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  • Question 1 - An 87-year-old man who lives in a care home is reported missing after...

    Incorrect

    • An 87-year-old man who lives in a care home is reported missing after breakfast. The care home actively tries to find him but is not able to for the next few hours. A police report is made, and later that day, the man is found wandering two streets away from the care home. He is brought back to the care home, and the care home is concerned that he might try to get out again. The nurse caring for the patient reports that the man has been trying to get out of the care home for the past few weeks but did not manage to do so, as they were able to prevent him on time. The care home wants to fit a lock to the patient’s room door to restrict his mobility during busy times of the day when limited staff are available to make sure he does not get out. The patient is medically stable, has a diagnosis of dementia, and is known to lack capacity to make a decision about his treatment and freedom.
      Which of the following is the best course of action for this patient?

      Your Answer: Nothing as the patient has autonomy and should be free

      Correct Answer: The patient can be restricted for seven days under urgent DoLS authorisation

      Explanation:

      Understanding Urgent DoLS Authorisation

      In situations where a person’s best interest requires the authorisation of Deprivation of Liberty Safeguards (DoLS) but there is not enough time for a standard authorisation, an urgent authorisation can be applied for by the care home manager or hospital. This allows the individual to be deprived of their liberty for up to seven days. It is important to note that this can only be done if it is in the person’s best interest.

      In the case of a patient who lacks capacity, they cannot make decisions regarding their freedom and treatment. Therefore, the option of allowing the patient to be free is not applicable. However, if the patient is medically stable and does not require hospital admission, they should not be admitted.

      It is crucial to understand that an urgent DoLS authorisation can only be applied for seven days, not 21 days. Additionally, the Mental Health Act 1983 is not appropriate for detaining patients who are not in the hospital for assessment or treatment.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 2 - A 32-year-old female is initiated on haloperidol for treatment-resistant schizophrenia. She visits her...

    Incorrect

    • A 32-year-old female is initiated on haloperidol for treatment-resistant schizophrenia. She visits her primary care physician with a complaint of neck pain and limited neck movement for the past 24 hours. Upon examination, she displays normal vital signs except for a mild tachycardia of 105 and neck stiffness with restricted range of motion. Her neck is involuntarily flexed towards the right. Her facial movements are normal. What is the probable diagnosis?

      Your Answer: Tardive dyskinesia

      Correct Answer: Torticollis

      Explanation:

      The patient is exhibiting symptoms of acute dystonia, which is characterized by sustained muscle contractions such as torticollis or oculogyric crisis. In this case, the patient’s symptoms are likely a result of starting a typical antipsychotic medication, specifically haloperidol. Torticollis, or a wry neck, is present with unilateral pain and deviation of the neck, restricted range of motion, and pain upon palpation. While neuroleptic malignant syndrome is a medical emergency that can occur in patients taking antipsychotics, the patient’s lack of altered mental state and normal observations make it unlikely. An oculogyric crisis, which involves sustained upward deviation of the eyes, clenched jaw, and hyperextension of the back/neck with torticollis, is another example of acute dystonia, but the patient does not exhibit any facial signs or symptoms. Tardive dyskinesia, on the other hand, is a condition that occurs in patients on long-term typical antipsychotics and is characterized by uncontrolled facial movements such as lip-smacking.

      Antipsychotics are a group of drugs used to treat schizophrenia, psychosis, mania, and agitation. They are divided into two categories: typical and atypical antipsychotics. The latter were developed to address the extrapyramidal side-effects associated with the first generation of typical antipsychotics. Typical antipsychotics work by blocking dopaminergic transmission in the mesolimbic pathways through dopamine D2 receptor antagonism. They are associated with extrapyramidal side-effects and hyperprolactinaemia, which are less common with atypical antipsychotics.

      Extrapyramidal side-effects (EPSEs) are common with typical antipsychotics and include Parkinsonism, acute dystonia, sustained muscle contraction, akathisia, and tardive dyskinesia. The latter is a late onset of choreoathetoid movements that may be irreversible and occur in 40% of patients. The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients, including an increased risk of stroke and venous thromboembolism. Other side-effects include antimuscarinic effects, sedation, weight gain, raised prolactin, impaired glucose tolerance, neuroleptic malignant syndrome, reduced seizure threshold, and prolonged QT interval.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 3 - A middle-aged couple visits the clinic with concerns about the husband's behavior. The...

    Correct

    • A middle-aged couple visits the clinic with concerns about the husband's behavior. The wife reports that her partner has been acting strangely, constantly checking on their son throughout the day and night, sometimes up to twenty times. When questioned, he reveals that he had a frightening experience with his son last month and cannot stop reliving it in his mind. He avoids going to places where he might lose sight of his son and has trouble sleeping. There is no significant medical or psychiatric history. What is the most probable diagnosis?

      Your Answer: Post traumatic stress disorder (PTSD)

      Explanation:

      Understanding Post-Traumatic Stress Disorder (PTSD)

      Post-traumatic stress disorder (PTSD) is a mental health condition that can develop in individuals of any age following a traumatic event. This can include experiences such as natural disasters, accidents, or even childhood abuse. PTSD is characterized by a range of symptoms, including re-experiencing the traumatic event through flashbacks or nightmares, avoidance of situations or people associated with the event, hyperarousal, emotional numbing, depression, and even substance abuse.

      Effective management of PTSD involves a range of interventions, depending on the severity of the symptoms. Single-session interventions are not recommended, and watchful waiting may be used for mild symptoms lasting less than four weeks. Military personnel have access to treatment provided by the armed forces, while trauma-focused cognitive behavioral therapy (CBT) or eye movement desensitization and reprocessing (EMDR) therapy may be used in more severe cases.

      It is important to note that drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used, venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline, should be tried. In severe cases, NICE recommends that risperidone may be used. Overall, understanding the symptoms and effective management of PTSD is crucial in supporting individuals who have experienced traumatic events.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 4 - A 30-year-old bipolar woman has been readmitted to the hospital after attempting to...

    Correct

    • A 30-year-old bipolar woman has been readmitted to the hospital after attempting to harm herself. She is currently stable. What form of psychotherapy would be most appropriate in this case?

      Your Answer: Cognitive behavioural therapy

      Explanation:

      Psychotherapy Options for Schizophrenia

      There are several psychotherapy options available for individuals with schizophrenia. Cognitive behavioural therapy (CBT) is a structured, goal-directed, problem-focused, and time-limited therapy that combines principles of both behavioural and cognitive therapy. It focuses on the environment, behaviour, and cognition simultaneously. Brief psychodynamic psychotherapy primarily relies on insight, bringing unconscious or unclear material into awareness, and linking past and present experiences to address the patient’s difficulties. Interpersonal therapy is derived partially from a psychodynamic perspective and focuses primarily on the patient’s interpersonal relationships. It is fairly non-directive and addresses issues such as grief, role transitions, interpersonal role disputes, and interpersonal deficits as they relate to the patient’s current symptoms.

      Family therapy is another option that helps family members learn about the disorder, solve problems, and cope more constructively with the patient’s illness. There is evidence that family interventions can reduce relapse rates in schizophrenia. Systemic desensitisation is an exposure-based behavioural treatment that utilises gradual, systematic, repeated exposure to the feared object or situation to allow patients with anxiety disorders to become desensitised to the feared stimulus.

      The decision between CBT and family therapy would be highly influenced by patient preference. However, if only CBT is presented as an option, it would be the appropriate choice. It is important to consider the different psychotherapy options available and choose the one that best suits the patient’s needs and preferences.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 5 - A 45-year-old man with a history of schizophrenia no longer reports hallucinations or...

    Correct

    • A 45-year-old man with a history of schizophrenia no longer reports hallucinations or delusions. However, he spends many hours doing nothing, has trouble reading a book or watching a film and rarely speaks spontaneously or fluently. His grooming is poor and he is socially withdrawn.
      What is a positron emission tomography (PET) scan most likely to show?

      Your Answer: Hypoactivity of the prefrontal lobes, enlarged cerebral ventricles

      Explanation:

      Brain Function and Psychiatric Disorders: PET Scan Findings

      Major psychiatric syndromes, such as schizophrenia, mania, and depression, involve alterations in sensory processing, volitional behavior, environmental adaptation, and regulation of strong emotions. PET scans have shown that hypoactivity of the prefrontal lobes and enlarged cerebral ventricles are most likely to be associated with schizophrenia. On the other hand, hyperactivity of the prefrontal lobes is linked to obsessive-compulsive disorder (OCD). The prefrontal cortex plays a crucial role in planning, temporal sequencing, abstract thought, problem-solving, motility, attention, and the modulation of emotion. Lesions of these pathways impair pursuit of goal-oriented activity. PET scans have also revealed decreased metabolic activity in the temporal lobes in some patients with schizophrenia. However, increased occipital lobe activity is not likely to be seen on PET scans. Additionally, symmetrical enlargement of cerebral ventricles is a well-validated finding in patients suffering from schizophrenia.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 6 - A 35-year-old male with a history of daily alcohol consumption for the last...

