Download the full version of the ebook at ebookfinal.

com

Psychiatry Pretest Pretest Series 11th Edition

Debra L. Klamen

https://ebookfinal.com/download/psychiatry-pretest-pretest-
series-11th-edition-debra-l-klamen/

OR CLICK BUTTON

DOWNLOAD EBOOK

Download more ebook instantly today at https://ebookfinal.com

Instant digital products (PDF, ePub, MOBI) available
Download now and explore formats that suit you...

Pharmacology PreTest Self Assessment and Review Pretest

Series 12th edition Marshal Shlafer

https://ebookfinal.com/download/pharmacology-pretest-self-assessment-
and-review-pretest-series-12th-edition-marshal-shlafer/

ebookfinal.com

Microbiology PreTest Self Assessment Review Microbiology

Pretest Self Assessment Review 11th Edition James D.
Kettering
https://ebookfinal.com/download/microbiology-pretest-self-assessment-
review-microbiology-pretest-self-assessment-review-11th-edition-james-
d-kettering/
ebookfinal.com

Pathology PreTest Self Assessment and Review Pretest

Series 12th Edition Earl J. Brown

https://ebookfinal.com/download/pathology-pretest-self-assessment-and-
review-pretest-series-12th-edition-earl-j-brown/

ebookfinal.com

PreTest medicine PreTest self assessment and review 12th

Edition Robert S Urban

https://ebookfinal.com/download/pretest-medicine-pretest-self-
assessment-and-review-12th-edition-robert-s-urban/

ebookfinal.com
Medicine PreTest self assessment and review 10th ed
Edition Urban

https://ebookfinal.com/download/medicine-pretest-self-assessment-and-
review-10th-ed-edition-urban/

ebookfinal.com

Emergency Medicine PreTest Self Assessment and Review

Third Edition Adam Rosh

https://ebookfinal.com/download/emergency-medicine-pretest-self-
assessment-and-review-third-edition-adam-rosh/

ebookfinal.com

Physiology PreTest Self Assessment and Review 10th Edition

James P. Ryan

https://ebookfinal.com/download/physiology-pretest-self-assessment-
and-review-10th-edition-james-p-ryan/

ebookfinal.com

Neuroscience Pretest Self Assessment and Review 4th Ed 4th

Edition Allan Siegel

https://ebookfinal.com/download/neuroscience-pretest-self-assessment-
and-review-4th-ed-4th-edition-allan-siegel/

ebookfinal.com

Physical diagnosis PreTest self assessment and review 4th

ed Edition Jo-Ann Reteguiz

https://ebookfinal.com/download/physical-diagnosis-pretest-self-
assessment-and-review-4th-ed-edition-jo-ann-reteguiz/

ebookfinal.com
 Psychiatry
PreTest™ Self-Assessment and Review
 Notice

Medicine is an ever-changing science. As new research and clinical experience

broaden our knowledge, changes in treatment and drug therapy are required. The
authors and the publisher of this work have checked with sources believed to be
reliable in their efforts to provide information that is complete and generally in
accord with the standards accepted at the time of publication. However, in view of
the possibility of human error or changes in medical sciences, neither the authors
nor the publisher nor any other party who has been involved in the preparation or
publication of this work warrants that the information contained herein is in every
respect accurate or complete, and they disclaim all responsibility for any errors or
omissions or for the results obtained from use of the information contained in this
work. Readers are encouraged to confirm the information contained herein with
other sources. For example and in particular, readers are advised to check the prod-
uct information sheet included in the package of each drug they plan to administer
to be certain that the information contained in this work is accurate and that
changes have not been made in the recommended dose or in the contraindications
for administration. This recommendation is of particular importance in connection
with new or infrequently used drugs.
 Psychiatry
PreTest™ Self-Assessment and Review
Eleventh Edition

Debra L. Klamen, M.D., M.P.H.E., F.A.P.A.

Associate Dean, Education and Curriculum
Professor and Chair, Department of Medical Education
Southern Illinois University
Springfield, Illinois

Philip Pan, M.D.

Director, Outpatient Services
Assistant Professor, Department of Psychiatry
Southern Illinois University
Springfield, Illinois

McGraw-Hill
Medical Publishing Division
New York Chicago San Francisco Lisbon London Madrid Mexico City
Milan New Delhi San Juan Seoul Singapore Sydney Toronto
Copyright © 2006 by The McGraw-Hill Companies, Inc. All rights reserved. Manufactured in
the United States of America. Except as permitted under the United States Copyright Act of
1976, no part of this publication may be reproduced or distributed in any form or by any
means, or stored in a database or retrieval system, without the prior written permission of the
publisher.

0-07-159692-5

The material in this eBook also appears in the print version of this title: 0-07-145554-X

All trademarks are trademarks of their respective owners. Rather than put a trademark
symbol after every occurrence of a trademarked name, we use names in an editorial fashion
only, and to the benefit of the trademark owner, with no intention of infringement of the trade-
mark. Where such designations appear in this book, they have been printed with initial caps.

McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales
promotions, or for use in corporate training programs. For more information, please contact
George Hoare, Special Sales, at [email protected] or (212) 904-4069.

TERMS OF USE

This is a copyrighted work and The McGraw-Hill Companies, Inc. (“McGraw-Hill”) and its
licensors reserve all rights in and to the work. Use of this work is subject to these terms.
Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one
copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify,
create derivative works based upon, transmit, distribute, disseminate, sell, publish or subli-
cense the work or any part of it without McGraw-Hill’s prior consent. You may use the work
for your own noncommercial and personal use; any other use of the work is strictly prohibit-
ed. Your right to use the work may be terminated if you fail to comply with these terms.

THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO
GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COM-
PLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK,
INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK
VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY,
EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES
OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill
and its licensors do not warrant or guarantee that the functions contained in the work will meet
your requirements or that its operation will be uninterrupted or error free. Neither McGraw-
Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omis-
sion, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill
has no responsibility for the content of any information accessed through the work. Under no
circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental,
special, punitive, consequential or similar damages that result from the use of or inability to
use the work, even if any of them has been advised of the possibility of such damages. This
limitation of liability shall apply to any claim or cause whatsoever whether such claim or
cause arises in contract, tort or otherwise.

DOI: 10.1036/007145554X
 Professional

Want to learn more?

We hope you enjoy this
McGraw-Hill eBook! If
you’d like more information about this book,
its author, or related books and websites,
please click here.
Student Reviewers
Arlene Chung
Eastern Carolina University School of Medicine
Class of 2005

Sarah Harper
University of Pittsburgh School of Medicine
Class of 2005
This page intentionally left blank
 For more information about this title, click here

Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Evaluation, Assessment, and Diagnosis

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Human Behavior:
Theories of Personality and Development
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Human Behavior:
Biologic and Related Sciences
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Disorders of Childhood and Adolescence

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Cognitive Disorders and

Consultation-Liaison Psychiatry
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Schizophrenia and Other

Psychotic Disorders
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

vii
viii Contents

Psychotherapies
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

Mood Disorders
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188

Anxiety, Somatoform, and

Dissociative Disorders
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

Personality Disorders, Human Sexuality,

and Miscellaneous Syndromes
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226

Substance-Related Disorders
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248

Psychopharmacology and
Other Somatic Therapies
Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279

Law and Ethics in Psychiatry

Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
 Introduction
Psychiatry: PreTest™ Self-Assessment and Review, eleventh edition, has been
designed to provide medical students and international medical graduates
with a comprehensive and convenient instrument for self-assessment and
review. The 500 questions provided have been written to parallel the
topics, format, and degree of difficulty of the questions contained in the
United States Medical Licensing Examination (USMLE) Step 2.
Each question in the book is accompanied by an answer, a paragraph
explanation, and a specific page reference to a standard textbook or other
major resource. These books have been carefully selected for their educa-
tional excellence and ready availability in most libraries. A bibliography
listing all the sources used in the book follows the last chapter. Diagnostic
nomenclature is that of the fourth edition of Diagnostic and Statistical Man-
ual of Mental Disorders (DSM-IV-TR).
One effective way to use this book is to allow yourself one minute to
answer each question in a given chapter and to mark your answer beside
the question. By following this suggestion, you will be training yourself for
the time limits commonly imposed by examinations.
Since there are few absolutes in clinical practice, remember to simply
choose the best possible answer. There are no “trick” questions intended.
Rather, each question has been designed to address a significant topic.
Some important topics are deliberately duplicated in other sections of the
book when this is deemed helpful. All questions apply to the treatment of
adults unless otherwise indicated.
When you have finished answering the questions in a chapter, you
should then spend as much time as you need to verify your answers and to
absorb the explanations. Although you should pay special attention to the
explanations for the questions you answered incorrectly, you should read
every explanation. Each explanation is written to reinforce and supplement
the information tested by the question. When you identify a gap in your
fund of knowledge, or if you simply need more information about a topic,
you should consult and study the references indicated.

ix

Copyright © 2006 by The McGraw-Hill Companies, Inc. Click here for terms of use.
This page intentionally left blank
Evaluation, Assessment,
and Diagnosis
Questions
DIRECTIONS: Each item below contains a question followed by sug-
gested responses. Select the one best response to each question.

1. A 42-year-old man comes to the emergency room with the chief com-
plaint that “the men are following me.” He also complains of hearing a
voice telling him to hurt others. He tells the examiner that the news
anchorman gives him special messages about the state of the world every
night through the TV. This last belief is an example of which of the follow-
ing psychiatric findings?
a. Grandiose delusion
b. Illusion
c. Loose association
d. Idea of reference
e. Clouding of consciousness

2. A 32-year-old woman is seen in an outpatient psychiatric clinic for the

chief complaint of a depressed mood for four months. During the inter-
view, she gives very long, complicated explanations and many unnecessary
details before finally answering the original questions. This style of train of
thought is an example of which of the following psychiatric findings?
a. Loose association
b. Circumstantiality
c. Neologism
d. Perseveration
e. Flight of ideas

Copyright © 2006 by The McGraw-Hill Companies, Inc. Click here for terms of use.
2 Psychiatry

3. A 23-year-old man is brought to the emergency room after he walked

up to a stranger in a grocery store and began hitting her, claiming that he
“knew that she had been sent to spy on him.” In the emergency room he
was found to be alert and oriented to person, place, and time. He denied
hearing voices. He continued to insist that there were “special agents”
planted throughout the city to watch him. This symptom is an example of
which of the following psychiatric findings?
a. Delusion
b. Illusion
c. Perceptual representation of a sound or an image not actually present
d. Egomania
e. Dissociative fugue

4. A 55-year-old man is brought to the psychiatrist by his wife after she

found him wandering outside their home wearing only his underwear. On
exam, the patient notes that his memory is “not as good as it used to be.”
Which of the following tests is most likely to be helpful in the diagnosis of
this patient?
a. EEG
b. MRI
c. Serum glucose
d. Serum amylase
e. Urinary myoglobin

5. A 56-year-old man has been hospitalized for a myocardial infarction.

Two days after admission, he awakens in the middle of the night and
screams that there is a man standing by the window in his room. When the
nurse enters the room and turns on a light, the patient is relieved to learn
that the “man” was actually a drape by the window. This misperception of
reality is best described by which of the following psychiatric terms?
a. Delusion
b. Hallucination
c. Illusion
d. Projection
e. Synesthesia
 Evaluation, Assessment, and Diagnosis 3

6. A 1-year-old girl is brought to the physician by her mother. The child

had been developing normally until about 6 to 9 months of age. At 9
months, her mother noticed that the girl’s head growth had begun to decel-
erate, she seemed “floppy,” and she had lost interest in playing. She had
recently been noted to have episodes of crying, screaming, and intense
hyperactivity. Which of the following is the most likely diagnosis?
a. Asperger’s disorder
b. Down syndrome
c. Congenital rubella
d. Rett’s disorder
e. Childhood disintegrative disorder

7. A 72-year-old woman is admitted to the burn unit with second- and

third-degree burns covering 35% of her body, which she received in a
house fire. At 8 P.M. on the fourth day of her hospital stay, she pulls out her
IV and begins screaming that people are trying to hurt her. Several hours
later she is found to be difficult to arouse and disorented. Which of the fol-
lowing is the most likely diagnosis?
a. Emergence of an underlying dementia
b. Brief reactive psychosis
c. Acute manic episode
d. Delirium
e. Acute stress disorder

