, with no sign of spasm. Before revealing the answer: is this acute dystonia?
• A woman shows a flat, unreactive expression only when discussing one specific traumatic memory, but her expression, tone, and gesture are otherwise full and appropriately varied across every other topic in the interview. Before revealing the answer: is this affect blunting?
• A patient shows almost no interest in activities he previously enjoyed, rarely initiating anything on his own, and appears outwardly indifferent even when told genuinely significant news about his own health. Before revealing the answer: is this constriction of affect?
• During a single conversation, a patient moves rapidly between tearfulness, laughter, and irritability, each shift abrupt and more pronounced than the conversation would seem to call for, though she is able to compose herself again within moments each time. Before revealing the answer: is this affective incontinence?
• A patient cannot understand anything said to him, though he can hear that speech is occurring and other sounds normally, but reads and writes without any difficulty at all. Before revealing the answer: is this agnostic alexia?
• A woman recently started on an antipsychotic reports feeling 'more anxious' and is noted to be pacing in the waiting room. Her team considers whether this represents a worsening of her underlying anxiety or something else. Before revealing the answer: what should specifically be asked to clarify this?
• A psychiatric inpatient becomes unresponsive and immobile over several hours, but on recovery accurately recalls conversations that took place around her during the episode, including details she should not have been able to register if her consciousness had genuinely been impaired throughout. Before revealing the answer: does this fit akinetic mutism?
• Asked to shake hands, a patient makes no attempt whatsoever, simply refusing outright with no visible hesitation, partial movement, or apparent internal conflict, and this same flat refusal is seen across every request made of her throughout the interview. Before revealing the answer: is this ambitendency?
• A patient with dementia cannot recall attending her granddaughter's wedding last month, but when asked about it, she confidently and in detail describes a different wedding — one that, on checking, never took place — with no apparent awareness that anything is wrong. Before revealing the answer: is this simply amnesia?
• A patient recovering from a serious head injury three months ago can recall his life in vivid detail up to the day before the injury, and now shows normal immediate recall on testing (repeating a list of words just given to him), but cannot remember anything from the days spent in intensive care or reliably learn new information day-to-day. Before revealing the answer: is this an amnestic state?
• A patient presenting for assessment of a separate mood disorder is noted, incidentally, to keep an extremely detailed and rigid daily schedule going back over a decade, to become visibly agitated by minor changes to it, and to have caused repeated arguments by insisting his family follow his exact standards for household organisation. He does not raise this pattern himself as a concern. Before revealing the answer: is the fact that he did not raise it himself unusual for this presentation?
• A 45-year-old woman with low mood says she still goes out to dinner with friends every week because "it's just what we do," but when asked directly, admits the food tastes the same as always and the conversation doesn't lift her mood the way it used to — she just goes through the evening. Before revealing the answer: what is this finding, and why is it significant that she still attends despite this?
• A 71-year-old man is admitted after a right-hemisphere stroke. On the ward round he is cheerful and talkative. Asked to squeeze the doctor's hand with his left hand, nothing happens; he says he did squeeze it, and when his flaccid left arm is lifted and dropped onto the bed in front of him, he seems unbothered and remarks that the physiotherapist "hasn't gotten round to that side yet." Before revealing the answer: what would you document in the mental state examination, and what would you specifically avoid concluding?
• A man recalls, in detail, everything that happened up to and including the moment of his accident, but has no memory of the several hours immediately afterward, during which witnesses say he was talking and behaving normally. Before revealing the answer: is this retrograde or anterograde amnesia, and what does the witnesses' account add?
• A patient recently started on an antipsychotic sits calmly during the interview and denies feeling unwell, but when asked directly whether he feels any inner restlessness or urge to move, he says yes, describing it as tension he can never quite shake and has not mentioned to anyone. Before revealing the answer: does the calm outward appearance rule out a movement disorder here?
• A patient is found wandering in an unfamiliar town, unable to recall her own name or personal history, though she has been managing daily tasks and behaving appropriately with strangers; this began abruptly after witnessing a violent assault two days earlier. Before revealing the answer: is this anxiety amnesia?
• A patient describes sudden episodes, several times a week, in which within a couple of minutes her heart pounds, she feels she cannot breathe, and she is gripped by a fear that she is about to die — each episode passing within about twenty minutes, after which she feels essentially back to normal until the next one. Before revealing the answer: is this simply anxiety?
• A man describes brief episodes, several times a week, in which intense dread suddenly overwhelms him, peaking within a few minutes along with a racing heart and breathlessness, before subsiding completely and leaving him feeling entirely normal in between episodes. Before revealing the answer: is this anxious foreboding?
• A woman describes intense fear specifically and only when required to eat in front of others or speak at meetings, but is otherwise socially confident, has a wide circle of established friends, and does not describe any generalised low self-worth. Before revealing the answer: is this anxious (avoidant) personality disorder?
• A patient facing a difficult, ongoing legal dispute describes feeling helpless and discouraged specifically about that situation, while remaining actively engaged, motivated, and emotionally responsive in every other area of her life, including work and her relationships with friends and family. Before revealing the answer: is this apathy?
• A patient with a confirmed brain tumour affecting the left temporal lobe has marked difficulty finding the right words in conversation, though her comprehension of what is said to her remains largely intact, and there are no other signs of broader psychiatric disturbance. Before revealing the answer: is this best classified as aphasia?
• A grieving widow reports hearing her late husband's voice, but is clear that it feels like an inner experience rather than a real external sound — she describes it as 'in my mind, not in my ears' and knows, even as it happens, that it is not really him speaking aloud. Before revealing the answer: is this a true auditory hallucination?
• While looking at an ordinary traffic light change from red to green, a patient suddenly becomes completely convinced that this means he must abandon his family immediately, a belief he holds with total, unshakeable conviction from that moment on. Before revealing the answer: is this an autochthonous delusion?
• A patient follows straightforward, reasonable instructions during an examination but declines an instruction that would cause obvious pain, explaining that it would hurt. Before revealing the answer: is this automatic obedience?
• A patient describes floating above their own body during a medical emergency, looking down at themselves lying on the ground, with their sense of viewpoint clearly located above rather than in their physical body. Before revealing the answer: is this autoscopy?
• A man with a functional non-epileptic seizure disorder discusses his diagnosis calmly and seems relatively untroubled by it, but when you ask directly, he says he does worry about it and simply prefers not to dwell on it, and his sleep and appetite have been affected. Before revealing the answer: is this la belle indifference?
• A severely depressed patient states, with complete conviction, that his legs no longer exist at all, insisting this is a literal fact despite clear visual evidence to the contrary, and that his body has effectively ceased to be. Before revealing the answer: is this body image disturbance?
• On an inpatient ward, a patient praises one nurse extravagantly as "the only person who actually cares," while calling another "completely incompetent and uncaring" after a minor disagreement about visiting hours. By the following week, which nurse is 'good' and which is 'bad' has completely swapped. Before revealing the answer: what is this pattern called, and why does it matter for how the clinical team manages it?
• A man with dementia becomes convinced his daughter, who visits him daily and whom he agrees looks exactly like his real daughter, is "an impostor sent to trick him," and asks staff to call the police each time she visits. Before revealing the answer: is this Capgras syndrome?
• During a catatonia examination, a patient is not warned beforehand that they need not hold any position their limb is placed in, and their arm remains raised for several minutes after being lifted. Before revealing the answer: is this finding fully reliable as catalepsy?
• Following a traumatic assault, a patient cannot recall her own name or family history for several days, though she can still perform complex everyday tasks competently, before her full memory and sense of identity gradually return. Before revealing the answer: is this catathymic amnesia?
• Asked what colour the sky is, a patient answers, in a completely normal speaking voice, "green," and asked what colour grass is, answers "blue," with every answer showing clear understanding of the question but consistently and noticeably wrong. Before revealing the answer: is this catatonic speech disturbance?
• A 30-year-old man with a known diagnosis of schizophrenia is found rigid, mute, and unresponsive on the ward, his face utterly blank. When a nurse gently lifts his arm and lets go, it remains suspended in the air where she left it. Before revealing the answer: what is this specific finding on his arm called, and what does its presence, alongside his other features, tell you about the type of stupor he is in?
• A patient's grammar, sentence structure, and comprehension are all entirely intact, but she has a specific, isolated difficulty finding the names of objects when asked, sometimes substituting a vague description in place of the correct word. Before revealing the answer: is this central aphasia?
• A patient reports seeing a small, brightly coloured figure standing in the corner of an otherwise empty room, describing it with the same full perceptual vividness as anything else she looks at, though nothing is actually there. Before revealing the answer: is this chromatopsia?
• Asked a simple question, a patient produces a rapid stream of associated ideas — one word or image suggesting the next through rhyme, chance resemblance, or passing distraction — and after several minutes has still not addressed, or seemingly even registered, the original question at all. Before revealing the answer: is this circumstantiality?
• A patient describes recurrent, intrusive thoughts that he might have left the stove on, causing him significant distress and preoccupation throughout the day, but he does not actually go and check the stove or perform any related action in response. Before revealing the answer: is this a compulsion?
• A 58-year-old man with a history of heavy alcohol use is asked what he did over the weekend. He answers instantly and confidently that he attended his daughter's graduation — but she graduated three years ago and was not visiting this weekend. He shows no hesitation and becomes mildly irritated when this is gently questioned. Before revealing the answer: what is happening here, and what feature of his response would make you doubt this was simply a lie?
• A patient with a significant organic memory impairment, when asked what she did yesterday, confidently and elaborately describes attending a family celebration that did not take place and that bears no resemblance to anything she is known to have previously experienced. Before revealing the answer: is this cryptamnesia?
• A 45-year-old man walking into a hotel lobby for the first time is suddenly gripped by absolute certainty that he has stood in that exact spot before, right down to the pattern of the carpet, even though he has never visited before and knows this is impossible. The feeling passes within seconds and he is only mildly unsettled by it. Before revealing the answer: what is this, and what specifically about his account makes it not a delusion?
• A profoundly depressed patient believes with complete conviction that she has committed a terrible, unforgivable sin and deserves to be punished. When asked how she came to this conclusion, she explains it follows naturally from how worthless and wicked her depression makes her feel about herself. Before revealing the answer: is this a primary delusion?
• A woman with severe depressive illness tells you, with complete conviction, that she is responsible for a house fire that occurred in her neighbourhood three years ago, despite having been abroad at the time — a fact her family has confirmed to her repeatedly and which she cannot recall disputing when told. Before revealing the answer: is this a delusion of guilt?
• A man tells you he is certain his internal organs have "stopped working properly" and that he is slowly dying from the inside, despite a full set of recent investigations, including blood tests and imaging, all returning entirely normal. He becomes visibly more distressed, not reassured, when you mention the normal results. Before revealing the answer: is this a delusion of ill health?
• A man with a long history of heavy alcohol use tells you he is certain his partner is having an affair, describing in detail how he has begun checking her phone daily and timing her return from work to the minute. He becomes agitated and mentions that he "won't let this go on." Before revealing the answer: what should this specific detail about his agitation and intent prompt you to assess directly?
• A woman tells you with complete conviction that a senior colleague she has spoken to only briefly is secretly in love with her, and that his recent promotion to a role in another building is a coded message meant only for her to understand. She has begun waiting outside his usual entrance each morning. Before revealing the answer: is this a delusion of love?
• A patient believes his former business partner, who recently defrauded him in a documented, ongoing legal dispute, is now trying to sabotage his new business — and describes specific, verifiable actions consistent with this. Before revealing the answer: is this a delusion of persecution?
• A retired man with severe depressive illness refuses to let his wife buy groceries, insisting they "can't afford it and never will again," despite a substantial pension being paid into their account every month, which you confirm with his wife present. He does not appear reassured even as she shows him the most recent statement on her phone. Before revealing the answer: is this a delusion of poverty?
• A patient reports that, on seeing a red car parked outside his house one morning, he suddenly and completely understood, with absolute conviction, that this was a coded signal that he was about to be arrested. Before revealing the answer: is this delusional mood?
• A 29-year-old woman says that the moment she saw a red car pull into her street, she instantly and completely knew that she had begun being watched by a government agency. She cannot explain how the car led to this conclusion, only that the certainty arrived all at once. Before revealing the answer: what is this finding, and why does it not simply count as an illusion?
• A woman managing a difficult, prolonged legal dispute over several years describes feeling worn down and doubtful she can see it through, but remains actively engaged with her hobbies, her friendships, and her work, describing her low feeling as entirely about the legal situation itself. Before revealing the answer: is this most likely a depressive illness?
• A patient describes, in a calm and curiously matter-of-fact tone, a serious car accident she survived, giving a full and accurate account of every distressing detail without any apparent emotional reaction. Before revealing the answer: is this denial?
• A 29-year-old woman's partner ended their relationship two weeks ago. She describes feeling unable to function, has already begun urgently seeking a new relationship "so someone can look after things again," and says she has always let partners make even minor decisions for her because she "doesn't trust her own judgement." Before revealing the answer: does this fit dependent personality disorder, or would you want to know more first?
• A 19-year-old man under heavy exam pressure and sleeping poorly describes feeling "like I'm on autopilot, watching myself from a few feet behind my own head" for the past several days. He finds it unpleasant and says he knows, rationally, that this is just how it feels rather than what's actually happening. Before revealing the answer: what is this, and what feature of his account rules out a nihilistic delusion?
• A patient facing a stressful, unresolved workplace dispute describes feeling low and discouraged specifically about work, but continues to sleep normally, eat well, enjoy time with friends and family, and maintain her usual concentration and energy in every other area of life. Before revealing the answer: is this a depressive illness?
• An older woman presents with several months of worsening memory complaints. She is tearful throughout the assessment, repeatedly apologises for "being so useless," and says she is terrified she is developing dementia like her mother did. Before revealing the answer: does her marked distress and awareness of her own cognitive difficulties make a diagnosis of true dementia more or less likely at this stage?
• A patient in a profound stuporose state shows a flat, deadpan facial expression with no change when emotionally significant topics are raised, altered muscle tone with limbs that can be moulded into new positions and remain there, and episodes of urinary incontinence. Before revealing the answer: is this depressive stupor?
• A 27-year-old woman going through a highly stressful period at work says that her flat has started to feel like a stage set rather than her real home, the furniture and rooms somehow flat and distant, even though she knows perfectly well nothing has actually changed there. She adds that she still feels entirely like herself throughout. Before revealing the answer: what is this, and what detail specifically rules out depersonalisation here?
• A patient begins a sentence describing his weekend, and partway through, without any grammatical break, the sentence itself trails off mid-clause into an entirely unrelated and structurally garbled ending. Before revealing the answer: is this desultory thinking?
• A patient's face and voice both convey markedly less emotion than expected throughout the interview, including reduced vocal tone variation, and this is not confined to any specific pattern of physical gesture; the patient does not notice any change in themselves. Before revealing the answer: is this a disorder of expressive movement?
• A long-term inpatient with chronic schizophrenia gives vague or wrong answers when asked the date and his location, but staff who know him well say this has been his pattern for years and does not represent any recent change. Before revealing the answer: should this be treated as acute disorientation requiring urgent investigation?
• A young man has multiple convictions for theft and assault, all of which occurred exclusively during periods of heavy alcohol and drug use, with no antisocial behaviour at all during his extended periods of sobriety. Before revealing the answer: does this amount to dissocial personality disorder?
• Throughout a lengthy interview covering a wide range of topics, both neutral and emotionally significant, a patient's face, voice, and gestures remain flat and unchanging, showing no more feeling in response to distressing content than to mundane content. Before revealing the answer: is this dissociation of affect?