    Correct

    • A 35-year-old male with a history of daily alcohol consumption for the last five years is admitted to the hospital emergency room. He is experiencing acute visual hallucinations, seeing spiders all around him, and is unable to recognize his family members. He is also exhibiting aggressive behavior and tremors. The patient had stopped drinking alcohol for two days prior to admission. On examination, he has a blood pressure of 170/100 mmHg, tremors, increased psychomotor activity, fearful affect, hallucinatory behavior, disorientation, impaired judgment, and insight. What is the most likely diagnosis?

      Your Answer: Delirium tremens

      Explanation:

      Delirium Tremens

      Delirium tremens (DT) is a severe and potentially life-threatening condition that can occur when someone abruptly stops drinking alcohol. Symptoms can begin within a few hours of cessation, but they may not peak until 48-72 hours later. The symptoms of DT can include tremors, irritability, insomnia, nausea and vomiting, hallucinations (auditory, visual, or olfactory), confusion, delusions, severe agitation, and seizures. Physical findings may be non-specific and include tachycardia, hyperthermia, hypertension, tachypnea, diaphoresis, tremor, mydriasis, ataxia, altered mental status, hallucinations, and cardiovascular collapse.

      It is important to note that not everyone who stops drinking alcohol will experience DT. However, those who have a history of heavy alcohol use or have experienced withdrawal symptoms in the past are at a higher risk. DT can be a medical emergency and requires immediate treatment.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 7 - A 27-year-old woman presents with a 3-day history of inability to use her...

    Incorrect

    • A 27-year-old woman presents with a 3-day history of inability to use her right arm. She has been staying with her mother for the past 5 days after experiencing domestic abuse from her husband. The patient reports feeling very stressed. She denies any history of trauma. On examination, there is normal tone and reflexes but 0/5 power in all muscle groups of the right upper limb. The affected arm falls to the patient's side when held above her face and released. What is the probable diagnosis?

      Your Answer: Somatisation disorder

      Correct Answer: Conversion disorder

      Explanation:

      The probable diagnosis for this patient is conversion disorder, which is a psychiatric condition that involves the loss of motor or sensory function and is often caused by stress. There is no evidence of neurological disease in the patient’s history or clinical findings. The condition is likely triggered by recent domestic abuse and stress. The patient also exhibits a positive drop-arm test, which is a controlled drop of the arm to prevent it from hitting the face, and is an unconscious manifestation of psychological stress.

      Acute stress disorder is a condition that occurs after life-threatening experiences, such as abuse, and is characterized by symptoms of hyperarousal, re-experiencing of the traumatic event, avoidance of stimuli, and distress. However, it does not involve physical weakness. It typically lasts between 3 days and 1 month.

      Post-traumatic stress disorder is another condition that occurs after life-threatening experiences, such as abuse, and has similar symptoms to acute stress disorder. However, it lasts longer than 1 month.

      Patients with somatisation disorder have multiple bodily complaints that last for months to years and persistent anxiety about their symptoms. However, based on this patient’s history and physical findings, conversion disorder is the most likely diagnosis.

      Given the patient’s normal tone and reflexes and the absence of trauma to the neck or spine, it is highly unlikely that a spinal cord lesion is causing total arm paralysis.

      Psychiatric Terms for Unexplained Symptoms

      There are various psychiatric terms used to describe patients who exhibit symptoms for which no organic cause can be found. One such disorder is somatisation disorder, which involves the presence of multiple physical symptoms for at least two years, and the patient’s refusal to accept reassurance or negative test results. Another disorder is illness anxiety disorder, which is characterized by a persistent belief in the presence of an underlying serious disease, such as cancer, despite negative test results.

      Conversion disorder is another condition that involves the loss of motor or sensory function, and the patient does not consciously feign the symptoms or seek material gain. Patients with this disorder may be indifferent to their apparent disorder, a phenomenon known as la belle indifference. Dissociative disorder, on the other hand, involves the process of ‘separating off’ certain memories from normal consciousness, and may manifest as amnesia, fugue, or stupor. Dissociative identity disorder (DID) is the most severe form of dissociative disorder and was previously known as multiple personality disorder.

      Factitious disorder, also known as Munchausen’s syndrome, involves the intentional production of physical or psychological symptoms. Finally, malingering is the fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain. Understanding these psychiatric terms can help healthcare professionals better diagnose and treat patients with unexplained symptoms.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 8 - A 47-year-old man is prescribed haloperidol, a first-generation antipsychotic, for an acute psychotic...

    Correct

    • A 47-year-old man is prescribed haloperidol, a first-generation antipsychotic, for an acute psychotic episode. He had previously been on olanzapine, a second-generation antipsychotic, but discontinued it due to adverse reactions. What adverse effect is he more prone to encounter with this new medication in comparison to olanzapine?

      Your Answer: Torticollis

      Explanation:

      Antipsychotic medications can cause acute dystonic reactions, which are more frequently seen with first-generation antipsychotics like haloperidol. These reactions may include dysarthria, torticollis, opisthotonus, and oculogyric crises. Atypical antipsychotics are more likely to cause diabetes mellitus and dyslipidemia, while neither typical nor atypical antipsychotics are commonly associated with osteoporosis.

      Antipsychotics are a group of drugs used to treat schizophrenia, psychosis, mania, and agitation. They are divided into two categories: typical and atypical antipsychotics. The latter were developed to address the extrapyramidal side-effects associated with the first generation of typical antipsychotics. Typical antipsychotics work by blocking dopaminergic transmission in the mesolimbic pathways through dopamine D2 receptor antagonism. They are associated with extrapyramidal side-effects and hyperprolactinaemia, which are less common with atypical antipsychotics.

      Extrapyramidal side-effects (EPSEs) are common with typical antipsychotics and include Parkinsonism, acute dystonia, sustained muscle contraction, akathisia, and tardive dyskinesia. The latter is a late onset of choreoathetoid movements that may be irreversible and occur in 40% of patients. The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients, including an increased risk of stroke and venous thromboembolism. Other side-effects include antimuscarinic effects, sedation, weight gain, raised prolactin, impaired glucose tolerance, neuroleptic malignant syndrome, reduced seizure threshold, and prolonged QT interval.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 9 - A 42-year-old woman is seen in the clinic after a recent visit to...

    Correct

    • A 42-year-old woman is seen in the clinic after a recent visit to the psychiatrist who recommended an increase in her lithium dose for better symptom control. Her renal function is stable and you prescribe the recommended dose increase. When should her levels be re-checked?

      Your Answer: In 1 week

      Explanation:

      Lithium levels should be monitored weekly after a change in dose until they become stable. This means that after an increase in lithium dose, the levels should be checked again after one week, and then weekly until they stabilize. The ideal time to check lithium levels is 12 hours after the dose is taken. Waiting for a month after a dose adjustment is too long, while checking after three days is too soon. Once the levels become stable, they can be checked every three months for the first year. After a year, if the levels remain stable, low-risk patients can have their lithium testing reduced to every six months, according to the BNF. However, NICE guidance recommends that three-monthly testing should continue indefinitely. Additionally, patients on lithium should have their thyroid function tests monitored every six months.

      Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in treatment-resistant depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. The mechanism of action is not fully understood, but it is believed to interfere with inositol triphosphate and cAMP formation. Adverse effects may include nausea, vomiting, diarrhea, fine tremors, nephrotoxicity, thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, hyperparathyroidism, and hypercalcemia.

      Monitoring of patients taking lithium is crucial to prevent adverse effects and ensure therapeutic levels. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until levels are stable. Once established, lithium levels should be checked every three months. Thyroid and renal function should be monitored every six months. Patients should be provided with an information booklet, alert card, and record book to ensure proper management of their medication. Inadequate monitoring of patients taking lithium is common, and guidelines have been issued to address this issue.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 10 - A 35-year-old man presents to a psychiatrist after his wife demands he sees...

    Correct

    • A 35-year-old man presents to a psychiatrist after his wife demands he sees someone to manage his ‘endless nagging’. He has no interest in being here. He reports that his wife is always frustrating him because she simply will not do things the right way. He cites frequent eruptions over how to load the dishwasher properly and how his wife continues to load it improperly. When asked what happens if she loads it her way, the patient describes feeling frustrated that it is not loaded the right way and expressing his frustration to his wife. When asked what he hopes to get out of this visit, the patient wants to learn if there are better ways of effectively communicating the right way to do things.