8. A psychiatric resident is called to consult on the case of a 75-year-old

woman who had undergone a hip replacement two days before. On exam-
ination, the resident notes that the patient states the date as 1956, and she
thinks she is at her son’s house. These impairments illustrate which aspect
of the mental status examination?
a. Concentration
b. Memory
c. Thought process
d. Orientation
e. Level of consciousness
4 Psychiatry

9. A 52-year-old man is sent to see a psychiatrist after he is disciplined at

his job because he consistently turns in his assignments late. He insists that
he is not about to turn in anything until it is “perfect, unlike all of my col-
leagues.” He has few friends because he annoys them with his demands for
“precise timeliness” and because of his lack of emotional warmth. This has
been a lifelong pattern for the patient, though he refuses to believe the
problems have anything to do with his personal behavior. Which of the fol-
lowing is the most likely diagnosis for this patient?
a. Obsessive-compulsive disorder
b. Obsessive-compulsive personality disorder
c. Borderline personality disorder
d. Bipolar disorder, mixed state
e. Anxiety disorder not otherwise specified

10. A 23-year-old woman comes to the psychiatrist because she “cannot

get out of the shower.” She tells the psychiatrist that she has been unable to
go to her job as a secretary for the past three weeks because it takes her at
least four hours to shower. She describes an elaborate ritual in which she
must make sure that each part of her body has been scrubbed three times,
in exactly the same order each time. She notes that her hands are raw and
bloody from all the scrubbing. She states that she hates what she is doing
to herself but becomes unbearably anxious each time she tries to stop. She
notes that she has always taken long showers, but the problem has been
worsening steadily for the past five months. She mentions that she also has
a checking ritual when locking her doors (each time she locks the door she
has to check five times that it is indeed locked). She denies problems with
friends or at work, other than the problems that currently are keeping her
from going to work. Which of the following is the most likely diagnosis?
a. Attention deficit hyperactivity disorder
b. Obsessive-compulsive disorder
c. Obsessive-compulsive personality disorder
d. Separation anxiety disorder
e. Brief psychotic disorder
 Evaluation, Assessment, and Diagnosis 5

DIRECTIONS: Each group of questions below consists of lettered

options followed by a set of numbered items. For each numbered item,
select the one lettered option with which it is most closely associated. Each
lettered option may be used once, more than once, or not at all.

Questions 11–15
Match each of the following vignettes with the most likely diagnosis.
a. Panic disorder
b. Generalized anxiety disorder
c. Schizoid personality disorder
d. Schizotypal personality disorder
e. Anxiety secondary to a general medical condition
f. Factitious disorder
g. Malingering
h. Schizophreniform disorder
i. Schizophrenia

11. A 21-year-old woman comes to the psychiatrist because she is afraid

she is “losing her mind.” The patient notes that the symptoms first began
two months previously while she was riding home on the subway. She now
avoids riding the subway because she is afraid the symptoms will recur
there. She experiences “waves of anxiety” that occur randomly approxi-
mately four to five times per day. She denies the use of drugs or alcohol,
and her physical examination is normal.

12. A 28-year-old man comes to the psychiatrist because his employer

required it. The patient says that he does not know why the employer
required it—that his job is good and that he likes it because it requires him
to sit in front of a computer screen all day. He notes he has one friend
whom he has had for over 20 years and “doesn’t need anyone else.” The
friend lives in another state and the patient has not seen him for at least a
year. The patient denies any psychotic symptoms. His eye contact is poor
and his affect is almost flat.
6 Psychiatry

13. A 42-year-old woman is admitted to the hospital for complaints of

abdominal pain. Her history notes that her mother was a nurse and she
herself is trained as a phlebotomist. On physical examination, she presents
with multiple abdominal scars and marked abdominal tenderness. The
patient is evasive when asked where she had the surgeries, but she can
describe in great detail what was done in each.

14. An 18-year-old man is brought to the emergency room by his college

roommate, after the roommate discovered that the patient had not left his
room for the past three days, neither to eat nor to go to the bathroom. The
roommate noted that the patient was kind of “weird.” Mental status exam-
ination reveals that the patient has auditory hallucinations of two voices
commenting upon his behavior. The patient’s parents note that their son
has always been somewhat of a loner and unpopular, but otherwise did
fairly well in school.

15. A 32-year-old woman comes to the psychiatrist with a chief complaint

of anxiety. She notes that she worries about paying the mortgage on time,
whether or not she will get stuck in traffic and be late for appointments, her
husband’s and daughter’s health, and the war in Iraq. She notes that she has
always been anxious, but since the birth of her daughter two years ago, the
anxiety has worsened to the point that she feels she cannot function as well
as she did previously.

DIRECTIONS: Each item below contains a question followed by sug-

gested responses. Select the one best response to each question.

16. A 23-year-old woman comes to the emergency room with the chief
complaint that she has been hearing voices for seven months. Besides the
hallucinations, she has the idea that the radio is giving her special mes-
sages. When asked the meaning of the proverb “People in glass houses
should not throw stones,” the patient replies, “Because the windows would
break.” Which of the following mental status findings does this patient dis-
play?
a. Poverty of content
b. Concrete thinking
c. Flight of ideas
d. Loose associations
e. Autistic thinking
 Evaluation, Assessment, and Diagnosis 7

17. Which of the following is the most likely diagnosis for the patient
described in question 16?
a. Dysthymic disorder
b. Schizophreniform disorder
c. Schizoid personality disorder
d. Communication disorder
e. Schizophrenia

18. A 69-year-old man is brought to see his physician by his wife. She
notes that over the past year he has experienced a slow, stepwise decline in
his cognitive functioning. One year ago she felt his thinking was “as good
as it always had been,” but now he gets lost around the house and can’t
remember simple directions. The patient insists that he feels fine, though
he is depressed about his loss of memory. He is eating and sleeping well.
Which of the following is the most likely diagnosis?
a. Multi-infarct dementia
b. Mood disorder secondary to a general medical condition
c. Schizoaffective disorder
d. Delirium
e. Major depression

19. A 50-year-old woman becomes depressed after her son dies in a car
crash. She and her husband are devastated by the loss. Although the
patient has been in otherwise good health, she has lost 10 lb in the last two
months. She tells the physician that she would be better off dead. Which of
the following statements with regard to the assessment of suicide risk in
this patient is true?
a. The patient’s gender puts her at higher risk for a completed suicide than if she
were male
b. The patient is unlikely to commit suicide because she was able to talk about it
c. The patient’s age puts her at higher risk than a younger (<40 years old) patient
d. The patient’s good health puts her at higher risk for a successful attempt at
suicide
e. The patient’s marital status puts her at higher risk of suicide than if she were
single
8 Psychiatry

20. A 6-year-old girl is brought to the physician by her mother, who says
the child has been falling behind at school. She notes that the girl did not
speak until the age of 4. She is friendly at school, but is unable to complete
most tasks, even when aided. She is noted to have a very short attention
span and occasional temper tantrums at school and at home. Which of the
following tests would be most helpful in establishing the diagnosis?
a. Electroencephalogram (EEG)
b. Hearing test
c. IQ testing
d. Complete blood count (CBC)
e. Lumbar puncture

21. A 24-year-old man is admitted to the inpatient psychiatry unit after his
mother observed him standing in place for hours at a time in abnormal
postures. During his exam, the patient stands with one arm raised directly
above his head and the other straight out in front of him. He is mute, does
not appear aware of his surroundings, and actively resists any attempts to
change his position. Which of the following best describes the patient’s
behavior?
a. Apraxia
b. Dystonia
c. Synesthesia
d. Catatonia
e. Trance state

22. The symptoms shown by the patient in question 21 are indicative of

which of the following diagnoses?
a. Schizophrenia
b. Delirium
c. Parkinson’s disease
d. Neuroleptic malignant syndrome
e. Huntington’s disease
 Evaluation, Assessment, and Diagnosis 9

23. A psychiatrist is seeing a patient in his outpatient practice. The patient

treats the psychiatrist as if he were unreliable and punitive, though he had
not been either. The patient’s father was an alcoholic who often did not
show up to pick her up from school and frequently hit her. The psychiatrist
begins to feel as if he must overprotect the patient and treat her gingerly,
much the way he treated his younger sister when she was small. The psy-
chiatrist’s behavior is an example of which of the following psychological
mechanisms?
a. Reaction formation
b. Projection
c. Countertransference
d. Identification with the aggressor
e. Illusion

24. A 36-year-old woman with schizophrenia comes to the emergency

room with the chief complaint that “they are trying to kill me.” In the
examining room, she is hypervigilant and insists on sitting in the corner
with her back to the wall. Suddenly she begins to stare intently into the
corner and say, “No, you can’t make me do that!” Which of the following
symptoms is this patient most likely experiencing?
a. Concrete thinking
b. Depersonalization
c. Flight of ideas
d. Hallucination
e. Idea of reference

25. A patient is able to appreciate subtle nuances in thinking and can

use metaphors and understand them. This patient’s thinking can be best
defined by which of the following terms?
a. Intellectualization
b. Abstract
c. Rationalization
d. Concrete
e. Isolation of affect
10 Psychiatry

26. A 65-year-old man, who had been hospitalized for an acute pneumo-
nia three days previously, begins screaming for his nurse, stating that “there
are people in the room out to get me.” He then gets out of bed and begins
pulling out his IV line. On exam, he alternates between agitation and som-
nolence. He is not oriented to time or place. His vital signs are as follows:
pulse, 126 beats per minute; respiration, 32 per minute; blood pressure
(BP), 80/58; temperature, 39.2°C (102.5°F). Which of the following diag-
noses best fits this patient’s clinical picture?
a. Dementia
b. Schizophreniform disorder
c. Fugue state
d. Delirium
e. Brief psychotic episode

27. A 35-year-old man is brought to see a psychiatrist by his wife, who

states that her husband keeps getting lost, even in places he has been famil-
iar with for years. The patient’s father was institutionalized and died at age
37. On exam, the patient is oriented to person only. He cannot accurately
make change for a dollar, though he used to work as a banker. Which of the
following diagnostic tests would be most useful for this patient?
a. EEG
b. Liver function tests
c. Serum amylase
d. Blood toxicology screen
e. Magnetic resonance imaging (MRI)

28. A 34-year-old woman comes to her physician with the chief complaint
of a depressed mood. She also notes trouble concentrating, hypersomnia, a
20-lb weight gain, and slowed mentation. Which of the following diagnos-
tic tests will be most helpful in diagnosing this patient?
a. Thyroid function tests
b. Liver function tests
c. Serum ceruloplasmin
d. EEG
e. Urine amino acids
 Evaluation, Assessment, and Diagnosis 11

29. A 23-year-old man presents to the emergency room with the history of
a fever up to 38°C (100.5°F) intermittently over the past two weeks, a per-
sistent cough, and a 10-lb weight loss in the past month. He notes that he has
also been becoming increasingly forgetful for the past month and that his
thinking is “not always clear.” He has gotten lost twice recently while driving.
Which of the following diagnostic tests will be most helpful with this patient?
a. EEG
b. Liver function tests
c. Thyroid function tests
d. HIV antibody test
e. Skull x-ray

30. A 27-year-old woman comes to her physician because she has passed
out several times in the past three weeks. The patient states that she does
not remember what happens, but suddenly she “wakes up on the floor.”
Her husband notes that each of these episodes has occurred in the middle
of a fight between the two. He says that his wife will suddenly crumple to
the floor, “jerk all over,” and remain that way for approximately five min-
utes. When she wakes up, he says, she is fully alert and oriented. Which of
the following diagnostic tests will be most helpful with this patient?
a. EEG
b. ECG
c. MRI
d. Dexamethasone suppression test
e. Serum amylase

31. A 19-year-old woman presents to the emergency room with the chief
complaint of a depressed mood for two weeks. She notes that since her
therapist went on vacation she has experienced suicidal ideation, crying
spells, and an increased appetite. She states that she has left 40 messages on
the therapist’s answering machine telling him that she is going to kill her-
self and that it would serve him right for leaving her. Physical exam reveals
multiple well-healed scars and cigarette burns on the anterior aspect of
both forearms. Which of the following diagnoses best fits this patient’s clin-
ical presentation?
a. Dysthymic disorder
b. Bipolar disorder
c. Panic disorder
d. Borderline personality disorder
e. Schizoaffective disorder
12 Psychiatry