• A young man involved in a serious road traffic collision, in which a close friend died, is unable to recall the collision itself or the weeks immediately surrounding it, though his memory for his life before and after that period is intact, and he successfully continues working and managing his daily responsibilities throughout. Before revealing the answer: is this dissociative amnesia?
• A patient describes walking into a shop she is certain she has never visited before, yet experiencing an overwhelming, inexplicable sense that she has been there before, in exact detail, though she cannot say when. Before revealing the answer: is this a distortion of recall?
• A patient with schizophrenia has, over several weeks, developed a fixed, elaborated conviction that her neighbour has been replaced by a physically identical impostor, maintained despite all reassurance. Before revealing the answer: is this an ordinary distortion of recognition?
• Mid-sentence, a patient suddenly stops speaking altogether, her expression going blank for a few seconds, with no external sound or movement nearby to explain it, and afterward she cannot say what she had been about to say. Before revealing the answer: is this distractibility?
• A meticulous, always well-groomed university lecturer is brought in appearing dishevelled, giving vague, patchy answers about the last day, and unable to say clearly what day of the week it is, following a urinary tract infection with fever. Before revealing the answer: is this most likely dementia?
• A severely depressed elderly patient states with complete conviction that she has already died and that her body is now empty inside, and cannot be persuaded otherwise despite clear evidence to the contrary. Before revealing the answer: is this a disturbance of awareness of self-activity?
• A patient describes feeling strangely detached from her own actions, as though she is watching herself go through the motions of daily life without any genuine sense that these actions are truly hers, though she describes no sense of any outside force or boundary being crossed. Before revealing the answer: is this a disturbance of the boundaries of the self?
• A patient reports that, in the middle of ordinary conversations, she sometimes feels as if there are two of her present at once, one speaking normally and another watching and commenting from just behind, though she knows perfectly well this isn't literally true. Before revealing the answer: is this a disturbance of the continuity of self?
• A man states, without any qualification and with full conviction, that he is genuinely two separate people who happen to share one body, each with a distinct name, history, and way of speaking. Before revealing the answer: is this best described as disturbance of self-unity?
• A 68-year-old woman recovering from surgery insists there are insects crawling on the wall and becomes distressed trying to brush them off, entirely convinced they are real. She cannot say what day it is but greets her son by name the moment he enters. A nurse tells you she was calm and lucid an hour ago. Before revealing the answer: what is this presentation, and what does the fluctuation over the last hour tell you?
• While describing his weekend in an otherwise clear, well-organised way, a patient's account is suddenly and repeatedly punctuated by short, unrelated, self-contained remarks about entirely different topics, each of which makes complete sense on its own before the original account resumes. Before revealing the answer: is this drivelling thinking?
• A patient reports seeing a tiny, fully formed group of people walking across her empty living room floor, with no real object or person actually present. Before revealing the answer: is this dysmegalopsia?
• Asked what year it is, a patient with known cognitive impairment answers correctly. Asked next what season it is, he instead answers 'what year it is' — his own previous question topic intruding into the new answer. Before revealing the answer: is this echolalia?
• On a ward round, a psychiatry student notices that a patient with schizophrenia touches his own nose every time the consultant touches hers, seemingly without registering that he is doing it. He does not respond when asked directly whether he noticed. Before revealing the answer: what is this finding, and what other catatonic signs would be worth specifically checking for given this observation?
• A patient has been persistently cheerful, expansive, and overly familiar with strangers for several weeks, describing life as generally wonderful and full of good feeling, but without any sense of mystical transcendence, unity, or profound cosmic significance when asked to elaborate. Before revealing the answer: is this ecstasy?
• A patient, sitting quietly in a clinic waiting room, suddenly and involuntarily perceives a detailed scene unfolding in front of him as though it were happening right now, with no awareness that he is remembering rather than currently perceiving something. Before revealing the answer: is this eidetic imagery?
• A patient shows extraordinary instability of relationships, mood, and self-image, with chronic feelings of emptiness, an intense fear of abandonment, repeated self-harm, and relationships that swing between idealisation and sudden rejection. Before revealing the answer: is describing this patient using only the umbrella term "emotionally unstable personality disorder," without further specification, the most clinically informative approach?
• A woman has shown a hostile, suspicious, and socially withdrawn manner for as long as anyone who knows her can remember, tracing back to her teenage years, with no identifiable triggering event or illness at any point. Before revealing the answer: is this enduring personality change after a catastrophic experience?
• After drinking only a single small measure of alcohol, a man suddenly becomes violently aggressive toward those around him for about an hour, showing none of the usual unsteadiness or slurred speech of ordinary intoxication, and afterward has no memory of the episode at all. Before revealing the answer: is this best described simply as excitement, or does it fit a more specific named pattern?
• A patient sits through an entire interview producing no spoken words whatsoever, not even a single sound, despite appearing to understand and attend closely to everything said to him, though he does eventually communicate a brief message by writing on paper. Before revealing the answer: is this expressive aphasia?
• A father with severe, delusional depressive illness, believing his family faces certain financial ruin and that this is entirely his fault, expresses a plan to end his own life alone, with no mention of harming his children. Before revealing the answer: does this meet the pattern of extended suicide?
• A patient reports hearing a voice clearly coming from just behind his left shoulder, a location well within his normal field of hearing, with full sensory conviction and no real speaker present. Before revealing the answer: is this an extracampine hallucination?
• During a police interview, a vulnerable, highly suggestible man repeatedly denies involvement in an offence, but after prolonged, suggestive questioning eventually says he 'remembers' committing it, in vague and shifting detail that changes each time he is asked. Before revealing the answer: could this be a false memory, and why does it matter?
• A patient firmly and repeatedly insists that his wife, whom he acknowledges looks and sounds identical to his real wife in every way, is actually an impostor who has secretly replaced her, becoming suspicious and hostile toward her as a result. Before revealing the answer: is this false reconnaissance?
• A woman says that whenever she wants to, she can recall the moment she heard about a major national tragedy in extraordinary, stable detail — exactly where she was standing, what she was wearing, who she was with — and she is highly confident in the accuracy of every detail, though the memory has never once intruded on her unbidden. Before revealing the answer: is this a flashback?
• A man vividly and confidently recalls exactly where he was when he heard about a major national event twenty years ago, but when an old diary entry from the actual day is later found, several key details turn out to be inaccurate. Before revealing the answer: does this inaccuracy mean it wasn't a genuine flashbulb memory?
• A 41-year-old man in a hypomanic episode wanders through several unrelated topics when asked a simple question, but each time, after a minute or two of tangents, he laughingly says "anyway, back to your question" and gives a reasonably direct answer. Before revealing the answer: is this flight of ideas, and what specific feature of his speech tells you which variant this is?
• An examiner asks a catatonic patient to stand on one foot for as long as possible; the patient does so despite it becoming visibly painful, and continues to comply fully each time the same uncomfortable instruction is repeated, without ever refusing or adjusting. Before revealing the answer: is this forced grasping?
• A patient speaks rapidly and at length, moving quickly from one topic to the next, each new idea clearly triggered by a word or sound from the last, so that a listener can always follow exactly how she got from one thought to the next, even though she never settles on any single topic. Before revealing the answer: is this formal thought disorder?
• A patient on a hospital ward says that every time the bedside fan switches on, she hears a voice arguing somewhere within the noise; when the fan is off, there is no voice. She can hear the fan itself completely normally throughout, and confirms this happens every single time. Before revealing the answer: what is this finding, and why is it not simply an illusion?
• A fully alert, oriented patient consistently gives approximate wrong answers to simple questions, with an amused, facetious manner, but shows no clouding of consciousness, disorientation, or hallucinations at any point. Before revealing the answer: is this Ganser syndrome?
• On examination, a patient's arm resists all attempts at passive movement, gentle or firm, with a marked, apparently motiveless force that does not simply scale with the examiner's own effort, and the same pattern is seen when the examiner tries to reposition his legs and turn his head. Before revealing the answer: is this Gegenhalten?
• A man with elevated mood and pressured speech tells you he has invented a device that will "solve the energy crisis for the entire planet," and that several world governments are already secretly in contact with him about it, though he cannot produce any evidence of this contact when asked. Before revealing the answer: is this a grandiose delusion?
• A patient reports smelling burning rubber throughout the day, with no accompanying taste symptom at all, and no external source anyone else can identify. Before revealing the answer: is this a gustatory hallucination?
• Walking through a dimly lit garden at dusk, a patient briefly mistakes a coat hanging on a hook for a person standing still, and on turning on a light, immediately recognises her error. Before revealing the answer: is this a hallucination?
• A patient with a long history of heavy drinking reports ongoing auditory hallucinations. Before revealing the answer: is assessing his orientation and clarity of consciousness a necessary part of confirming this is hallucinosis rather than something more urgent?
• A patient with left-sided weakness, when asked directly about her left arm, insists with conviction that it belongs to her sister and offers a detailed explanation of how it supposedly came to be attached to her body. Before revealing the answer: is this hemiasomatognosia?
• A patient following a stroke fails to recognise her own left arm as belonging to her, insisting it belongs to someone else, but she readily notices and responds normally to objects, food, and people on her left side more generally. Before revealing the answer: is this hemispatial neglect?
• A man becomes markedly more dramatic, flirtatious, and attention-seeking than usual during a hypomanic episode, a pattern his family says is completely unlike him when well. Before revealing the answer: does this amount to histrionic personality disorder?
• When asked what she did over the weekend, which she cannot actually recall due to a genuine gap in her memory, a patient promptly and confidently describes a detailed outing that never happened, showing no hesitation or awareness that anything is wrong. Before revealing the answer: is this hyperamnesia?
• In the middle of an otherwise ordinary afternoon, fully awake and alert, a patient hears a voice commenting on his actions, an experience that recurs several times over the following hours. Before revealing the answer: is this a hypnagogic hallucination?
• A man is found wandering after a period of impaired awareness, and EEG monitoring during a similar subsequent episode shows clear epileptiform discharges, with sudden onset and end each time. Before revealing the answer: is this a hysterical twilight state?
• A tired night-shift worker, glancing quickly across a poorly lit corridor, briefly perceives a mop propped against the wall as a person standing there, but immediately recognises the mistake on a second, closer look and is not troubled by it afterwards. Before revealing the answer: is this clinically significant?
• A mother with severe, delusional depressive illness, convinced she has passed an incurable genetic curse to her children, kills her two children before attempting to take her own life, later explaining she believed she was sparing them from a lifetime of suffering. Before revealing the answer: is this impulsive behaviour?
• A man with no prior history of temper problems develops, over the past two weeks during a manic episode, a markedly lowered threshold for irritation, snapping at trivial remarks that would never have bothered him before; his temper returns to normal as the episode resolves. Before revealing the answer: is this impulsive personality disorder?
• A 33-year-old man smiles broadly while describing being made redundant from his job of fifteen years and losing his flat shortly afterward. When his clinician comments gently that this sounds like it must have been very difficult, he continues smiling and seems unsure why she said that. Before revealing the answer: what is this finding, and how would you document it precisely rather than just noting it as 'odd'?
• Mid-sentence, describing his weekend, a patient suddenly stops speaking entirely, looking momentarily blank, and afterward cannot recall what he had been about to say, though his speech had been at a completely normal pace right up until that moment. Before revealing the answer: is this inhibition of thinking?
• A patient's spontaneous speech is fluent but he cannot name any of the common objects shown to him, though his grammar, sentence structure, and comprehension of both spoken and written language are entirely intact. Before revealing the answer: is this best described simply as intermediate aphasia, or does it fit one of its more specific named sub-types?
• A patient who has taken antipsychotic medication for many years develops gradually worsening, repetitive, purposeless movements of the mouth and tongue, with no family history of any neurological condition and no other relevant medical illness. Before revealing the answer: is this best described as one of the broader involuntary neurological movement signs?
• Following a neurological illness, a patient bursts into sudden, uncontrollable laughter or tears at minor or even neutral remarks, with the intensity and nature of the display markedly disconnected from how she actually reports feeling at the time, and she cannot bring the display under control once it begins. Before revealing the answer: is this irritability?
• A woman's mood shifts across a session — she is tearful when discussing a recent loss, calmer when discussing work, and briefly amused by a shared joke — with each shift proportionate to, and clearly connected with, the topic at hand. Before revealing the answer: is this lability of affect?
• Over several months, a patient has developed an increasingly persistent and pervasive difficulty finding the names of common objects and people, a difficulty that does not resolve on its own and is now affecting his ability to hold ordinary conversations. Before revealing the answer: is this lethologia?
• A man with severe depression says he feels nothing when he sees his newborn grandchild, and concludes from this that he must be a fundamentally bad, unloving person. Before revealing the answer: how should this feeling and his interpretation of it be understood?
• A 74-year-old man is admitted with a severe chest infection. Over the following days he becomes profoundly slowed, apathetic, and gives only brief, unclear answers, sometimes repeating the same phrase, with no hallucinations or restlessness noted by staff. His family, worried, asks whether he now has dementia. Before revealing the answer: what would you tell them, and what would you want to check over the following weeks?
• A 19-year-old university student, with no psychiatric history, has an unusual, exaggerated bow whenever she greets a lecturer, a habit her friends say is 'just her thing' and find endearing rather than concerning. Before revealing the answer: is this a mannerism in the clinical sense, and what does this case illustrate about interpreting mannerisms in isolation?
• A patient's arm is passively raised by the examiner and remains held in that raised position for over a minute, felt as a smooth, even resistance throughout the movement, until the examiner repositions it again. Before revealing the answer: is this Mitmachen?
• The night before a major exam, a student feels intensely anxious, with a racing heart and churning stomach, but the feeling resolves entirely once the exam is over and does not recur afterward. Before revealing the answer: is this morbid anxiety?
• A patient's underlying mood appears entirely normal on careful direct questioning, but his face has become notably stiff and unchanging, and his family reports this change, of which he seems entirely unaware, developing gradually over recent months. Before revealing the answer: is this a morbid disorder of emotion?
• A woman recently promoted at work describes feeling genuinely delighted and proud for a few days, enjoying celebratory dinners with friends, before her mood settles back to its usual baseline the following week. Before revealing the answer: is this morbid euphoria?
• A woman deliberately keeps a composed expression in front of colleagues despite feeling intense grief, and when asked privately, readily acknowledges that she is consciously suppressing how she feels and finds it exhausting to maintain. Before revealing the answer: is this a morbid expression of emotion?
• A woman with no history of neurological illness describes feeling unusually cheerful, optimistic, and full of energy for the past two weeks, with an expansive good mood but no particular tendency toward joking or facetiousness beyond her normal sense of humour. Before revealing the answer: is this moria?
• During a bedside cognitive assessment, a patient is asked to draw a series of five-pointed stars. After completing the first star correctly, he continues drawing additional star points well beyond the outline, unable to stop the pen even when reminded the task is complete. Before revealing the answer: is this motor perseveration?
• A patient describes sometimes acting or speaking in a way that feels automatic, as though driven by another part of herself, while readily acknowledging that this is just how it feels, not a literal belief that she is genuinely two separate people. Before revealing the answer: is this the experience of multiple personalities?
• A young man facing an upcoming court appearance tells increasingly elaborate, grandiose stories of past heroic exploits to his friends, with no medical presentations involved at all; when a friend produces clear documentary proof he was elsewhere at the time, he eventually admits the stories were invented. Before revealing the answer: is this Munchausen's syndrome?
• Following a focal neurological event, a patient produces no speech at all, but reading comprehension and handwritten communication both remain entirely normal and unaffected. Before revealing the answer: is this simply mutism, with nothing more specific to say?
