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  • Question 1 - A 76 year old female who is admitted to the ward complains that...

    Incorrect

    • A 76 year old female who is admitted to the ward complains that she is experiencing visual hallucinations. She was admitted following a decline in mobility that was thought to be secondary to a urinary tract infection. Improvements have been seen clinically and biochemically while she has been admitted and she is currently awaiting discharge. Upon review, she states that she has seen wolves walking around her bed. She has a background of hypertension, depression and age-related macular degeneration. What is the most appropriate step in this patient's management?

      Your Answer: Urgent psychiatric evaluation

      Correct Answer: Reassure the patient

      Explanation:

      Charles Bonnet syndrome (CBS) involves visual hallucinations due to eye disease, usually associated with a sharp decline in vision. The phenomenon is seen in patients with moderate or severe visual impairment. It can occur spontaneously as the vision declines or it may be precipitated, in predisposed individuals, by concurrent illness such as infections elsewhere in the body.

      It is not clear why CBS develops or why some individuals appear to be predisposed to it. It is particularly noted in patients with advanced macular degeneration. It has been suggested that reduced or absent stimulation of the visual system leads to increased excitability of the visual cortex (deafferentation hypothesis). This release phenomenon is compared to phantom limb symptoms after amputation.

      CBS is much more common in older patients because conditions causing marked visual loss are more common in older people. However, it can occur at any age and has been described in children.
      The prevalence is hard to assess due to considerable under-reporting, perhaps because patients frequently fear that it is a sign of mental illness or dementia. However, it is thought to occur in:
      About 10-15% of patients with moderate visual loss.
      Possibly up to 50% of people with severe visual loss.
      Presentation:
      The nature of the hallucination depends on the part of the brain that is activated. The hallucinations may be black and white or in colour. They may involve grids/brickwork/lattice patterns but are typically much more complex:

      The hallucinations are always outside the body.
      The hallucinations are purely visual – other senses are not involved.
      The hallucinations have no personal meaning to the patient.
      Hallucinations may last seconds, minutes or hours.
      CBS tends to occur in a ‘state of quiet restfulness’. This may be after a meal or when listening to the radio (but not when dozing off).
      Symptoms also have a tendency to occur in dim lighting conditions.
      Patients may report high levels of distress, with some patients reporting anger, anxiety and even fear associated with the hallucinations.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 2 - A 21-year-old female presents to the emergency department having taken an overdose of...

    Incorrect

    • A 21-year-old female presents to the emergency department having taken an overdose of 40 x 500mg paracetamol tablets and 400ml of vodka. This is her fourth attendance with an overdose over the past 3 years. She is also known to the local police after an episode of reckless driving/road rage. On arrival, she is tearful and upset. Vital signs and general physical examination are normal apart from evidence of cutting on her arms. She is given activated charcoal. Which of the following is the most likely diagnosis?

      Your Answer: Bipolar disorder

      Correct Answer: Borderline personality disorder

      Explanation:

      The given clinical scenario is highly suggestive of a borderline personality disorder.

      Borderline personality disorder is marked out by instability in moods, behaviour, and relationships. The diagnosis is confirmed by the presence of at least 5 of the following symptoms;
      1) Extreme reactions including panic, depression, rage, or frantic actions to abandonment, whether real or perceived
      2) A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love to extreme dislike or anger
      3) Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future (such as school or career choices)
      4) Impulsive and often dangerous behaviours, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating
      5) Recurring suicidal behaviours or threats or self-harming behaviour, such as cutting, intense and highly changeable moods, with each episode lasting from a few hours to a few days
      6) Chronic feelings of emptiness and/or boredom
      7) Inappropriate, intense anger or problems controlling anger
      8) Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.

      Other options:
      There are no features consistent with endogenous depression, such as early morning wakening or loss of appetite.
      There are also no features consistent with hypomania such as pressure of speech, a flight of ideas, or over-exuberant behaviour.
      The lack of history of drug abuse rules out drug-induced psychosis.
      An anti-social personality disorder is characterized by a failure to conform to social norms and repeated lawbreaking. There is consistent irresponsibility, impulsivity, and disregard for both their safety and that of others. This is not the case in the given scenario.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 3 - A 20-year-old talented violinist is brought by her parents as they are concerned...

    Incorrect

    • A 20-year-old talented violinist is brought by her parents as they are concerned that she had a stroke as she is reporting weakness on her right side. Neurological examination is inconsistent with the provided history, suspecting a non-organic cause for her symptoms her GP provides reassurance. Despite it, the girl remains unable to move her right arm. What is the most probable diagnosis of this patient?

      Your Answer: Munchausen's syndrome

      Correct Answer: Conversion disorder

      Explanation:

      The most probable diagnosis in this patient is conversion disorder.

      There may be underlying tension regarding her musical career which could be manifesting as apparent limb weakness.

      Conversion disorder typically involves loss of motor or sensory function. The patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering). Patients may be indifferent to their apparent disorder – la belle indifference – although this has not been backed up by studies.

      Other options:
      Unexplained symptoms
      There are a wide variety of psychiatric terms for patients who have symptoms for which no organic cause can be found:

      Somatization disorder
      Multiple physical symptoms present for at least 2 years
      the patient refuses to accept reassurance or negative test results

      Hypochondriacal disorder
      The persistent belief in the presence of an underlying serious disease, e.g. cancer.
      The patient again refuses to accept reassurance or negative test results

      Dissociative disorder
      Dissociation is a process of ‘separating off’ certain memories from normal consciousness
      Unlike conversion disorder, it involves psychiatric symptoms e.g. amnesia, fugue, stupor
      Dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder

      Munchausen’s syndrome
      Also known as factitious disorder
      The intentional production of physical or psychological symptoms

      Malingering
      Fraudulent simulation or exaggeration of symptoms with the intention of financial or another gain.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 4 - A prescription for Olanzapine is written for a 28 year old lady with...

    Correct

    • A prescription for Olanzapine is written for a 28 year old lady with a history of schizophrenia. Which adverse effect is she most likely to experience?

      Your Answer: Weight gain

      Explanation:

      Weight gain is an extremely common (5-40%) adverse effect of atypical antipsychotics such as olanzapine (dose dependent). Olanzapine causes orthostatic hypotension ≥20% of reported cases. Parkinsonism reactions occurs in 4% of people.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 5 - A 62 year old man expresses to his doctor that he believes that...

    Incorrect

    • A 62 year old man expresses to his doctor that he believes that his partner is being unfaithful. When asked if he has any evidence to prove that this is true, he says no. However, he appears to be distressed and believes that he is right. Which condition could this be a symptom of?

      Your Answer: Charles Bonnet syndrome

      Correct Answer: Othello's syndrome

      Explanation:

      Othello syndrome (OS) is a type of paranoid delusional jealousy, characterized by the false absolute certainty of the infidelity of a partner, leading to preoccupation with a partner’s sexual unfaithfulness based on unfounded evidence. OS has been associated with psychiatric and neurological disorders including stroke, brain trauma, brain tumours, neurodegenerative disorders, encephalitis, multiple sclerosis, normal pressure hydrocephalus, endocrine disorders, and drugs.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 6 - Which of the following symptoms are more indicative of mania than hypomania? ...

    Incorrect

    • Which of the following symptoms are more indicative of mania than hypomania?

      Your Answer: Predominately elevated mood

      Correct Answer: Delusions of grandeur

      Explanation:

      The delusion of grandeur is more indicative of mania than hypomania.
      While criteria (e.g. ICD-10, DSM-5) vary regarding the diagnosis between hypomania and mania, the consistent difference between mania and hypomania is the presence of psychotic symptoms.