32. A 28-year-old man comes to the physician with the chief complaint
that he has been depressed for years. He notes that his mood is never good,
though he has never seriously considered suicide. He often feels hopeless
and has problems concentrating. His sleep pattern and appetite have not
changed. He denies hallucinations of any kind. Based on this clinical pic-
ture, which of the following is the most likely diagnosis?
a. Conversion disorder
b. Avoidant personality disorder
c. Dysthymic disorder
d. Major depression
e. Adjustment disorder

33. A 29-year-old man is brought to the emergency room by his wife after
he woke up with paralysis of his right arm. The patient reports that the day
before, he had gotten into a verbal altercation with his mother over her
intrusiveness in his life. The patient notes that he has always had mixed
feelings about his mother, but that people should always respect their
mothers above all else. Which of the following diagnoses best fits this
patient’s clinical picture?
a. Major depression
b. Conversion disorder
c. Histrionic personality disorder
d. Fugue state
e. Adjustment disorder

34. A 28-year-old business executive sees her physician because she is

having difficulty in her new position, as it requires her to do frequent pub-
lic speaking. She states that she is terrified she will do or say something that
will cause her extreme embarrassment. The patient says that when she
must speak in public, she becomes extremely anxious and her heart beats
uncontrollably. Based on this clinical picture, which of the following is the
most likely diagnosis?
a. Panic disorder
b. Avoidant personality disorder
c. Specific phobia
d. Agoraphobia
e. Social phobia
 Evaluation, Assessment, and Diagnosis 13

35. A 24-year-old man comes to the physician with the chief complaint
that his nose is too big, to the point of being hideous. The patient states that
his nose is a constant embarrassment to him, and he would like it surgically
reduced. He tells the physician that three previous surgeons had refused to
operate on him because they said his nose was fine, but the patient asserts
that “they just didn’t want such a difficult case.” The physician observes that
the patient’s nose is of normal size and shape. Based on this patient’s clinical
picture, which of the following is the most likely diagnosis?
a. Schizophrenia
b. Narcissistic personality disorder
c. Body dysmorphic disorder
d. Anxiety disorder not otherwise specified
e. Schizoaffective disorder

36. Which of the following terms best fits the definition “the proportion of
a population affected by a disorder at a given time”?
a. Prevalence
b. Incidence
c. Validity
d. Reliability
e. Relative risk

37. A diagnostic test has a sensitivity of 64% and a specificity of 99%.

Such a test would carry the risk of which kind of problem?
a. High relative risk
b. Low likelihood ratio
c. False negatives
d. False positives
e. Low power
14 Psychiatry

38. A 56-year-old man is brought to the physician’s office by his wife

because she has noted a personality change during the past three months.
While the patient is being interviewed, he answers every question with the
same three words. Which of the following symptoms best fits this patient’s
behavior?
a. Negative symptoms
b. Disorientation
c. Concrete thinking
d. Perseveration
e. Circumstantiality

39. A 32-year-old patient is being interviewed in his physician’s office. He

responds to each question, but he gives long answers with a great deal of
tedious and unnecessary detail. Which of the following symptoms best
describes this patient’s presentation?
a. Blocking
b. Tangentiality
c. Circumstantiality
d. Looseness of associations
e. Flight of ideas

40. An 18-year-old man is brought to the emergency room by the police

after he is found walking along the edge of a high building. In the emer-
gency room, he mumbles to himself and appears to be responding to in-
ternal stimuli. When asked open-ended questions, he suddenly stops his
answer in the middle of a sentence, as if he has forgotten what to say. Which
of the following symptoms best describes this last behavior?
a. Incongruent affect
b. Blocking
c. Perseveration
d. Tangentiality
e. Thought insertion
 Evaluation, Assessment, and Diagnosis 15

41. A 26-year-old woman with panic disorder notes that during the mid-
dle of one of her attacks she feels as if she is disconnected from the world,
as though it were unreal or distant. Which of the following terms best
describes this symptom?
a. Dulled perception
b. Illusion
c. Retardation of thought
d. Depersonalization
e. Derealization

42. A patient with a chronic psychotic disorder is convinced that she has
caused a recent earthquake because she was bored and wishing for some-
thing exciting to occur. Which of the following symptoms most closely
describes this patient’s thoughts?
a. Thought broadcasting
b. Magical thinking
c. Echolalia
d. Nihilism
e. Obsession

43. A 43-year-old man tells his psychiatrist that he is spending several

hours in the morning checking all the light switches to make sure they are
off. He states that if he does not do this, he is overcome with anxiety. This
is an example of which of the following symptoms?
a. Catalepsy
b. Compulsions
c. Magical thinking
d. Anhedonia
e. Folie à deux

44. A 45-year-old man with a chronic psychotic disorder is interviewed

after being admitted to a psychiatric unit. He mimics the examiner’s body
posture and movements during the interview. Which of the following
terms best characterizes this patient’s symptom?
a. Folie à deux
b. Dereistic thinking
c. Echolalia
d. Echopraxia
e. Fugue
16 Psychiatry

DIRECTIONS: Each group of questions below consists of lettered

options followed by a set of numbered items. For each numbered item,
select the one lettered option with which it is most closely associated. Each
lettered option may be used once, more than once, or not at all.

Questions 45–47
Match the patient’s symptoms with the most appropriate diagnostic
axis.
a. Axis I
b. Axis II
c. Axis III
d. Axis IV
e. Axis V

45. A 32-year-old man complains of depressed mood, poor concentration,

a 25-lb weight gain, and hypersomnia. He is subsequently diagnosed with
hypothyroidism.

46. A 46-year-old college professor has been unable to go to work for the
past six weeks because of his psychiatric symptoms.

47. A 23-year-old woman works in a sheltered workshop. She is unable to

make change for a dollar or read beyond a second-grade level. She has a
genetic makeup of 47 chromosomes with three copies of chromosome 21.
Evaluation, Assessment,
and Diagnosis
Answers
1. The answer is d. (Kaplan, pp 252, 285.) An idea of reference is the
belief that an object, event, or person in one’s environment (commonly
the television or radio) has particular personal significance. A delusion is
a fixed, false belief, and a grandiose delusion has a theme that attributes
special powers or talents to the delusional person. An illusion is the mis-
perception or misinterpretation of real external sensory stimuli. A loose
association describes a disturbance in the continuity of thought in which
ideas expressed do not seem to be logically related. Clouding of con-
sciousness refers to an overall reduced awareness of the surrounding
environment.

2. The answer is b. (Kaplan, pp 252, 282.) Circumstantiality indicates the

loss of a goal-directed thought process: the patient brings in many irrele-
vant details and comments, but eventually will get back to the point. A
neologism is a fabricated word made up by the patient, which is usually a
combination of existing words. Perseveration, often associated with cogni-
tive disorders, refers to a response that persists even after a new stimulus
has been introduced—for example, a patient asked to repeat the phrase “no
ifs, ands, or buts” responds by saying, “no ifs, ifs, ifs, ifs.” Flight of ideas is
a disorder of thinking in which the patient expresses thoughts very rapidly,
with constant shifting from one idea to another, though the ideas are often
connected.

3. The answer is a. (Kaplan, pp 252, 283, 665.) A delusion is a fixed, false

belief that is not in keeping with a patient’s cultural background. The per-
ceptual misrepresentation of a real sensory image is an illusion. The per-
ceptual representation of a sound or an image that is not actually present is
a hallucination. A pathological self-preoccupation is the definition of ego-
mania. A dissociative fugue is a state in which patients travel away from
their homes or work and assume new identities or occupations while for-
getting important aspects and details of their former lives.

17

Copyright © 2006 by The McGraw-Hill Companies, Inc. Click here for terms of use.
18 Psychiatry

4. The answer is b. (Kaplan, pp 264–266. Stoudemire, pp 137–138.) An

MRI may be helpful in ruling out organic causes of an apparent dementia,
especially tumors or subcortical arteriosclerotic encephalopathy. An EEG is
not sensitive for detecting dementia—it is often normal in the early and
middle stages. (It is, however, quite sensitive for detecting delirium.) Very
low or high serum glucose levels can be associated with delirium, and
hypoglycemia is also associated with panic attacks, anxiety, and depression,
but not dementia. Serum amylase may be increased in bulimia nervosa.
Increased urine myoglobin is seen in neuroleptic malignant syndrome, in a
variety of drug intoxications, and in patients in restraints.

5. The answer is c. (Kaplan, pp 220, 282–284.) An illusion is the misper-

ception or misinterpretation of a real sensory stimulus, as opposed to a hal-
lucination, which is a false sensory perception unrelated to any real sensory
stimulus. A delusion is a fixed, false belief that is unrelated to a patient’s
intelligence or cultural background. By definition, a delusion cannot be
corrected with the use of logic or reasoning. Projection is a defense mech-
anism in which the patient reacts to an inner unacceptable impulse as if it
were outside the self—for example, a paranoid patient reacts to others as if
they were going to hurt him. This is because the patient’s unacceptable hos-
tile impulses are projected onto others, and the patient reacts as if the
others have hostile impulses of their own toward the patient. Synesthesia is
a sensation or hallucination caused by another sensation (for example, a
visual sensation triggers the hallucination of an auditory sensation).

6. The answer is d. (Ebert, pp 546–556.) Patients diagnosed with Rett’s

disorder have normal prenatal and postnatal development, but between
the ages of 5 and 30 months they begin to lose previously acquired
purposeful hand skills and develop stereotyped hand movements (hand-
wringing or hand washing) and poorly coordinated gait or trunk move-
ments. These patients have severe to profound mental retardation and
severe receptive and expressive language deficits. They also lose all inter-
est in social interaction. Characteristically, head circumference is normal
at birth, but between five months and four years of age, the rate of the
head growth decelerates rapidly. Rett’s disorder has been described only in
females and is very rare.

7. The answer is d. (Ebert, pp 197–202.) The diagnostic criteria for delir-

ium include a disturbance of consciousness (i.e., this woman’s decreased
 Evaluation, Assessment, and Diagnosis Answers 19

arousal) and a change in cognition (i.e., the sudden appearance of paranoia

in this woman). The disturbance must develop over a short period of time
and tends to fluctuate over the course of a day. There also must be evidence
that the disturbance is caused by the direct physiological consequence of a
general medical condition, which must be assumed in this case. Since no
prior history of a mental disorder was given, and the disturbance was not
present immediately upon admission, it is unlikely the patient has an
emerging dementia or is experiencing an acute manic episode. Since the
patient’s consciousness is waxing and waning, it is also unlikely that she is
experiencing either a brief psychotic episode or an acute stress reaction.

8. The answer is d. (Kaplan, pp 250–254.) Orientation refers to the state

of awareness of the individual as to time and place, and to the awareness of
the identity of oneself and others in the environment. This is the reason
patients’ cognitive states are often referred to as “oriented × 3,” meaning
oriented to person, place, and time.

9. The answer is b. (Kaplan, p 775.) The essential feature of obsessive-

compulsive personality disorder is a preoccupation with perfection, order-
liness, and control. Individuals with this disorder lose the main point of an
activity and miss deadlines because they pay too much attention to rules
and details and are not satisfied with anything less than “perfection.” As in
other personality disorders, symptoms are ego-syntonic and create inter-
personal, social, and occupational difficulties. Obsessive-compulsive disor-
der is differentiated from obsessive-compulsive personality disorder by the
presence of obsessions and compulsions. In addition, patients with symp-
toms of obsessive-compulsive disorder view them as ego-dystonic. Patients
with borderline personality disorder present with a history of pervasive
instability of mood, relationships, and self-image beginning by early adult-
hood. Their behavior is often impulsive and self-damaging. Patients with
bipolar disorder present with problems of mood stability; mood may be
depressed for several weeks at a time, then euphoric. Patients with an anx-
iety disorder not otherwise specified present with anxiety as a main symp-
tom, though they do not specifically fit any other, more specific anxiety
disorder as per DSM-IV-TR.

10. The answer is b. (Ebert, p. 351.) The essential features of obsessive-

compulsive disorder are obsessions (recurrent and persistent thoughts that
20 Psychiatry

are experienced as intrusive and inappropriate and that cause anxiety) and
compulsions (repetitive behaviors that the person feels driven to perform).
In this disorder, the patient’s symptoms are ego-dystonic to him/her, unlike
the person with an obsessive-compulsive personality disorder. Patients
with attention deficit hyperactivity disorder have problems with inatten-
tion, hyperactivity, and/or impulsivity. Patients with separation anxiety dis-
order worry about losing or harming major attachment figures and become
anxious when separation from home or those major figures is anticipated.
Patients with brief psychotic disorder show evidence of either delusions or
hallucinations for a short period of time, usually after exposure to some
external stressor.