• A 38-year-old man describes feeling "completely humiliated" and becoming furious for days after a minor, constructive piece of feedback from his manager, despite an otherwise strong performance review. He says he deserves to be running the department himself and describes colleagues who disagree with him as "just jealous." Before revealing the answer: which features here point toward narcissistic personality disorder specifically, rather than just an unusually thin skin?
• A patient refuses to take prescribed medication, explaining clearly that he believes it is being used to poison him. Before revealing the answer: is this negativism?
• A man with a known stroke affecting language areas produces the word 'spron' when trying to say 'spoon', consistently substituting similar-sounding but incorrect words throughout the interview, with no evidence of psychotic symptoms and clear frustration at his own errors. Before revealing the answer: is this a neologism?
• Following a right parietal stroke, a patient with an obviously paralysed left arm insists nothing is wrong with it and becomes annoyed when the paralysis is pointed out, while readily acknowledging the arm itself exists and is his. Before revealing the answer: is this a nihilistic delusion?
• A patient's spontaneous speech shows frequent grammatical errors, word-substitution mistakes, and difficulty both understanding what is said to him and producing appropriate responses, in addition to word-finding trouble. Before revealing the answer: is this nominal aphasia?
• A woman describes recurrent thoughts of contamination that she finds distressing, but on further questioning she says she is not actually sure the thoughts are irrational — she feels genuinely convinced her hands are contaminated no matter how much she washes them, and this conviction does not waver even when shown clear evidence otherwise. Before revealing the answer: is this a straightforward obsession?
• A severely depressed patient moves, speaks, and thinks noticeably slowly and consistently throughout the entire interview, with no sudden stops or unpredictable interruptions, simply a uniform, steady slowness across everything he does. Before revealing the answer: is this obstruction?
• A fully alert, oriented patient with a lifelong odd, exaggerated way of shaking hands, an idiosyncratic quirk his colleagues have always found amusing, is otherwise entirely well and shows no confusion or disorientation of any kind. Before revealing the answer: is this occupational delirium?
• A patient reports smelling her late mother's distinctive perfume, briefly and vividly, while looking through an old photo album, and immediately recognises this as a memory triggered by the photographs rather than a present, real smell. Before revealing the answer: is this an olfactory hallucination?
• A patient with no history of head injury or physical illness suddenly cannot recall her own name, family, or personal history following a traumatic event, while still being able to drive, hold a coherent conversation, and manage everyday tasks competently. Before revealing the answer: is this organic amnesia?
• A patient reliably hears a hallucinated voice only while the kitchen tap is running, and the voice stops the moment the tap is turned off; he has no relevant physical illness or injury. Before revealing the answer: is this an organic hallucination?
• A woman has, over many years and with no diagnosed mental illness, developed a passionate, dominating conviction about a particular social cause, which shapes much of her life and which she discusses with intensity, though she is willing to hear and seriously consider opposing arguments, even if she remains ultimately unconvinced by them. Before revealing the answer: could this be an overvalued idea, and does the absence of any diagnosed mental illness rule it out?
• A man presents to the emergency department convinced he is having a heart attack, with chest pain, palpitations, and severe shortness of breath that came on abruptly ten minutes ago. Cardiac investigations are unremarkable. Before revealing the answer: what should be considered alongside cardiac causes?
• A woman reports a complete blank for an entire week of her life, with no memory content of any kind for that period, however hard she tries or however she is prompted. Before revealing the answer: is this an example of a paramnesia?
• A woman describes a lifelong pattern of assuming colleagues are undermining her, reading hostile intent into neutral comments, and gradually losing most of her friendships as a result, though she has never held a single fixed, specific belief that any one person is definitely plotting against her in a particular way. Before revealing the answer: is this best understood as a delusion of persecution?
• A patient with no history of neurological illness, admitted with acute psychosis, repeatedly uses an invented word, "grendlock," to describe a private, indescribable experience, embedded within otherwise fluent, grammatically intact speech. Before revealing the answer: is this a paraphasia?
• A patient confidently states that the arm attached to her left shoulder belongs to her nurse, not to her, and offers this explanation readily and without distress when the limb is pointed out to her. Before revealing the answer: is this paraschemazia?
• A woman says she sometimes feels a strong urge to check the front door repeatedly, which she recognises is excessive but cannot easily resist, and which she describes as 'like something is making me do it', though she agrees on further questioning that it is her own anxious urge and no outside force is actually controlling her body. Before revealing the answer: is this a passivity phenomenon?
• A man with a long history of heavy regular drinking becomes loudly argumentative and unsteady on his feet after finishing most of a bottle of spirits at a party, later apologising the next day and recalling the argument clearly. Before revealing the answer: is this pathological drunkenness?
• A patient describes, with full clarity and coherent understanding of her circumstances, a persistent and distressing feeling that something terrible is about to happen to her family, though she cannot say what or why, and she otherwise makes complete sense of her surroundings. Before revealing the answer: is this perplexity?
• A patient responds to every single question in an assessment, regardless of its content, with the same fixed phrase, 'I don't know, I don't know', showing no variation in relation to what is actually being asked. Before revealing the answer: is this perseveration?
• An examiner passively moves a patient's arm into an unusual position and feels a smooth, even, wax-like resistance throughout the entire movement; once positioned, the arm remains there for several minutes, with the patient not appearing to actively resist at any point. Before revealing the answer: is this perseveration of posture?
• A previously easy-going, sociable man becomes markedly suspicious, rigid, and difficult to reason with for several weeks, exactly matching the pattern of a specific personality disorder, but this change appeared only during a severe depressive episode and has begun resolving as his mood improves. Before revealing the answer: should this be diagnosed as a personality disorder?
• A patient describes constant, free-floating unease that is present most days regardless of circumstances, with no particular object or situation she can identify as triggering it, and no specific avoidance behaviour, since there is nothing obvious to avoid. Before revealing the answer: is this a phobia?
• A woman with several weeks of severe depressed mood and profound guilt develops a fixed belief that she has committed a terrible unforgivable sin and deserves to be punished. Before revealing the answer: is this a primary or secondary delusion?
• A 15-year-old girl tells you she sometimes 'sees' her late grandmother standing at the end of her bed at night. Before revealing the answer: what two follow-up questions would help you work out whether this is a pseudohallucination, and why does age make you take particular care here?
• A patient with a confirmed history of significant head injury and cognitive impairment confidently but incorrectly describes attending an event that never took place, showing no awareness that the account might be false and no particular life crisis prompting it. Before revealing the answer: is this pseudologia fantastica?
• A 68-year-old woman with severe depressive illness sits mostly motionless during the interview, answers only after long pauses, and her daughter reports she now takes over an hour to get dressed in the morning, compared with about ten minutes previously. Before revealing the answer: is this psychomotor retardation?
• A patient cannot recognise or read aloud any written words placed in front of him, though he can copy the same words by hand, and he understands everything said to him without any difficulty. Before revealing the answer: is this pure word deafness?
• A patient produces only a handful of expletives and fixed phrases when trying to speak, and his written answers, while generally understandable, also show frequent spelling errors and abbreviated, telegram-style sentences he would not have produced before his illness. Before revealing the answer: is this pure word-dumbness?
• When an examiner asks a patient to open his mouth, the patient instead clamps it firmly shut, and when asked to raise his arm, he lowers it instead, in what appears to be a consistent, reflex-like pattern of doing the opposite of every instruction given. Before revealing the answer: is this a disorder of reactive movements?
• During a single interview, a patient cycles rapidly between tearfulness, sudden laughter, and irritability within a few minutes, with no clear external event prompting each shift and the changes appearing far more abrupt and pronounced than anything discussed would warrant. Before revealing the answer: is this reactivity of mood?
• A patient clearly understands every spoken and written instruction given to him, following each one correctly, but struggles severely to produce any spoken response, managing only a few effortful, halting words at a time. Before revealing the answer: is this receptive aphasia?
• A patient explains that she has, for as long as she can remember, experienced a distinct colour whenever she hears music, finding the experience pleasant and unremarkable rather than distressing. Before revealing the answer: is this a reflex hallucination?
• A patient, disoriented for time and place but oriented for person, describes vivid, terrifying visions of small animals crawling on the walls, so convincing that she cannot tell them apart from things actually in the room. Before revealing the answer: is this restriction of consciousness?
• Two days after a fall, a woman cannot recall the half hour before her fall. Assessed again a week later, that gap has narrowed to only the last few minutes before the fall. Before revealing the answer: is this evolution expected, and what does it tell you about the underlying process?
• A patient recently diagnosed with depression describes her whole life, including periods collateral history confirms were happy and successful, as "one long failure from the beginning." She holds no delusional beliefs of any kind. Before revealing the answer: is this a retrospective delusion?
• Asked about a specific weekend last year, a patient confidently describes attending a family wedding in detail, an event that, on checking, never took place, with no other explanation offered for the gap in his actual memory of that time. Before revealing the answer: is this retrospective falsification?
• Following a single head injury, a patient has persistent difficulty forming new memories from that point onward, but this difficulty has remained stable in extent over the following year rather than progressively widening, and his memory for events well before the injury remains fully intact. Before revealing the answer: is this Ribot's law of memory regression?
• A woman describes a single voice that speaks directly to her, saying 'you are worthless, you should stop trying', appearing at moments unrelated to what she happens to be doing at the time. Before revealing the answer: is this running commentary voices?
• A patient with left-sided paralysis following a stroke insists nothing is wrong with her arm and offers a vague, confident explanation for why she is not moving it when asked, showing little concern about the situation. Before revealing the answer: is this schemazia distortion?
• A woman describes a recent, distressing sense of watching herself from outside her own body, as though acting on autopilot, and says this feels like a frightening change from how she used to experience herself. Before revealing the answer: is this schizoid personality disorder?
• Following a confirmed stroke affecting the language areas of the brain, a patient produces severely disorganised, hard-to-follow speech, and also shows clear difficulty with everyday practical tasks that require following instructions, alongside evident frustration at his own communication difficulties. Before revealing the answer: is this schizophasia?
• A patient has shown a consistent, unchanging pattern of complete emotional detachment and social withdrawal since adolescence, with no interest whatsoever in forming relationships, no fluctuating episodes, no odd beliefs, and no unusual communication style. Before revealing the answer: is this schizotypal personality disorder?
• In therapy, a man's vivid memory of a happy family holiday is explored, and it emerges that the holiday did happen, but one detail he consistently recalls — that his older brother was present and cheerful throughout — turns out to be inaccurate, since his brother was, in fact, absent for most of the trip following a family argument. Before revealing the answer: what does this pattern suggest?
• A man with no preceding change in mood, perception, or personality suddenly and inexplicably becomes convinced, out of nowhere, that a television broadcaster is sending him personal messages, with no other experience that could account for how this belief arose. Before revealing the answer: is this a secondary delusion?
• A recently widowed man reports feeling his late wife's presence in the house, and a junior colleague suggests this should be treated as a concerning symptom warranting urgent psychiatric review. Before revealing the answer: is this concern warranted on the information given?
• In dim evening light, a patient glances at a coat hanging on a hook and, for a moment, is convinced it is a person standing in the room, before realising her mistake on looking more closely. Before revealing the answer: is this sensory intensity distortion?
• A woman with a limb that has stopped working, with no medical cause found, describes the problem readily and in detail but shows a notable lack of worry about it, remaining calm and even mildly cheerful while discussing a symptom that most people would find alarming. Before revealing the answer: is this smiling depression?
• A man recently diagnosed with a terminal illness continues to make detailed plans for events years in the future, insisting to his family that the diagnosis must be a mistake, and shows no physical symptoms or complaints related to depression at all. Before revealing the answer: is this somatisation?
• A man with left-sided weakness after a stroke is asked to lift his left arm. He does not attempt to, and when asked why, says nothing is wrong with his arm and that he simply doesn't feel like moving it right now. Before revealing the answer: is this somatoparaphrenia?
• A patient sits silently through an entire interview, producing no spoken words at all despite appearing alert and occasionally nodding, though he does eventually write brief answers on a notepad when offered one. Before revealing the answer: is this stammering?
• An examiner passively raises a patient's arm into an awkward, uncomfortable position during examination; the patient then maintains that exact position for several minutes after being released, with no instruction to do so and no attempt to adopt it beforehand. Before revealing the answer: is this a stereotyped posture?
• A patient's facial expression, vocal tone, and gestures all convey noticeably less feeling than expected across the whole interview, regardless of the topic, and she does not recognise any change in herself when this is pointed out. Before revealing the answer: is this stiffening of affect?
• A patient is immobile, mute, and unresponsive to voice, but his eyes remain open and appear to track movement around the room; neurological examination reveals a lesion affecting the third ventricle, and there is no history of depressive or catatonic illness. Before revealing the answer: is this simply psychiatric stupor?
• A patient with an acute psychotic illness reports seeing vivid colours and hearing music even in a completely silent, dark room, with no real sound or light present to account for either experience. Before revealing the answer: is this synaesthesia?
• A patient reports a persistent sensation of ants crawling across her scalp and neck, leading her to shower repeatedly through the day, but she is clear that she does not actually believe there are real insects present — she says "I know it isn't really happening, but it feels exactly like it is." Before revealing the answer: does the absence of a belief in real infestation rule out a tactile hallucination here?
• Asked simple factual questions, a patient's answers are frequently incoherent and difficult to follow, with sentences that trail off, blend unrelated ideas together, and never clearly answer what was asked at all. Before revealing the answer: is this talking past the point?
• Two days after starting an antipsychotic medication, a patient suddenly develops a sustained, uncomfortable twisting of the neck to one side. Before revealing the answer: is this tardive dyskinesia?
• A woman describes recurrent, unpleasant thoughts about contamination that intrude against her will, which she finds excessive and irrational, but which she is clear come from her own mind rather than from anywhere else. Before revealing the answer: is this thought alienation?
• A 24-year-old woman describes stopping mid-conversation multiple times a day, each time completely losing the thread of what she was saying, with no recollection afterward of her original point. She denies any sense that someone or something is removing her thoughts — she says it 'just goes blank.' Before revealing the answer: what is the finding here, and what detail in her account would make you suspicious this was thought withdrawal instead?
• A patient says that a voice sometimes speaks his thoughts aloud, just after he has thought them, as though echoing them back to him — but he does not believe anyone else can access his thoughts directly, and no one else is mentioned as being aware of his thinking. Before revealing the answer: is this thought broadcasting?
• A patient reports hearing a voice that narrates what he is doing throughout the day — "he is getting up, he is walking to the kitchen" — but the voice never repeats anything he has actually thought. Before revealing the answer: is this thought echo?
• A young woman says that intrusive violent thoughts sometimes enter her mind and that she finds them horrifying and wishes they would stop, but she is clear they are her own thoughts, arising from her own mind, however unwelcome. Before revealing the answer: is this thought insertion?
• A patient describes his mind suddenly going blank mid-sentence, with no thought there at all where a moment before there had been one — but when asked what caused it, he simply says he doesn't know, it just happened, with no sense of anyone or anything taking it from him. Before revealing the answer: is this thought withdrawal?
• A patient describes time feeling as though it is moving in bursts, sometimes seeming to leap forward suddenly. When asked, he can still correctly state the date, day of the week, and his location. Before revealing the answer: does his accurate orientation rule out a genuine disturbance in how he is experiencing time?
• A patient with no history of substance use reports seeing a fully formed, detailed animal moving across an empty room, where nothing at all is actually present, describing it with full conviction as though genuinely there. Before revealing the answer: is this trailing phenomena?
• A patient begins a sentence with a complete, grammatically intact plan to describe a complex worry involving several connected concerns, but as she speaks, the parts become muddled and jumbled together so the overall meaning is lost, even though she remains aware something is not right. Before revealing the answer: is this transitory thinking?