      Hypomania vs. mania:
      The presence of psychotic symptoms such as delusions of grandeur
      auditory hallucinations point towards mania rather than hypomania/

      The following symptoms are common to both hypomania and mania
      Mood:
      Predominately elevated
      Irritable

      Speech and thought:
      Pressured
      Flight of ideas
      Poor attention

      Behaviour
      Insomnia
      Loss of inhibitions: sexual promiscuity, overspending, risk-taking
      increased appetite

    • This question is part of the following fields:

      • Psychiatry
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  • Question 7 - Which statement is true regarding anorexia nervosa? ...

    Incorrect

    • Which statement is true regarding anorexia nervosa?

      Your Answer: If amenorrhoea is present a hormonal disorder needs to be excluded

      Correct Answer: It is the most common cause of admissions to child and adolescent psychiatric wards

      Explanation:

      Anorexia nervosa is an eating disorder characterized by an abnormally low body weight, an intense fear of gaining weight and a distorted perception of weight. People with anorexia place a high value on controlling their weight and shape, using extreme efforts that tend to significantly interfere with their lives.

      The minimum level of severity is based, for adults, on current body mass index (BMI) (see below) or for
      children and adolescents, on BMI percentile. The ranges below are derived from World Health
      Organization categories for thinness in adults; for children and adolescents, corresponding BMI percentiles
      should be used. The level of severity may be increased to reflect clinical symptoms, the degree of
      functional disability, and the need for supervision.
      Mild: BMI > 17 kg/m2
      Moderate: BMI 16-16.99 kg/m2
      Severe: BMI 15-15.99 kg/m2
      Extreme: BMI < 15 kg/m2 Anorexia nervosa is more common in women than in men, with a female-to-male ratio of 10-20:1 in developed countries. The prognosis of anorexia nervosa is guarded. Morbidity rates range from 10-20%, with only 50% of patients making a complete recovery. Of the remaining 50%, 20% remain emaciated and 25% remain thin. The main change in the diagnosis of Anorexia Nervosa was to remove the criterion of amenorrhea (loss of menstrual cycle). Removing this criterion means that boys and men with Anorexia will finally be able to receive an appropriate diagnosis.
      Similarly, girls and women who continue to have their period despite other symptoms associated with Anorexia, such as weight loss and food restriction, will now be eligible for a diagnosis of Anorexia.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 8 - A 21-year-old man is brought by his girlfriend who says he has 'not...

    Correct

    • A 21-year-old man is brought by his girlfriend who says he has 'not been himself' and has been feeling 'out of sorts' for the past 3 weeks. There is no history of past mental health problems. Which of the following symptoms is highly suggestive of depression in this patient?

      Your Answer: Early morning waking

      Explanation:

      Early morning waking is a highly suggestive feature of depression in this patient.

      NICE use the DSM-IV criteria to grade depression:
      1. Depressed mood most of the day, nearly every day
      2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
      3. Significant weight loss or weight gain when not dieting or decrease or increase in appetite nearly every day
      4. Insomnia or hypersomnia nearly every day
      5. Psychomotor agitation or retardation nearly every day
      6. Fatigue or loss of energy nearly every day
      7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day
      8. Diminished ability to think or concentrate, or indecisiveness nearly every day
      9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

      Subthreshold depressive symptoms: Fewer than 5 symptoms
      Mild depression: Few, if any, symptoms over the 5 required to make the diagnosis, and symptoms result in only minor functional impairment
      Moderate depression: Symptoms or functional impairment are between ‘mild’ and ‘severe’
      Severe depression: Most symptoms and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms.

      Treatment of depression:
      Psychotherapy (in the form of cognitive behavioural therapy or interpersonal therapy) alone or in combination with medications such as:
      – Selective serotonin reuptake inhibitors (SSRIs)
      – Serotonin/norepinephrine reuptake inhibitors (SNRIs)
      – Atypical antidepressants
      – Serotonin-Dopamine Activity Modulators (SDAMs)
      – Tricyclic antidepressants (TCAs)

      There is also empirical support for the ability of CBT to prevent relapse.

      Electroconvulsive therapy is a useful treatment option for patients with severe depression refractory to medication or those with psychotic symptoms. The only absolute contraindications is raised intracranial pressure.

      Side-effects:
      Headache
      Nausea
      Short term memory impairment
      Memory loss of events before ECT
      Cardiac arrhythmia
      Long-term side-effects: Impaired memory

    • This question is part of the following fields:

      • Psychiatry
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  • Question 9 - A 28-year-old fireman presents following a recent traumatic incident where a child died...

    Incorrect

    • A 28-year-old fireman presents following a recent traumatic incident where a child died in a house fire. He describes recurrent nightmares and flashbacks which have been present for the past 2 months. Suspecting a diagnosis of post-traumatic stress disorder what is the first-line treatment for this patient?

      Your Answer:

      Correct Answer: Cognitive behavioural therapy or eye movement desensitisation and reprocessing therapy

      Explanation:

      The most probable diagnosis in this patient is post-traumatic stress disorder (PTSD). The first-line treatment for this patient would be cognitive behavioural therapy or eye movement desensitization and reprocessing therapy.

      Post-traumatic stress disorder (PTSD) can develop in people of any age following a traumatic event, for example, a major disaster or childhood sexual abuse. It encompasses what became known as ‘shell shock’ following the first world war. One of the DSM-IV diagnostic criteria is that symptoms have been present for more than one month.

      Clinical features:
      Re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
      Avoidance: avoiding people, situations or circumstances resembling or associated with the event
      Hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
      Emotional numbing – lack of ability to experience feelings, feeling detached from other people
      Depression
      Drug or alcohol misuse
      Anger

      Management:
      Following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
      Watchful waiting may be used for mild symptoms lasting less than 4 weeks
      Trauma-focused cognitive-behavioural therapy (CBT) or eye movement desensitization and reprocessing (EMDR) therapy may be used in more severe cases
      Drug treatments for PTSD should not be used as a routine first-line treatment for adults.
      If drug treatment is used then paroxetine or mirtazapine are recommended.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 10 - An 77-year-old female has been admitted in the psychiatric ward for the past...

    Incorrect

    • An 77-year-old female has been admitted in the psychiatric ward for the past 6 months with a fixed belief that her insides are rotting as she is deceased. Which of the following terms best describe this type of delusion?

      Your Answer:

      Correct Answer: Cotard delusion

      Explanation:

      The most probable diagnosis of this patient is Cotard syndrome.

      Cotard syndrome is a rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary. Cotard syndrome is often associated with severe depression and psychotic disorders.

      Other options:
      – Othello syndrome is a delusional belief that a patients partner is committing infidelity despite no evidence of this. It can often result in violence and controlling behaviour.
      – De Clerambault syndrome (otherwise known as erotomania), is where a patient believes that a person of higher social or professional standing is in love with them. Often this presents with people who believe celebrities are in love with them.
      – Ekbom syndrome is also known as delusional parasitosis and is the belief that they are infected with parasites or have ‘bugs’ under their skin. This can vary from the classic psychosis symptoms in narcotic use where the user can ‘see’ bugs crawling under their skin or can be a patient who believes that they are infested with snakes.
      – Capgras delusion is the belief that friends or family members have been replaced by an identical-looking imposter.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 11 - A 36 year old female who has been suffering from depression for the...

    Incorrect

    • A 36 year old female who has been suffering from depression for the past 5 years was recently admitted to the psychiatric intensive care unit. She is currently being managed on Sertraline. In clinic she was observed to be sitting in a fixed position for several hours, awake but unable to move. What would be an appropriate treatment for this patient?

      Your Answer:

      Correct Answer: ECT

      Explanation:

      Catatonia is a state of apparent unresponsiveness to external stimuli and apparent inability to move normally in a person who is apparently awake. Catatonia can be acute and occur in severely ill patients with underlying psychiatric or other medical disorders.