11–15. The answers are 11-a, 12-c, 13-f, 14-h, 15-b. (Kaplan, pp
504–508, 596–597, 623–627, 654–659, 782–783.) Patients with panic disor-
der experience anxiety attacks in a more or less random pattern, with no
precipitating factors of which the patient is aware. Patients are often quite
afraid of another attack and will constrict their daily activities to avoid re-
creating the environment in which the attack first occurred. It is quite com-
mon for them to fear that they are dying or losing their minds during these
attacks as well.
Patients with schizoid personality disorder are notable in that their
symptoms (social isolation, inability to connect emotionally with others,
tendency to daydream) are ego-syntonic—that is, they do not cause a prob-
lem for the patient and are not seen as such. These patients may have very
few social connections, and unlike patients with avoidant personality dis-
order, they do not seem to miss the contact.
Patients with factitious disorder are trying to achieve the role of a per-
son with an illness (usually physical) so that they may be cared for by the
health care system. This constitutes primary gain, in that there is usually
nothing they are trying to avoid by adopting the sick role (as opposed to
the secondary gain of malingering, whereby a patient might enter the hos-
pital, for example, to avoid being arrested by the police). Patients often will
have undergone a series of medical procedures, and it is not unusual to find
a history of a family member (or the patient himself/herself) being involved
in a medical field as a line of work.
Schizophreniform disorder is best thought of as a schizophrenia-like
illness that simply has not been manifested for long enough to be called
schizophrenia (six months is the cutoff point between the two). Psychotic
 Evaluation, Assessment, and Diagnosis Answers 21

symptoms such as auditory or visual hallucinations are common, as is a

premorbid history of being “weird” or a “loner.”
Generalized anxiety disorder is identified by the fact that the patient
has multiple worries, not just one or two. For example, the patient in ques-
tion 15 is not worried just about having an anxiety attack, or about the
health of her daughter, or about the war in Iraq. She is worried about a
number of different scenarios, and they are not all related.

16. The answer is b. (Kaplan, pp 251–252.) Patients who present with

concrete thinking have lost the ability to form abstract concepts, such as
metaphors, and focus instead on actual things and facts. Concrete thinking
is the norm in children and is seen in cognitive disorders (mental retarda-
tion, dementia) and schizophrenia.

17. The answer is e. (Kaplan, p 481.) Hearing voices for seven months,
having ideas of reference, and displaying concrete abstract interpretation
on exam all point to a likely diagnosis of schizophrenia. Key features of
schizophrenia include at least two psychotic symptoms (hallucinations,
delusions, evidence of a thought disorder, disorganized or catatonic behav-
ior, or negative symptoms) present for at least one month; impairment in
social or occupational functioning; duration of at least six months; symp-
toms not due to either a mood disorder or a medical or substance-induced
disorder. Schizophreniform patients must fulfill all the same criteria except
that the duration of illness is less than six months.

18. The answer is a. (Ebert, p 216.) Multiple cerebral infarcts cause a pro-
gressive dementia (usually described as stepwise), focal neurological signs,
and often neuropsychiatric symptoms such as depression, mood lability
(but usually not elated mood), and delusions. Loose associations, catatonic
posturing, and bizarre proverb interpretations occurring with affective
symptoms are typical of schizoaffective disorder. In delirium, one would
expect to see the waxing and waning of consciousness over time, including
problems with orientation to person, place, and time.

19. The answer is c. (Stoudemire, p 707.) Males have a higher risk of com-
pleted suicide than do females (though females attempt suicide more fre-
quently). People who commit suicide usually talk about their intent with
others before going ahead with their plans. People over 45 are at higher
22 Psychiatry

risk than younger people. Good health lowers the risk for suicide, and poor
health increases it. People who live with others or are married are less at
risk of committing suicide than people who live alone.

20. The answer is c. (Kaplan, pp 1148–1151.) The diagnosis of mental

retardation is made after a history, IQ test, and measures of adaptive func-
tioning indicate that the behavior is significantly below the level expected.
An EEG is rarely helpful except for those patients who have grand mal
seizures. Although mentally retarded individuals may often present with
hearing deficits, and in some instances hearing loss can mimic mental
retardation, it is unlikely that this issue would not have been picked up by
the age of six. Metabolic disorders can cause mental retardation, but a CBC
would be unlikely to pick this up. A lumbar puncture would be helpful
only if the physician believed these symptoms to be secondary to an infec-
tious process—unlikely, given the time course.

21. The answer is d. (Ebert, p 262.) The voluntary assumption of an inap-

propriate or bizarre posture for long periods of time is called catatonic pos-
turing and is usually seen in schizophrenia, especially of the catatonic type.
In catatonic posturing, patients resist attempts to make them change posi-
tion (this is also called negativism). A similar symptom, waxy flexibility,
refers to patients who maintain the body position into which they are
placed. Apraxia refers to the inability to perform voluntary motor activity
although there are no motor or sensory deficits. Dystonia refers to the pro-
tracted contraction of a group of muscles. In synesthesia, the stimulation of
one sensory modality produces a sensation belonging to another sensory
modality (e.g., a color is perceived as a smell). Trance is a sleeplike condi-
tion characterized by a reduced state of consciousness.

22. The answer is a. (Ebert, p 262.) Although Parkinson’s disease, neu-

roleptic malignant syndrome, and Huntington’s disease can all present with
motor abnormalities, schizophrenia is the only choice in this question that
may present with catatonia.

23. The answer is c. (Ebert, p 113.) Countertransference is the name given

to the analyst’s or psychotherapist’s transference response to the patient.
As with patients’ transference, the particular form the countertransference
takes depends on the therapist’s past experiences, relationships, and unre-
 Evaluation, Assessment, and Diagnosis Answers 23

solved conflicts. As with transference, countertransference is not limited to

the patient-therapist relationship, but may be present in any relationship. By
analyzing his or her countertransference toward the patient, the therapist
may acquire useful insight into the patient’s dynamics and his or her own.
Consequently, even negative countertransference feelings can be helpful
tools in the psychotherapy process. Reaction formation, projection, and
identification with the aggressor are unconscious defense mechanisms. An
illusion is a perceptual misinterpretation of a real stimulus.

24. The answer is d. (Ebert, p 261.) A hallucination is the perception of

a stimulus when no sensory stimulus is, in fact, present. Hallucinations
can be auditory, visual, tactile, gustatory, olfactory, or kinesthetic (body
movements). Auditory hallucinations are most commonly associated with
psychotic illness, whereas visual, tactile, gustatory, and olfactory hallucina-
tions often are associated with neurologic disorders. Concrete thinking is
the inability to form abstract concepts, such as metaphors, and to focus
instead on actual things and facts. Depersonalization is the subjective sen-
sation of the self being disconnected from the world, unreal, or distant.
Flight of ideas is a thought process in which consecutive thoughts, while
related to some degree, are sequentially tangential. An idea of reference is
the belief that something in the environment (commonly the TV or radio)
is giving the person special messages meant only for him or her.

25. The answer is b. (Kaplan, p 286.) The capacity to generalize and to

formulate concepts is called abstract thinking. The inability to abstract is
called concreteness and is seen in organic disorders and sometimes in
schizophrenia. Abstract thinking is commonly assessed by testing similari-
ties, differences, and the meaning of proverbs. Intellectualization, rational-
ization, and isolation of affect are all unconscious defenses.

26. The answer is d. (Kaplan, p 323.) The patient’s persecutory delusions

and disorganized thinking could suggest a psychotic disorder such as
schizophrenia or brief reactive psychosis, but fluctuations in consciousness
and disorientation are typically found in delirium. Memory, language, and
sleep-wake cycle disturbances are also typical of delirium. Delusions, hal-
lucinations, illusions, and misperceptions are also common. The causes of
delirium are many and include metabolic encephalopathies (including
fever and hypoxia, as in the patient in the question), intoxications with
24 Psychiatry

drugs and poisons, withdrawal syndromes, head trauma, epilepsy, neo-

plasms, vascular disorders, allergic reactions, and injuries caused by phys-
ical agents (heat, cold, radiation).

27. The answer is e. (Ebert, p 514.) Huntington’s disease is a progressive

neurodegenerative disorder, inherited as an autosomal dominant trait, that
usually manifests between 35 and 40 years of age. Affected individuals
present with a progressive dementia, choreoathetoid movements, and, often,
psychiatric symptoms. Computed tomography (CT) scan and nuclear MRI
demonstrate gross atrophy of the putamen and the caudate.

28. The answer is a. (Ebert, p 514.) The woman is suffering from

hypothyroidism, which frequently presents with mood symptomatology
(often depression). The psychiatric picture of hypothyroidism is character-
ized by lethargy, mental sluggishness, and cognitive slowing. Typical phys-
ical signs and symptoms of the illness include dry skin, slow reflexes,
bradycardia, nonpitting edema over the face and limbs, hair loss, and men-
strual changes. Rarely, gross psychosis (myxedema madness) may also be
seen, in addition to the cognitive and depressive features of the disease. It
is therefore essential to test the thyroid function of patients presenting with
a depressed mood.

29. The answer is d. (Stoudemire, p 137.) The patient has HIV-associated

dementia, a disorder caused by the direct toxic effect of HIV on the brain.
A CD4 count below 200 is usually associated with HIV dementia, since this
disorder typically occurs in the more advanced stages of AIDS. More rarely,
cognitive impairments may be the first manifestation of HIV infection.

30. The answer is a. (Stoudemire, p 27.) The woman has nonepileptic

seizures, a form of conversion disorder. Nonepileptic seizures can often be
differentiated from epileptic episodes by the presence of unusual and wild
movements and vocalizations, a lack of postictal confusion, and an associ-
ation with a psychosocial stressor. Sometimes the diagnosis can be made
only by documenting that the behavioral manifestations of the seizure are
not accompanied by epileptic activity on the EEG.

31. The answer is d. (Ebert, p 475.) Individuals with borderline person-

ality disorder characteristically form intense but very unstable relation-
 Evaluation, Assessment, and Diagnosis Answers 25

ships. Since they tend to perceive themselves and others as either totally
bad or perfectly good, borderline individuals either idealize or devalue any
person who occupies a significant place in their lives. Usually these per-
ceptions do not last, and the person idealized one day can be seen as com-
pletely negative the next day.

32. The answer is c. (Ebert, p 307.) Dysthymic disorder is characterized

by a depressed mood for most of the day, for more days than not, for at least
two years. While the effects of this mood disorder can be severe, including
poor appetite, insomnia, low energy, fatigue, poor concentration, and
hopelessness, the symptoms are not severe enough to meet the criteria for
a major depression.

33. The answer is b. (Ebert, p 161.) Conversion disorder is characterized

by the sudden appearance of often dramatic neurological symptoms that
are not associated with the usual diagnostic signs and test results expected
for the symptoms being presented. Conversion disorder occurs in the con-
text of a psychosocial stressor or an insoluble interpersonal or intrapsychic
conflict. The psychological distress is not consciously acknowledged, but it
is expressed through a metaphorical body dysfunction. In this example, the
man who is torn between his duty to his mother and his intense anger at
her resolved his impulse to hit her by developing a physical paralysis of his
right arm.

34. The answer is e. (Ebert, p 334.) A social phobia is a persistent and

overwhelming fear of humiliation or embarrassment in social or perfor-
mance situations. This leads to high levels of distress and avoidance of
those situations. Often, physical symptoms of anxiety such as blushing,
trembling, sweating, or tachycardia are triggered when the patient feels
under evaluation or scrutiny.

35. The answer is c. (Ebert, p 373.) An extreme feeling of dislike for a part
of the body in spite of a normal or nearly normal appearance is the main
characteristic of body dysmorphic disorder. The fear of being ugly or repul-
sive is not decreased by reassurance and compliments and has almost a
delusional quality. The social, academic, and occupational lives of individ-
uals with this disorder are greatly affected, due to avoidance of social inter-
actions for fear of embarrassment, the time spent in checking mirrors and
26 Psychiatry

seeking surgical treatment or cosmetic remedies, and the chronic emo-

tional distress that accompanies the disorder.