• A woman describes feeling gradually more and more absorbed in vivid, dream-like scenes over several hours, with the boundary between her ordinary awareness and the altered state impossible for her to pinpoint. Before revealing the answer: is this a twilight state?
• A patient insists with complete conviction that he is secretly a member of the royal family, becoming irritated and dismissive when this is questioned, and offers no acknowledgement that this could be anything other than plain fact. Before revealing the answer: is this undirected fantasy thinking?
• Asked "what day is it today?", a patient correctly answers "Tuesday." Asked next "what is your name?", she again answers "Tuesday," and continues answering "Tuesday" to several subsequent, unrelated questions before eventually giving correct answers again. Before revealing the answer: is this verbal stereotypy?
• Asked "how did you sleep?", a patient replies "the garden." Asked next "what is today's date?", he again replies "the garden," before eventually returning to giving relevant, correct answers to later questions. Before revealing the answer: is this verbigeration?
• A patient describes a persistent sensation of his liver "twisting and shrinking" inside him, causing significant distress, in the context of a normal physical examination and normal liver function tests already performed by his GP. Before revealing the answer: what should happen next, given the phenomenon's own guidance on this kind of presentation?
• A patient can see and describe the shapes of the letters on a page perfectly clearly, but cannot make sense of them as written language, and when asked to copy the same words onto another sheet, he is unable to reproduce them at all. Before revealing the answer: is this visual asymbolia?
• A patient describes, during a period of intense grief, occasionally "seeing" her late husband sitting in his usual chair — she says the image appears in her mind's eye rather than truly out in the room, and she knows straight away that he is not really there. Before revealing the answer: is this a visual hallucination?
• An examiner gently raises a patient's arm; it moves easily and without unusual resistance, and the patient immediately lowers it back down themselves once released, clearly attentive and following the examiner's actions. Before revealing the answer: is this waxy flexibility?

Discriminate Activities

• A patient's emotional response seems disproportionate. Before revealing the answer, decide what distinguishes an abnormal emotional reaction from a morbid disorder of emotion.
• A patient's emotional feeling seems to differ from how it is being shown. Before revealing the answer, decide what distinguishes an abnormal expression of emotion from an abnormal emotional reaction.
• A patient is holding an abnormal, sustained muscular posture. Before revealing the answer, decide what distinguishes acute dystonia from a catatonic stereotyped posture.
• A patient seems to show less emotion and less drive than would be expected. Before revealing the answer, decide what distinguishes affect blunting from apathy.
• A patient shows a limited emotional display. Before revealing the answer, decide what distinguishes constriction of affect from apathy.
• A patient's emotional display shifts and intensifies unusually. Before revealing the answer, decide what distinguishes affective incontinence from lability of affect.
• A patient shows a specific pattern of language-comprehension disturbance. Before revealing the answer, decide what distinguishes agnostic alexia from pure word deafness.
• A patient on long-term antipsychotic treatment has developed abnormal movements. Before revealing the answer, decide what distinguishes akathisia from tardive dyskinesia.
• A patient is unresponsive and immobile. Before revealing the answer, decide what distinguishes akinetic mutism from catatonic stupor.
• A patient shows an unusual, hesitant response to a requested action. Before revealing the answer, decide what distinguishes ambitendency from negativism proper.
• A patient has a disturbance affecting a period of personal memory. Before revealing the answer, decide what distinguishes amnesia from paramnesia.
• A man spends over an hour each morning checking that his front door is locked exactly seven times, finds the checking exhausting and pointless, and wishes he could simply stop, but feels compelled to continue regardless. Is this best understood as anankastic personality disorder?
• Two patients each seem to have withdrawn from activities they used to care about. Before revealing the answer, decide what question would tell anhedonia apart from apathy.
• Two patients each seem, on the surface, to be refusing to accept that something is badly wrong. One has had a stroke and insists their paralysed arm works fine; the other has just been told they have a serious illness and keeps making long-term plans as if nothing has changed. Before revealing the answer, decide: what single question would you ask to tell these two apart at the bedside, and why?
• A patient with a head injury has a memory gap. Before revealing the answer, decide what single question settles whether this is anterograde or retrograde amnesia.
• A patient started on an antipsychotic ten days ago becomes stiff and restless, pacing the ward and unable to sit still, describing an unpleasant inner tension. A second patient, with no recent medication change, sits motionless for hours with a blank, deadpan expression, lively eyes, and a limb that remains fixed in whatever position it is placed. Are both of these best understood as antipsychotic-induced movement disorder?
• A patient reports memory difficulty in the context of a mood or anxiety disturbance. Before revealing the answer, decide what distinguishes anxiety amnesia from dissociative amnesia.
• A patient describes apprehension along with physical symptoms such as a racing heart and sweating. Before revealing the answer, decide what distinguishes anxiety from a panic attack.
• A patient describes fear about the future. Before revealing the answer, decide what distinguishes anxious foreboding from a panic attack.
• A patient describes long-standing social isolation. Before revealing the answer, decide what distinguishes anxious (avoidant) personality disorder from schizoid personality disorder.
• A patient shows reduced engagement and motivation. Before revealing the answer, decide what distinguishes apathy from demoralization.
• A patient describes hearing something with no external source. Before revealing the answer, decide what distinguishes a true auditory hallucination from a pseudohallucination.
• A patient suddenly develops a fixed, false belief. Before revealing the answer, decide what distinguishes an autochthonous delusion from a delusional perception.
• A patient shows an unusual degree of compliance during a motor examination. Before revealing the answer, decide what distinguishes automatic obedience from Mitmachen and Mitgehen.
• A patient describes an unsettling sense of being detached from themselves. Before revealing the answer, decide what single question distinguishes autoscopy from depersonalisation.
• A patient with a striking physical symptom seems remarkably unbothered by it. Before revealing the answer, decide what distinguishes la belle indifference from denial.
• A patient describes an abnormal experience involving part of their body. Before revealing the answer, decide what distinguishes body image disturbance from a nihilistic delusion.
• Two patients each have a history of intense relationships, impulsivity, and difficulty with other people. Before revealing the answer, decide what would tell borderline personality disorder apart from dissocial personality disorder.
• A patient's limb stays where it is placed during a motor examination. Before revealing the answer, decide what distinguishes catalepsy from waxy flexibility.
• A patient cannot recall a distressing part of her past. Before revealing the answer, decide what distinguishes catathymic amnesia from dissociative amnesia.
• A patient's speech sounds unusual. Before revealing the answer, decide what distinguishes catatonic speech disturbance from talking past the point.
• Two patients present in a profound stupor, barely responsive to their surroundings. Before revealing the answer, name the bedside features you would check to tell catatonic stupor apart from depressive stupor.
• A patient shows a substantial language disturbance. Before revealing the answer, decide what distinguishes central aphasia from receptive aphasia.
• A patient describes an abnormal visual experience. Before revealing the answer, decide what distinguishes chromatopsia from a visual hallucination.
• A patient's speech takes a long, roundabout path before reaching a point. Before revealing the answer, decide what distinguishes circumstantiality from flight of ideas.
• A patient describes a repetitive urge and an accompanying repetitive action. Before revealing the answer, decide what distinguishes a compulsion from an obsession.
• Two patients each tell detailed, inaccurate stories about their recent activities. Before revealing the answer, decide what you would ask to tell confabulation apart from pseudologia fantastica.
• A patient produces content that turns out not to be a genuinely new creation. Before revealing the answer, decide what distinguishes cryptamnesia from confabulation.
• Two patients each describe a mismatch between what actually happened and how familiar or new it felt. Before revealing the answer, decide what direction of mismatch tells déjà vu apart from cryptamnesia.
• Both a delusion of guilt and a nihilistic delusion are classically seen in the most severe presentations of depressive illness and often occur together. A patient says: "I don't exist anymore, I'm already dead, there's nothing left of me." Is this a delusion of guilt?
• A patient has for several years been intensely preoccupied with the idea that she has an undiagnosed heart condition, has read extensively about cardiac disease, and dominates most conversations with this concern — but when a cardiologist she trusts spends time carefully reviewing her results with her, she becomes, at least temporarily, somewhat reassured. Is this a delusion of ill health?
• A man becomes convinced that his neighbours are conspiring against him, monitoring his movements, and have poisoned his water supply. Separately, he has also become convinced his wife is secretly meeting other men, based on the same generalised sense of being watched. Which delusion is the water-supply belief?
• A woman with elevated mood believes both that she has been specially chosen to write the definitive theory unifying physics, and that a famous physicist she has never met is secretly in love with her and communicating this through television interviews. Which of these two beliefs is the grandiose delusion?
• A patient holds a persecutory belief. Before revealing the answer, decide what distinguishes a delusion of persecution from delusional perception.
• Delusions of poverty and guilt often occur together as part of the same severe depressive delusional constellation, alongside delusions of ill health. A patient with severe depressive illness says: "We'll have nothing left, I've ruined the family financially, we'll be on the streets." Is this a delusion of guilt?
• A patient holds a false, fixed belief. Before revealing the answer, decide what distinguishes a primary delusion from a secondary (delusion-like) idea.
• A patient describes an unsettling sense that something significant is happening. Before revealing the answer, decide what distinguishes delusional mood from delusional perception.
• Two patients each hold a strange, fixed belief with great confidence. Before revealing the answer, decide what would help you tell a delusional perception apart from an overvalued idea.
• A patient discusses a distressing situation without the expected emotional reaction. Before revealing the answer, decide what distinguishes denial from dissociation of affect.
• Two patients both seem to organise their lives around other people's attention and approval. Before revealing the answer, decide what distinguishes dependent personality disorder from histrionic personality disorder.
• Two patients each describe, in their own way, 'not really existing.' Before revealing the answer, decide what single question best separates depersonalisation from a nihilistic delusion.
• A patient describes persistent low mood related to difficult circumstances. Before revealing the answer, decide what distinguishes a depressive illness from demoralization.
• One patient develops broad difficulty with memory, concentration, and everyday tasks alongside a severe, unmistakable low mood, is acutely distressed by her own decline, and recovers her cognitive function almost completely once the depression is treated. A second patient, following a head injury with no mood disturbance at all, cannot learn or recall any new information from the day of the injury onward, while his other cognitive abilities, immediate recall, and memories from before the injury all remain intact. Are both of these best understood as depressive pseudodementia?
• A severely depressed patient shows profound slowing. Before revealing the answer, decide what distinguishes depressive stupor from psychomotor retardation more broadly.
• A patient describes a pervasive sense of unreality but hasn't specified exactly what feels unreal. Before revealing the answer, decide what single question separates derealisation from depersonalisation.
• A patient's train of thought is repeatedly disrupted mid-course. Before revealing the answer, decide what distinguishes desultory thinking from transitory thinking.
• A patient shows a reduced range of movement accompanying their emotional expression. Before revealing the answer, decide what distinguishes a disorder of expressive movement from blunting of affect.
• A patient seems confused during assessment. Before revealing the answer, decide what distinguishes disorientation from perplexity.
• A patient has a long history of turbulent relationships and behaviour that has harmed others. Before revealing the answer, decide what distinguishes dissocial personality disorder from borderline personality disorder, especially since the two can be confused, particularly in women.
• A patient shows a mismatch between emotionally significant content and the feeling displayed. Before revealing the answer, decide what distinguishes dissociation of affect from affect blunting.
• A patient's memory has been affected in some way. Before revealing the answer, decide what distinguishes distortion of recall from distortion of recognition.
• A patient's train of thought or speech is repeatedly interrupted. Before revealing the answer, decide what distinguishes distractibility from thought blocking.
• A patient following a head injury is drowsy, responds only to loud voice or firm touch, and drifts back toward sleep whenever not actively stimulated, with no dream-like or fluctuating quality to the presentation. Is the correct, most specific term here simply "a disturbance of consciousness"?
• A patient describes a profound, distressing change in how their own existence feels. Before revealing the answer, decide what distinguishes disturbance of awareness of self-activity from a nihilistic delusion.
• A patient describes a disturbed relationship between themselves and their thoughts or actions. Before revealing the answer, decide what distinguishes disturbance of the boundaries of the self from disturbance of awareness of self-activity.
• A patient describes a disturbed sense of who they are. Before revealing the answer, decide what distinguishes a disturbance of the continuity of self from a disturbance of self-unity.
• A patient describes something unsettling about the sense that their actions belong to them. Before revealing the answer, decide what distinguishes disturbance of self-unity from a passivity phenomenon.
• Two elderly patients each show some disturbance of consciousness following an acute physical illness. Before revealing the answer, decide what single feature best separates a dream-like change of consciousness from lowering of consciousness.
• A patient's explanation of a complex idea does not come out coherently. Before revealing the answer, decide what distinguishes drivelling thinking from desultory thinking.
• A patient describes a distorted visual experience. Before revealing the answer, decide what distinguishes dysmegalopsia from a visual hallucination.
• A patient repeats something during the interview. Before revealing the answer, decide what distinguishes echolalia from perseveration.
• A patient with catatonia seems to be automatically copying the interviewer. Before revealing the answer, decide what would tell you whether this is echopraxia or echolalia.
• A patient describes an abnormally elevated mood. Before revealing the answer, decide what distinguishes ecstasy from morbid euphoria.
• A patient describes an unusually vivid visual experience. Before revealing the answer, decide what distinguishes eidetic imagery from a visual hallucination.
• A clinician is describing a patient's personality pattern. Before revealing the answer, decide what distinguishes emotionally unstable personality disorder from borderline personality disorder specifically.
• A patient shows a lasting change in character following a severe stressor. Before revealing the answer, decide what distinguishes enduring personality change after a catastrophic experience from a personality disorder in the general sense.
• A patient shows markedly increased motor activity. Before revealing the answer, decide what distinguishes excitement in general from pathological drunkenness specifically.
• A patient's spoken output is severely reduced. Before revealing the answer, decide what distinguishes expressive aphasia from mutism.
• A patient describes a hallucinatory perception. Before revealing the answer, decide what specifically distinguishes an extracampine hallucination from a hallucination more generally.
• A patient's account of a past event turns out to be inaccurate. Before revealing the answer, decide what distinguishes a false memory from retrospective falsification.
• A patient fails to recognise someone they genuinely know. Before revealing the answer, decide what distinguishes false reconnaissance from Capgras syndrome.
• A patient describes an unusually vivid memory of a significant past event. Before revealing the answer, decide what distinguishes a flashback from a flashbulb memory.
• A patient takes a long, winding route through many side-topics before finishing their answer. Before revealing the answer, decide what would tell flight of ideas apart from circumstantiality.
• A patient's behaviour does not match a given instruction. Before revealing the answer, decide what distinguishes forced grasping from automatic obedience.
• A patient's speech is difficult to follow. Before revealing the answer, decide what distinguishes formal thought disorder from flight of ideas.
• Two patients each describe a real sound reliably triggering a hallucination. Before revealing the answer, decide what single question tells a functional hallucination apart from a reflex hallucination.
• A patient consistently gives approximate, noticeably wrong answers to simple questions. Before revealing the answer, decide what distinguishes Ganser syndrome from talking past the point in general.
• You are examining a patient's response to passive limb movement. Before revealing the answer, decide what distinguishes Gegenhalten (opposition) from Mitmachen and Mitgehen.
• A patient reports both an unusual taste and an unusual smell with nothing present to account for either. Before revealing the answer, decide what distinguishes a gustatory hallucination from an olfactory hallucination.
• A patient reports an unusual perceptual experience. Before revealing the answer, decide what distinguishes a hallucination from an illusion.