      A history of behavioural responses to others usually includes the presence of the following:
      – Mutism (absence of speech)
      – Negativism (performing actions contrary to the commands of the examiner)
      – Echopraxia (repeating the movements of others)
      – Echolalia (repeating the words of others)
      – Waxy flexibility (slight, even resistance to positioning by examiner)
      – Withdrawal (absence of responses to the environment).

      In the presence of a catatonic state, both first and second generation antipsychotics (SGA) may contribute to maintaining or worsening the catatonic state and increase the risk of developing NMS (neuroleptic malignant syndrome).

      Electroconvulsive therapy (ECT) is effective in all forms of catatonia, even after pharmacotherapy with benzodiazepines has failed. Response rate ranges from 80% to 100% and results superior to those of any other therapy in psychiatry. ECT should be considered first-line treatment in patients with malignant catatonia, neuroleptic malignant syndrome, delirious mania or severe catatonic excitement, and in general in all catatonic patients that are refractory or partially responsive to benzodiazepines. Early intervention with ECT is encouraged to avoid undue deterioration of the patient’s medical condition.

      Electroconvulsive therapy (ECT) is a procedure, done under general anaesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental health conditions.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 12 - Which among the following factors is not associated with a poor prognosis in...

    Incorrect

    • Which among the following factors is not associated with a poor prognosis in patients with schizophrenia?

      Your Answer:

      Correct Answer: Acute onset

      Explanation:

      A patient with a gradual onset of schizophrenia is to be associated with a poor prognosis.

      Schizophrenia is a functional psychotic disorder characterized by the presence of delusional beliefs, hallucinations, and disturbances in thought, perception, and behaviour.

      Clinical features:
      Schneider’s first-rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions:

      Auditory hallucinations of a specific type:
      Two or more voices discussing the patient in the third person
      Thought echo
      Voices commenting on the patient’s behaviour

      Thought disorder:
      Thought insertion
      Thought withdrawal
      Thought broadcasting

      Passivity phenomena:
      Bodily sensations being controlled by external influence
      Actions/impulses/feelings – experiences which are imposed on the Individual or influenced by others

      Other features of schizophrenia include
      Impaired insight (a feature of all psychoses)
      Incongruity/blunting of affect (inappropriate emotion for circumstances)
      Decreased speech
      Neologisms: made-up words
      Catatonia
      Negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation).

      Treatment:
      For the initial treatment of acute psychosis, it is recommended to commence an oral second-generation antipsychotics such as aripiprazole, olanzapine, risperidone, quetiapine, etc.
      Once the acute phase is controlled, switching to a depot preparation like aripiprazole, paliperidone, zuclopenthixol, fluphenazine, haloperidol, pipotiazine, or risperidone is recommended.
      Cognitive-behavioural therapy (CBT) and the use of art and drama therapies help counteract the negative symptoms of the disease, improve insight, and assist relapse prevention.
      Clozapine is used in case of treatment resistance.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 13 - A 40 year old patient of yours requests to stop treatment using Citalopram...

    Incorrect

    • A 40 year old patient of yours requests to stop treatment using Citalopram after taking it for the past two years for his depression. You have agreed to this because he feels well for the past year. What is the most appropriate method of discontinuing Citalopram?

      Your Answer:

      Correct Answer: Withdraw gradually over the next 4 weeks

      Explanation:

      Citalopram is an antidepressant medication that works in the brain. It is approved for the treatment of major depressive disorder (MDD). Stopping citalopram abruptly may result in one or more of the following withdrawal symptoms: irritability, nausea, feeling dizzy, vomiting, nightmares, headache, and/or paraesthesia (prickling, tingling sensation on the skin).

      When discontinuing antidepressant treatment that has lasted for >3 weeks, gradually taper the dose (e.g., over 2 to 4 weeks) to minimize withdrawal symptoms and detect re-emerging symptoms. Reasons for a slower titration (e.g., over 4 weeks) include use of a drug with a half-life <24 hours (e.g., paroxetine, venlafaxine), prior history of antidepressant withdrawal symptoms, or high doses of antidepressants.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 14 - A 30-year-old female is brought by her concerned mother. The patient reports that...

    Incorrect

    • A 30-year-old female is brought by her concerned mother. The patient reports that the president is secretly in love with her, despite the fact that there has never been any contact between them. What is the probable psychiatric condition from which the patient is suffering from?

      Your Answer:

      Correct Answer: De Clerambault's syndrome

      Explanation:

      The most probable diagnosis in this patient is De Clerambault’s syndrome, also known as erotomania, which is a form of paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.

      Other options:
      – Bouffée délirante is an acute psychotic disorder in which hallucinations, delusions or perceptual disturbances are obvious but markedly variable, changing from day to day or even from hour to hour.
      – Fregoli delusion is the mistaken belief that some people currently present in the deluded person’s environment (typically a stranger) is a familiar person in disguise.
      – Capgras delusion is the belief that significant others have been replaced by impostors, robots or aliens.
      – Couvade is the common but poorly understood phenomenon whereby the expectant father experiences somatic symptoms during the pregnancy for which there is no recognized physiological basis.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 15 - A 25-year-old man asks to be referred to a plastic surgeon as he...

    Incorrect

    • A 25-year-old man asks to be referred to a plastic surgeon as he claims that his ears are too big in proportion to his face and he seldom leaves the house because of this. His records show that he was treated for anxiety and depression with fluoxetine previously and has been off work with back pain for the past 4 months. On examination, his ears appear to be normal. What is the most appropriate term of this behaviour?

      Your Answer:

      Correct Answer: Dysmorphophobia

      Explanation:

      The most probable diagnosis in the given scenario would be body dysmorphic disorder or dysmorphophobia

      It is a mental disorder where patients have a significantly distorted body image.

      Diagnostic and Statistical Manual (DSM) IV criteria:
      Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.
      The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
      The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).

      Treatment:
      Cognitive-behavioural therapy (CBT) is the most commonly used and most empirically supported intervention to improve body image.
      Several drugs have been targets of study in anorexia nervosa treatment, including selective serotonin reuptake inhibitors, antidepressants, antipsychotics, nutritional supplementation, and hormonal medications.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 16 - Which among the following is most likely to be beneficial to a patient...

    Incorrect

    • Which among the following is most likely to be beneficial to a patient with schizophrenia?

      Your Answer:

      Correct Answer: Cognitive behavioural therapy

      Explanation:

      Among the given options, cognitive-behavioural therapy is the most likely to benefit a patient with schizophrenia.

      Schizophrenia is a functional psychotic disorder characterized by the presence of delusional beliefs, hallucinations, and disturbances in thought, perception, and behaviour.

      Clinical features:
      Schneider’s first-rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions:

      Auditory hallucinations of a specific type:
      Two or more voices discussing the patient in the third person
      Thought echo
      Voices commenting on the patient’s behaviour

      Thought disorder:
      Thought insertion
      Thought withdrawal
      Thought broadcasting

      Passivity phenomena:
      Bodily sensations being controlled by external influence
      Actions/impulses/feelings – experiences which are imposed on the Individual or influenced by others

      Other features of schizophrenia include
      Impaired insight (a feature of all psychoses)
      Incongruity/blunting of affect (inappropriate emotion for circumstances)
      Decreased speech
      Neologisms: made-up words
      Catatonia
      Negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation).