      Which of the following is most likely?

      Your Answer: Obsessive-compulsive personality disorder (OCPD)

      Explanation:

      The patient’s behavior of being fixated on the right way to load a dishwasher could be indicative of either obsessive-compulsive personality disorder (OCPD) or obsessive-compulsive disorder (OCD). The key difference between the two is whether or not the individual experiences distress over their obsession. In this case, the patient does not seem to experience any distress and instead wants to control how his wife loads the dishwasher. This suggests OCPD rather than OCD. Histrionic personality disorder, antisocial personality disorder, and narcissistic personality disorder are not as applicable to this situation.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 11 - A 20-year-old woman presents to her General Practitioner (GP) with a 2-year history...

    Correct

    • A 20-year-old woman presents to her General Practitioner (GP) with a 2-year history of restricting food intake and self-induced vomiting. She attends her GP for the first time with her sibling reporting a recent worsening of her symptoms. The GP suspects anorexia nervosa.
      Which is the most appropriate investigation to determine whether the patient requires urgent hospital admission?

      Your Answer: Electrocardiogram (ECG)

      Explanation:

      Medical Investigations for Anorexia Nervosa: What to Expect

      Anorexia nervosa is a serious eating disorder that can have significant impacts on a person’s physical health, including their cardiovascular system. When assessing a patient with anorexia nervosa, there are several medical investigations that may be considered. Here is what you can expect:

      Electrocardiogram (ECG): This is a baseline test that assesses heart rate and the QT interval. Electrolyte imbalances caused by eating disorders can affect cardiac stability, so it’s important to check for any cardiovascular instability.

      24-hour Holter monitor: This test may be considered if there is a problem with the baseline ECG or a history of cardiac symptoms such as palpitations.

      Chest X-ray: This is not routinely required unless there are other respiratory symptoms present.

      Serum prolactin: This test is not routinely required unless there is a history of galactorrhoea or amenorrhoea.

      Transthoracic echocardiography: This test is not routinely required unless there are clinical indications for imaging of the heart.

      Overall, medical investigations for anorexia nervosa are tailored to the individual patient’s needs and medical history. It’s important to work closely with a healthcare provider to determine which tests are necessary for each patient.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 12 - A 42-year-old man comes to the Emergency Department claiming that he is infested...

    Correct

    • A 42-year-old man comes to the Emergency Department claiming that he is infested with fleas. He reports feeling extremely itchy and is requesting treatment. This is his fourth visit in the past year for this issue. The patient has no notable medical history and denies using any illicit drugs. He drinks 12 units of alcohol per week and is employed full-time as a teacher.

      What is the probable diagnosis?

      Your Answer: Delusional parasitosis

      Explanation:

      The correct diagnosis for a patient who has a fixed, false belief that they are infested by bugs is delusional parasitosis. This rare condition can occur on its own or alongside other psychiatric disorders, but typically does not significantly impair the patient’s daily functioning. Capgras syndrome, delirium tremens, and Fregoli syndrome are all incorrect diagnoses for this particular case.

      Understanding Delusional Parasitosis

      Delusional parasitosis is a condition that is not commonly known but can be debilitating for those who suffer from it. It is characterized by a persistent and false belief that one is infested with bugs, parasites, mites, bacteria, or fungus. This delusion can occur on its own or in conjunction with other psychiatric conditions. Despite the delusion, patients may still be able to function normally in other aspects of their lives.

      In simpler terms, delusional parasitosis is a rare condition where a person believes they have bugs or other organisms living on or inside their body, even though there is no evidence to support this belief. This can cause significant distress and anxiety for the individual, and they may go to great lengths to try and rid themselves of the perceived infestation. It is important for those who suspect they may be suffering from delusional parasitosis to seek professional help, as treatment can greatly improve their quality of life.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 13 - A 35-year-old male with a history of agoraphobia for the past 3 months...

    Incorrect

    • A 35-year-old male with a history of agoraphobia for the past 3 months presents for a telemedicine consultation to discuss his current issues. He reports feeling unable to leave his home due to a fear of contamination and illness. He explains that he feels the outside world is too dirty and that he will become sick and die if he leaves his house. He also reports washing his hands six times with soap and water after touching anything, which has resulted in his hands becoming dry, cracked, and erythematosus. He has lost his job as a result of missing deadlines and not being able to complete his work due to his compulsive hand washing behavior. Despite his awareness of the negative impact of his behavior, he feels unable to stop himself from washing his hands exactly six times every time.

      During the telemedicine consultation, his mental state examination is unremarkable. However, upon requesting to see his hands over the video conversation, it is noted that they appear dry, cracked, and erythematosus.

      What is the most appropriate management strategy for this patient?

      Your Answer: Intensive exposure and response prevention (ERP)

      Correct Answer: SSRI and CBT (including ERP)

      Explanation:

      Obsessive-compulsive disorder (OCD) is characterized by the presence of obsessions and/or compulsions that can cause significant functional impairment and distress. Risk factors include family history, age, pregnancy/postnatal period, and history of abuse, bullying, or neglect. Treatment options include low-intensity psychological treatments, SSRIs, and more intensive CBT (including ERP). Severe cases should be referred to the secondary care mental health team for assessment and may require combined treatment with an SSRI and CBT or clomipramine as an alternative. ERP involves exposing the patient to an anxiety-provoking situation and stopping them from engaging in their usual safety behavior. Treatment with SSRIs should continue for at least 12 months to prevent relapse and allow time for improvement.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 14 - A 55-year-old man with a history of paranoid schizophrenia experiences a recurrence of...

    Incorrect

    • A 55-year-old man with a history of paranoid schizophrenia experiences a recurrence of symptoms due to irregular medication intake, leading to his admission under section 2 of the Mental Health Act following a formal mental state assessment. He had been taking Risperidone orally once daily for several years, which had effectively stabilized his mental state while living in the community. Considering his non-adherence, what treatment option would be most appropriate for this individual?

      Your Answer: Referral to the home treatment team to administer medication

      Correct Answer: Switching to a once monthly IM anti-psychotic depo injection

      Explanation:

      Patients who struggle with taking their antipsychotic medication as prescribed may benefit from receiving a once monthly intramuscular depo injection. It is important to maintain a stable mental state and overall well-being for these patients, and switching medications can increase the risk of relapse and recurring symptoms. The goal is to provide the least restrictive treatment possible and minimize hospitalization time as outlined by the Mental Health Act. While daily visits from a home treatment team to administer medication may be a temporary solution, it is not a sustainable long-term option. Similarly, a once-daily intramuscular injection may not be practical or feasible for the patient.

      Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.

      Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 15 - A 35-year-old woman arrives at the emergency department with symptoms of restlessness and...

    Incorrect

    • A 35-year-old woman arrives at the emergency department with symptoms of restlessness and confusion that have been present for one day. Upon further examination, she is found to have an elevated heart rate and body temperature. The patient has a history of depression and has been taking sertraline for several years without any changes in dosage or overdose incidents. However, her partner reports that she was recently prescribed a new medication by her general practitioner, which may have interacted with her regular medication. What is the most likely medication responsible for this interaction?

      Your Answer: Omeprazole

      Correct Answer: Zolmitriptan

      Explanation:

      Patients who are taking a SSRI should not use triptans.

      Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.

      The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.

      When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.

      When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 16 - A 22-year-old first-year graduate student presents to the Student Health Clinic because she...

    Correct

    • A 22-year-old first-year graduate student presents to the Student Health Clinic because she feels depressed. She describes feeling homesick and is so sad that it is interfering with her ability to focus, work or make new friends. Her sleep, appetite and energy have been unaffected. She denies suicidal ideation or feelings of guilt. She thought it would have gotten better by now, but she said it has already been 2 months since she left home and she is still unhappy. She is worried that she is experiencing major depression.
      Which of the following is the most appropriate diagnosis?

      Your Answer: Adjustment disorder

      Explanation:

      Differentiating Adjustment Disorder from Other Mood Disorders

      Adjustment disorder is a type of mood disorder that occurs in response to a major stressor. It is characterized by symptoms of depression or anxiety that present within three months of the stressor and last for less than six months. In contrast, major depressive disorder requires two episodes of major depression with a symptom-free interval, all in two months. Dysthymia, on the other hand, requires a depressive mood for at least two years. Bipolar disorder is characterized by manic symptoms, which the patient in question does not exhibit. Acute stress disorder is associated with psychotic symptoms that last less than one month from an identifiable stressor. Therefore, it is important to differentiate adjustment disorder from other mood disorders to provide appropriate treatment.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 17 - A 25-year-old man with Down syndrome is brought to see the General Practitioner...