• One patient with a long history of heavy alcohol use reports hearing hostile voices for several days, while remaining fully oriented, coherent, and able to give an accurate, detailed account of recent events. A second patient, following a severe chest infection, appears muddled, cannot reliably say where he is, occasionally seems to misperceive staff as figures from his past, and drifts in and out of clear awareness of his surroundings. Are both of these best understood as hallucinosis?
• A patient with a right hemisphere lesion shows an odd relationship to their left limb. Before revealing the answer, decide what distinguishes hemiasomatognosia from somatoparaphrenia.
• A patient fails to attend to one side following a right parietal lesion. Before revealing the answer, decide what distinguishes hemispatial neglect from hemiasomatognosia.
• Two patients each seem to organise much of their life around securing other people's attention and care, but in very different styles — one dramatic and demanding centre stage, the other quiet and compliant. Before revealing the answer, decide which is histrionic and which is dependent personality disorder, and what tells them apart.
• A patient describes an unusually vivid memory. Before revealing the answer, decide what distinguishes hyperamnesia from confabulation.
• A person reports a brief, vivid sensory experience with no real stimulus. Before revealing the answer, decide what distinguishes a hypnagogic hallucination from a hallucination occurring during ordinary wakefulness.
• A patient has had an episode matching the pattern of a twilight state. Before revealing the answer, decide what distinguishes a hysterical (dissociative) twilight state from an organic one.
• A patient suddenly carries out a violent act. Before revealing the answer, decide what distinguishes impulsive behaviour from extended suicide.
• A patient shows a pattern of quick, disproportionate anger. Before revealing the answer, decide what distinguishes impulsive personality disorder from irritability.
• Two patients each seem to show 'the wrong amount' of emotion during an interview. Before revealing the answer, decide what would tell incongruity of affect apart from blunting of affect.
• A patient's thinking seems disrupted. Before revealing the answer, decide what distinguishes inhibition of thinking from thought blocking.
• A patient shows a specific, more circumscribed language disturbance. Before revealing the answer, decide what distinguishes intermediate aphasia from nominal aphasia specifically.
• A patient shows an involuntary movement pattern with a possible medication history. Before revealing the answer, decide what distinguishes the broader family of involuntary neurological movement signs from tardive dyskinesia specifically.
• A patient shows a heightened emotional reactivity. Before revealing the answer, decide what distinguishes irritability from affective incontinence.
• A patient's emotional display seems abnormal, but you're not sure in which direction. Before revealing the answer, decide what distinguishes lability of affect from stiffening of affect.
• A person has difficulty recalling a name. Before revealing the answer, decide what distinguishes lethologia from nominal aphasia.
• A patient describes a reduced emotional response. Before revealing the answer, decide what distinguishes loss of emotional resonance from affect blunting.
• Two patients each show some disturbance of consciousness following an acute event, without any hallucinations. Before revealing the answer, decide what would tell lowering of consciousness apart from restriction of consciousness.
• A patient repeatedly performs an unusual movement. Before revealing the answer, decide what would tell a mannerism apart from a stereotyped posture.
• A patient's limb can be passively moved with no resistance. Before revealing the answer, decide what distinguishes Mitmachen from waxy flexibility.
• A patient reports feeling anxious much of the time. Before revealing the answer, decide what distinguishes morbid anxiety from anxiety as an ordinary emotional reaction.
• A patient shows a significant disturbance of emotion. Before revealing the answer, decide what distinguishes a morbid disorder of emotion from a morbid expression of emotion.
• A patient's outward display of emotion has changed in a way others have noticed. Before revealing the answer, decide what distinguishes a morbid expression of emotion from an abnormal expression of emotion.
• A patient shows an abnormally elevated mood. Before revealing the answer, decide what distinguishes moria from morbid euphoria.
• A patient, asked a question about his name, answers correctly. Asked next what year it is, he again says his own name. Is this motor perseveration?
• A patient describes an unusual experience of self. Before revealing the answer, decide what distinguishes the experience of multiple personalities from a disturbance of self-unity.
• A patient shows a pattern of elaborate, fluent false stories. Before revealing the answer, decide what distinguishes Munchausen's syndrome from pseudologia fantastica more broadly.
• A patient has stopped speaking entirely. Before revealing the answer, decide what distinguishes general mutism from the specific pattern of pure word-dumbness.
• Two patients each seem to crave a great deal of attention from others. Before revealing the answer, decide what would help you tell narcissistic personality disorder apart from histrionic personality disorder.
• A patient resists passive movement or instructions during examination. Before revealing the answer, decide what distinguishes negativism from Gegenhalten.
• A patient uses an unusual, non-standard word. Before revealing the answer, decide what distinguishes a neologism from a paraphasia.
• A patient makes a striking claim about his own body. Before revealing the answer, decide what distinguishes a nihilistic delusion from anosognosia.
• A patient shows a specific pattern of aphasic language disturbance. Before revealing the answer, decide what distinguishes nominal aphasia from central aphasia.
• A patient describes an unwanted thought that keeps intruding into their mind. Before revealing the answer, decide what single question distinguishes an obsession from thought insertion.
• A patient's movements are slowed or hindered. Before revealing the answer, decide what distinguishes obstruction from psychomotor retardation.
• A patient performs an unusual repetitive movement. Before revealing the answer, decide what distinguishes occupational delirium from a mannerism.
• A patient presents with significant memory loss. Before revealing the answer, decide what distinguishes organic amnesia from dissociative amnesia.
• A patient describes a persistent hallucination with a plausible physical explanation. Before revealing the answer, decide what distinguishes an organic hallucination from a functional hallucination.
• A patient holds a belief with strong, persistent conviction. Before revealing the answer, decide what distinguishes an overvalued idea from a delusion.
• A patient describes episodes of intense fear. Before revealing the answer, decide what distinguishes a panic attack from a phobic reaction.
• A patient's account of the past seems unreliable. Before revealing the answer, decide what distinguishes a paramnesia from amnesia.
• A man has, for as long as his wife can remember, been generally suspicious of colleagues, neighbours, and now increasingly of her — but recently this has crystallised into an absolutely fixed, unshakeable conviction, unaltered by any reassurance or evidence, that she is having a specific ongoing affair with a named colleague. Is the fixed belief about the affair itself best understood simply as part of his paranoid personality disorder?
• A patient describes an unusual, distressing change in how a body part feels. Before revealing the answer, decide what distinguishes paraschemazia from somatoparaphrenia.
• A patient describes a disturbing sense that something is being taken away or controlled by an outside force. Before revealing the answer, decide what distinguishes a passivity phenomenon from thought withdrawal.
• A patient appears distressed and unsettled about their current experience. Before revealing the answer, decide what distinguishes perplexity from anxious foreboding.
• A patient's limb, once placed in an unusual position, remains there for an extended period. Before revealing the answer, decide what distinguishes perseveration of posture from waxy flexibility.
• A patient repeats the same word or phrase more than once during an assessment. Before revealing the answer, decide what distinguishes perseveration from verbal stereotypy.
• A patient describes a fear response. Before revealing the answer, decide what distinguishes a phobia from generalised anxiety.
• A patient holds a fixed, false belief. Before revealing the answer, decide what single question distinguishes a primary delusion from a secondary one.
• A patient describes seeing something that isn't there. Before revealing the answer, decide what two questions would tell a pseudohallucination apart from a true hallucination.
• A patient shows a specific pattern of language comprehension disturbance. Before revealing the answer, decide what distinguishes pure word deafness from visual asymbolia.
• A patient produces no spoken output at all. Before revealing the answer, decide what distinguishes pure word-dumbness from expressive aphasia.
• A patient shows an unusual pattern of responsiveness to stimuli in their environment. Before revealing the answer, decide what distinguishes a disorder of reactive movements from negativism.
• A patient's mood shows frequent, marked shifts. Before revealing the answer, decide what distinguishes reactivity of mood from lability of affect.
• A patient shows an aphasic language disturbance. Before revealing the answer, decide what distinguishes receptive aphasia from expressive aphasia.
• A stimulus in one sense reliably triggers an experience in a different sense. Before revealing the answer, decide what distinguishes a reflex hallucination from synaesthesia.
• A patient shows disorientation with an altered level of consciousness. Before revealing the answer, decide what distinguishes restriction of consciousness from a dream-like change of consciousness.
• A patient with a head injury has a memory gap. Before revealing the answer, decide what single question settles whether this is retrograde or anterograde amnesia.
• A patient's account of their own past has been altered to fit their current state. Before revealing the answer, decide what distinguishes a retrospective delusion from retrospective falsification.
• A patient's account of their past does not match what actually happened. Before revealing the answer, decide what distinguishes retrospective falsification from confabulation.
• A patient shows a marked pattern of memory loss. Before revealing the answer, decide what distinguishes Ribot's law of memory regression from an amnestic state.
• A patient describes hearing a voice that seems tightly linked to what they are doing or thinking. Before revealing the answer, decide what single question distinguishes running commentary voices from thought echo.
• A patient describes a felt change in how large a body part seems. Before revealing the answer, decide what distinguishes schemazia distortion from anosognosia.
• A person describes feeling emotionally cut off from others. Before revealing the answer, decide what distinguishes schizoid personality disorder from depersonalisation.
• A patient's speech is severely disorganised and hard to follow. Before revealing the answer, decide what distinguishes schizophasia from aphasia.
• A patient shows a longstanding pattern of social withdrawal and detachment. Before revealing the answer, decide what distinguishes schizotypal personality disorder from schizoid personality disorder.
• A patient's memory of a past event turns out, on closer examination, not to be entirely accurate. Before revealing the answer, decide what single question distinguishes a screen memory from a false memory.
• A patient describes feeling that someone else is nearby. Before revealing the answer, decide what distinguishes a sense of presence from a hallucination.
• A patient reports a real stimulus is being perceived abnormally. Before revealing the answer, decide what distinguishes sensory intensity distortion from an illusion.
• A patient's outward presentation seems out of keeping with an underlying problem. Before revealing the answer, decide what distinguishes smiling depression from la belle indifférence.
• A patient with an underlying mood disturbance presents primarily with physical complaints. Before revealing the answer, decide what distinguishes somatisation from denial.
• A patient with left-sided paralysis after a right hemisphere stroke says something odd about their affected limb. Before revealing the answer, decide what distinguishes somatoparaphrenia from anosognosia.
• A patient's speech is markedly disrupted. Before revealing the answer, decide what distinguishes stammering (stuttering) from mutism.
• A patient maintains an unusual posture for an extended period. Before revealing the answer, decide what distinguishes a stereotyped posture from perseveration of posture.
• A patient's emotional display appears unusually resistant to change. Before revealing the answer, decide what distinguishes stiffening of affect from blunting of affect.
• A patient is immobile and mute, with no reaction to external stimuli. Before revealing the answer, decide what distinguishes psychiatric stupor from akinetic mutism.
• A person describes an unusual cross-sensory experience. Before revealing the answer, decide what distinguishes synaesthesia from a hallucination.
• A patient describes a sensation of something moving deep inside his chest, distinct from his heartbeat, rather than on the surface of his skin. Is this a tactile hallucination?
• A patient's answers to direct questions are consistently incorrect in an unusual way. Before revealing the answer, decide what distinguishes talking past the point from a formal thought disorder.
• A patient on antipsychotic medication develops an abnormal involuntary movement. Before revealing the answer, decide what distinguishes tardive dyskinesia from acute dystonia.
• A patient describes an unwanted thought. Before revealing the answer, decide what distinguishes thought alienation from an obsession.
• A patient stops speaking abruptly mid-sentence and cannot say what they were about to say. Before revealing the answer, decide: what single question would tell you whether this is thought blocking or thought withdrawal?
• A patient reports a disturbance affecting the privacy or ownership of his own thoughts. Before revealing the answer, decide what distinguishes thought broadcasting from thought insertion.
• A patient reports a disturbance in which her private thoughts are somehow no longer entirely her own affair. Before revealing the answer, decide what distinguishes thought echo from thought broadcasting.
• A patient describes an unsettling change in the privacy of his thoughts, but you are not yet sure whether this is thought insertion or thought broadcasting. Before revealing the answer, decide what single question separates the two.
• A patient describes a disturbance affecting the contents of his own mind, attributed to an outside force. Before revealing the answer, decide what distinguishes thought withdrawal from thought insertion.
• One patient in a severe depressive episode describes each hour feeling as though it drags on endlessly, yet when asked directly she correctly states the date, the day of the week, and her current location. A second patient, acutely unwell following a urinary infection, cannot say what day it is, believes he is still at home rather than in hospital, and is unsure how long he has been unwell. Are both of these best understood as a distortion of the experience of time?
• A patient describes an unusual visual experience involving a moving object. Before revealing the answer, decide what distinguishes trailing phenomena from a visual hallucination.
• A patient's individual thoughts and sentences seem to lose their constancy mid-course. Before revealing the answer, decide what distinguishes transitory thinking from drivelling thinking.
• A patient has had an episode of narrowed awareness with relatively organised behaviour. Before revealing the answer, decide what distinguishes a twilight state from restriction of consciousness more broadly.
• A patient describes unrealistic thought content. Before revealing the answer, decide what distinguishes undirected fantasy thinking from a delusion.
• A patient's speech contains repeated content that does not fit the current question. Before revealing the answer, decide what distinguishes verbal stereotypy from perseveration.
• A patient repeats the same verbal content over and over. Before revealing the answer, decide what distinguishes verbigeration from perseveration.
• A patient cannot read written words despite intact vision. Before revealing the answer, decide what distinguishes visual asymbolia from agnostic alexia.
• A patient reports seeing something not actually present. Before revealing the answer, decide what distinguishes a visual hallucination from a visual pseudohallucination.

Elicit Activities

• You are assessing whether a patient's emotional response is an abnormal emotional reaction. Before revealing the answer, decide how you would assess for this.
• You suspect an abnormal expression of emotion in a patient. Before revealing the answer, decide how you would assess for this.
• You suspect acute dystonia in a patient recently started on antipsychotic medication. Before revealing the answer, decide how you would assess for this.
• You are assessing a patient for affect blunting during a routine interview. Before revealing the answer, decide what you would specifically observe.
• You suspect a patient shows constriction of affect. Before revealing the answer, decide how you would assess for this.
• You suspect a patient may show affective incontinence. Before revealing the answer, decide how you would assess for this.
• You suspect agnostic alexia in a patient. Before revealing the answer, decide how you would assess for this.
• You are reviewing a patient recently started on an antipsychotic and want to assess for akathisia. Before revealing the answer, decide what you would look for and ask about.
• You are assessing an unresponsive patient and want to establish whether this is akinetic mutism rather than catatonic stupor. Before revealing the answer, decide what you would look for.
• A patient shows an unusual hesitation when asked to perform a simple action. Before revealing the answer, decide how you would assess whether this is ambitendency.
• A patient reports difficulty remembering a period of her life. Before revealing the answer, decide how you would explore this.
• You suspect a patient may have an amnestic state rather than dementia. Which single bedside approach would most efficiently help distinguish the two?
• You suspect a patient may have anankastic traits but want to establish whether they reach the threshold of a personality disorder rather than simply being a valued personal quality. Which single question is most useful?
• You suspect a patient with low mood may also have anhedonia, which they haven't mentioned spontaneously. Before revealing the answer, decide how you would specifically ask about it.
• A patient with a confirmed left-sided paralysis following a stroke has not mentioned any weakness. Which single question would most usefully help establish whether anosognosia is present?
• You are assessing a patient shortly after a head injury and want to establish whether they have anterograde amnesia. Before revealing the answer, decide how you would assess for it.
• You are reviewing a patient recently started on antipsychotic medication and want to screen for a subtle movement disorder that might not be obvious just from watching them. Which single question is most appropriate to ask?