      Treatment:
      For the initial treatment of acute psychosis, it is recommended to commence an oral second-generation antipsychotics such as aripiprazole, olanzapine, risperidone, quetiapine, etc.
      Once the acute phase is controlled, switching to a depot preparation like aripiprazole, paliperidone, zuclopenthixol, fluphenazine, haloperidol, pipotiazine, or risperidone is recommended.
      Cognitive-behavioural therapy (CBT) and the use of art and drama therapies help counteract the negative symptoms of the disease, improve insight, and assist relapse prevention.
      Clozapine is used in case of treatment resistance.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 17 - A 35 year old female is observed wiping off the door handle before...

    Incorrect

    • A 35 year old female is observed wiping off the door handle before going outside. She also says that she has to wash her hands before and after leaving the house. She explains that she gets very uptight and anxious if these are not done in a certain order. This has been ongoing for the past four years and is upsetting her deeply. What is the most appropriate treatment for the likely diagnosis?

      Your Answer:

      Correct Answer: Exposure-response prevention (ERP) therapy

      Explanation:

      Obsessive-Compulsive Disorder (OCD) is a common, chronic and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and behaviours (compulsions) that he or she feels the urge to repeat over and over.
      People with OCD may have symptoms of obsessions, compulsions, or both. These symptoms can interfere with all aspects of life, such as work, school, and personal relationships.

      Obsessions are repeated thoughts, urges, or mental images that cause anxiety. Common symptoms include:
      Fear of germs or contamination
      Unwanted forbidden or taboo thoughts involving sex, religion, and harm
      Aggressive thoughts towards others or self
      Having things symmetrical or in a perfect order

      Compulsions are repetitive behaviours that a person with OCD feels the urge to do in response to an obsessive thought. Common compulsions include:
      -Excessive cleaning and/or handwashing
      -Ordering and arranging things in a particular, precise way
      -Repeatedly checking on things, such as repeatedly checking to see if the door is locked or that the oven is off
      -Compulsive counting

      Research also shows that a type of CBT called Exposure and Response Prevention (ERP) is effective in reducing compulsive behaviours in OCD, even in people who did not respond well to SRI medication. ERP has become the first-line psychotherapeutic treatment for OCD

    • This question is part of the following fields:

      • Psychiatry
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  • Question 18 - An elderly woman is taken to the clinic by her husband because she...

    Incorrect

    • An elderly woman is taken to the clinic by her husband because she has been complaining about seeing ghosts in their house. She no longer wants to enter in the house. You wonder if this might be Charles-Bonnet syndrome. Which of the following risk factors may pre-dispose this woman to Charles-Bonnet syndrome?

      Your Answer:

      Correct Answer: Peripheral visual impairment

      Explanation:

      Charles Bonnet syndrome (CBS) involves visual hallucinations due to eye disease, usually associated with a sharp decline in vision. The phenomenon is seen in patients with moderate or severe visual impairment. It can occur spontaneously as the vision declines or it may be precipitated, in predisposed individuals, by concurrent illness such as infections elsewhere in the body.

      It is not clear why CBS develops or why some individuals appear to be predisposed to it. It is particularly noted in patients with advanced macular degeneration. It has been suggested that reduced or absent stimulation of the visual system leads to increased excitability of the visual cortex (deafferentation hypothesis). This release phenomenon is compared to phantom limb symptoms after amputation.

      CBS is much more common in older patients because conditions causing marked visual loss are more common in older people. However, it can occur at any age and has been described in children.
      The prevalence is hard to assess due to considerable under-reporting, perhaps because patients frequently fear that it is a sign of mental illness or dementia. However, it is thought to occur in:
      About 10-15% of patients with moderate visual loss.
      Possibly up to 50% of people with severe visual loss.
      Presentation:
      The nature of the hallucination depends on the part of the brain that is activated. The hallucinations may be black and white or in colour. They may involve grids/brickwork/lattice patterns but are typically much more complex:

      The hallucinations are always outside the body.
      The hallucinations are purely visual – other senses are not involved.
      The hallucinations have no personal meaning to the patient.
      Hallucinations may last seconds, minutes or hours.
      CBS tends to occur in a ‘state of quiet restfulness’. This may be after a meal or when listening to the radio (but not when dozing off).
      Symptoms also have a tendency to occur in dim lighting conditions.
      Patients may report high levels of distress, with some patients reporting anger, anxiety and even fear associated with the hallucinations.

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      • Psychiatry
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  • Question 19 - A 76-year-old male presents with recurrent episodes of hallucinations. He often sees faces...

    Incorrect

    • A 76-year-old male presents with recurrent episodes of hallucinations. He often sees faces smaller than normal or other objects out of proportion. He says he knows they're not real. His past medical history includes macular degeneration and an episode of depression 15 years ago following the death of his wife. Neurological examination is unremarkable. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Charles-Bonnet syndrome

      Explanation:

      The most probable diagnosis in the given scenario would be Charles-Bonnet syndrome.

      Charles-Bonnet syndrome (CBS) is characterized by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally against a background of visual impairment (although visual impairment is not mandatory for a diagnosis). Insight is usually preserved. This must occur in the absence of any other significant neuropsychiatric disturbance.

      Risk factors include:
      Advanced age
      Peripheral visual impairment
      Social isolation
      Sensory deprivation
      Early cognitive impairment

      CBS is equally distributed between sexes and does not show any familial predisposition. The most common ophthalmological conditions associated with this syndrome are age-related macular degeneration, followed by glaucoma and cataract.

      Well-formed complex visual hallucinations are thought to occur in 10-30 percent of individuals with severe visual impairment. The prevalence of CBS in visually impaired people is thought to be between 11 and 15 percent.

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      • Psychiatry
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  • Question 20 - An 12 year old girl is taken to the clinic for a review....

    Incorrect

    • An 12 year old girl is taken to the clinic for a review. Despite being normally fit and well and not visiting a doctor for the past four years, her father is concerned about her behaviour in the past week. The girl has expressed plans to run for president, is active with planning all through the night and seems overtly excited. When asked, she admits to smoking cannabis once a few months ago and has drank alcohol a few times in the past year. The last time she had alcohol was a week ago. Prior to her deterioration a few weeks ago her father describes her as a happy, well-adjusted, sociable girl. Which one of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Mania

      Explanation:

      Mania is a state of extreme physical and emotional elation. A person experiencing mania or a manic episode may present with the following symptoms:
      -Elevated mood. The person feels extremely ‘high’, happy and full of energy; he or she may describe the experience as feeling on top of the world and invincible. The person may shift rapidly from an elevated,
      happy mood to being angry and irritable if they perceive they have been obstructed.
      -Increased energy and overactivity. The person may have great difficulty remaining still.
      -Reduced need for sleep or food. The person may be too active to eat or sleep.
      -Irritability. The person may become angry and irritated with those who disagree with or dismiss his or her sometimes unrealistic plans or ideas.
      -Rapid thinking and speech. The person’s thoughts and speech are more rapid than usual.
      -Grandiose plans and beliefs. It is quite common for a person in a hypomanic or manic state to believe that he or she is unusually talented or gifted or has special friends in power. For example, the person may believe that he or she is on a special mission from God.
      -Lack of insight. A person in a hypomanic or manic state may understand that other people see his or her ideas and actions as inappropriate, reckless or irrational. However, he or she is unlikely to personally accept that the behaviour is inappropriate, due to a lack of insight.
      – Distractibility. The person has difficulty maintaining attention and may not be able to filter out external stimuli.

      Careful assessment to rule out organic conditions is an important first step in the management of mania. Often hospitalisation is required for someone who is experiencing acute mania. Both mood-stabilising agents such as lithium carbonate or sodium valproate and an antipsychotic may be needed to treat psychotic symptoms, agitation, thought disorder and sleeping difficulties. Benzodiazepines may be useful to reduce hyperactivity. Treatment with lithium alone may have a relatively slow response rate (up to two weeks after a therapeutic blood level is established), so that adjunctive medication such as sodium valproate is usually required. Regular monitoring of blood levels for lithium and valproate is essential because of the potential for toxicity.