    Correct

    • A 25-year-old man with Down syndrome is brought to see the General Practitioner (GP) by his mother to discuss his acne. His mother takes care of all his medications, as he cannot understand the instructions. He lives with his parents and depends on them to do all his cooking and washing. He does not work but attends a day centre a few days per week, where he enjoys craft activities and has a number of close friends. The staff report he is always very polite and interacts well with everyone at the centre. His mother says he is unable to be left alone in the house and cannot go out on his own without the support of another adult.
      Which one of the following conditions does he have?

      Your Answer: Learning disability

      Explanation:

      The patient is unable to function independently and relies on his parents for daily care, indicating a possible diagnosis of a learning disability. This condition is defined by the Department of Health as a significant reduction in the ability to learn new skills and understand complex information, leading to a decreased ability to cope independently. Symptoms must have started before adulthood and have a lasting impact on development. Other potential diagnoses, such as ADHD, autism spectrum disorder, learning difficulty, and oppositional defiant disorder, do not fit the patient’s symptoms and behaviors.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 18 - A 63-year-old man presents to his general practitioner with stiffness in his muscles,...

    Correct

    • A 63-year-old man presents to his general practitioner with stiffness in his muscles, difficulty initiating movements such as getting up from a chair, slow movements and hand shaking, which started 5 weeks ago. He has a medical history of schizophrenia and has had good compliance with his medication for the past 3 months. He is taking haloperidol. On examination, his temperature is 37.5 °C, blood pressure 120/81 mmHg and pulse 98 bpm. On examination, there is decreased facial expression, pill-rolling tremor, cogwheel rigidity and festinating gait.
      Which of the following terms describes the symptoms of this patient?

      Your Answer: Bradykinesia

      Explanation:

      Common Neurological Side Effects of Medications

      Medications can sometimes cause neurological side effects that mimic symptoms of neurological disorders. One such side effect is called pseudo-parkinsonism, which is characterized by bradykinesia or slowness in movements. This can be caused by typical and atypical antipsychotic medication, anti-emetics like metoclopramide, and some calcium channel blockers like cinnarizine.

      Another side effect is acute dystonia, which is the sudden and sustained contraction of muscles in any part of the body, usually following the administration of a neuroleptic agent. Akathisia is another symptom associated with antipsychotic use, which is characterized by restlessness and the inability to remain motionless.

      Tardive dyskinesia is a neurological side effect that is characterized by involuntary muscle movements, usually affecting the tongue, lips, trunk, and extremities. This is seen in patients who are on long-term anti-dopaminergic medication such as antipsychotic medication (both typical and atypical), some antidepressants, metoclopramide, prochlorperazine, carbamazepine, phenytoin, and others.

      Finally, neuroleptic malignant syndrome is a life-threatening condition associated with the use of antipsychotic medication. It is characterized by hyperthermia, muscle rigidity, changes in level of consciousness, and autonomic instability. Management is supportive, and symptoms generally resolve within 1-2 weeks.

      Understanding the Neurological Side Effects of Medications

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      • Psychiatry
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  • Question 19 - A 26-year-old man comes for his scheduled psychiatry visit after being prescribed Risperidone...

    Incorrect

    • A 26-year-old man comes for his scheduled psychiatry visit after being prescribed Risperidone for his recent diagnosis of schizophrenia. Although he has been stable since starting this medication, he reports experiencing milky discharge from both nipples and inquires about alternative medications that can manage his schizophrenia without causing this side effect. What would be the most suitable medication to consider as an alternative?

      Your Answer: Olanzapine

      Correct Answer: Aripiprazole

      Explanation:

      Aripiprazole is the most suitable medication to try for this patient as it has the least side effects among atypical antipsychotics, especially in terms of prolactin elevation. This is important as the patient’s nipple discharge is likely caused by high prolactin levels. Chlorpromazine, a typical antipsychotic, is not recommended as it has a higher risk of extrapyramidal side effects. Clozapine, another atypical antipsychotic, is not appropriate for this patient as it is only used for treatment-resistant schizophrenia and requires two other antipsychotics to be trialled first. Haloperidol, a typical antipsychotic, is also not recommended due to its higher risk of extrapyramidal side effects.

      Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.

      Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.

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      • Psychiatry
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  • Question 20 - A 28-year-old female patient complains of experiencing difficulty sleeping for the past six...

    Correct

    • A 28-year-old female patient complains of experiencing difficulty sleeping for the past six months. She frequently stays awake at night due to worrying about work and family-related stressors. These episodes of anxiety are often accompanied by chest tightness and palpitations. Despite trying mindfulness, sleep hygiene, and reducing caffeine intake, she has not experienced significant improvement and is now considering medication. What would be the most suitable medication to prescribe?

      Your Answer: Sertraline

      Explanation:

      Sertraline is the recommended first-line medication for generalised anxiety disorder (GAD). This is because the patient has already tried non-pharmacological measures with little benefit. Diazepam, a benzodiazepine, is not recommended due to the risk of tolerance and addiction. Duloxetine, a serotonin-norepinephrine reuptake inhibitor (SNRI), is not first-line but may be considered if the patient does not respond to sertraline. Mirtazapine, a noradrenergic and specific serotonergic antidepressant (NaSSA), is not generally recommended for GAD.

      Anxiety is a common disorder that can manifest in various ways. According to NICE, the primary feature is excessive worry about multiple events associated with heightened tension. It is crucial to consider potential physical causes when diagnosing anxiety disorders, such as hyperthyroidism, cardiac disease, and medication-induced anxiety. Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants, and caffeine.

      NICE recommends a step-wise approach for managing generalised anxiety disorder (GAD). This includes education about GAD and active monitoring, low-intensity psychological interventions, high-intensity psychological interventions or drug treatment, and highly specialist input. Sertraline is the first-line SSRI for drug treatment, and if it is ineffective, an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI) such as duloxetine or venlafaxine may be offered. If the patient cannot tolerate SSRIs or SNRIs, pregabalin may be considered. For patients under 30 years old, NICE recommends warning them of the increased risk of suicidal thinking and self-harm and weekly follow-up for the first month.

      The management of panic disorder also follows a stepwise approach, including recognition and diagnosis, treatment in primary care, review and consideration of alternative treatments, review and referral to specialist mental health services, and care in specialist mental health services. NICE recommends either cognitive behavioural therapy or drug treatment in primary care. SSRIs are the first-line drug treatment, and if contraindicated or no response after 12 weeks, imipramine or clomipramine should be offered.

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  • Question 21 - A 78-year-old man is admitted with new-onset confusion. He is usually independent and...

    Correct

    • A 78-year-old man is admitted with new-onset confusion. He is usually independent and enjoys gardening in his spare time. When he didn't show up for his weekly gardening club meeting, a friend went to his house. The friend noticed that the patient appeared disoriented and was speaking nonsensically, prompting them to call for medical assistance.
      What distinguishes delirium from dementia?

      Your Answer: Fluctuating level of consciousness

      Explanation:

      Dementia vs Delirium: Understanding the Differences

      Dementia and delirium are two conditions that can affect cognitive abilities and behavior. While they share some similarities, there are also important differences between them.

      Dementia is a group of neurodegenerative disorders that cause a progressive decline in cognition and/or behavior from previous levels of functioning. It is characterized by a slow, insidious progression and is rarely reversible. Memory loss, executive functioning problems, speech and language difficulties, social interaction loss, personality changes, and visuospatial problems are some of the areas of loss associated with dementia. Mobility and gait disturbances are also common.

      Delirium, on the other hand, is an acute confusional state characterized by a relatively rapid onset and variable, fluctuating progression. It may cause a global reduction in cognitive abilities but is usually reversible if the underlying cause is promptly identified. Common causes include sepsis, medications, metabolic derangement, and causes of raised intracranial pressure.

      While there are some similarities between dementia and delirium, there are also some differences. For example, dementia is never associated with a persistent fluctuating level of consciousness, which is a feature of delirium. Visual hallucinations are present in both delirium and dementia, particularly Lewy body dementia. Impaired memory and dysarthria are also present in both conditions, as is urinary incontinence.

      In summary, understanding the differences between dementia and delirium is important for proper diagnosis and treatment. While both conditions can affect cognitive abilities and behavior, they have distinct features that can help differentiate them.

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      • Psychiatry
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  • Question 22 - A 50-year-old man is brought to the emergency department by the authorities after...

    Incorrect

    • A 50-year-old man is brought to the emergency department by the authorities after causing a disturbance in public. He is visibly anxious and upset, insisting that there are bugs crawling under his skin and that your face is melting. Upon reviewing his medical history, it is evident that he has a history of alcohol abuse and has been in contact with Drug and Alcohol Services. What scoring system would be best suited for assessing this patient once he is stabilized?