• A patient reports feeling on edge much of the time. Before revealing the answer, decide how you would explore this.
• You suspect anxiety amnesia in a patient. Before revealing the answer, decide how you would assess for this.
• You are assessing a patient for anxious foreboding. Before revealing the answer, decide what you would ask.
• You are assessing a patient for features of anxious (avoidant) personality disorder. Before revealing the answer, decide what you would ask about.
• A patient's family reports that he seems to have lost interest in everything. Before revealing the answer, decide how you would explore whether this is apathy.
• You suspect a patient's speech disturbance may be aphasia rather than a primarily psychiatric speech disorder such as schizophasia. Which single line of enquiry would most usefully help clarify this?
• You are assessing a patient for auditory hallucinations. Before revealing the answer, decide what you would ask.
• A patient describes a belief that seemed to appear suddenly, out of nowhere. Before revealing the answer, decide how you would explore whether this is an autochthonous delusion.
• You want to test a patient for automatic obedience. Before revealing the answer, decide how you would go about it.
• A patient has mentioned briefly 'seeing myself' during a stressful period. Before revealing the answer, decide how you would clarify whether this was autoscopy.
• You are assessing a patient with a functional neurological symptom and want to establish whether la belle indifference is present. Before revealing the answer, decide what you would specifically look and listen for during the assessment.
• You suspect a patient shows body image disturbance. Before revealing the answer, decide how you would assess for this.
• You are assessing a patient for features of borderline personality disorder. Before revealing the answer, decide what areas you would explore, and how you would approach the more sensitive parts of the history.
• You suspect a patient may hold a Capgras-type delusion about a family member. Which single question would most usefully help confirm this specific pattern, rather than a more general sense of unfamiliarity?
• You want to test a patient for catalepsy during a motor examination. Before revealing the answer, decide how you would go about it.
• A patient cannot recall one specific painful episode from her past. Before revealing the answer, decide how you would explore whether this is catathymic amnesia.
• You suspect a patient shows catatonic speech disturbance. Before revealing the answer, decide how you would assess for this.
• You want to examine a mute, unresponsive patient specifically for catatonic stupor. Before revealing the answer, decide what you would actually check.
• You suspect central aphasia in a patient. Before revealing the answer, decide how you would assess for this.
• A patient reports that his vision has taken on an unusual colour tinge. Before revealing the answer, decide how you would assess whether this is chromatopsia.
• You want to assess whether a patient's speech pattern is circumstantiality. Before revealing the answer, decide what you would specifically observe.
• A patient mentions performing a repetitive action many times a day. Before revealing the answer, decide how you would explore whether this is a compulsion.
• You suspect a patient may be confabulating. Before revealing the answer, describe how you would actually test for it during the interview.
• A patient has produced content that you suspect may not be as original as they believe. Before revealing the answer, decide how you would explore whether this is cryptamnesia.
• You want to ask a patient about déjà vu as part of a broader assessment, including screening for possible temporal lobe seizure activity. Before revealing the answer, decide how you would raise it and what follow-up questions you would ask.
• A patient has expressed a belief that strikes you as false and out of keeping with his background. Before revealing the answer, decide how you would explore whether this is a delusion.
• You suspect a patient with severe depressive illness may hold a delusion of guilt but they have not mentioned it spontaneously. Which single question would most efficiently open this area for direct exploration?
• A patient has had several normal medical investigations but remains highly preoccupied with a feared serious illness. Which single question would best help clarify whether this is a delusion of ill health rather than ordinary health anxiety?
• You suspect a patient may hold a delusion of infidelity about their partner. Beyond confirming the belief itself, which single additional question is most important to ask given the known risks associated with this delusion?
• A patient describes a strong conviction that a specific, largely unknown person is secretly in love with them. Which single question would most usefully clarify whether this is a delusion of love, given the phenomenon's own distinctive recognition feature?
• A patient has expressed a belief that he is being targeted by others. Before revealing the answer, decide how you would explore whether this is a delusion of persecution.
• A patient with depressive symptoms expresses significant worry about money. Which single question would best help establish whether this is a delusion of poverty rather than realistic financial concern?
• A patient describes a vague, unsettling sense that something is going on. Before revealing the answer, decide how you would explore whether this is delusional mood.
• A patient hints at a strange realisation they had recently. Before revealing the answer, decide how you would interview them to establish whether this was a delusional perception.
• You want to establish whether a patient's low mood in the context of chronic illness reflects demoralization or a full depressive illness. Which single question is most useful?
• You suspect a patient may be showing denial about a serious diagnosis. Before revealing the answer, decide how you would assess for this.
• You are assessing a patient you suspect may have dependent personality disorder. Before revealing the answer, decide how you would explore this during the interview.
• A patient seems withdrawn and is hard to read. You want to check specifically for depersonalisation without leading them into an answer. Before revealing the answer, decide what you would actually ask.
• A patient describes persistent low mood. Before revealing the answer, decide how you would assess whether this represents a depressive illness.
• An older patient presents with both low mood and significant memory complaints. Which single line of questioning is most useful for judging whether the cognitive difficulty is likely to be depressive pseudodementia?
• A severely depressed patient has become profoundly withdrawn and largely unresponsive. Before revealing the answer, decide how you would assess whether this is depressive stupor.
• A patient seems distracted and describes things feeling 'off' lately. You want to check specifically for derealisation. Before revealing the answer, decide what you would actually ask.
• You suspect a patient's speech shows desultory thinking. Before revealing the answer, decide how you would assess for this.
• You are assessing a patient for a possible disorder of expressive movement. Before revealing the answer, decide how you would assess for this.
• You want to test a patient's orientation formally. Before revealing the answer, decide how you would assess it and in what order you would expect any loss to appear.
• You are assessing a patient for features of dissocial personality disorder. Before revealing the answer, decide what you would specifically ask about.
• You suspect dissociation of affect in a patient. Before revealing the answer, decide how you would assess for this.
• You are assessing a patient with a sudden, apparently trauma-related memory loss and want to gather information supporting dissociative amnesia over an organic cause, without assuming the diagnosis. Which single approach is most appropriate?
• A patient has described a memory that you suspect may not be entirely accurate. Before revealing the answer, decide how you would explore whether this is a distortion of recall.
• You want to establish whether a patient's reported misidentification of a family member is a brief, everyday experience or a persistent, elaborated pattern. Which single question is most useful?
• You suspect a patient shows distractibility. Before revealing the answer, decide how you would assess for this.
• You are assessing a patient whose presentation seems mildly out of keeping with what family describe as their normal baseline, but nothing is dramatically abnormal. Which single approach would most usefully help establish whether a disturbance of consciousness is present?
• You suspect a patient has a disturbance of awareness of self-activity. Before revealing the answer, decide how you would assess for this.
• You suspect a patient is describing a disturbance of the boundaries of the self. Before revealing the answer, decide how you would assess for this.
• You suspect a patient is describing a disturbance of the continuity of self. Before revealing the answer, decide how you would assess for this.
• You suspect a patient may be experiencing disturbance of self-unity. Before revealing the answer, decide how you would assess for it.
• You are assessing an elderly patient overnight staff describe as 'confused and frightened.' Before revealing the answer, decide how you would assess specifically for a dream-like change of consciousness.
• You suspect a patient's speech shows drivelling thinking. Before revealing the answer, decide how you would assess for this.
• You suspect dysmegalopsia in a patient. Before revealing the answer, decide how you would assess for this.
• You want to test a patient for echolalia during an assessment. Before revealing the answer, decide how you would go about it.
• You want to check a patient with suspected catatonia for echopraxia. Before revealing the answer, decide what you would actually do.
• A patient describes an intensely elevated mood state. Before revealing the answer, decide how you would explore whether this is ecstasy.
• A patient describes an unusually vivid recollection. Before revealing the answer, decide how you would explore whether this is eidetic imagery.
• You are assessing a patient and considering whether emotionally unstable personality disorder is the appropriate framing. Before revealing the answer, decide how you would approach this.
• You suspect enduring personality change after a catastrophic experience in a patient. Before revealing the answer, decide how you would assess for this.
• You are assessing a patient showing excitement. Before revealing the answer, decide how you would assess for this.
• You suspect a patient has expressive aphasia. Before revealing the answer, decide how you would assess for this.
• You are assessing a parent with severe, delusional depressive illness and are concerned about risk to their children. Which single question is most essential to ask directly?
• A patient has described a hallucination in an unusual location. Before revealing the answer, decide how you would explore whether this is extracampine.
• You suspect a patient may hold a false memory of a past event. Before revealing the answer, decide how you would assess this.
• You suspect a patient shows false reconnaissance. Before revealing the answer, decide how you would assess for this.
• You are assessing a patient with a history of significant trauma and want to establish whether they experience flashbacks. Before revealing the answer, decide what you would ask.
• A patient describes an unusually vivid memory of hearing shocking news, and you want to explore it without either dismissing its vividness or treating it as guaranteed to be accurate. Which single approach best reflects the phenomenon's own guidance?
• You suspect a patient in an elated mood state may have flight of ideas. Before revealing the answer, decide how you would assess for it during the interview.
• You suspect a patient shows forced grasping. Before revealing the answer, decide how you would assess for this.
• You suspect a patient's speech shows a disturbance in the structure of their thinking. Before revealing the answer, decide how you would assess this.
• A patient reports hearing voices. You want to check specifically whether this might be a functional hallucination. Before revealing the answer, decide what you would actually ask.
• You suspect a patient may have Ganser syndrome. Before revealing the answer, decide how you would assess for this.
• You want to establish whether a patient shows Gegenhalten on examination. Before revealing the answer, decide how you would assess this.
• A patient with elevated mood makes an offhand comment suggesting unusually exalted self-belief, but does not elaborate further. Which single follow-up question would best help establish whether this is a grandiose delusion?
• You suspect a gustatory hallucination in a patient. Before revealing the answer, decide how you would assess for this.
• A patient reports perceiving something that you suspect may not correspond to any real external stimulus. Before revealing the answer, decide how you would explore whether this is a hallucination.
• A patient with a long history of heavy alcohol use reports hearing voices. Which single line of assessment is most important before concluding this is hallucinosis?
• You are examining a patient with a right parietal lesion and want to assess for hemiasomatognosia. Before revealing the answer, decide what you would look for.
• A patient following a right-sided brain lesion seems to be missing things on one side. Before revealing the answer, decide how you would assess for hemispatial neglect.
• You are assessing a patient for features of histrionic personality disorder. Before revealing the answer, decide what you would specifically ask about and observe during the interview.
• You suspect hyperamnesia in a patient. Before revealing the answer, decide how you would assess for this.
• A patient describes a brief unusual sensory experience. Before revealing the answer, decide how you would assess whether this is a hypnagogic hallucination.
• A patient presents after an episode of wandering with impaired awareness, and you want to establish whether this was a hysterical twilight state. Before revealing the answer, decide what you would specifically ask about and investigate.
• A patient briefly mentions having "seen something odd" in low light recently. Which single follow-up question would most usefully help establish whether this was an illusion?
• You suspect impulsive behaviour in a patient. Before revealing the answer, decide how you would assess for this.
• You suspect impulsive personality disorder in a patient. Before revealing the answer, decide how you would assess for this.
• You want to assess a patient specifically for incongruity of affect during a mental state examination. Before revealing the answer, decide what you would actually do.
• You suspect a depressed patient shows inhibition of thinking. Before revealing the answer, decide how you would assess for this.
• You suspect intermediate aphasia in a patient. Before revealing the answer, decide how you would assess for this.
• You suspect an involuntary neurological movement sign in a patient. Before revealing the answer, decide how you would assess for this.
• A patient's family reports that he has become unusually short-tempered. Before revealing the answer, decide how you would explore whether this is irritability.
• You are assessing a patient and want to establish whether lability of affect is present. Before revealing the answer, decide what you would look for during the interview.
• A person mentions frequently forgetting names momentarily. Before revealing the answer, decide how you would assess whether this is lethologia.
• You are assessing a depressed patient and want to establish whether loss of emotional resonance is present. Before revealing the answer, decide what you would ask.
• You are assessing an elderly patient who appears profoundly slowed and vague soon after a medical illness, and dementia has been raised as a possibility. Before revealing the answer, decide how you would assess specifically for lowering of consciousness instead.
• You want to check for mannerisms during a mental state examination without over-interpreting ordinary personal quirks. Before revealing the answer, decide what you would actually do.
• You suspect a patient may show Mitmachen or Mitgehen. Before revealing the answer, decide how you would assess for this on examination.
• You are assessing a patient for possible morbid anxiety. Before revealing the answer, decide how you would assess for this.
• You suspect a morbid disorder of emotion in a patient. Before revealing the answer, decide how you would assess for this.
• A patient describes feeling wonderful and full of plans. Which single question would most usefully help establish whether this is morbid euphoria rather than ordinary good spirits?
• You suspect a morbid expression of emotion in a patient. Before revealing the answer, decide how you would assess for this.
• You are assessing a patient with suspected frontal lobe pathology and want to check for moria. Before revealing the answer, decide what you would look for.
• You want to test for motor perseveration at the bedside. Which single approach would most efficiently elicit it if it is present?
• You suspect a patient is describing the experience of multiple personalities. Before revealing the answer, decide how you would assess for this.
• You suspect Munchausen's syndrome in a patient. Before revealing the answer, decide how you would assess for this.
• A patient has not spoken for some time. Before revealing the answer, decide how you would assess this mutism further.
• You want to assess a patient for features of narcissistic personality disorder during an interview, without simply labelling them as arrogant. Before revealing the answer, decide what you would actually explore.
• You want to test a patient for negativism during a motor examination. Before revealing the answer, decide how you would go about it.
• A patient has used an unfamiliar word during the interview and you want to establish whether it is a neologism. Before revealing the answer, decide how you would explore this.
• A severely depressed patient has made an unusual claim about his own body. Before revealing the answer, decide how you would explore whether this is a nihilistic delusion.
• You suspect nominal aphasia in a patient. Before revealing the answer, decide how you would assess for this.
• You suspect a patient may be experiencing obsessions but they are reluctant to describe the content in detail. Before revealing the answer, decide how you would approach eliciting this.
• You notice a patient's movements are being interrupted in an unusual way. Before revealing the answer, decide how you would assess whether this is obstruction.
• You suspect a confused patient shows occupational delirium. Before revealing the answer, decide how you would assess for this.
• A patient mentions smelling something odd occasionally. Which single follow-up question would most usefully help clarify whether this is an olfactory hallucination?
• A patient presents with memory difficulties following a known physical illness or injury. Before revealing the answer, decide how you would assess whether this is organic amnesia.
• You suspect an organic hallucination in a patient. Before revealing the answer, decide how you would assess for this.
• You are assessing a patient's strongly held belief and want to establish whether it is an overvalued idea. Before revealing the answer, decide what you would explore.
• You are assessing a patient for panic attacks. Before revealing the answer, decide what you would ask about.
• You suspect a patient's account of the past may involve a paramnesia. Before revealing the answer, decide how you would assess this.
• You suspect a patient's longstanding suspicious pattern may have crystallised into a fixed delusional belief rather than remaining at the level of a personality trait. Which single question would most usefully test this?
• A patient uses an unusual or incorrect word during conversation. Which single line of enquiry would most usefully help establish whether this is a paraphasia rather than a psychiatric neologism?
• You suspect paraschemazia in a patient. Before revealing the answer, decide how you would assess for this.
• You want to establish whether a patient is experiencing passivity phenomena. Before revealing the answer, decide what you would ask.
• You are assessing a patient with a history of a sudden, violent episode after drinking. Which single piece of information is most important to establish to support or rule out pathological drunkenness?