36. The answer is a. (Kaplan, p 174.) Prevalence refers to the portion of

the population that has a specific disorder at a specific point in time, regard-
less of when the disorder started. The point in time may be a date (point
prevalence), a given time span (e.g., six months), or the entire life of an indi-
vidual (life prevalence). The incidence of a disease refers to a rate that
includes only those people who develop the disease during a specific period
of time (usually one year). Validity refers to the accuracy and verifiability of
a study. It is usually demonstrated by agreement between two attempts to
measure the same issue by different methods. Reliability refers to the chance
that the same experiment, done again, would have the same result; thus, the
higher the reliability reported, the better. Relative risk is the ratio of the inci-
dence of a disease among people exposed to the risk factor to the incidence
among those not exposed. For example, the relative risk of lung cancer is
much greater for heavy smokers than for nonsmokers.

37. The answer is c. (Kaplan, p 175.) Sensitivity is defined as the number

of true positives divided by the sum of the number of true positives and
false negatives. It is the proportion of patients with the condition in ques-
tion that the test can detect. Thus, if the sensitivity is only 64%, the num-
ber of false negatives will most likely be unacceptably high.

38. The answer is d. (Ebert, p 106.) Perseveration and circumstantiality

are forms of thought disorder. In perseveration, the patient displays an
inability to change the topic or gives the same response to different ques-
tions. Circumstantiality is a disturbance in which the patient digresses into
unnecessary details before communicating the central idea. The capacity to
generalize and to formulate concepts is called abstract thinking. The inabil-
ity to abstract is called concreteness and is seen in organic disorders and
sometimes in schizophrenia. Abstract thinking is commonly assessed by
testing similarities, differences, and the meaning of proverbs. Negative
symptoms include amotivation, apathy, and social withdrawal. These
symptoms are often seen in schizophrenia.

39. The answer is c. (Ebert, p 106.) Tangentiality, circumstantiality, flight

of ideas, and looseness of associations are forms of thought disorder. Cir-
 Evaluation, Assessment, and Diagnosis Answers 27

cumstantiality is a disturbance in which the patient digresses into unneces-

sary details before communicating the central idea. Tangentiality is present
when the patient wanders and digresses to unnecessary details and the
substance of the idea is not communicated. In flight of ideas, there are
rapid, continuous verbalizations or plays on words that produce constant
shifting from one idea to another. Ideas tend to be connected. In looseness
of associations, the flow of thought is disconnected—ideas shift from one
subject to another in a completely unrelated way.

40. The answer is b. (Ebert, p 106.) In blocking, the patient suddenly

stops talking, usually in the middle of a sentence, and cannot complete his
or her thoughts. Affect is said to be incongruent when what is observed by
the examiner (affect) does not match the subjective statement of how the
patient feels (mood). Perseveration is a form of thought disorder in which
the patient displays an inability to change the topic or gives the same
response to different questions. Thought insertion refers to the patient’s
idea that some thought content is being inserted directly into the patient’s
mind.

41. The answer is e. (Ebert, p 107.) Derealization is the subjective sense

that the environment is strange or unreal, as if reality had been changed.
Perception is a physical sensation given a meaning or the integration of
sensory stimuli to form an image or impression; in dulled perception, this
capacity is diminished. Retardation of thought refers to the slowing of
thought processes that may be seen in major depression. Response time to
questions may be increased. Depersonalization refers to feeling that one is
falling apart or not one’s self, that one’s self is unreal or detached.

42. The answer is b. (Kaplan, p 282.) Magical thinking is a form of think-

ing similar to that of preoperational phase children (Jean Piaget) in which
thoughts and ideas are believed to have special powers (for example, to
cause or stop outside events). In thought broadcasting, the patient senses
that his or her thoughts are being stolen, are leaking out of the mind, or are
being sent out to others across radio or television. Echolalia refers to the
repetition of the examiner’s words or phrases by the patient. Nihilism is the
belief that oneself, others, or the world are either nonexistent or are com-
ing to an end. An obsession is the ego-dystonic persistence of a thought or
feeling that cannot be eliminated from consciousness voluntarily.
28 Psychiatry

43. The answer is b. (Goldman, p 111.) A compulsion is the need to act

on an impulse (often an obsession) that is accompanied by anxiety if the
impulse is resisted. Often the compulsion has no end in itself, other than to
prevent something from occurring in the future. Catalepsy is the general
term for an immobile position that is constantly maintained. Magical
thinking is a form of thinking similar to that of preoperational phase chil-
dren (Jean Piaget) in which thoughts and ideas are believed to have special
powers (for example, to cause or stop outside events). Anhedonia, which
occurs frequently in major depressive disorders, is the lack of enjoyment or
interest in outside pursuits or hobbies previously enjoyed. Folie à deux is a
shared psychotic (delusional) belief held by two people.

44. The answer is d. (Goldman, p 112.) Echopraxia is the mimicking of

the examiner’s body posture and movements by the patient. This can be
seen in chronic schizophrenia. Folie à deux is a shared psychotic (delu-
sional) belief held by two people. Dereistic thinking is a thought activity
not concordant with logic or experience. Echolalia refers to the repetition
of the examiner’s words or phrases by the patient. Fugue is the taking on of
a new identity with no memory of the old one. It often involves travel to a
new environment.

45–47. The answers are 45-c, 46-e, 47-b. (Goldman, p 175.) Axis I is the
place to record all primary psychiatric disorders other than mental retarda-
tion or personality disorders, which are recorded on Axis II. Axis III is
where medical conditions of all kinds, whether or not they are related to
the primary psychiatric diagnosis, are recorded. Axis IV is the place to
record stressors that are occurring in the patient’s life—including social,
legal, or financial situations. Axis V records the global assessment of func-
tioning, on a scale of 0 to 100.
 Human Behavior:
Theories of Personality
and Development
Questions
DIRECTIONS: Each item below contains a question followed by sug-
gested responses. Select the one best response to each question.

48. A 6-month-old male infant is noted by his mother to be difficult to

care for. He is very difficult to feed or soothe, and often responds to cud-
dling by crying and becoming rigid in his mother’s arms. Physical exami-
nation and laboratory work are all entirely normal. Which of the following
psychiatric disorders is this infant at a higher risk to display in his early
school years?
a. Conduct disorder
b. Childhood schizophrenia
c. Separation anxiety disorder
d. Antisocial personality disorder
e. Pica

49. A 2-year-old girl is being toilet trained by her parents. Each time she
soils her diaper, she is told that she is a very bad girl and she is punished
by having a toy taken away. When she uses the toilet appropriately, she is
not praised by her parents. Which of the following sequelae is the child
likely to experience as a result of this kind of parental behavior?
a. A basic sense of mistrust
b. Shame and self-doubt
c. Guilt
d. Stagnation of her development
e. An absence of intimacy as an adult

29

Copyright © 2006 by The McGraw-Hill Companies, Inc. Click here for terms of use.
30 Psychiatry

50. A 20-month-old boy loves running around and exploring the environ-
ment, but every few minutes he returns to his mother to check on her and
solicit a quick hug. Which of the following best describes this behavior,
according to Margaret Mahler?
a. Depressive position
b. Secure attachment
c. Insecure attachment
d. Rapprochement
e. Autonomy, versus shame and doubt

51. Margaret Mahler is best known for which of the following theories?
a. Psychosocial development
b. Psychosexual maturation
c. Cognitive development
d. Moral development
e. Separation-individuation

52. Which of the following theorists focused primarily on the importance

of early parental behavior, such as mirroring, leading to the development of
a cohesive and stable sense of self?
a. Piaget
b. Erikson
c. Freud
d. Klein
e. Kohut

53. Piaget is best known for which of the following theories?

a. Cognitive development
b. Psychosexual development
c. Psychosocial development
d. Interpersonal development
e. Attachment
 Human Behavior: Theories of Personality and Development 31

54. A 2-year-old child carries around an old, tattered blanket wherever he

goes. When he is sad or upset, he calms himself by hugging and stroking
his blanket. He also needs it to settle down before sleep. For this child,
which of the following does his blanket represent?
a. Fetish
b. Obsession
c. Transitional object
d. Phallic substitute
e. Imaginary friend

55. A 30-year-old man comes to the psychiatrist because he is worried

that “the life I have chosen may not be the life I want.” He states that he is
married and has one child and works as an accountant. He notes that he
wishes he had pursued some of his earlier interests, such as playing the gui-
tar. He wonders if he married the “right woman” and becomes anxious as
he talks about raising his 18-month-old child. He notes that he has felt
mildly anxious and depressed about these topics, but not severely so.
Which of the following actions should the psychiatrist take?
a. Start the patient on an antidepressant
b. Tell the patient he is a likely candidate for psychoanalysis
c. Tell the patient that he is having a crisis of middle adulthood
d. Tell the patient that he is in the Ericksonian stage of generativity versus despair
e. Reassure the patient that this developmental stage is a normal, if painful, one.

56. A 32-year-old woman is given the news by her physician that she has
breast cancer and will need surgery, followed by chemotherapy. She returns
home after the appointment, and her husband asks how the visit went. She
tells him that “everything was fine.” For the rest of the evening, she behaves
as if there has been no bad news given to her. In fact, she appears to be in
good spirits. Which of the following defense mechanisms is likely being
employed by this woman?
a. Denial
b. Projection
c. Sublimation
d. Reaction formation
e. Altruism
32 Psychiatry

57. A 3-year-old boy stands on one side of a large sculpture and is asked
to describe what he sees. When asked to describe what a person on the
other side of the sculpture sees, the child answers that the other person
sees just what he does. Which of the following theories uses the concept
described above?
a. Psychosexual development
b. Moral development
c. Cognitive development
d. Social development
e. Autism

58. A 70-year-old woman is admitted to the hospital after a fall in which

she broke her left hip. She is a difficult patient during her rehabilitation
phase, passively resisting attempts to get her up and walking, contending
that it does not matter whether she regains her capacity to walk on her own
since she is so advanced in age. She states that while she is fearful of dying,
she feels disgust at her own body because it is “falling apart.” Which of the
following Eriksonian states is this patient working through?
a. Integrity versus despair
b. Intimacy versus isolation
c. Generativity versus stagnation
d. Identity versus role diffusion
e. Industry versus inferiority

59. Which of the following statements is true about temperament?

a. It is biologically determined
b. It is unchangeable throughout life
c. It is always caused by poor parenting
d. Children with temperaments that are slow to warm up cannot be taught to be
less fearful of change
e. It is a synonym for personality
 Human Behavior: Theories of Personality and Development 33

60. A young woman with a history of childhood neglect feels suddenly

worthless and devastated when her supervisor makes a mildly negative
comment about her work performance. According to Heinz Kohut, which
of the following explanations accounts for her hypersensitivity to criticism?
a. An unresolved oedipal complex due to her parents’ divorce when the woman
was 4 years old
b. An inability to make stable commitments to others
c. A punitive superego due to harsh and critical parents
d. A fragmented sense of self due to the empathic failure of her parents
e. Autistic traits

61. Carl Jung, a psychoanalyst who once was a disciple of Freud, devel-
oped the concept of archetypes. Which of the following statements best
defines an archetype?
a. Unconscious traits possessed by humans
b. Representational images and configurations with universal symbolic meanings
c. Feeling-tones—ideas that develop as a result of personal experience
d. A process by which people develop a unique sense of their own identity
e. An inner world of thoughts, intuitions, emotions, and sensations

62. A 23-year-old woman constantly goes to great lengths to avoid being

criticized, even when this requires going against her own beliefs and wishes.
Although she is good-looking and successful, she is tormented by doubts
about her abilities and her physical appearance. According to Kohutian the-
ory, which of the following is the most likely to explain her behavior?
a. Overly harsh toilet training when she was 3 years old
b. Overindulgent parents who freely dispensed praise
c. A lack of self-esteem, which causes a constant need for validation
d. An overly punitive superego
e. A shy temperament
34 Psychiatry

63. A 16-year-old boy is diagnosed with osteosarcoma. Surgery and

chemotherapy are not successful as treatments, and it is apparent that the
child will die from his disease. The child, rather than focusing on his death,
seems more concerned with the fact that he has lost all his hair from the
chemotherapy. He is difficult to work with in the hospital, as he insists on
seeing visitors only when he chooses to and wants to work with only his
favorite nurses. Which of the following is the best explanation for his
behavior?
a. He is regressing under the stress of his terminal illness
b. He is an adolescent and these responses are quite typical for the age group
c. He has developed a major depression
d. He is in denial of his impending death
e. He is having a cognitive disturbance secondary to brain metastases