      Your Answer: CAGE questionnaire

      Correct Answer: Clinical Institute Withdrawal Assessment (CIWA-Ar)

      Explanation:

      Alcohol withdrawal occurs when an individual who has been consuming alcohol chronically suddenly stops or reduces their intake. Chronic alcohol consumption enhances the inhibitory effects of GABA in the central nervous system, similar to benzodiazepines, and inhibits NMDA-type glutamate receptors. However, alcohol withdrawal leads to the opposite effect, resulting in decreased inhibitory GABA and increased NMDA glutamate transmission. Symptoms of alcohol withdrawal typically start at 6-12 hours and include tremors, sweating, tachycardia, and anxiety. Seizures are most likely to occur at 36 hours, while delirium tremens, which includes coarse tremors, confusion, delusions, auditory and visual hallucinations, fever, and tachycardia, peak at 48-72 hours.

      Patients with a history of complex withdrawals from alcohol, such as delirium tremens, seizures, or blackouts, should be admitted to the hospital for monitoring until their withdrawals stabilize. The first-line treatment for alcohol withdrawal is long-acting benzodiazepines, such as chlordiazepoxide or diazepam, which are typically given as part of a reducing dose protocol. Lorazepam may be preferable in patients with hepatic failure. Carbamazepine is also effective in treating alcohol withdrawal, while phenytoin is said to be less effective in treating alcohol withdrawal seizures.

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      • Psychiatry
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  • Question 23 - A 32-year-old woman visits her GP for a follow-up on her depression. She...

    Correct

    • A 32-year-old woman visits her GP for a follow-up on her depression. She is experiencing mild to moderate symptoms of low mood, anhedonia, poor appetite, and poor sleep, despite completing a full course of cognitive behavioural therapy. Her therapist has recommended medication, and the patient is open to this option. What is the appropriate first-line treatment for her depression?

      Your Answer: Sertraline

      Explanation:

      Antidepressant Medications: Recommended Use and Precautions

      Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for moderate to severe depression or mild depression that has not responded to initial interventions. Tricyclic antidepressants, such as amitriptyline and dosulepin, are not recommended as first-line treatment due to their toxicity in overdose. Dosulepin, in particular, has been linked to cardiac conduction defects and other arrhythmias. Monoamine oxidase inhibitors (MAOIs), like phenelzine, may be prescribed by a specialist in refractory cases but are not recommended as first-line treatment. Venlafaxine, a serotonin and noradrenaline reuptake inhibitor, is also not recommended as first-line treatment due to the risk of hypertension, arrhythmias, and potential toxicity in overdose. It is important to consult with a healthcare provider to determine the most appropriate medication for individual cases of depression.

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      • Psychiatry
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  • Question 24 - A 26-year-old man presents to your clinic six months after he was assaulted...

    Correct

    • A 26-year-old man presents to your clinic six months after he was assaulted on his way home from work. He was mugged and punched in the stomach by his attacker before he fled. Six months later, the patient continues to have severe and incapacitating periumbilical pain where he was punched. He denies any gastrointestinal symptoms or any other issues. Previous investigations and imaging have been unremarkable for any underlying anatomical, neurological or vascular abnormality.
      What is the most appropriate description of the patient's current complaints during the clinic visit?

      Your Answer: Pain disorder

      Explanation:

      Differentiating between Psychiatric Disorders: Pain Disorder, Conversion Disorder, Somatization Disorder, PTSD, and Acute Stress Disorder

      When evaluating a patient with unexplained physical symptoms, it is important to consider various psychiatric disorders that may be contributing to their presentation. In this case, the patient’s symptoms do not fit the criteria for somatization disorder, PTSD, or acute stress disorder. However, there are other disorders that should be considered.

      Pain disorder is characterized by intense, long-standing pain without a somatic explanation. The patient’s pain is out of proportion to the injury and is not explained by any underlying somatic pathology. This disorder is restricted to physical pain and does not include other somatic complaints.

      Conversion disorder, on the other hand, presents as a neurological deficit in the absence of a somatic cause. Patients are usually unconcerned about the symptom, unlike this patient. It usually follows a psychosocial stressor.

      Somatization disorder refers to patients with a constellation of physical complaints that are not explained by a somatic process. This would include odd distributions of pain, numbness, GI upset, headache, nausea, vomiting, shortness of breath, palpitations, etc. However, this patient is fixated on a particular disease and does not fit the criteria for somatization.

      PTSD presents with persistent re-experiencing of the trauma, nightmares, flashbacks, intense fear, avoidant behaviour and/or increased arousal. Symptoms must persist for at least 1 month and impair his quality of life. There are no clear signs of PTSD in this patient.

      Acute stress disorder is an anxiety condition precipitated by an acute stress that resolves within a month. This is well beyond the window for acute stress, and it does not fit the symptomatology of acute stress.

      In conclusion, it is important to consider various psychiatric disorders when evaluating a patient with unexplained physical symptoms. By ruling out certain disorders, a proper diagnosis and treatment plan can be established.

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      • Psychiatry
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  • Question 25 - A 60-year-old man is admitted from the angiography suite after the cardiologist discovered...

    Incorrect

    • A 60-year-old man is admitted from the angiography suite after the cardiologist discovered severe triple vessel disease. He awaits transfer to a tertiary hospital for a coronary artery bypass graft. After 48 hours of admission, you receive a call to see him as he has become confused, sweaty, tremulous, and agitated.

      Upon reviewing his record, you note a history of asthma, variceal bleed, and cirrhosis secondary to alcohol excess. His observations show a pyrexia at 37.9ºC, heart rate of 105 bpm, and blood pressure 175/98 mmHg. What would be the most appropriate immediate intervention given the likely diagnosis?

      Your Answer: IV antibiotics

      Correct Answer: Chlordiazepoxide

      Explanation:

      Chlordiazepoxide or diazepam are effective treatments for delirium tremens and alcohol withdrawal. Symptoms of alcohol withdrawal can include confusion, agitation, tremors, hallucinations, and autonomic dysfunction such as high blood pressure, sweating, and fever.

      Chlordiazepoxide is the most appropriate answer for this scenario. While confusion, sweating, and agitation can be signs of infection, the patient’s alcohol history suggests that delirium tremens is the more likely diagnosis. IV antibiotics would not address the primary issue of alcohol withdrawal. The patient’s high blood pressure also suggests that infection is not the cause of their symptoms.

      Intravenous hydration may be necessary if the patient is experiencing excessive fluid loss due to sweating, but it would not be the best treatment for alcohol withdrawal in this case.

      Alcohol withdrawal occurs when an individual who has been consuming alcohol chronically suddenly stops or reduces their intake. Chronic alcohol consumption enhances the inhibitory effects of GABA in the central nervous system, similar to benzodiazepines, and inhibits NMDA-type glutamate receptors. However, alcohol withdrawal leads to the opposite effect, resulting in decreased inhibitory GABA and increased NMDA glutamate transmission. Symptoms of alcohol withdrawal typically start at 6-12 hours and include tremors, sweating, tachycardia, and anxiety. Seizures are most likely to occur at 36 hours, while delirium tremens, which includes coarse tremors, confusion, delusions, auditory and visual hallucinations, fever, and tachycardia, peak at 48-72 hours.

      Patients with a history of complex withdrawals from alcohol, such as delirium tremens, seizures, or blackouts, should be admitted to the hospital for monitoring until their withdrawals stabilize. The first-line treatment for alcohol withdrawal is long-acting benzodiazepines, such as chlordiazepoxide or diazepam, which are typically given as part of a reducing dose protocol. Lorazepam may be preferable in patients with hepatic failure. Carbamazepine is also effective in treating alcohol withdrawal, while phenytoin is said to be less effective in treating alcohol withdrawal seizures.

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      • Psychiatry
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  • Question 26 - You are asked to see a 50-year-old woman who reports feeling down for...

    Correct

    • You are asked to see a 50-year-old woman who reports feeling down for several months. Upon further questioning, you discover that she has lost interest in activities she previously enjoyed, such as hiking and going to the theater. She has also been experiencing fatigue, causing her to miss work, and has had occasional thoughts of not wanting to be alive, although she denies any intention of harming herself. In the past month, her symptoms have worsened, with episodes of anxiety occurring at least once a week. These episodes last around five minutes and are characterized by hyperventilation, nausea, and a fear of having a heart attack. No physical abnormalities have been found. What is the most likely diagnosis?