• A patient appears outwardly confused and hesitant during the interview. Before revealing the answer, decide how you would explore whether this is perplexity.
• You want to test a patient for perseveration during a cognitive assessment. Before revealing the answer, decide how you would go about it.
• You suspect perseveration of posture in a patient. Before revealing the answer, decide how you would assess for this.
• You are assessing whether a patient's current difficult traits represent a personality disorder or are better explained by a current episode of illness. Which single question is most useful?
• A patient mentions avoiding certain situations out of fear. Before revealing the answer, decide how you would explore whether this is a phobia.
• You are assessing a patient's delusional belief and want to establish whether it is primary or secondary. Before revealing the answer, decide how you would explore its history.
• A patient mentions, almost in passing, seeing something that wasn't there. Before revealing the answer, decide how you would establish whether this was a pseudohallucination.
• You suspect a patient's elaborate account of a dramatic personal history may be pseudologia fantastica rather than confabulation or ordinary lying. Which single approach would most usefully help clarify this?
• You are assessing a patient with known depressive illness and want to establish whether psychomotor retardation is present. Which single question or approach would most efficiently confirm it at interview?
• You suspect pure word deafness in a patient. Before revealing the answer, decide how you would assess for this.
• You suspect pure word-dumbness in a patient. Before revealing the answer, decide how you would assess for this.
• You suspect a disorder of reactive movements in a patient. Before revealing the answer, decide how you would assess for this.
• You suspect reactivity of mood in a patient. Before revealing the answer, decide how you would assess for this.
• You suspect a patient has receptive aphasia. Before revealing the answer, decide how you would assess for this.
• A patient reports that certain sounds seem to bring on other perceptual experiences. Before revealing the answer, decide how you would assess whether this is a reflex hallucination.
• You suspect a patient shows restriction of consciousness. Before revealing the answer, decide how you would assess for this.
• You are assessing a patient shortly after a head injury and want to establish whether they have retrograde amnesia. Before revealing the answer, decide how you would assess for it during the interview.
• You suspect a patient is exhibiting a retrospective delusion. Before revealing the answer, decide how you would assess for this.
• You suspect a patient's account of their past may show retrospective falsification. Before revealing the answer, decide how you would assess for this.
• You suspect a patient's memory loss follows Ribot's law of memory regression. Before revealing the answer, decide how you would assess for this.
• You are assessing a patient for auditory hallucinations and want to establish whether running commentary voices are present. Before revealing the answer, decide what you would ask.
• You suspect schemazia distortion in a patient. Before revealing the answer, decide how you would assess for this.
• You are assessing a patient for possible schizoid personality disorder. Before revealing the answer, decide how you would assess for this.
• A patient's speech is so disorganised it is difficult to follow. Before revealing the answer, decide how you would assess whether this is schizophasia.
• A patient shows a longstanding pattern of social oddness. Before revealing the answer, decide how you would explore whether this is schizotypal personality disorder.
• You suspect a patient's account of a particular childhood memory may be a screen memory. Before revealing the answer, decide how you would approach establishing this.
• A patient describes a fixed delusional belief. Which single question would most usefully help establish whether this is a secondary delusion rather than a primary one?
• A bereaved patient mentions feeling that someone is with them. Before revealing the answer, decide how you would explore this.
• A patient reports that ordinary sensations feel unusually intense. Before revealing the answer, decide how you would assess whether this is sensory intensity distortion.
• You suspect smiling depression in a patient. Before revealing the answer, decide how you would assess for this.
• You suspect somatisation in a patient presenting with physical complaints. Before revealing the answer, decide how you would assess for this.
• You are examining a patient with left hemiplegia after a stroke and want to assess for somatoparaphrenia. Before revealing the answer, decide what you would specifically ask.
• You suspect a patient's speech disruption is a stammer. Before revealing the answer, decide how you would assess for this.
• You suspect a patient shows a stereotyped posture. Before revealing the answer, decide how you would assess for this.
• You suspect stiffening of affect in a patient. Before revealing the answer, decide how you would assess for this.
• You are assessing a patient who is immobile and largely unresponsive. Before revealing the answer, decide how you would explore whether this is stupor.
• A person describes an unusual pairing of sensory experiences. Before revealing the answer, decide how you would explore whether this is synaesthesia.
• A patient scratches repeatedly at their arms during the interview without spontaneously explaining why. Which single question would most efficiently help clarify whether a tactile hallucination is present?
• You suspect a patient may be talking past the point. Before revealing the answer, decide how you would assess for this.
• You are assessing a long-term antipsychotic user for tardive dyskinesia. Before revealing the answer, decide how you would assess for this on examination.
• You want to establish whether a patient is experiencing thought alienation in some form. Before revealing the answer, decide what you would ask.
• You're conducting a mental state examination and want to check specifically for thought blocking, not just note it if it happens to occur unprompted. Before revealing the answer, decide what you would actually say and do.
• A patient has hinted that other people somehow know what he is thinking. Before revealing the answer, decide how you would explore this further.
• A patient has mentioned hearing a voice that seems connected to her own thinking. Before revealing the answer, decide how you would explore whether this is thought echo.
• You suspect a patient may be experiencing thought insertion but they have not described it spontaneously. Before revealing the answer, decide how you would ask about this during the interview.
• A patient describes a sudden gap in his thinking. Before revealing the answer, decide how you would explore whether this is thought withdrawal.
• You want to screen a patient with a significant mood disturbance for a distortion of the experience of time. Which single opening question is most appropriate?
• A patient describes an unusual distortion in how movement appears to them. Before revealing the answer, decide how you would explore whether this is trailing phenomena.
• You suspect transitory thinking in a patient. Before revealing the answer, decide how you would assess for this.
• A patient describes a period of 'losing time' and you want to establish whether this was a twilight state. Before revealing the answer, decide what you would ask about.
• You suspect undirected fantasy thinking in a patient. Before revealing the answer, decide how you would assess for this.
• You notice a patient using the same short phrase repeatedly across an interview, regardless of the question. Before revealing the answer, decide how you would explore this.
• A patient has been repeating the same phrase continuously for some time. Before revealing the answer, decide how you would explore whether this is verbigeration.
• A patient mentions in passing that something "feels wrong inside" without further detail. Which single follow-up question would best help clarify whether this is a visceral hallucination?
• You suspect a patient has visual asymbolia. Before revealing the answer, decide how you would assess for this.
• A patient reports seeing something unusual. Before revealing the answer, decide how you would explore whether this is a visual hallucination.
• You want to test for waxy flexibility at the bedside in a patient with reduced spontaneous movement. Which single approach is most appropriate?

Explain Activities

• Explain why an abnormal emotional reaction is described as the mildest and most clinically ambiguous rung of disordered emotion.
• Explain why an abnormal expression of emotion is described as sitting a step further along the spectrum of disordered emotion than a simple abnormal emotional reaction.
• Explain why acute dystonia is treated as an urgent presentation requiring prompt recognition, in contrast to other, more gradual extrapyramidal effects of antipsychotic medication.
• Explain why the fact that affect blunting is typically not recognised by the patient themselves is clinically significant.
• Explain why constriction of affect and blunting of affect are described as sitting on the same spectrum rather than being entirely separate signs.
• Explain why affective incontinence is described as a particularly important sign to prompt physical assessment.
• Explain why agnostic alexia and pure word deafness are described as usually associated with lesions in different, specific brain locations.
• Explain why failing to specifically recognise akathisia as a medication effect, rather than as anxiety or worsening illness, can lead to a genuinely harmful clinical error.
• Explain why the outward appearance of a patient with akinetic mutism can be misleading, and why this matters for how the condition is assessed.
• Explain why ambitendency is described as a specific form of ambivalence expressed through the body, and why this framing is clinically useful.
• Explain why the pattern of an amnesic gap — its onset, extent, and whether personal identity is affected or spared — matters clinically, beyond simply confirming that memory loss has occurred.
• A patient with a persisting memory gap has normal immediate recall, intact distant memories, and preserved general conversation, but cannot learn new information reliably. Why does the preservation of general conversation specifically help rule out dementia?
• A patient's meticulous scheduling and insistence on order have caused real, repeated conflict with his family. Why does his own comfort with these traits (rather than distress about them) not rule out a personality disorder diagnosis?
• Explain why anhedonia is specifically and routinely asked about in a depression assessment, rather than being assumed to be present whenever a patient reports low mood.
• A patient with a confirmed paralysis offers a confident but inaccurate explanation for why her arm isn't moving, showing no distress about it. Why is this understood as a genuine failure of self-monitoring rather than deliberate denial?
• Explain why a patient with anterograde amnesia can appear to behave completely normally during the affected period, despite having no later memory of it at all.
• Why is it important to take a careful history of movement symptoms present before any antipsychotic medication was started, rather than assuming any movement abnormality seen during treatment is medication-induced?
• Explain why anxiety is described as an abnormal emotional reaction only when it is out of proportion to, or persists beyond, whatever provoked it, rather than simply by its presence.
• Explain why anxiety amnesia is described as an important trap to be aware of in older or more severely anxious patients.
• Explain why the vagueness of the anticipated misfortune in anxious foreboding is itself a clinically meaningful feature, rather than simply a patient's inability to articulate their fear clearly.
• Explain why the presence of a strong underlying wish for friendship is considered a defining, rather than incidental, feature of anxious (avoidant) personality disorder.
• Explain why apathy is recognised as a feature of a range of organic and neurological conditions, not only of depressive illness.
• A patient's language disturbance following a confirmed stroke is disproportionate to any accompanying disorganisation of his broader thinking. Why is this disproportion clinically significant?
• Explain why the perceptual force and location of an auditory experience, rather than its content, is what actually determines whether it is a true hallucination.
• Explain why content and context both matter when assessing a sudden idea for whether it represents an autochthonous delusion, rather than relying on its sudden onset alone.
• Explain why the failure to adjust behaviour after an unpleasant consequence, rather than simply a high degree of cooperativeness, is what actually defines automatic obedience.
• Explain why the location of the person's own sense of viewpoint, rather than simply whether they 'saw themselves', is the detail that actually distinguishes autoscopy from an out-of-body experience.
• Explain why la belle indifference is not simply a more dramatic form of denial.
• Explain why body image disturbance is described as a family of related phenomena rather than a single, uniform experience.
• Explain why it would be a mistake to describe self-harm in borderline personality disorder as simply 'attention-seeking' or manipulative.
• A patient with Capgras syndrome fully acknowledges that the person in front of them looks exactly like their spouse, yet still insists it isn't really them. Why is this combination the defining feature of the syndrome, rather than a contradiction?
• Explain why telling the patient beforehand that they need not hold the position is essential to testing for catalepsy validly, rather than an optional courtesy.
• Explain why the underlying mechanism proposed for catathymic amnesia, and the reliability of any later "recovered" memory, are described as genuinely disputed rather than settled.
• Explain why continuous whispering in a catatonic patient is worth exploring further rather than dismissing as an odd mannerism.
• Explain why the combination of a deadpan face with lively eyes is considered a useful bedside clue in catatonic stupor specifically.
• Explain why the combination of disturbed grammar and paraphasic errors together is considered a particularly distinguishing feature of central aphasia.
• Explain why chromatopsia's association with toxic exposures and medication effects matters for how it should be worked up clinically.
• Explain why retained goal-directedness, despite the inefficiency, is what actually defines circumstantiality rather than simply talking at length.
• Explain why resistance to a compulsion typically produces anxiety that the compulsive act itself then relieves, and why this pattern matters clinically.
• Explain, in your own words, why confabulation is not considered a form of lying, even though the account given is false.
• Explain why cryptamnesia is described as "not remembering that one is remembering" rather than simply as a failure of memory.
• Explain why déjà vu, despite its name and its association with memory, is not classified as a true memory disorder.
• Explain why the falseness of a delusional belief is not, by itself, what makes it delusional.
• A patient's conviction of having ruined her family through a moral failing years ago persists despite her family directly and repeatedly telling her this never happened. Why does this remain a delusion of guilt rather than resolving once corrected?
• A patient's conviction of serious illness persists, and actually worsens in distress, after being shown entirely normal test results. Why is this best explained as a delusion of ill health rather than simply severe health anxiety?
• A man reinterprets his partner's ordinary late bus home as "proof" of an affair, despite this being explained and verified. Why is careful documentation of this delusion's content important beyond simply recording it as "jealousy"?
• A woman explains the complete absence of any contact from the person she believes loves her by concluding that her letters must be being secretly intercepted. Why is this explaining-away pattern itself clinically significant?
• Explain why a clinician should always consider whether a persecutory belief could be grounded in a real threat before concluding it is delusional.
• A man refuses to buy groceries despite his wife showing him their actual, healthy bank balance on her phone in real time. Why does this remain a delusion of poverty rather than resolving once he sees the evidence?
• Explain why delusional mood is considered clinically useful to recognise, even though it lacks any specific, identifiable content of its own.
• Explain why delusional perception is traditionally classified as a primary, 'un-understandable' delusion rather than a secondary one.
• A man discouraged by a chronic illness remains able to enjoy his grandchildren and his hobbies. Why does this preserved enjoyment matter for distinguishing demoralization from a depressive illness?
• Explain why denial is generally understood as a psychological response to distress rather than a delusion, even when it appears highly entrenched.
• Explain why dependent personality disorder is considered a disorder of personality, rather than simply a description of someone who is unusually reliant on their partner.
• Explain why retained insight is considered such an important feature of depersonalisation, both for recognising it and for reassuring a distressed patient.
• Explain why distinguishing a depressive illness from demoralization matters clinically, given that both involve persistent low mood.
• Why is a trial of antidepressant treatment, followed by reassessment of cognition, often both a diagnostically useful step and an appropriate clinical intervention in a suspected case?
• Explain why depressive stupor is described as representing a point on a continuum with ordinary psychomotor retardation, rather than a qualitatively distinct condition.
• Explain why derealisation does not mean a person has stopped believing in objective reality.
• Explain why each intruding idea in desultory thinking is described as being, in itself, a "simple and reasonable thought."
• Explain why the specific quality of a disorder of expressive movement (diminished, stiff and masked, or exaggerated) is clinically useful information.
• Explain why orientation for time is typically lost before orientation for place, and place before person, as a disturbance of consciousness develops.
• Explain why 'most violent people do not have dissocial personality disorder' is an important caution when assessing for this diagnosis.
• Explain why dissociation of affect is described as having a more automatic, involuntary quality rather than the person simply choosing to appear composed.
• A trauma survivor with sudden, dramatic memory loss continues to function well in complex daily tasks. Why does this combination support the diagnosis rather than suggesting the presentation is exaggerated?
• Explain why suggestibility is considered a recurring, clinically relevant theme across the different named patterns of distortion of recall.
• A brief déjà vu experience in a healthy person and a persistent, elaborated Capgras-type misidentification are both classified under distortion of recognition. Why does this shared classification not mean they carry the same clinical significance?
• Explain why distractibility can look similar on the surface across very different underlying conditions, and why this matters clinically.
• A meticulous professional presents acutely dishevelled and disoriented following a febrile illness. Why is it important to compare this presentation against his known baseline rather than assessing it in isolation?
• Explain why retained insight is described as the key feature separating a disturbance of awareness of self-activity from a nihilistic delusion.
• Explain why passivity phenomena are described as the clearest and most severe expression of a disturbance of the boundaries of the self.
• Explain why the experience of multiple distinct personalities is described as the most severe and specific form within this family of disturbance, rather than a separate phenomenon altogether.
• Explain why the presence or absence of the qualifying 'as if' matters so much clinically when assessing disturbance of self-unity.
• Explain why a patient experiencing a dream-like change of consciousness cannot simply be reassured that their hallucinations 'aren't real.'