64. A 23-year old man impulsively steals a pack of gum at a convenience

store. He has never stolen anything previously, and almost immediately
upon exiting the store with the gum, he begins to feel extremely guilty.
Which of the following concepts introduced by Freud is most likely
responsible for this man’s emotional response to his theft?
a. Id
b. Ego
c. Superego
d. Preconscious function
e. Conscious function

65. A 20-month-old girl is admitted to a pediatric ward because she

weighs only 15 lb. An extensive medical work-up does not reveal any
organic cause for the child’s failure to thrive. The child is listless and apa-
thetic and does not smile. The parents rarely come to visit, and when they
do, they do not pick the child up and do not play or interact with her.
Which of the following statements best explains this scenario?
a. Lack of adequate emotional nurturance causes depression and failure to thrive
in infants
b. Neglected infants fail to thrive but do not have the intrapsychic structures nec-
essary for experiencing depression
c. Infants reared in institutions are likely to become autistic
d. Neglected infants are at higher risk for developing schizophrenia
e. Environmental variables have little impact on the health of infants as long as
enough food is provided
 Human Behavior: Theories of Personality and Development 35

66. A 25-year-old woman sees a psychiatrist for a chief complaint of hav-

ing a depressed mood for her “entire life.” She begins psychotherapy and
sees the physician once per week. After three months of therapy, she tells
the psychiatrist that she is very afraid of him because he is “so angry all the
time.” She behaves as if this is true and that the psychiatrist will explode
with rage at any minute. The psychiatrist is not normally seen as an angry
person and is unaware of any anger toward the patient. Which of the fol-
lowing defense mechanisms is this patient likely displaying?
a. Distortion
b. Blocking
c. Isolation
d. Projection
e. Dissociation

Questions 67–68

67. A healthy 9-month-old girl is brought to her pediatrician by her con-

cerned parents. Previously very friendly with everyone, she now bursts
into tears when she is approached by an unfamiliar adult. Which of the fol-
lowing best describes this child’s behavior?
a. Separation anxiety
b. Insecure attachment
c. Simple phobia
d. Depressive position
e. Stranger anxiety

68. A mother calls her pediatrician to discuss her concerns about her
nine-month-old daughter’s separation anxiety. Which of the following is
true about this kind of behavior?
a. It is common in normal infants
b. It is always a symptom of insecure attachment
c. It is present only in children who will subsequently develop anxiety disorders
d. It is likely to persist if it is not adequately treated
e. It is a symptom of pervasive developmental disorder
36 Psychiatry

69. A 25-month-old boy plays with a ball, which rolls under a couch. The
boy promptly crawls under the couch to retrieve the ball. According to
Piaget’s theories of cognitive development, which thinking process best
describes this child’s behavior?
a. Object permanence
b. Basic trust
c. Initiative versus guilt
d. Object constancy
e. Sensorimotor stage

70. According to Sigmund Freud, which of the following best describes

primary processes?
a. Typically conscious
b. Nonlogical and primitive
c. Absent during dreaming
d. Characteristic of the neuroses
e. Rational and well-organized

71. Harry Stack Sullivan’s theory of personality development is character-

ized by which of the following emphases?
a. Psychosexual development
b. Genetic determinism
c. Infant-mother interaction
d. Interpersonal relations
e. Object relations

72. Erikson’s developmental theories differ from Freud’s in that Erikson

placed greater emphasis on which of the following?
a. Cultural factors in development
b. Instinctual drives
c. Interpersonal relations
d. Psychosexual development
e. Object relations
 Human Behavior: Theories of Personality and Development 37

73. A woman has a verbal altercation with her boss at work. She meekly
accepts his harsh words. That night, she picks a fight with her husband.
Which of the following defense mechanisms is being used by this woman?
a. Displacement
b. Acting out
c. Reaction formation
d. Projection
e. Sublimation

74. A 24-year-old woman lives with her mother, whom she intensely dis-
likes. She feels embarrassed by this, and compensates by hovering over her
mother, attending to her every need. Which of the following defense mech-
anisms is being used by this woman?
a. Displacement
b. Acting out
c. Reaction formation
d. Rationalization
e. Sublimation

75. A writer of mystery novels, who has never had legal problems, jokes
about his “dark side” and his hidden fantasies about leading an exciting
life of crime. Which of the following defense mechanisms is being used by
this man?
a. Anticipation
b. Sublimation
c. Identification with the aggressor
d. Introjection
e. Distortion

76. A 35-year-old man is being seen by his psychiatrist for depressed mood.
The patient is irritated at his therapist for pushing him on several issues in
the last session. The patient does not show up or call for his next session.
Which of the following defense mechanisms is this patient displaying?
a. Introjection
b. Sublimation
c. Identification with the aggressor
d. Acting out
e. Intellectualization
38 Psychiatry

77. A 45-year-old man accidentally crashes his car into another vehicle.
He feels extremely guilty, and in order to avoid these feelings of self-
reproach, he explains in meticulous detail to anyone listening all of the
steps leading up to his accident. Which of the following defense mecha-
nisms is this patient displaying?
a. Sublimation
b. Repression
c. Intellectualization
d. Acting out
e. Rationalization

78. A 45-year-old woman is admitted to the hospital after her son finds
her unconscious at home. She is treated for diabetic ketoacidosis and her
recovery is a difficult one, necessitating that she stay in the hospital for five
days. During this period of time, she is often angry, irrational, and demand-
ing, all of which are not her usual modes of behavior or thinking, accord-
ing to her husband. What is the most likely explanation for the change in
this woman’s behavior?
a. The fluid shifts that are occurring during the stabilization of her diabetes are
causing an organic mood disorder
b. Her fear of a newly diagnosed illness is causing her to dissociate
c. The stress of her illness and hospital stay is causing her to regress
d. She is delirious secondary to brain damage from her period of unconsciousness
e. A previously unrecognized personality disorder is coming to the fore.

79. A 38-year-old woman comes to a psychiatrist for help with the man-
agement of her obsessive-compulsive disorder. She describes an impulse
that she has frequently and that frightens her. This impulse is to murder
her three children by blowing out the pilot light on her home’s heater and
thereby blowing up her house. As a result, she finds herself checking on the
pilot light in her home at least 30 times a day. She carries a book of matches
with her during these checks so that she might immediately relight the
pilot light if she finds that it is out. Which of the following defense mecha-
nisms does this act of checking the pilot light represent?
a. Reaction formation
b. Isolation
c. Undoing
d. Denial
e. Altruism
Exploring the Variety of Random
Documents with Different Content
 VIII
ONE WOMAN

T HE WORLD will be incredulous when it is given the final

picture of the complexity and completeness of the Belgian Relief
Organization. In all the communes, all the provinces, in the capital,
for over two years, groups of Belgians have been shut in their
bureaux with figures and plans, matching needs with relief.

There must be bread and clothing for everybody, shelter for the
homeless, soup for the hungry, food boxes for prisoners in Germany,
milk for babies, special nourishment for the tubercular, orphanages
and crèches for the tiny war victims, work for the idle, some means
of secours for merchants, artists, teachers and thousands of
“ashamed poor”—665,000 idle workmen with their 1,000,000
dependents, 1,250,000 on the soupes, 53,000 babies and 200,000
children under normal health in the cantines—how much of the story
can these figures tell?
Yet the efforts of the organization have been so continuous and
comprehensive, the C. R. B. has been so steadily bringing to them
the vital foodstuffs, and holding for them the guaranty of their
freedom to act, that from the committee-rooms it has sometimes
seemed as if there were really nothing more to be done for Belgium!
But one has only to spend a few days at the other end, to get
quickly disabused of this idea! No amount of organization can truly
meet the needs of the seven and a half million people of a small
industrial country, suddenly and entirely cut off from all normal
contact with the rest of the world. Despite all the food that has been
distributed, the resistance of the people has been lowered.
Tuberculosis has seized its opportunity, and is making rapid strides. I
have visited home after home where a heartbreaking courage was
trying to cover up a losing struggle. Over and above all the
organized “Relief,” there remains an enormous task for just such
splendid women as Madame....
Madame is the wife of a lawyer, with two sons at the front. As
soon as the war broke out she organized a Red Cross center. Then
the refugees came pouring into Brussels, and she felt that among
them there must be many to whom it would be torture to be
crowded into the big relief shelters. She said little, but by the end of
August she had managed to squeeze five families in with her own.
From the day the Germans abolished the Belgian Red Cross she gave
her entire time to helping the homeless who had been in
comfortable circumstances before the war to some quiet corner
where they might wait its end. There was never any announcement
of her work, but the word spread like wildfire—many had to be
turned away daily. Then she found a big home on the Boulevard,
rather shabby inside, but conveniently arranged for suites of two or
even three rooms. Here a considerable number of families might
have space for a complete ménage; plenty of light and air, and room
to cook and sleep. Before long she was housing ninety-eight, but a
few of these were able to re-establish themselves, so when I visited
her in September, 1916, there were sixty-five. As her own funds
were limited, and fast disappearing, she had in the end to appeal to
the “Relief” to subsidize this “Home.”
On the first floor she had a little pantry-shop, where each family
received the permitted ration of bread, sugar, bacon and other
foodstuffs. One day a woman came to her, hungry. She was a widow
with two little girls, who, before the war, had earned a good salary in
the post-office. Somehow she had managed to exist for two years,
but now there was nothing left. She was given charge of the pantry
at ten cents a day. I have seen many processions of people
descending long stairways. I shall forget them. But I shall never
forget this one of the refugees from the upper floors winding down
the stairways at the shop hour, with their pathetic plates and bowls
ready for the bacon and bread that made living possible. They could,
perhaps, add vegetables and fruit, or an egg or two, to the ration to
piece out the meal. On the lowest shelf of this miniature shop were
a few dozen cans of American corn, which even yet the people have
not learned to like. Having been brought up to regard corn in all
forms as fit only for cattle and chickens, even disaster can not
convince them that it is a proper food for man!
Later we went upstairs to visit some of the apartments. They were
bright and clean, with cheery flower-pots on all the window-sills.
Every one showed a fine appreciation of what was done for him by
making the most of all he had; an attitude quite different from that
of many less used to comfort, less intelligent, who neither hesitate
to demand charity, nor to complain of what they receive. Each family
had a small, practical stove, which served for both cooking and
heating.
One family of eight was content in its two rooms. They had had a
copper shop and a pension at Dinant; were very comfortably off,
when, suddenly, Dinant was struck. All their property was in flames,
men were being shot, their own grandmother, eighty-one years old,
had her leg broken, and, terror-stricken, they fled with her up and
down hill, over rocks and through brush till they reached Namur, and
finally arrived at Brussels where they heard of Madame’s “Home.”
The grandmother, whose leg is mended but still crooked, was sitting
in front of the red geraniums at a window, knitting socks. She knits
one pair a week and receives five cents for each pair from the
clothing committee. The young girls help Madame in various ways;
the father tries to work in copper, but if he earns fifty cents a week,
considers himself lucky. The particular struggle for this family is to
get eggs for the grandmother, who can not get along on the bacon
and bread. Eggs cost ten cents each. Happily, this is a kind of
situation that “special funds” from the United States have often
relieved. Everybody was courageous, trying simply to hold on till the
terrible war should be ended and he could go back to rebuild
something on the ruins of his home.
 There was another Dinant ménage next door, but a ménage for
one. I quickly read this poor woman’s story on the walls. On one was
tacked a large picture of Dinant, beautiful, smiling, winding along
the river, as in July, 1914. Above it was the photograph of her
husband, shot in August; on the other wall a handsome son in
uniform. He was at the front. She stopt peeling her potatoes to go
over again those horrible days. They had been so well-off, so happy,
father, mother and son. When they saw their city in flames, they
were too bewildered, too terror-stricken to realize what it meant. Her
husband left to help restore a bridge—he did not return. The son
hurried to follow his King; she somehow reached Brussels.
There was a fine young chap of about fifteen, whose father had
been killed at Manceau sur Sambre. He and his mother had found
this haven, but now she was in the hospital undergoing a capital
operation. Madame was trying to arrange a special diet for her on
her return. They had been in very comfortable circumstances; now
everything was gone.
And so it was—the same story, and from all parts of Belgium. They
had come from Verviers, Aerschot, Dinant, from Termonde and Ypres
—the striking thing was the courage, the gentleness, the fine spirit
of all.
This “Home,” as I said, has now been subsidized, but along with it
Madame still carries on another admirable work entirely on her own
responsibility. Some friends help her, but she really lives from day to
day! On the ground floor of this same building she has a restaurant,
also known only as the word passes from mouth to mouth, where
any one may come for a good dinner at noon. There is no limit to
what one may pay, but the charge is a franc, or twenty cents. The
majority pay less.
It has quite the atmosphere of one of the little Paris restaurants of
the Latin quarter—two adjoining rooms bright with flowers and
colored cloths and gay china, separated from the kitchen only by
screens. It is frequented chiefly by artists and teachers, some young
girls from the shops, and a few business men. Madame does not go
from table to table as the Paris host does, greeting his guests, but
they come to her table to shake hands and chat for a minute. They
linger over their coffee—there is the general atmosphere of cheer
and bien être. And what this means in this time of gloom to the sixty
or more who gather there daily!
Young girls of the families of the refugees serve the meals. The
cook, herself a refugee, works for twenty francs a month.
I said any one might come, but that is, of course, not exact. Any
one may ask to come, but he must prove to Madame that he needs
to come. After he explains his situation, she has ways of checking up
this information and deciding herself whether the need is a real one.
The dinner consists of soup, a meat and vegetable dish, and dessert,
with beer or coffee.
I was looking over the meal tickets and noticed that while most of
them were unstamped (the one franc ones) a good number had
distinguishing marks. Then I learned that if a person was unable to
pay a franc for this meal, he might have it for fifteen or even ten
cents, and his ticket was stamped accordingly. I found one ticket
with no stamp, but with the “o” of “No” blotted out. This might be
chance, but after finding a half-dozen or more with this same ink
blot, I suspected a meaning. And the explanation revealed the spirit
of Madame’s work. “Yes,” she said, “there is a meaning. There are
some so badly off that they can pay nothing; to save them the pain
of having to look at, and to have others look at, a stamp registering
this misery, I do not stamp their tickets, but, since I must keep
count, I blot that little ‘o,’ which at once suggests ‘zero’ to me!”
Choosing at random, I found registered for one day in July, 1916:
1 dinner at 1 franc, 10 centimes.
58 dinners at 1 franc.
43 dinners at 75 centimes (15 cents).
10 dinners at 50 centimes.
4 dinners at 0.
 IX
THE CITY OF THE CARDINAL