      Your Answer: Depression with secondary panic attacks

      Explanation:

      Understanding Different Types of Anxiety and Related Disorders

      Anxiety and related disorders can manifest in various ways, making it important to understand the different types and their symptoms. Depression with secondary panic attacks is a common occurrence, where panic attacks and other anxiety symptoms are a secondary feature of depression. Agoraphobia is an excessive fear of being in situations where escape or help may not be available, leading to avoidance of such situations. Generalised anxiety disorder is characterised by uncontrollable and irrational worry or anxiety about a wide range of issues and situations. Panic disorder is diagnosed when a person has recurrent, severe panic attacks without an obvious precipitant. Chronic fatigue syndrome is characterised by persistent, unexplained fatigue over several months. Understanding these disorders and their symptoms can help in proper diagnosis and treatment.

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  • Question 27 - A 28-year-old male with depression is evaluated by his psychiatrist. He expresses his...

    Correct

    • A 28-year-old male with depression is evaluated by his psychiatrist. He expresses his ongoing depressed mood and shares with his psychiatrist that he experiences a sense of detachment from reality.

      Which term best describes the abnormality exhibited by the patient?

      Your Answer: Depersonalisation

      Explanation:

      Depersonalisation and Derealisation

      Depersonalisation and derealisation are two distinct experiences that can occur in individuals with mental health conditions. Depersonalisation refers to the feeling that one’s own self is not real, while derealisation refers to the feeling that the world around them is not real.

      In depersonalisation, individuals may feel as though they are observing themselves from outside of their body or that they are disconnected from their thoughts and emotions. This can be a distressing experience and may lead to feelings of detachment and isolation.

      On the other hand, derealisation can cause individuals to feel as though the world around them is unreal or dreamlike. This can lead to feelings of confusion and disorientation, as well as difficulty with concentration and memory.

      It is important to note that these experiences can occur in a variety of mental health conditions, including anxiety, depression, and dissociative disorders. While anhedonia, delusions of guilt, and reduced affect display may be present in some individuals with depression, they are not necessarily associated with depersonalisation or derealisation.

      Overall, these experiences can help individuals and their loved ones better recognize and manage symptoms of mental illness.

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  • Question 28 - A 19-year-old male presents to the Emergency Department after consuming eight paracetamol tablets,...

    Correct

    • A 19-year-old male presents to the Emergency Department after consuming eight paracetamol tablets, four cans of strong cider and two mouthfuls of bleach in an attempt to end his life. He reports feeling extremely anxious and low in mood for the past week following a recent argument with his girlfriend. He believes he has no worth in society and thinks he is 'better off dead', hoping his girlfriend will understand how low he has been recently now that he has almost succeeded in ending his own life. He takes no regular medication and has a history of depression for which he sees his GP. He has no relevant family history. He has been to the emergency department with suicide attempts eight times in the last six months. He has no history of deliberate self-harm otherwise.

      What is the necessary feature required for a diagnosis of a personality disorder?

      Your Answer: Over 18 years of age

      Explanation:

      Undesirable personality traits that are pervasive are characteristic of personality disorders. These disorders cause long-term difficulties in interpersonal relationships and functioning in society. Diagnosis is only possible once a person’s personality has fully developed and their adaptive behaviours have become fixed, typically after the age of 18. However, borderline personality disorder may be diagnosed earlier if there is sufficient evidence that the patient has undergone puberty.

      Personality disorders are a set of personality traits that are maladaptive and interfere with normal functioning in life. It is estimated that around 1 in 20 people have a personality disorder, which are typically categorized into three clusters: Cluster A, which includes Odd or Eccentric disorders such as Paranoid, Schizoid, and Schizotypal; Cluster B, which includes Dramatic, Emotional, or Erratic disorders such as Antisocial, Borderline (Emotionally Unstable), Histrionic, and Narcissistic; and Cluster C, which includes Anxious and Fearful disorders such as Obsessive-Compulsive, Avoidant, and Dependent.

      Paranoid individuals exhibit hypersensitivity and an unforgiving attitude when insulted, a reluctance to confide in others, and a preoccupation with conspiratorial beliefs and hidden meanings. Schizoid individuals show indifference to praise and criticism, a preference for solitary activities, and emotional coldness. Schizotypal individuals exhibit odd beliefs and magical thinking, unusual perceptual disturbances, and inappropriate affect. Antisocial individuals fail to conform to social norms, deceive others, and exhibit impulsiveness, irritability, and aggressiveness. Borderline individuals exhibit unstable interpersonal relationships, impulsivity, and affective instability. Histrionic individuals exhibit inappropriate sexual seductiveness, a need to be the center of attention, and self-dramatization. Narcissistic individuals exhibit a grandiose sense of self-importance, lack of empathy, and excessive need for admiration. Obsessive-compulsive individuals are occupied with details, rules, and organization to the point of hampering completion of tasks. Avoidant individuals avoid interpersonal contact due to fears of criticism or rejection, while dependent individuals have difficulty making decisions without excessive reassurance from others.

      Personality disorders are difficult to treat, but a number of approaches have been shown to help patients, including psychological therapies such as dialectical behavior therapy and treatment of any coexisting psychiatric conditions.

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  • Question 29 - A 32-year-old man visits his General Practitioner (GP) for an annual mental health...

    Incorrect

    • A 32-year-old man visits his General Practitioner (GP) for an annual mental health review. He was diagnosed with schizophrenia eight years ago. He has been on medication since diagnosis and takes this daily without any side-effects. He has regular contact with the community mental health team. He is working part-time as a shop assistant, which he enjoys. He has a good appetite, sleeps well and exercises regularly.

      What is true regarding the treatment of schizophrenia in a 32-year-old man who has been diagnosed with the condition for eight years and is currently on medication without any side-effects, has regular contact with the community mental health team, works part-time, and has good appetite, sleep, and exercise habits?

      Your Answer: All patients with schizophrenia require an electrocardiogram (ECG) before starting antipsychotic medication

      Correct Answer: People with a first episode of psychosis should be offered oral antipsychotic treatment, along with psychological interventions

      Explanation:

      Mythbusting: Common Misconceptions About Schizophrenia Treatment

      1. Oral antipsychotic treatment and psychological interventions should be offered to those with a first episode of psychosis.
      2. Patients with schizophrenia should remain under the care of a psychiatrist lifelong, but can be eligible for shared care with a GP after 12 months of stability.
      3. An ECG is only necessary before starting antipsychotic medication in certain circumstances.
      4. Before starting any oral antipsychotic medication, various health factors need to be checked in all patients.
      5. The choice of antipsychotic medication should be made on an individual basis, taking into account potential side-effects.
      6. Early intervention in psychosis services should be accessed urgently for anyone presenting with a first episode of psychosis. Antipsychotic medication should not be initiated in primary care without the advice of a psychiatrist.

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  • Question 30 - A 50-year-old woman presents with complaints of lower back pain, constipation, headaches, low...

    Correct

    • A 50-year-old woman presents with complaints of lower back pain, constipation, headaches, low mood, and difficulty concentrating. Which medication is most likely responsible for her symptoms?

      Your Answer: Lithium

      Explanation:

      Hypercalcaemia, which is indicated by the presented signs and symptoms, can be a result of long-term use of lithium. The mnemonic ‘stones, bones, abdominal moans, and psychic groans’ can be used to identify the symptoms. The development of hyperparathyroidism and subsequent hypercalcaemia is believed to be caused by lithium’s effect on calcium homeostasis, leading to parathyroid hyperplasia. To diagnose this condition, a U&Es and PTH test can be conducted. Unlike lithium, other psychotropic medications are not associated with the development of hyperparathyroidism and hypercalcaemia.

      Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in treatment-resistant depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. The mechanism of action is not fully understood, but it is believed to interfere with inositol triphosphate and cAMP formation. Adverse effects may include nausea, vomiting, diarrhea, fine tremors, nephrotoxicity, thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, hyperparathyroidism, and hypercalcemia.

      Monitoring of patients taking lithium is crucial to prevent adverse effects and ensure therapeutic levels. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until levels are stable. Once established, lithium levels should be checked every three months. Thyroid and renal function should be monitored every six months. Patients should be provided with an information booklet, alert card, and record book to ensure proper management of their medication. Inadequate monitoring of patients taking lithium is common, and guidelines have been issued to address this issue.

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  • Question 31 - A middle-aged man presents with persecutory delusions and auditory hallucinations. His expression appears...

    Incorrect

    • A middle-aged man presents with persecutory delusions and auditory hallucinations. His expression appears to have a reduced affect. He has disorganised speech and thinking.
      What is the most probable diagnosis for this patient?