      The symptoms of hypomania are similar to those of mania: elevated mood, inflated self-esteem, decreased need for sleep, etc. except that they don’t significantly impact a person’s daily function and never include any psychotic symptoms.

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      • Psychiatry
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  • Question 21 - A 49 year old man states that he is feeling down and has...

    Incorrect

    • A 49 year old man states that he is feeling down and has not been sleeping well. An assessment is done using a validated symptom measure which indicates that he is moderately depressed. He is currently taking Ramipril, Simvastatin and Aspirin for ischaemic heart disease. What is the most appropriate course of action?

      Your Answer:

      Correct Answer: Start sertraline + lansoprazole

      Explanation:

      Results of a randomized trial confirm that the antidepressant sertraline can be used safely in patients with recent MI or unstable angina and is effective in relieving depression in these patients.

      There are theoretical reasons for believing that selective serotonin reuptake inhibitors (SSRIs), widely used to treat depression, might increase the risk of gastrointestinal bleeding. Gastroprotective drugs are advocated for high risk patients taking non-steroidal anti-inflammatory drugs, another class of drug that causes gastrointestinal bleeding.

      Serotonin is released from platelets in response to vascular injury and promotes vasoconstriction and a change in the shape of the platelets that leads to aggregation. Platelets cannot themselves synthesise serotonin. SSRIs inhibit the serotonin transporter, which is responsible for the uptake of serotonin into platelets. It could thus be predicted that SSRIs would deplete platelet serotonin, leading to a reduced ability to form clots and a subsequent increase in the risk of bleeding.

      The well established association between nonsteroidal anti-inflammatory drugs and upper gastrointestinal bleeding is estimated to result in 700-2000 deaths/year in the UK. This has led to the recommendation that patients in high risk groups should receive gastroprotection in the form of an H2 antagonist, proton pump inhibitor (lansoprazole), or misoprostol.

      Proton pump inhibitors have been shown to reduce endoscopically diagnosed mucosal damage and heal ulcers induced by non-steroidal anti-inflammatory drugs but not to reduce the incidence of severe gastrointestinal bleeds.

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      • Psychiatry
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  • Question 22 - A patient is started on imipramine for depression. Which combination of side-effects is...

    Incorrect

    • A patient is started on imipramine for depression. Which combination of side-effects is most likely to be associated with the intake of this class of antidepressants?

      Your Answer:

      Correct Answer: Blurred vision + dry mouth

      Explanation:

      Blurring of vision and dry mouth are antimuscarinic side-effects that are more common with imipramine than other types of tricyclic antidepressants.

      Tricyclic antidepressants (TCAs) are used less commonly now for depression due to their side-effects and toxicity in overdose. They are however used widely in the treatment of neuropathic pain, where smaller doses are typically required.

      Mechanism of action: Tricyclic antidepressants impose their therapeutic effects by inhibiting presynaptic reuptake of norepinephrine and serotonin in the central nervous system (this, may give rise to seizures).

      Common side-effects:
      Drowsiness
      Dry mouth
      Blurred vision
      Constipation
      Urinary retention

      Low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headaches (both tension and migraine).
      Lofepramine has a lower incidence of toxicity in overdose
      Amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose.

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      • Psychiatry
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  • Question 23 - A 61 year old male is noted to be depressed following a recent...

    Incorrect

    • A 61 year old male is noted to be depressed following a recent heart attack. He has a history of ischaemic heart disease. Which antidepressant would be appropriate for this patient?

      Your Answer:

      Correct Answer: Sertraline

      Explanation:

      Major depression (MD) often occurs after MI and has been shown to be an independent predictor of poor cardiovascular (CV) outcome.

      Results of a randomized trial confirm that the antidepressant sertraline can be used safely in patients with recent MI or unstable angina and is effective in relieving depression in these patients.

      Adverse effects to note:
      Sertraline – Diarrhoea (13-24%), Nausea (13-30%), Headache (20-25%),
      Insomnia (12-28%)
      Imipramine – ECG changes, orthostatic hypotension, tachycardia
      Confusion, extrapyramidal symptoms (EPS), dizziness, paraesthesia, tinnitus
      Flupentixol – seizures, irregular/fast heartbeat, increased sweating
      Paroxetine – Hypertension, Tachycardia, Emotional lability, Pruritus
      Venlafaxine – Abnormal vision (4-6%), Hypertension (2-5%), Paraesthesia (2-3%), Vasodilation (2-6%), Aneurism, Deep vein thrombophlebitis, Takotsubo cardiomyopathy

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      • Psychiatry
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  • Question 24 - A 31-year-old female is admitted to the E.D complaining of severe abdominal pain....

    Incorrect

    • A 31-year-old female is admitted to the E.D complaining of severe abdominal pain. On examination, she is seen trembling and rolling around the trolley. She has previously been investigated for abdominal pain and no cause has been found. She states that she will commit suicide unless she is given morphine for the pain. Which condition is this is an example of?

      Your Answer:

      Correct Answer: Malingering

      Explanation:

      Malingering is not considered a mental illness. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), malingering receives a V code as one of the other conditions that may be a focus of clinical attention. The DSM-5 describes malingering as the intentional production of false or grossly exaggerated physical or psychological problems. Motivation for malingering is usually external (e.g., avoiding military duty or work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs).

      Malingering should be strongly suspected if any combination of the following factors is noted to be present: (1) medicolegal context of presentation; (2) marked discrepancy between the person’s claimed stress or disability and the objective findings; (3) lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen; and (4) the presence in the patient of antisocial personality disorder (ASPD).

      This patient is be pretending to be sick in order to get morphine.

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  • Question 25 - A 63-year-old male presents with behavioural disturbances. He has a history of chronic...

    Incorrect

    • A 63-year-old male presents with behavioural disturbances. He has a history of chronic alcohol intake and previous Wernicke's encephalopathy. He has not consumed alcohol in the past 2 years. Which among the following phenomena is he likely to display on further assessment?

      Your Answer:

      Correct Answer: Confabulation

      Explanation:

      In a patient with chronic alcoholism, one can expect confabulations, which point towards a diagnosis of Korsakoff’s syndrome.

      Korsakoff’s is characterized by confabulation and amnesia, typically occurring in alcoholics secondary to chronic vitamin B1 (thiamine) deficiency.

      Other options:
      Dysthymia refers to mild depression.
      Hydrophobia is a feature of rabies
      Lilliputians may be observed in delirium tremens.
      Perseveration is repetitive speech patterns, commonly seen after traumatic brain injury.

      According to the Caine criteria, the presence of any two among the four following criteria can be used to clinically diagnose Wernicke’s Encephalopathy:
      Dietary deficiency
      Oculomotor abnormalities
      Cerebellar dysfunction
      Either altered mental status or mild memory impairment
      Korsakoff psychosis:
      Altered mental status – disorientation, confabulations
      Oculomotor findings – most often horizontal nystagmus, ophthalmoplegia, cranial nerve IV palsy, conjugate gaze
      Ataxia – wide-based gait

      Treatment:
      The mainstay of treatment in an acute presentation is thiamine replacement.
      Electrolyte abnormalities should be corrected and fluids replaced.
      In particular, magnesium requires replacement, as thiamine-dependent enzymes cannot operate in a magnesium-deficient state.
      After the acute phase of vitamin and electrolyte replacement, memory rehabilitation is beneficial in Korsakoff syndrome.

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  • Question 26 - A 40 year old man who has a 12 year history of bipolar...