U NQUESTIONABLY the Belgian above all others the

Germans would rid themselves of if they could, is Cardinal
Mercier. He is the exalted Prince of the Church, but in the hour of
decision, he stept swiftly down and, with a ringing call to courage,
took his place with the people. Ever since that day he has helped
them to stand united, defiant, waiting the day of liberation. Others
have been silenced by imprisonment or death, but the greatest
power has not dared to lay hands on the Cardinal. He is the voice,
not only of the Church, but of Belgium heartening her children.

Malines has her cantines and soupes and ouvroirs, all the
branches of secours necessary to a city that was one of the centers
of attack; but these are not the most interesting things about
Malines. It is above all as the city of the Cardinal that she stands
forth in this war. Her “œuvre” has been to give moral and spiritual
secours, not only to her own people, but to those of every part of
Belgium.
Since under the “occupation” the press has naturally been
“controlled,” this secours has been distributed chiefly through the
famous letters of the Cardinal sent to priests to be re-read to their
people. We remember the thrill with which the first one was read in
America. After the war there will be pilgrimages to the little room
where it was printed. I had the privilege of having it shown me by
that friend of the Cardinal who was the printer of the first letter, and
whose brother was at this time a prisoner in Germany for having
printed the second. The room was much as it had been left after the
search; books were still disarranged on their shelves, papers and
pamphlets heaped in confusion on the tables. The red seals with
which the Germans had closed the keyholes had been broken, but
their edges still remained. Standing in the midst of the disarray,
remembering that the owner had already been six months in a
German prison, and looking out on the shattered façade at the end
of the garden, I realized, at least partly, another moment of the war.
This quickening secours, then, is distributed chiefly by letter, but
continually by presence and speech in Malines itself, and occasionally
in other parts of the country. On the 21st of July, 1916, the
anniversary of the independence of Belgium, all Brussels knew that
the Cardinal was coming to celebrate high mass in Sainte Gudule.
The mass was to begin at 11 o’clock, but at 9.30 practically every
foot of standing-room in the vast cathedral was taken. In the
dimness a great sea of people waited patiently, silently, the arrival of
their leader. Occasionally a whispered question or rumor flashed
along the nave. “He has come!” “He has been prevented!” There was
a tacit understanding that there should be no demonstration—the
Cardinal himself had ordered it. Every one was trying to control
himself, and yet, as the air grew thicker, and others fought their way
into the already packed transepts, one felt that anything might
happen! Almost every person had a bit of green ribbon (color of
hope) or an ivy leaf (symbol of endurance) pinned to his coat. The
wearing of the national colors was strictly forbidden, but the national
spirit found another way: green swiftly replaced the orange, black
and red.
We all knew that this meant trouble for Brussels, and the fact that
the shops (which had all been ordered to keep open this holiday)
were carrying on a continuous comedy at the expense of the
Germans, did not help matters. Their doors were open, to be sure,
but in many, the passage was blocked by the five or six employees
who sat in stiff rows with bows of green ribbon in their buttonholes,
and indescribable expressions on their faces. In the biggest
chocolate shop, the window display was an old pail of dirty water
with a slimsy rag thrown near it. There was no person inside but the
owner, who stood beside the cash register in dramatic and defiant
attitude, smoking a pipe. There were crowds in front of the window
which displayed large photographs of the King and Queen, draped
with the American flag. Another shop had only an enormous green
bow in the window. Almost every one took some part in the play.
Not a Belgian entered a shop, and if a German was brave enough to,
he was usually made the victim of his courage. One was delighted to
serve him, but, unfortunately, peaches had advanced to ten francs
each, or something of the sort!
Finally, after an hour and a half, a priest made an announcement,
which from our distance we misunderstood. We thought he said that
the mass would be celebrated, but unfortunately not by
Monseigneur, who had been detained. A few of us worked our way,
inch by inch, to the transept door, and out into the street. There I
found an excited group running around the rear of the cathedral to
the sacristy-door, and, when I reached it, I learned the Cardinal had
just passed through.
For no particular reason I waited there, and before long the door
was partly opened by an acolyte, who was apparently expecting
some one. He saw me and agreed that I might enter if I wished, for
was I not an American to whom all Belgium is open? So I slipt in and
found room to stand just behind the altar screen where all through
the celebration I could watch the face of the Cardinal—a face at
once keen and tender, strong, fearless, devout: one could read it all
there. He was tall, thin, dominating, a heroic figure, in his gorgeous
scarlet vestments, officiating at the altar of this beautiful Gothic
cathedral.
The congregation remained silent, three or four fainting women
were carried out, that was all. Then the Cardinal mounted the pulpit
at the further end of the nave to deliver his message, the same
message he had been preaching for two years—they must hold
themselves courageous, unconquered, with stedfast faith in God and
in their final liberation. Tears were in the eyes of many, but there
was no crying out.
From the pulpit he came back to the catafalque erected in the
middle of the nave for the Belgian soldiers dead in battle. It
represented a great raised coffin, simply and beautifully draped with
Belgian flags, veiled in crêpe. Tall, flaming candles surrounded it. As
the Cardinal approached, the dignitaries of the city, who had been
occupying seats of honor below the altar, marched solemnly down
and formed a circle about the catafalque. Then the Cardinal read the
service for the dead. The dim light of the cathedral, the sea of silent
people, the memorial coffin under the flag and lighted by tall
candles, the circle of those chosen to represent the city, the sad-
faced Cardinal saying the prayers for those who had died in defense
of the flag that now covered them—was it strange that as his voice
ceased and he moved slowly toward the sacristy-door by which he
was to depart, the overwhelming tide of emotion swept barriers, and
“Vive le Roi!” “Vive Monseigneur!” echoed once more from these
ancient walls! We held our breath. Men were pressing by me
whispering, “What shall we do? We have necessity to cry out—after
two years, we must cry out!” The Cardinal went straight forward,
looking neither to the right nor the left, the tears streaming down his
cheeks.
Outside, to pass from the rear of the cathedral to the Archbishop’s
palace, he was obliged to cross the road. As I turned up this road to
go back to the main portal, the crowd came surging down, arms
outthrust, running, waving handkerchiefs and canes, pushing aside
the few helpless Belgian police, quite beyond control, and shouting
wildly now, “Vive le Roi!” and “Vive Monseigneur!” I was able to
struggle free only after the gate had closed on the Cardinal.
This was the day when in times of peace all the populace brought
wreaths to the foot of the statue erected in honor of the soldiers
who died for the independence of Belgium. The Germans had placed
guards in the square and forbidden any one to go near it. So all day
long throngs of people, a constant, steady procession marched along
the street beyond, each man lifting his hat, women often their green
parasols, as soon as they came in view of their statue. All these
things, I repeat, did not help Brussels in the matter of the
demonstration at the cathedral. And a few days later a posted notice
informed her that she had been fined 1,000,000 marks!
 But the people had seen their Cardinal—they had received their
spiritual secours—he had brought heavenly comfort to their hearts,
put new iron in their blood. They had dared to cry just once their
loyalty to him and to their King, and they laughed at the 1,000,000
marks!
 X
THE TEACHERS

O NE afternoon I happened by a communal school in another

crowded quarter of Brussels, and, tho it was vacation, and I
knew the principal had been sadly overworked for two years and
ought to be in the country, I decided to knock at the bureau to see if
he were in.