      Your Answer: Early-onset dementia

      Correct Answer: Schizophrenia

      Explanation:

      Understanding Common Psychiatric Conditions

      Schizophrenia is a prevalent psychiatric condition that affects individuals with positive and negative symptoms, as well as a breakdown in thinking. Positive symptoms include delusions and hallucinations, while negative symptoms refer to reduced mood and blunted affect. Agoraphobia, on the other hand, is an anxiety disorder where patients perceive the outside environment as unsafe. Frontotemporal dementia and early-onset dementia are unlikely presentations for a young patient with disorganized speech and thinking and reduced affect. Endogenous depression, which is more common in women, presents with sudden loss of energy or motivation in daily routines and neurotic thinking, such as anxiety, sleep disturbance, and mood swings. Understanding these conditions can help individuals seek appropriate treatment and support.

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  • Question 32 - Venlafaxine is an antidepressant that is commonly prescribed for the treatment of major...

    Incorrect

    • Venlafaxine is an antidepressant that is commonly prescribed for the treatment of major depression, anxiety, and panic disorder. What is the most accurate description of the mechanism of action of this medication?

      Your Answer: Selective noradrenaline reuptake inhibitors

      Correct Answer: Serotonin and noradrenaline reuptake inhibitor

      Explanation:

      The mechanism of action of venlafaxine involves inhibiting the reuptake of serotonin and noradrenaline, which leads to increased levels of these neurotransmitters in the synaptic space. This is why it is effective in treating depression, as it targets the alpha 2 receptors, noradrenaline, and serotonin.

      Understanding Serotonin and Noradrenaline Reuptake Inhibitors

      Serotonin and noradrenaline reuptake inhibitors (SNRIs) are a type of antidepressant medication that work by increasing the levels of serotonin and noradrenaline in the brain. These neurotransmitters are responsible for regulating mood, emotions, and anxiety levels. By inhibiting the reuptake of these chemicals, SNRIs help to maintain higher levels of serotonin and noradrenaline in the synaptic cleft, which can lead to improved mood and reduced anxiety.

      Examples of SNRIs include venlafaxine and duloxetine, which are commonly used to treat major depressive disorders, generalised anxiety disorder, social anxiety disorder, panic disorder, and menopausal symptoms. These medications are relatively new and have been found to be effective in treating a range of mental health conditions. SNRIs are often preferred over other types of antidepressants because they have fewer side effects and are less likely to cause weight gain or sexual dysfunction.

      Overall, SNRIs are an important class of medication that can help to improve the lives of people struggling with mental health conditions. By increasing the levels of serotonin and noradrenaline in the brain, these medications can help to regulate mood and reduce anxiety, leading to a better quality of life for those who take them.

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  • Question 33 - You are requested to assess a 25-year-old man who has been urgently referred...

    Incorrect

    • You are requested to assess a 25-year-old man who has been urgently referred to the Community Mental Health Team. He has recently left his job to work on 'a groundbreaking project' which he believes will eradicate world poverty. He has also been neglecting his basic needs such as eating and sleeping as he 'cannot afford to waste time on such trivialities'. Upon examination, the patient appears restless and lacks awareness of their condition. The patient has a history of depression and is currently on an antidepressant medication.

      What would be the most suitable course of action in managing this patient?

      Your Answer: Start lithium and continue antidepressant

      Correct Answer: Start antipsychotic and stop antidepressant

      Explanation:

      The appropriate management for a patient experiencing mania/hypomania while taking antidepressants is to discontinue the antidepressant and initiate antipsychotic therapy. This is because the patient’s symptoms, such as delusions of grandeur and hyperactivity, suggest an episode of mania, which requires the use of a rapidly acting antipsychotic or benzodiazepine. Electroconvulsive therapy (ECT) is not typically used for the treatment of mania, and lithium is not the first-line treatment for acute episodes of mania. Therefore, starting antipsychotic therapy and discontinuing antidepressants is the most appropriate course of action.

      Understanding Bipolar Disorder

      Bipolar disorder is a mental health condition that is characterized by alternating periods of mania/hypomania and depression. It typically develops in the late teen years and has a lifetime prevalence of 2%. There are two recognized types of bipolar disorder: type I, which involves mania and depression, and type II, which involves hypomania and depression.

      Mania and hypomania both refer to abnormally elevated mood or irritability, but mania is more severe and can include psychotic symptoms for 7 days or more. Hypomania, on the other hand, involves decreased or increased function for 4 days or more. The presence of psychotic symptoms suggests mania.

      Management of bipolar disorder may involve psychological interventions specifically designed for the condition, as well as medication. Lithium is the mood stabilizer of choice, but valproate can also be used. Antipsychotic therapy, such as olanzapine or haloperidol, may be used to manage mania/hypomania, while fluoxetine is the antidepressant of choice for depression. It is important to address any co-morbidities, as there is an increased risk of diabetes, cardiovascular disease, and COPD in individuals with bipolar disorder.

      If symptoms suggest hypomania, routine referral to the community mental health team (CMHT) is recommended. However, if there are features of mania or severe depression, an urgent referral to the CMHT should be made. Understanding bipolar disorder and its management is crucial for healthcare professionals to provide appropriate care and support for individuals with this condition.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 34 - A 78-year-old man with known dementia is admitted to hospital for treatment of...

    Correct

    • A 78-year-old man with known dementia is admitted to hospital for treatment of a community acquired pneumonia. Unfortunately, he was not accompanied by a family member and the history provided by the patient seems confused. Upon arrival of the daughter, she confirms that her father has been confusing real events with those from his imagination. Through this process he appears to be able to maintain a superficial conversation despite significant cognitive impairment.
      Which of the following describes this phenomenon?

      Your Answer: Confabulation

      Explanation:

      Differentiating Confabulation, Delusions, and Other Psychiatric Phenomena

      Confabulation, delusions, and other psychiatric phenomena can be confusing and difficult to differentiate. Confabulation is a phenomenon where patients fabricate imaginary experiences due to memory loss, often seen in patients with cognitive impairment. Delusions, on the other hand, are beliefs held with strong conviction despite evidence to the contrary, commonly seen in conditions such as schizophrenia. Flight of ideas, pressure of speech, and hallucinations are other psychiatric phenomena that can be seen in different conditions. Understanding the differences between these phenomena is crucial in making accurate diagnoses and providing appropriate treatment.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 35 - A 28-year-old unemployed man is evaluated by the Community Psychiatry Team due to...

    Correct

    • A 28-year-old unemployed man is evaluated by the Community Psychiatry Team due to a decline in his schizophrenia. The patient was initiated on medication two months ago after being diagnosed with the condition. However, he was unable to tolerate the initial treatment prescribed, and the patient's mother reports that her son's psychotic symptoms have persisted and may have even slightly worsened, despite starting a different type of medication. What is the most potent antipsychotic for stubborn psychotic symptoms?

      Your Answer: Clozapine

      Explanation:

      Antipsychotic Medications: Types and Side Effects

      Antipsychotic medications are commonly used to treat psychotic symptoms such as delusions and hallucinations. There are different types of antipsychotics, including typical and atypical medications. Here are some of the commonly used antipsychotics and their side effects:

      Clozapine: This medication is effective for resistant psychotic symptoms, but it is not used as a first-line treatment due to potential adverse effects. It requires haematological monitoring and can cause serious side effects such as neutropenia and thromboembolism. Common side effects include sedation, constipation, and weight gain.

      Olanzapine: This atypical antipsychotic is commonly used for schizophrenia and bipolar disorder. Its major side effect is weight gain, and patients should have their lipids and blood sugars monitored regularly.

      Risperidone: This medication is helpful for acute exacerbations of schizophrenia, bipolar disorder, and irritability in autism. It is a qualitatively atypical antipsychotic with a relatively low risk of extrapyramidal side effects.

      Haloperidol: This typical antipsychotic is used for schizophrenia, tics in Tourette’s, mania in bipolar disorder, and nausea and vomiting. It should be avoided in Parkinson’s disease and can cause tardive dyskinesia, QT prolongation, and neuroleptic malignant syndrome.

      Quetiapine: This atypical antipsychotic is used for schizophrenia, bipolar disorder, and major depressive disorder. Common side effects include sleepiness, constipation, weight gain, and dry mouth.

      In conclusion, antipsychotic medications can be effective in treating psychotic symptoms, but they also come with potential side effects that need to be monitored. It is important to work closely with a healthcare provider to find the right medication and dosage for each individual.

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      • Psychiatry
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  • Question 36 - A 60-year-old patient with a history of bipolar disorder visits your GP clinic...