    Incorrect

    • A 40 year old man who has a 12 year history of bipolar disorder is placed on Lithium. How often should his Lithium levels be checked once a stable dose has been achieved?

      Your Answer:

      Correct Answer: Every 3 months

      Explanation:

      Lithium acts by:
      – I inhibiting postsynaptic D2 receptor super sensitivity
      – Altering cation transport in nerve and muscle cells and influencing reuptake of serotonin or norepinephrine
      – Inhibiting phosphatidylinositol cycle second messenger systems

      The NICE guidelines for depression and bipolar disorder both recommend Lithium as an effective treatment; patients who take lithium should have regular blood tests to monitor the amount of lithium in their blood (every 3 months), and to make sure the lithium has not caused any problems with their kidneys or thyroid (every 6 months).

      Lithium adverse effects include:
      – Leucocytosis (most patients) which is when the white cells are above the normal range in the blood.
      – Polyuria/polydipsia (30-50%)
      – Dry mouth (20-50%)
      – Hand tremor (45% initially, 10% after 1 year of treatment)
      – Confusion (40%)
      – Decreased memory (40%)
      – Headache (40%)
      – Muscle weakness (30% initially, 1% after 1 year of treatment)
      – Electrocardiographic (ECG) changes (20-30%)
      – Nausea, vomiting, diarrhoea (10-30% initially, 1-10% after 1-2 years of treatment)
      – Hyperreflexia (15%)
      – Muscle twitch (15%)
      – Vertigo (15%)

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      • Psychiatry
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  • Question 27 - A 28 year old woman is reviewed after giving birth one week ago....

    Incorrect

    • A 28 year old woman is reviewed after giving birth one week ago. She complains about having difficulty sleeping and feeling anxious and tearful. She is also concerned about her mood because this is her first pregnancy and she is miserable. She is also not breast feeding. She has no history of any mental health disorder. What is the most appropriate approach to manage this patient?

      Your Answer:

      Correct Answer: Explanation and reassurance

      Explanation:

      Most new moms experience postpartum baby blues after childbirth, which commonly include mood swings, crying spells, anxiety and difficulty sleeping. Baby blues typically begin within the first two to three days after delivery, and may last for up to two weeks.

      Signs and symptoms of baby blues may include:
      Mood swings
      Anxiety
      Sadness
      Irritability
      Feeling overwhelmed
      Crying
      Reduced concentration
      Appetite problems
      Trouble sleeping

      The exact cause of the “baby blues” is unknown at this time. It is thought to be related to the hormone changes that occur during pregnancy and again after a baby is born. These hormonal changes may produce chemical changes in the brain that result in depression.
      Although the experience of baby blues is unpleasant, the condition usually subsides within two weeks without treatment. All the mom needs is reassurance and help with the baby and household chores.

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      • Psychiatry
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  • Question 28 - A 56-year-old male was admitted to the in-patient psychiatric unit last night. He...

    Incorrect

    • A 56-year-old male was admitted to the in-patient psychiatric unit last night. He is a poor historian, answering most questions minimally and stating he does not need to be here as he is deceased, and hospitals should be for living patients. What is the type of delusion in this patient and what is it commonly associated with?

      Your Answer:

      Correct Answer: Cotard syndrome and Major Depressive Disorder

      Explanation:

      The most probable diagnosis of this patient is Cotard syndrome with major depressive disorder.

      Cotard syndrome is a rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary. Cotard syndrome is often associated with severe depression and psychotic disorders (like schizophrenia).

      Other delusional syndromes:
      – Othello syndrome is a delusional belief that a patients partner is committing infidelity despite no evidence of this. It can often result in violence and controlling behaviour.
      – De Clerambault syndrome (otherwise known as erotomania), is where a patient believes that a person of higher social or professional standing is in love with them. Often this presents with people who believe celebrities are in love with them.
      – Capgras syndrome is characterised by a person believing their friend or relative had been replaced by an exact double.
      – Couvade syndrome is also known as ‘sympathetic pregnancy’. It affects fathers, particularly during the first and third trimesters of pregnancy, who suffer the somatic features of pregnancy.
      – Ekbom syndrome is also known as delusional parasitosis and is the belief that they are infected with parasites or have ‘bugs’ under their skin. This can vary from the classic psychosis symptoms in narcotic use where the user can ‘see’ bugs crawling under their skin or can be a patient who believes that they are infested with snakes.

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      • Psychiatry
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  • Question 29 - A 25-year-old female is brought to the OPD by her husband. She has...

    Incorrect

    • A 25-year-old female is brought to the OPD by her husband. She has been refusing to go outside for the past 3 months, telling her husband she is afraid of catching avian flu. On exploring this further, she is concerned because of the high number of migrating birds that she can see in her garden. She reports that the presence of her husband's socks on the washing line in the garden alerted her to this. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Acute paranoid schizophrenia

      Explanation:

      Based on the given clinical scenario, the most probable diagnosis in this patient is acute paranoid schizophrenia.

      Schizophrenia is a functional psychotic disorder characterized by the presence of delusional beliefs, hallucinations, and disturbances in thought, perception, and behaviour.

      Clinical features:
      Schneider’s first-rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions:

      Auditory hallucinations of a specific type:
      Two or more voices discussing the patient in the third person
      Thought echo
      Voices commenting on the patient’s behaviour

      Thought disorder:
      Thought insertion
      Thought withdrawal
      Thought broadcasting

      Passivity phenomena:
      Bodily sensations being controlled by external influence
      Actions/impulses/feelings – experiences which are imposed on the Individual or influenced by others

      Other features of schizophrenia include
      Impaired insight (a feature of all psychoses)
      Incongruity/blunting of affect (inappropriate emotion for circumstances)
      Decreased speech
      Neologisms: made-up words
      Catatonia
      Negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation).

      Treatment:
      For the initial treatment of acute psychosis, it is recommended to commence an oral second-generation antipsychotics such as aripiprazole, olanzapine, risperidone, quetiapine, etc.
      Once the acute phase is controlled, switching to a depot preparation like aripiprazole, paliperidone, zuclopenthixol, fluphenazine, haloperidol, pipotiazine, or risperidone is recommended.
      Cognitive-behavioural therapy (CBT) and the use of art and drama therapies help counteract the negative symptoms of the disease, improve insight, and assist relapse prevention.
      Clozapine is used in case of treatment resistance.

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      • Psychiatry
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  • Question 30 - A young man complains that he feels paralysed and is unable to move...

    Incorrect

    • A young man complains that he feels paralysed and is unable to move when he wakes up and less often when he is falling asleep. He complains of having hallucinations and sees other strangers in the room. His anxiety has also increased with these episodes. What is his likely diagnosis?

      Your Answer:

      Correct Answer: Sleep paralysis

      Explanation:

      Sleep paralysis is a temporary inability to move or speak that occurs when you’re waking up or falling asleep. Paralysis is often accompanied by hallucinations

      REM is a stage of sleep when the brain is very active and dreams often occur. The body is unable to move, apart from the eyes and muscles used in breathing, possibly to stop the person from acting out the dreams and hurting himself.

      It’s not clear why REM sleep can sometimes occur while one is awake, but it has been associated with:
      -not getting enough sleep (sleep deprivation or insomnia)
      -irregular sleeping patterns – for example, because of shift work or jet lag
      -narcolepsy – a long-term condition that causes a person to suddenly fall asleep at inappropriate times
      -a family history of sleep paralysis
      -sleeping on one’s back

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      • Psychiatry
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  • Question 31 - A 30-year-old female in her second week post delivery presents for review with...

    Incorrect

    • A 30-year-old female in her second week post delivery presents for review with her husband. He is worried due to her depressed mood and her poor interaction with the baby. He describes her mood three days ago being much different. She was talking in a rapid and incoherent fashion about the future. The mother denies any hallucinations but states that her child has been brought into a 'very bad world'. What is the most appropriate treatment for this patient?

