Psychopathology, phenomenology, and psychiatric interviewing/diagnostic formulation
This domain tests the precision of your descriptive language. Examiners reward the candidate who can name a phenomenon accurately, distinguish it from its neighbours, and build a formulation from it.
Core rules
- Mental state examination domains: appearance and behaviour, speech, mood and affect (subjective versus observed), thought form (rate, flow, coherence: derailment, loosening, thought blocking, flight of ideas, clang associations) and thought content, perception, cognition, insight, judgement.
- Schneiderian first-rank symptoms: audible thoughts, voices arguing or commenting, thought insertion/withdrawal/broadcast, made feelings, made impulses, made volitional acts, somatic passivity, delusional perception.
- Delusion subtypes: persecutory, grandiose, erotomanic, jealous, somatic, nihilistic (Cotard), and misidentification syndromes (Capgras, Fregoli, intermetamorphosis). Illusion is a misinterpretation of a real percept; hallucination is perception without object; pseudohallucination is recognized as unreal and located in inner space.
- Obsession versus delusion: an obsession is ego-dystonic, resisted, recognized as arising from the self, and preserved insight (DSM-5-TR records insight as good/fair, poor, absent/delusional).
- Formulation uses predisposing, precipitating, perpetuating and protective factors across biological, psychological and social axes, plus a cultural formulation.
Worked example
A woman reports that she must mentally count to seven before entering a room or her mother will die. She knows the idea is irrational, finds it intrusive and fights it, spending two hours a day. This is an obsession with a compulsion and good insight (obsessive-compulsive disorder), not a delusion, because of ego-dystonicity, resistance and preserved reality testing.
Traps
Calling every fixed idea a delusion; confusing loosening of associations with circumstantiality; naming affect as mood; writing a formulation as a list of diagnoses without mechanism.