I had my answer in the corridor, where rows of unhappy mothers

and miserable fathers were waiting to see him. Inside there were
more. He was examining a little girl with a very bad eye; and I
realized why there could be no vacation for the principal!
As I sat there, I heard the noise of marching in the court below,
and when I asked what it was, he opened the window for me to see.
There were 720 children between six and fourteen years, gaily
tramping round and round under the trees, making their
“promenade” before the 4 o’clock “repas scolaire” (school children’s
repast) which the Relief Organization is now trying to furnish to each
of the 1,200,000 children in the free schools of Belgium who may
need it—incidentally at an outlay of $2,500,000 a month.
Over 8,500 children in the sixty communal schools of Brussels
proper receive this dinner. It is quite distinct from the eleven o’clock
meal furnished at the cantines for children below normal health—
they may have both—and it is served in the school building.
Naturally the school-teachers are carrying a large share in this
stupendous undertaking.
For the children, the “repas” is the great event of the day, and,
since the vacation, they gather long before the hour. One sees, too,
hundreds of little ones on the sidewalks before the Enfants Débiles
dining-rooms, as early as 8 A.M., clutching their precious cards and
waiting already for their eleven o’clock potatoes and phosphatine.
This school is also a communal soup center, tho the teachers have
nothing to do with the distribution. Every day from 2,500 to 3,000
men and women line up—worn, white enamel pitchers in one hand,
cards in the other, to receive the family ration of soup and bread.
As I passed one morning, I saw a little bare-legged girl sitting on a
doorstep opposite. Her mother had evidently left her to guard their
portion, and she sat huddled up against the tall, battered pitcher full
of steaming soup, her little arms tight about four round loaves—
which meant many brothers and sisters. The father was in the
trenches. She sat there, a slim, wistful little thing, guarding the soup
and bread, the picture of what war means to women and children.
Monsieur was particularly happy because he had just succeeded in
sending fifteen children, who very much needed to be built up, to
the seacoast for fifteen days. It is his hope to establish homes, in
the country so far as possible, which shall be limited to from thirty to
forty children.
He has continually to arrange, too, for the care of those who may
not be in truth orphans, but who belong to the thousands of
wretched little ones set adrift by the war. I saw one little boy who
had been found all alone in a most pitiful plight beside a gun, in one
of the devastated districts. If his parents are still living, no one has
yet succeeded in tracing them.
That morning an old uncle had begged Monsieur to take charge of
his nephew and niece; he had not a penny left, they must starve
unless something were done for them. Some months before, the
father had been wounded at the front, and the mother had foolishly
hurried away to try to reach him, leaving the children with her
brother. Months had gone by—he had had no word from any one—
and now he was quite at the end of his resources. And so it was with
case after case. Something must be done!
 Besides being the section kitchen and dining-room, this school has
become a social center. Every Sunday afternoon the children are
invited to gather there to have a good time. They are taught to play
games, each is given a bonbon, a simple sweet of some sort
—“nothing of the kind to encourage luxury!” They are occupied,
happy, and kept off the streets and out of homes made miserable
through lack of employment.
We see, then, that “every day” means literally every day, and we
realize how arduous is the task of the thousands of devoted teachers
who are standing between the war and those who would otherwise
be its victims.
And as they tell us over and over again that the one thing that
makes them able to stand is their confidence in the love and
sympathy of the United States, we begin to realize our responsibility.
It is not only that the wheat and cloth are essential, the
encouragement of the presence of even the few (forty to fifty)
Americans is the great necessity!
At 8.30 the next morning I visited one of the “Jardins d’Enfants”—
schools for children between two and a half and six years of age.
There were the teachers already busy in that new department of
their work—the war-food department; 460 tiny tots were being given
their first meal of the day—a cup of hot cocoa, and, during that
month, a little white bread bun. No American can understand what
this single piece of white bread means to a French or Belgian child. I
am sure that if a tempting course dinner were set at one side, and a
slice of white bread at the other, he would not hesitate to choose the
bread. It is white bread that they all beg for, tho the brown war
bread made from flour milled at 82 per cent. is really very palatable,
and superior to the war bread of other countries.
A sheaf of letters sent from a school in Lille to thank the C. R. B.
director for the improved brown (not nearly white) bread gave me
my first impression of the all-importance of the color and quality of
the bread.
 Amélie B. wrote:
“Before May 5, 1915, we had to eat black bread, which we
preferred to make into flowers of all sorts as souvenirs of the war!
But after that date we have had the good, light bread—so eatable. It
is for this we thank you.”
Another says:
“Since we have had the good bread the happiest people are the
mothers, who before had to let their “chers petits” suffer from
hunger, because their delicate stomachs would not digest the bad,
black bread.”
Further:
“The mothers of little children wept with joy and blest you, as they
went to get their good, light bread.”
One little girl wrote:
“When on the 5th of May, 1915, maman returned with the new
bread, and we all ran to taste it, we found it good. The bread we
had been eating long months had been dark and moist. Further, rice
had been our daily food. It is without doubt to show your gratitude
to the French, who went to drive the English away from you in 1783,
that you have thought to soften our suffering. Merci! Merci! Many
died because of that bad bread, and many more should have died,
had you not come to our aid with the good bread.”
Another little girl writes:
“If ever in the future America is in need, France will not forget the
good she has done and will reach a hospitable hand to her second
country, who has saved her unhappy children. It is you who have
made it possible for all mothers to give bread to their children.
Without the rice and beans, what would have become of us! You
have helped us to have coal and warm clothing against the cold. In
the name of all the mothers we thank you, and all the little children
send you a great kiss of thanks.”
 The babies had all finished their cocoa and buns, so I went to the
Girls’ Technical Training School in the neighborhood. It was having a
particularly hard time because of the lack of materials and of
opportunity to sell the articles made by the children. But two
wonderful women—one the director, the other the art teacher—were
courageously fighting to keep things going.
The pupils are largely from poor families. When they were going
through the beautiful figures of their gymnasium exercise for me, I
saw that the bloomers were mostly made of odds and ends of cloth.
The shoes, too, quickly told the tale—all sorts of substitutes for
leather, patched woolen shoes or slippers, wooden soles with cloth
tops, clogs.
In the room for design I was greeted with most cordial smiles as
Madame introduced me as her friend from America, the country
which meant hope to them. Then happened swiftly one of the things
it is difficult to prevent—the shouting in one breath of “Vive le Roi!”
and “Vive l’Amérique!” Who would doubt that a good part of the joy
of shouting “Vive l’Amérique” comes from the opportunity it gives
them to couple with it the cry of their hearts, “Vive la Belgique!”
By the time we returned to her bureau, Madame trusted me
entirely, and explained that this was the center of a kind of
“Assistance Discrète” she had established for her girls and their
families. She opened several cabinets, and showed me what they
had made to help one another. Certain women have been
contributing materials—old garments, bits of cloth, trimming for
hats, all of which have been employed to extraordinary advantage.
What struck me most were the attractive little babies’ shirts, made
from the upper parts of worn stockings.
Madame opened a paper sack and showed me nine hard-boiled
eggs that were to be given to the weaker girls, who most needed
extra nourishment that day.
Her most precious possession was a record of the gifts of the
pupils and their friends for this “Assistance Discrète.” It is a list of
contributions of a few centimes, or a franc or two, given as thank
offerings for some blessing; oftenest for recovery from illness, or for
good news received. It showed, too, that the children had been
bringing all the potato peelings from home, to be sold as food for
cattle. Sometimes a girl brought as much as twenty-eight centimes
(over five cents) worth of peelings. But in May, 1916, the potato
peelings stopt—they were not having potatoes at home.
 XI
GABRIELLE’S BABY

B EFORE the war Madame was very close to the Queen. She
lived in our quarter of Brussels; we became friends. And how
generous the friendship between a Belgian and an American can be,
only the members of the Commission for Relief truly know! It is swift
and complete.

I had been in Brussels five months when she said to me one day:
“My dear, I understand only too well the difficulties of your
position—the guaranty you gave on entering. As you know, I have
never once suggested that you carry a note for me, or bring a
message—tho I have seen you starting in your car behind your
blessed little white flag for the city of my daughter and my
grandchildren! Nor have I,” she laughed, with the swift play so
typical of the Belgian mind, “once hinted at a pound of butter or a
potato! But lately I have been suffering so many, many fears, that I
am tempted just to ask if you think this would be wrong for you—if
it would, forget that I asked it: I have a relation who has always
been closer to me than a brother—we were brought up together. He
is eighty-two now, and, at the beginning of the war, was living near
X in Occupied France. He was important in his district, his name is
known. Now, if I should merely give you that name, and, when you
next see your American delegate from that district, you should speak
it, might it not be possible that he would recognize it, and could tell
you if my dear, dear M. is suffering, or if he is yet able to care for
himself? Would that be breaking your agreement?”
As she stood there—intelligence, distinction speaking from all her
person—fearfully putting this pitiful question, I experienced another
of those maddening moments we live through in Belgium. One
swiftly doubts one’s reason—the situation—everything! The world
simply can not be so completely lost as it seems!
Mercifully this would not be breaking any promise; and I begged
for the name.
But even then I was rather hopeless that our American would
know. In the North of France he must live with his German officer;
he is not free to mingle with the French people.
Thursday, conference day, came, when all the little white flags
rush in from their provinces, bringing our splendid American men—
their faces stern, strained, but with that beautiful light in them that
testifies they are giving without measure the best they have to
others.
Never will any one, who has experienced it, forget the thrill he felt
when he saw those fifteen cars with their forty-two men rushing up,
one after the other to 66, rue des Colonies, nor the line of them all
day on the curb with their fluttering white flags carrying the red C.
R. B.! There were no other cars to be seen. Each person, as he
passed, knew that these fifteen white flags meant wheat and life to
10,000,000 people.
As I stood there I heard a band. I looked up the street and saw
the German soldiers goose-stepping before their guard mount. This
happens every morning, just a square above our offices. The white
flags and the goose-step—they pretty much sum up the situation!
I hurried inside, hoping fervently to hear the longed-for answer, as
I put the name and my question.
But the name was strange to S., he could tell me nothing, tho he
felt sure that by keeping his ears open that week, he might learn
something.
How often through those days I thought of these two, caught in
this war-night of separation. For two and a half years neither had
been able to call across it even the name of the other. And then of
the word thrown into the night with hope and prayer!
On the next meeting day, as he hurried toward me, I could see
from S.’s face that he had news. “Yes,” he said eagerly, “he is still
there, he draws his ration—he is not suffering from want, he has
enough left to pay for his food. But when he heard that somebody
would possibly carry this news to his dearest living relation, he cried:
‘Oh! Would it not be possible to do just one thing more! I am eighty-
two; I may die before this terrible war is ended. In pity will not
somebody tell me before I die if any of my nieces has had a little
baby, or if any one of them is going to have a little baby?’”
“And now,” S. said, “you and I know that if the Relief stops, we’ve
got to find out for that poor old man that there is a baby!”
And I went about it. On Thursday, when he rushed over to me I
could call: “Yes, there is one! It’s Gabrielle’s! A little girl, five months
old and doing beautifully!”
“Hurrah!” he shouted, and hurried back to his tons and calories.
It is four months since then, and I do not know if there are any
more babies, or if that old gentleman of a distinguished house has
had any other than this single connection with the loved ones of this
family in over two and a half years.
 XII
THE “DROP OF MILK”

B ELGIUM is succoring her weak children, but she is going

deeper than this: she is trying to prevent weak children. All
through the country there are cantines where an expectant or young
mother without means may receive free a daily dinner, consisting
usually of a thick soup, a meat or egg dish with vegetables, a
dessert with lactogenized cream, and a measure of milk. Light
service, like the peeling of vegetables, is often required in return.
The mother may come as early as three months before the birth of
her child, and if she is still nursing it, may continue nine months
after its birth. About 7,000 mothers are receiving this dinner, and
6,000 more come to the affiliated consultation cantines for advice.

Of course, there are always those who can not nurse their
children, or who can carry them through but a short period, when
the question of pasteurized milk becomes all-important. The “Goutte
de Lait” (drop of milk) sections meet this problem by offering the
necessary feedings of pure milk. The mother may pay for the
bottles, and have them delivered, or she may, if necessitous, receive
them free by calling or sending for them.
 A MEAL FOR YOUNG MOTHERS

In Antwerp, where this work has assumed unusual proportions, a

big-hearted president of the Belgian Provincial Committee got
permission to purchase 100 cows in Holland and to hold them
without danger of requisition. He installed a model dairy on his
place, and now gives all the baby cantines pure milk. He is always
most anxious to finish his arduous day’s work at the bureau, so that
he may return to his dairy, examine the milk tests, and review his
fine herd. One of his daughters, in addition to hours spent in the
cantines, takes the entire responsibility of the management of this
dairy. Other towns are less fortunate, and must struggle continually
to get the milk they require. There is a beautiful development of the
work of a “Goutte de Lait” in Hasselt, in a cantine occupying part of
a maternity hospital. There they have an admirable equipment for
sterilization and pasteurization. At 7 o’clock in the morning I found
the women directors already busy with the preparation of the milk.
Each feeding has its separate bottle, and may be kept sealed till the
baby receives it. After seven months, white phosphatine, a mixture
of the flour of wheat, rice and corn, with salt, sugar and phosphate
of lime, is furnished; at fourteen months, cocoa is added, and after
two years, soup and bread.
I happened to arrive on the weekly weighing day. One hundred
mothers were gathered in a large, cheery room, their babies in their
arms, many of them gay in the pretty bonnets the doctor’s wife had
made for those who had the best records. They passed, a few at a
time, into the smaller room where the doctor and his wife examined,
weighed, counseled, while two assistants registered important
details; the three young nurses generally aided the mothers and
their chiefs.
Then I was shown an adjoining room, where, in the corners, there
were heaps of little white balls rolled in wax paper. From a distance
they looked more than anything else like tiny popcorn balls. What
could they mean? I took one in my hand and saw that they meant
that the most precious prize that can be offered a Belgian mother to-
day is a tiny ball of white lard! With the more ignorant, this prize-
system is the swiftest means of opening the way. The doctor
laughed as he recounted his struggle with one obstinate woman,
who argued stoutly that because the cow is a great, strong creature,
while she herself is but small and frail, undoubtedly its milk would be
infinitely more strengthening to her child than her own! Where
argument failed, the prize convinced. If a mother can nurse her baby
but neglects to, she is forced to feed it regularly before some
member of the committee. Nurses visit all the homes registered.
The attempt is being made everywhere to induce mothers who are
not actually in want, to enroll in these cantines, while paying for
their food, that they may have the benefit of the pure milk and the
physician’s care. The “Relief” is not counting the cost of this
fundamental work—the baby cantines are the promise of the future.
They are already closely watching the development of 53,000
babies. The educational value alone can not be measured; women
who had not the faintest conception of the simplest laws of hygiene
are being trained, forced to learn, because their own and their
children’s food can come to them only from the hand of their
teacher. While the war has brought unutterable misery, it has also
brought extraordinary opportunity, and Belgium is seizing this
opportunity wherever she can.