      Your Answer:

      Correct Answer: Arrange urgent admission

      Explanation:

      The given clinical scenario warrants urgent admission and psychiatric evaluation as the mother seems to be suffering from puerperal psychosis.

      Post-partum mental health problems can range from the ‘baby-blues’ to puerperal psychosis.

      The Edinburgh Postnatal Depression Scale may be used to screen for depression:
      A 10-item questionnaire, with a maximum score of 30
      indicates how the mother has felt over the previous week
      score > 13 indicates a ‘depressive illness of varying severity’
      sensitivity and specificity > 90%. It includes a question about self-harm

      Postpartum psychosis has a complex multifactorial origin. Risk factors include a history of bipolar disorder, history of postpartum psychosis in a previous pregnancy, a family history of psychosis or bipolar disorder, a history of schizoaffective disorder or schizophrenia and discontinuation of psychiatric medications during pregnancy.
      Incidence rate: 2.6 per 1000 births.
      Onset usually within the first 2-3 weeks following birth
      Symptoms of puerperal psychosis include confusion, lack of touch with reality, disorganized thought pattern and behaviour, odd effect, sleep disturbances, delusions, paranoia, appetite disturbances, a noticeable change in the level of functioning from baseline, hallucinations and suicidal or homicidal ideation.
      The safety of the patient and new-born is of utmost importance, and thus, immediate hospitalization is warranted if there is a risk of harm to either one.
      Cognitive-behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe – whilst they are secreted in breast milk it is not thought to be harmful to the infant
      There is around a 20% risk of recurrence following future pregnancies

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      • Psychiatry
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  • Question 32 - A 30 year old male is reviewed following treatment using cognitive behaviour therapy...

    Incorrect

    • A 30 year old male is reviewed following treatment using cognitive behaviour therapy for bulimia. He thinks there has been no improvement in his condition and is interested in using pharmacological therapy. Which of the following is most suitable?

      Your Answer:

      Correct Answer: High-dose fluoxetine

      Explanation:

      Bulimia nervosa is a serious, potentially life-threatening eating disorder characterized by a cycle of bingeing and compensatory behaviours such as self-induced vomiting designed to undo or compensate for the effects of binge eating.

      According to the DSM-5, the official diagnostic criteria for bulimia nervosa are:
      Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
      Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
      A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).
      Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
      The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months.
      Self-evaluation is unduly influenced by body shape and weight.
      The disturbance does not occur exclusively during episodes of anorexia nervosa.

      Antidepressants as a group – particularly selective serotonin reuptake inhibitors (SSRIs) – are the mainstay of pharmacotherapy for bulimia nervosa. These may be helpful for patients with substantial concurrent symptoms of depression, anxiety, obsessions, or certain impulse disorder symptoms. They may be particularly good for patients who have not benefited from or had suboptimal response to suitable psychosocial therapy or who have a chronic, difficult course in combination with other treatments.

      Food and Drug Administration (FDA) approved treatments
      Fluoxetine (Prozac): Initial dose 20 mg/d with advance over 1–2 weeks to 60 mg/d in the morning as tolerated. Some patients may need to begin at a lower dose if side effects are intolerable. A maximum dose of 80 mg/d may be used in some cases.

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  • Question 33 - A 29 year old male visits the clinic and complains of increased anxiety,...

    Incorrect

    • A 29 year old male visits the clinic and complains of increased anxiety, dizziness, and headache which started a week after he crashed his motorcycle. A CT scan of his brain showed no abnormality when it was done. His symptoms resolved four months after he had that episode. What did his original symptoms likely represent?

      Your Answer:

      Correct Answer: Post-concussion syndrome

      Explanation:

      Post-concussion syndrome is a complex disorder in which various symptoms, such as headaches and dizziness, last for weeks and sometimes months after the injury that caused the concussion.

      Concussion is a mild traumatic brain injury that usually happens after a blow to the head. It can also occur with violent shaking and movement of the head or body. You don’t have to lose consciousness to get a concussion or post-concussion syndrome. In fact, the risk of post-concussion syndrome doesn’t appear to be associated with the severity of the initial injury.

      Post-concussion symptoms include:
      Headaches
      Dizziness
      Fatigue
      Irritability
      Anxiety
      Insomnia
      Loss of concentration and memory
      Ringing in the ears
      Blurry vision
      Noise and light sensitivity
      Rarely, decreases in taste and smell

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  • Question 34 - A 57 year old man is reviewed and discovered to be dependent on...

    Incorrect

    • A 57 year old man is reviewed and discovered to be dependent on Temazepam which was prescribed for him as a hypnotic. He wants to end his addiction and requests help. What is the most appropriate strategy?

      Your Answer:

      Correct Answer: Switch to the equivalent diazepam dose then slowly withdraw over the next 2 months

      Explanation:

      Temazepam is a medication that is often prescribed for the treatment of short-term insomnia. It belongs to the benzodiazepine family of drugs and is classed as intermediate-acting, meaning that it can take between six and twenty-four hours for the drug to take effect.

      Although it is known that shorter-acting benzodiazepines are more harmful and more likely to cause addiction, temazepam is, nevertheless, a highly addictive drug. It should not be taken for longer than four weeks.

      -Adverse effects associated with the use of benzodiazepine hypnotics (to which the elderly are most vulnerable) include confusion, over sedation, increased risks of falls and consequent fractures

      -Withdrawal from a benzodiazepine hypnotic must be agreed between the clinician and the patient – patients should never be forced or threatened. The risks of continued benzodiazepine use should be explained. An agreed schedule for reduction of and gradual withdrawal from the benzodiazepine hypnotic should also be agreed. This will involve substitution of the hypnotic with a long-acting benzodiazepine (e.g. diazepam) and a subsequent gradual reduction in dose of the substituted benzodiazepine -the substituted benzodiazepine can then be withdrawn in steps of about one-eighth to one-tenth every fortnight
      Example: withdrawal schedule for patient on temazepam 20mg nocte
      week 1 – temazepam 10mg, diazepam 5mg
      week 2 – stop temazepam, diazepam 10mg
      week 4 – diazepam 9mg
      week 6 – diazepam 8mg
      continue reducing dose of diazepam by 1mg every fortnight – tapering of dose may be slower if necessary

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  • Question 35 - A 22-year-old, thin drama student presents with weakness and muscle cramps. She has...

    Incorrect

    • A 22-year-old, thin drama student presents with weakness and muscle cramps. She has a past medical history of reflux and bronchial asthma, for which she takes lansoprazole 30mg once daily, inhaled salbutamol PRN, and a once-daily inhaled corticosteroid. She reports feeling stressed lately as she has a leading role in a significant stage production due to open in one week. Her heart rate is 87 bpm, blood pressure 103/71mmHg, respiratory rate 13/min. Her blood results are: pH: 7.46 Na+: 138 mmol/L, K+: 2.8 mmol/L, Chloride: 93 mmol/L, Magnesium: 0.61 mmol/L, What is the most likely aetiology for her symptoms?

      Your Answer:

      Correct Answer: Bulimia

      Explanation:

      The most probable diagnosis considering hypochloraemia and the mild metabolic alkalosis as well as the history of GERD (requiring a high dose of PPI to control) would be bulimia.

      Other options:
      Diuretic abuse tends to give a hypochloraemic acidosis.
      Gitelman syndrome also fits the diagnosis but, it is very rare compared to bulimia.
      Inhaled steroid use and stress would not be responsible for such marked electrolyte derangement.