• Explain why the patient's retained critical attitude in drivelling thinking is a clinically significant feature.
• Explain why dysmegalopsia is described as covering several differently-named sub-types rather than a single uniform experience.
• Explain why the automatic, meaning-independent quality of echolalia is what separates it from ordinary clarification-seeking repetition.
• Explain why echopraxia is described as differing from ordinary social mimicry, even though both involve copying another person's actions.
• Explain why ecstasy and a religious or mystical delusion can be difficult to disentangle, despite being conceptually distinct.
• Explain why eidetic imagery is classified as a memory phenomenon rather than as a form of hallucination, despite its unusually intense, almost hallucinatory quality.
• Explain why it matters that different major classification systems treat emotionally unstable personality disorder differently.
• Explain why enduring personality change after a catastrophic experience is described as producing two different characteristic pictures depending on its trigger.
• Explain why excitement is described as appearing to be the opposite of stupor, yet the two often occur within the same underlying illnesses.
• Explain why the "telegram style" quality of speech in expressive aphasia is a clinically useful feature to recognise.
• A parent who commits extended suicide typically describes the act, within their own delusional framework, as protective rather than hostile. Why is understanding this delusional logic clinically important?
• Explain why the spatial impossibility of an extracampine hallucination is worth noting specifically, given that it does not change the underlying perceptual quality of the experience.
• Explain why a false memory being held with full subjective conviction, rather than with any hint of doubt, makes it clinically and forensically significant.
• Explain why the overall extent of misidentification is described as a useful clue to whether an acute or a chronic process is at work.
• Explain why a flashback is described as bringing back the cognitive and emotional quality of the original event, and why this matters for how it is distinguished from an ordinary unwanted memory.
• A patient's vivid, confident memory of a shocking news event later turns out to contain factual inaccuracies. Why does this not necessarily mean the patient is being untruthful or that the memory isn't a genuine flashbulb memory?
• Explain why flight of ideas is often compared to a chain of dominoes, and why this image is a useful way to understand it.
• Explain why it matters clinically to distinguish forced grasping from the neurological grasp reflex.
• Explain why formal thought disorder is best assessed through spontaneous, unstructured speech rather than structured questioning.
• Explain why a functional hallucination is not the same as an illusion, even though both involve a real external stimulus.
• Explain why Ganser syndrome and malingering are frequently confused with one another in practice, and why this matters clinically.
• Explain why Gegenhalten, Mitmachen/Mitgehen, and negativism are best understood as points on a single spectrum rather than as entirely separate, unrelated signs.
• A man believes several world governments are secretly in contact with him about an invention, but cannot produce any evidence of this contact when asked directly. Why does his inability to produce evidence not resolve the belief?
• Explain why a gustatory hallucination is described as often occurring together with an olfactory hallucination, despite being conceptually distinct from it.
• Explain why the presence or absence of a real external stimulus is considered the single most fundamental distinction in assessing an unusual perceptual experience.
• Why does full clarity of consciousness, despite ongoing hallucinations, matter so much when assessing this presentation?
• Explain why hemiasomatognosia is considered a milder or earlier disturbance than somatoparaphrenia, rather than simply a different, unrelated finding.
• Explain why hemispatial neglect, hemiasomatognosia, and anosognosia are often seen together, and why recognising this cluster matters clinically.
• Explain why an initially charming, socially skilled first impression is not reassuring evidence against histrionic personality disorder, but can in fact be part of the pattern itself.
• Explain why hyperamnesia is described as covering several distinct, differently-named forms rather than a single uniform experience.
• Explain why a hypnagogic hallucination, on its own, should generally not be over-interpreted as a sign of psychiatric illness.
• Explain why the book acknowledges that distinguishing a hysterical twilight state from deliberate malingering can be genuinely difficult, rather than presenting the distinction as straightforward.
• A tired worker briefly misperceives a mop as a person in poor lighting, then immediately corrects the perception on a closer look. Why is this not, on its own, clinically significant?
• Explain why impulsive behaviour is described as common enough in catatonia specifically, despite also occurring in people without mental illness.
• Explain why impulsive personality disorder's classification is described as differing across diagnostic systems.
• Explain why it would be a mistake to assume that a patient laughing while describing something sad is simply being callous or uncaring.
• Explain why inhibition of thinking can be mistaken for early dementia, and why this distinction matters clinically.
• Explain why intermediate aphasia is described as comprising exactly two named, specific sub-types rather than a broader, loosely defined category.
• Explain why psychiatric assessors are described as needing to recognise involuntary neurological movement signs, even though these are primarily neurological rather than psychiatric in origin.
• Explain why irritability is described as a useful clue prompting a broader assessment of underlying mood state, rather than being specific to any one direction of mood disturbance.
• Explain why lability of affect and reactivity of mood can be easy to confuse in a brief clinical encounter, despite being different findings.
• Explain why lethologia is described as "not indicative of any pathology on its own," in contrast to many of the other memory phenomena it is often discussed alongside.
• Explain why loss of emotional resonance can compound guilt in a person with depressive illness, in a way that affect blunting, being unrecognised by the patient, typically does not.
• Explain why correctly recognising lowering of consciousness, rather than assuming dementia, matters clinically.
• Explain why a mannerism is not, by itself, considered evidence of schizophrenia or any other specific psychiatric illness.
• Explain why Mitgehen is considered a more extreme variant of Mitmachen rather than a wholly separate phenomenon.
• Explain why organic neurasthenia is considered a distinct subtype of morbid anxiety rather than simply an alternative label for the same thing.
• Explain why a morbid disorder of emotion is described as representing the most severe of the levels of disturbed emotion.
• A patient's elevated mood persists and intensifies despite a recent, genuinely difficult life event that would normally be expected to lower mood. Why is this persistence, rather than the mood's intensity alone, the key diagnostic clue?
• Explain why a morbid expression of emotion is described as encompassing a specific, recognised set of individual patterns rather than being a single uniform sign.
• Explain why the specific, shallow quality of the humour in moria — rather than simply the presence of joking — is what makes it a recognisable clinical sign rather than just a cheerful personality.
• A patient continues a drawing task well past its completion despite a clear verbal instruction to stop. Why is this classified as motor perseveration rather than simple forgetfulness about the instruction?
• Explain why the experience of multiple personalities requires careful, thorough differentiation from other conditions before being accepted as the diagnosis.
• Explain why Munchausen's syndrome is considered a variant of pseudologia fantastica rather than a wholly separate diagnosis.
• Explain why mutism is described as having "many possible causes and presentations" rather than being treated as a single, unified phenomenon.
• Explain why egocentricity alone is not considered sufficient to diagnose narcissistic personality disorder.
• Explain why the absence of an understandable motive, rather than the presence of resistance itself, is what actually defines negativism.
• Explain why a technical neologism, coined to name a private experience, is considered clinically distinct from other neologisms arising from disordered thought.
• Explain why a nihilistic delusion is most classically associated with severe, agitated depression, and why recognising it matters clinically.
• Explain why the specific pattern of which language components are affected in an aphasia is described as clinically useful beyond simply confirming that aphasia is present.
• Explain why the retained insight in an obsession — the person's own awareness that the thought is excessive or irrational — is itself a source of distress, rather than a reassuring feature.
• Explain why obstruction is described as closely paralleling thought blocking, and why this parallel is clinically useful.
• Explain why recognising occupational delirium for what it is matters clinically, rather than dismissing it as random or bizarre restlessness.
• A patient describes smelling burning rubber that no one else can detect, and a thorough check of the environment finds no source. Why does the involvement of other people in checking matter here?
• Explain why the preservation or loss of personal identity is considered such a clinically important distinguishing feature between organic and dissociative amnesia.
• Explain why phantom limb sensation is considered one of the best-known and most clearly understood examples of an organic hallucination.
• Explain why the distinction between an overvalued idea and a delusion is described as not always sharp in practice, rather than as a clear dividing line.
• Explain why the severity of physical symptoms in a panic attack often leads patients to seek medical rather than psychiatric help first.
• Explain why the book's division of paramnesia into distortions of recall and distortions of recognition is clinically useful, rather than simply an academic distinction.
• A woman with a lifelong pattern of suspiciousness says that, if shown clear evidence, she could at least imagine being wrong about a specific worry, even though she remains generally distrustful. Why is this detail clinically significant?
• A paraphasic word substitution and a psychiatric neologism can sound superficially similar. Why does the presence of a relevant neurological cause and other aphasic signs matter for telling them apart?
• Explain why retained insight into the unreality of the added structure is described as typical in paraschemazia.
• Explain why passivity phenomena are considered closely related to, but still distinct from, the alienation of thought seen in thought insertion, withdrawal, and broadcasting.
• A patient becomes violently aggressive after consuming only a small amount of alcohol, without the usual signs of intoxication. Why is this disproportion, rather than the violence alone, the clinically defining feature?
• Explain why perplexity is considered a useful clinical clue toward other underlying abnormal experiences, rather than simply a nonspecific sign of distress.
• Explain why perseveration getting worse as task difficulty increases is a clinically useful bedside observation.
• Explain why the presence or absence of resistance specifically at the moment the examiner releases the limb is described as a useful way of distinguishing perseveration of posture from waxy flexibility.
• A pattern of traits appearing only during a depressive episode, closely resembling a specific personality disorder, resolves as the depression lifts. Why does this timing rule out a personality disorder diagnosis?
• Explain why preserved insight — the patient's own recognition that the fear is excessive — is considered an important feature of a phobia rather than simply an incidental detail.
• Explain why the primary/secondary distinction is historically considered clinically important, beyond simply being a way of classifying delusions.
• Explain why the prefix 'pseudo' in pseudohallucination does not mean the experience is fake or clinically unimportant.
• A patient tells an elaborate false story and eventually admits the truth once shown clear proof. Why does this eventual admission support pseudologia fantastica rather than a fixed delusion?
• A patient's family reports she now takes far longer to complete everyday tasks than she used to, though she denies feeling unusually tired. Why is comparing her current pace against her own previous baseline more useful than asking about tiredness alone?
• Explain why pure word deafness is usually associated with a lesion in the dominant temporal lobe specifically.
• Explain why the clean dissociation between spoken and written language is described as the key distinguishing feature of pure word-dumbness.
• Explain why a disorder of reactive movements is described as able to go in either direction, diminished or excessive.
• Explain why reactivity of mood is described as an abnormal emotional reaction rather than a morbid disorder of emotion.
• Explain why receptive aphasia is described as a category containing three specific, distinctly named sub-types rather than a single uniform presentation.
• Explain why the consistency and reproducibility of the trigger-hallucination relationship matters when identifying a reflex hallucination.
• Explain why restriction of consciousness can be easy for an uninformed observer to miss, and why this matters clinically.
• Explain why the length of the retrograde amnesia gap is not fixed at the moment of injury, but tends to shrink over the following days.
• Explain why a retrospective delusion reshaping personal history "to fit" a current delusion is considered clinically useful information, rather than simply an incidental distortion.
• Explain why the direction of distortion in retrospective falsification is described as clinically useful.
• Explain why distant, well-rehearsed memories tend to remain strikingly well preserved even as recent memory deteriorates markedly under Ribot's law.
• Explain why the specific, real-time link between the voice's content and the patient's ongoing behaviour is what defines running commentary voices, rather than simply the voice's third-person phrasing.
• Explain why schemazia distortion is described as a family of experiences rather than one single, fixed pattern.
• Explain why schizoid personality disorder rarely comes to clinical attention on its own.
• Explain why the preserved capacity for non-verbal, practical functioning is considered such a useful clue in distinguishing schizophasia from a true aphasia.
• Explain why schizotypal personality disorder is classified differently across major diagnostic systems, and why this reflects a genuine underlying uncertainty rather than a simple labelling difference.
• Explain why establishing exactly which parts of a screen memory are true and which are substituted can be genuinely difficult, and why this matters clinically.
• A man's delusion of guilt can be traced directly back to his profound depressed mood. Why does tracing this origin matter clinically, beyond simply labelling the delusion as "secondary"?
• Explain why the absence of any specific sensory quality is what makes a sense of presence a genuinely distinct phenomenon, rather than simply a mild or vague hallucination.
• Explain why hyperaesthesia and hypoaesthesia are considered opposite poles of the same underlying disturbance rather than two unrelated phenomena.
• Explain why smiling depression carries particular clinical importance for suicide risk.
• Explain why somatisation is described as a pattern of presentation within depressive illness specifically, rather than a separate diagnosis in its own right.
• Explain why somatoparaphrenia is considered a more elaborated disturbance than simple hemiasomatognosia.
• Explain why a stammer resurfacing under stress in adulthood is clinically informative, even though the difficulty itself is not new.
• Explain why specific, named patterns like the psychological pillow and snout spasm are useful for clinicians to recognise by name.
• Explain why the observation that the affect itself may not be reduced in intensity is described as central to recognising stiffening of affect.
• Explain why establishing the underlying level of consciousness is the single most important step when assessing a patient in a stuporose state.
• Explain why lifelong synaesthesia is generally considered a normal variant of perceptual experience rather than a sign of illness.
• A patient describes a vivid crawling sensation under her skin but is clear she does not believe real insects are present. Why should the sensation still be documented as a tactile hallucination?
• Explain why the clinical context in which talking past the point occurs matters so much to how it should be interpreted.
• Explain why the occurrence of tardive dyskinesia in some patients who have never been exposed to antipsychotic medication is clinically significant.
• Explain why the three sub-types of thought alienation — insertion, withdrawal, and broadcasting — are described as varying by the 'direction' of the felt interference.
• In your own words, explain why thought blocking is classified as a disorder of the continuity of thought rather than a disorder of thought tempo. Think it through before revealing the model answer.
• Explain why thought broadcasting is grouped together with thought insertion and thought withdrawal as "passivity phenomena" despite the disturbance running in the opposite direction.
• Explain why the timing of the voice relative to the patient's thought is considered the single most useful detail to establish when assessing possible thought echo.
• Explain why the question of ownership, rather than the unpleasantness of the thought's content, is what makes thought insertion clinically distinct from an obsession.
• Explain why the presence or absence of a felt external agent is described as the single most useful detail for distinguishing thought withdrawal from superficially similar experiences.
• Why might time seem to pass unusually slowly for a patient during a severe depressive episode, in a way that is clinically meaningful rather than simply a vague complaint?
• Explain why trailing phenomena is classified as a distortion of movement perception rather than as a hallucination or an ordinary illusion.
• Explain why transitory thinking is described as affecting the constancy of individual thoughts, rather than the broader continuity or organisation of the whole train of thinking.
• Explain why a twilight state can be clinically easy to miss, despite involving a genuine disturbance of consciousness.
• Explain why undirected fantasy thinking is described as sitting on a spectrum with ordinary daydreaming, with no sharp boundary between the two.
• Explain why verbal stereotypy is considered clinically significant even though the repeated phrase itself is often meaningless or trivial in content.
• Explain why verbigeration is considered a motor phenomenon, closely related to catatonic presentations, rather than simply a disorder of thought content.
• A patient with a persistent, distressing sensation of an organ "shutting down" has already had a normal physical examination and normal relevant blood tests. Why is it still appropriate to consider a visceral hallucination rather than simply reassuring the patient that nothing is wrong?
• Explain why visual asymbolia is typically accompanied by additional neurological findings beyond the reading difficulty itself.
• Explain why visual hallucinations are considered more suggestive of an organic process than a primary psychiatric illness, in contrast to auditory hallucinations.
• During bedside testing, a patient's limb offers smooth, even resistance and then remains in the new position without active fighting against the movement. Why is the absence of active resistance an important part of this sign, rather than a separate, unrelated observation?