      Other potential signs of bulimia nervosa would be parotid gland swelling and dental enamel erosion induced by regular vomiting.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 36 - Which selective serotonin reuptake inhibitors listed below has the highest incidence of discontinuation...

    Incorrect

    • Which selective serotonin reuptake inhibitors listed below has the highest incidence of discontinuation symptoms?

      Your Answer:

      Correct Answer: Paroxetine

      Explanation:

      A couple of papers written by the same authors indicate that children and adolescents taking an SSRI definitely experience discontinuation reactions that can be mild, moderate or severe when the medication is stopped suddenly or high doses are reduced substantially. Among the SSRIs paroxetine seems to be the worst offender and fluoxetine the least while sertraline and fluvoxamine tend to be intermediate. The rate of discontinuation syndrome varies with the particular SSRI involved. It is generally quoted as 25% but is higher for SSRIs with shorter half-lives. Paroxetine has been associated with more frequent discontinuation symptoms than the other SSRIs.

      The use of fluoxetine with its long half-life appears safer in this respect than paroxetine and venlafaxine causing the most concerns.

      Paroxetine has the shortest half-life with 21 hours of all listed SSRIs and as such it would be expected to have a higher incidence or severity (greater number of symptoms) and fluoxetine would have the least since it has a half life of 96 hours. Citalopram has a half-life of 35 hours while escitalopram has a half-life of 30 hours.

      The most common symptoms reported are: dizziness, light-headedness, drowsiness, poor concentration, nausea, headache and fatigue.
      Another common symptom in adults is paraesthesia described as burning, tingling, numbness or electric shock feelings usually in the upper half of the body or proximal lower limbs.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 37 - A 43 year old ex-marine who has a history of post-traumatic stress disorder...

    Incorrect

    • A 43 year old ex-marine who has a history of post-traumatic stress disorder visits the office for a review. He is reluctant to try cognitive behavioural therapy. Which medication could be useful in this patient?

      Your Answer:

      Correct Answer: Mirtazapine

      Explanation:

      Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by stressful, frightening or distressing events.

      PTSD is a lasting consequence of traumatic ordeals that cause intense fear, helplessness, or horror, such as a sexual or physical assault, the unexpected death of a loved one, an accident, war, or natural disaster. Families of victims can also develop PTSD, as can emergency personnel and rescue workers.

      PTSD is diagnosed after a person experiences symptoms for at least one month following a traumatic event. However symptoms may not appear until several months or even years later. The disorder is characterized by three main types of symptoms:
      -Re-experiencing the trauma through intrusive distressing recollections of the event, flashbacks, and nightmares.
      -Emotional numbness and avoidance of places, people, and activities that are reminders of the trauma.
      -Increased arousal such as difficulty sleeping and concentrating, feeling jumpy, and being easily irritated and angered.

      The goal of PTSD treatment is to reduce the emotional and physical symptoms, to improve daily functioning, and to help the person better cope with the event that triggered the disorder. Treatment for PTSD may involve psychotherapy (a type of counselling), medication, or both.

      Eye Movement Desensitization and Reprocessing (EMDR) therapy was initially developed in 1987 for the treatment of posttraumatic stress disorder (PTSD) and is guided by the Adaptive Information Processing model. EMDR is an individual therapy typically delivered one to two times per week for a total of 6-12 sessions, although some people benefit from fewer sessions. Sessions can be conducted on consecutive days.

      Drug treatments (paroxetine, mirtazapine, amitriptyline or phenelzine) should be considered for the treatment of PTSD when a sufferer expresses a preference to not engage in trauma-focused psychological treatment.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 38 - Which of the following would suggest an increase risk of suicide in a...

    Incorrect

    • Which of the following would suggest an increase risk of suicide in a patient with a history of depression?

      Your Answer:

      Correct Answer: History of arm cutting

      Explanation:

      Risk factors specific to depression:
      -Family history of mental disorder.
      -History of previous suicide attempts (this includes self-harm).
      -Severe depression.
      -Anxiety.
      -Feelings of hopelessness.
      -Personality disorder.
      -Alcohol abuse and/or drug abuse.
      -Male gender.

      Protective Factors for Suicide.
      Protective factors buffer individuals from suicidal thoughts and behaviour. To date, protective factors have not been studied as extensively or rigorously as risk factors. Identifying and understanding protective factors are, however, equally as important as researching risk factors.

      Protective Factors:
      -Effective clinical care for mental, physical, and substance abuse disorders
      -Easy access to a variety of clinical interventions and support for help seeking
      -Family and community support (connectedness)
      -Support from ongoing medical and mental health care relationships
      -Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes
      -Cultural and religious beliefs that discourage suicide and support instincts for self-preservation

    • This question is part of the following fields:

      • Psychiatry
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  • Question 39 - A 45-year-old man presents with haematemesis. His consumption of alcohol has been estimated...

    Incorrect

    • A 45-year-old man presents with haematemesis. His consumption of alcohol has been estimated to be 120 units per week. Following alcohol withdrawal, when is the peak incidence of seizures expected in this patient?

      Your Answer:

      Correct Answer: 36 hours

      Explanation:

      The peak incidence of seizures is expected 36 hours following the onset of alcohol withdrawal.

      Pathophysiology:
      Chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors. Alcohol withdrawal is thought to lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission).

      Clinical course in alcohol withdrawal:
      Symptoms begin 6-12 hours following the onset of alcohol withdrawal
      Seizures occur 36 hours following the onset of withdrawal
      Delirium tremens (coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia) occurs approximately 72 hours after the onset of alcohol withdrawal.

      Management
      First-line: benzodiazepines e.g. lorazepam, chlordiazepoxide.
      Carbamazepine is also effective in the treatment of alcohol withdrawal.
      Phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 40 - A 46 year old woman with a history of depression visits the clinic...

    Incorrect

    • A 46 year old woman with a history of depression visits the clinic for a review. She was started on Fluoxetine 7 weeks earlier and is requesting that this medication be stopped because she feels well. What recommendation would you give with regards to the treatment?

      Your Answer:

      Correct Answer: It should be continued for at least another 6 months

      Explanation:

      Depressive disorders require long-term treatment with antidepressants, psychotherapy, or both. The goal of antidepressant therapy is complete remission of symptoms and return to normal daily functioning. Studies have shown that achieving remission and continuing antidepressant therapy long after the acute symptoms remit can protect against the relapse or recurrence of the psychiatric episode. Many patients, however, inadvertently or intentionally skip doses of their antidepressant, and even discontinue it, if their symptoms improve or if they experience side effects. Antidepressant discontinuation may increase the risk of relapse or precipitate certain distressing symptoms such as gastrointestinal complaints, dizziness, flu-like symptoms, equilibrium disturbances, and sleep disorders.

      Pharmacologic therapy should be continued long enough to sustain remission and avoid relapses and recurrences. Recurrence refers to a return of depression at a time beyond the expected duration of the index episode (> 9 months after remission). This means that physicians and patients alike should not be too eager to discontinue medication prematurely. An interval of 6 months has been thought to be the usual duration of antidepressant therapy. New recommendations, however, suggest that treatment should continue for up to 9 months after symptoms have resolved (continuation phase) to prevent relapse and for longer to help prevent recurrence (maintenance phase).

      SSRI discontinuation symptoms are similar to those of the TCAs, with dizziness, gastrointestinal symptoms, and sleep disorders common. Anecdotal reports have included complaints of “electric shock–like” sensations, flashes, and “withdrawal buzz.” The type and severity of the symptoms correlate with the relative affinities of the agents for the serotonin reuptake sites and with secondary effects on other neurotransmitters; with SRIs that also affect cholinergic systems, the symptoms possibly correlate with cholinergic rebound.

    • This question is part of the following fields:

      • Psychiatry
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