    Incorrect

    • A 60-year-old patient with a history of bipolar disorder visits your GP clinic for routine blood tests. Despite feeling completely fine, he wants to check his health status. Upon clinical examination, there are no signs of splenomegaly or lymphadenopathy.
      The following are the results:
      - Hb 140 g/L Male: (135-180) Female: (115 - 160)
      - Platelets 160 * 109/L (150 - 400)
      - WBC 14 * 109/L (4.0 - 11.0)
      - Na+ 144 mmol/L (135 - 145)
      - K+ 4.7 mmol/L (3.5 - 5.0)
      - Urea 5.4 mmol/L (2.0 - 7.0)
      - Creatinine 114 µmol/L (55 - 120)
      - Thyroid stimulating hormone (TSH) 5.2 mU/L (0.5-5.5)
      - Free thyroxine (T4) 9.5 pmol/L (9.0 - 18)
      - Lithium level 0.75 mmol/L (0.6 - 1.2)

      What advice would you give to this patient?

      Your Answer: Referral to haematology for further investigation

      Correct Answer: Safety net to return if symptoms develop, arrange repeat blood tests as per usual, under the normal monitoring schedule

      Explanation:

      Lithium, a mood-stabilizing drug commonly used in bipolar disorder, can lead to various health complications such as thyroid, cardiac, renal, and neurological issues. One of the common side effects of lithium is benign leucocytosis, which is also associated with other drugs like corticosteroids and beta-blockers. In this case, it is appropriate to continue with the normal monitoring schedule and safety netting for any signs of infection or malignancy, as there are no indications of either. Antibiotics would not be necessary. Malignant leucocytosis is unlikely as there are no accompanying symptoms such as night sweats, weight loss, bleeding, lymphadenopathy, or bone pain. Withholding lithium would not be advisable as it is effectively managing the patient’s condition. The psychiatric team should be consulted before making any decisions regarding the medication.

      Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in treatment-resistant depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. The mechanism of action is not fully understood, but it is believed to interfere with inositol triphosphate and cAMP formation. Adverse effects may include nausea, vomiting, diarrhea, fine tremors, nephrotoxicity, thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, hyperparathyroidism, and hypercalcemia.

      Monitoring of patients taking lithium is crucial to prevent adverse effects and ensure therapeutic levels. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until levels are stable. Once established, lithium levels should be checked every three months. Thyroid and renal function should be monitored every six months. Patients should be provided with an information booklet, alert card, and record book to ensure proper management of their medication. Inadequate monitoring of patients taking lithium is common, and guidelines have been issued to address this issue.

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      • Psychiatry
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  • Question 37 - You are discussing bipolar disorder with your consultant in a geriatric trainees teaching...

    Correct

    • You are discussing bipolar disorder with your consultant in a geriatric trainees teaching session as part of your psychiatry attachment.
      Which of the following is the most common medical treatment in the long-term management of bipolar disorder in older adults?

      Your Answer: Lithium

      Explanation:

      Pharmacological Treatments for Bipolar Disorder

      Bipolar disorder, also known as manic depression, is a mental health condition characterized by alternating episodes of mania and depression. Lithium is the most commonly used medication for long-term management of bipolar disorder. It helps to stabilize mood and prevent relapses of both manic and depressive episodes. However, it is important to note that medication alone is not enough to manage bipolar disorder effectively. Holistic care, including therapy and lifestyle changes, is essential for patients to cope with their condition.

      Carbamazepine is another medication used for mood stabilization in bipolar disorder, but it is less commonly used than lithium. Sertraline, on the other hand, is a selective serotonin reuptake inhibitor (SSRI) that is primarily used to treat depression, not bipolar disorder. Diazepam, a benzodiazepine, may be helpful in managing acute manic episodes, but it is not recommended for long-term use due to the risk of dependence.

      Clozapine is an atypical antipsychotic medication that is primarily used to treat treatment-resistant schizophrenia. It is not commonly used for bipolar disorder due to the risk of agranulocytosis, a potentially life-threatening condition that can occur with clozapine use. If clozapine is used for bipolar disorder, it should only be done under close monitoring and evaluation by a multidisciplinary psychiatric team.

      In summary, lithium is the most commonly used medication for long-term management of bipolar disorder, but holistic care is essential for effective management of the condition. Other medications may be used in certain situations, but they should be used with caution and under close supervision.

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      • Psychiatry
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  • Question 38 - A 24-year-old medical student presents to the emergency department accompanied by his partner,...

    Correct

    • A 24-year-old medical student presents to the emergency department accompanied by his partner, reporting a 10-hour history of aggression, irritability, and hallucinations. The partner suspects a mental breakdown due to sleep deprivation from studying for exams. Laboratory tests for drugs and infection are negative. The patient is admitted for observation and returns to baseline the following day.
      What is the probable diagnosis?

      Your Answer: Brief psychotic disorder

      Explanation:

      The correct answer is Brief psychotic disorder, which is a short-term disturbance characterized by the sudden onset of at least one positive psychotic symptom. These symptoms include delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. The disorder often resolves with a return to baseline functioning. Adjustment disorder, bipolar disorder, and schizoaffective disorder are not the correct answers as they are different mental health conditions with distinct symptoms and characteristics.

      Understanding Psychosis

      Psychosis is a term used to describe a person’s experience of perceiving things differently from those around them. This can manifest in various ways, including hallucinations, delusions, thought disorganization, alogia, tangentiality, clanging, and word salad. Associated features may include agitation/aggression, neurocognitive impairment, depression, and thoughts of self-harm. Psychotic symptoms can occur in a range of conditions, such as schizophrenia, depression, bipolar disorder, puerperal psychosis, brief psychotic disorder, neurological conditions, and drug use. The peak age of first-episode psychosis is around 15-30 years.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 39 - A 38-year-old woman who has often presented with various physical complaints is diagnosed...

    Correct

    • A 38-year-old woman who has often presented with various physical complaints is diagnosed with generalised anxiety disorder. Despite receiving low intensity psychological interventions, her symptoms remain unchanged. What medication would be the most suitable next step in her treatment?

      Your Answer: Sertraline

      Explanation:

      Anxiety is a common disorder that can manifest in various ways. According to NICE, the primary feature is excessive worry about multiple events associated with heightened tension. It is crucial to consider potential physical causes when diagnosing anxiety disorders, such as hyperthyroidism, cardiac disease, and medication-induced anxiety. Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants, and caffeine.

      NICE recommends a step-wise approach for managing generalised anxiety disorder (GAD). This includes education about GAD and active monitoring, low-intensity psychological interventions, high-intensity psychological interventions or drug treatment, and highly specialist input. Sertraline is the first-line SSRI for drug treatment, and if it is ineffective, an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI) such as duloxetine or venlafaxine may be offered. If the patient cannot tolerate SSRIs or SNRIs, pregabalin may be considered. For patients under 30 years old, NICE recommends warning them of the increased risk of suicidal thinking and self-harm and weekly follow-up for the first month.

      The management of panic disorder also follows a stepwise approach, including recognition and diagnosis, treatment in primary care, review and consideration of alternative treatments, review and referral to specialist mental health services, and care in specialist mental health services. NICE recommends either cognitive behavioural therapy or drug treatment in primary care. SSRIs are the first-line drug treatment, and if contraindicated or no response after 12 weeks, imipramine or clomipramine should be offered.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 40 - A 21-year-old woman comes to your clinic for an appointment scheduled by her...

    Incorrect

    • A 21-year-old woman comes to your clinic for an appointment scheduled by her father, who is worried about her lack of sleep. During the consultation, the patient reveals that she no longer feels the need to sleep for more than 2-3 hours. She appears talkative and mentions that she has been working on an online business that will bring her a lot of money. She is annoyed that people are questioning her, especially since she usually feels down, but now feels much better. There are no reports of delusions or hallucinations. What is the most probable diagnosis?

      Your Answer: Manic phase of bipolar disorder

      Correct Answer: Hypomanic phase of bipolar disorder

      Explanation:

      The patient is experiencing a significant decrease in sleep, but does not feel tired. This, along with other symptoms such as being excessively talkative and irritable, having an overconfident attitude towards their business, and a history of depression, suggests that they may be in a hypomanic phase of bipolar disorder. Insomnia, which typically results in feelings of tiredness and a desire to sleep, is less likely to be the cause of the patient’s symptoms. The absence of delusions or hallucinations rules out psychosis as a possible explanation. A manic phase of bipolar disorder is also unlikely, as the patient does not exhibit any delusions or hallucinations. The combination of symptoms suggests that there is more to the patient’s condition than just a resolution of depression.

      Understanding Bipolar Disorder

      Bipolar disorder is a mental health condition that is characterized by alternating periods of mania/hypomania and depression. It typically develops in the late teen years and has a lifetime prevalence of 2%. There are two recognized types of bipolar disorder: type I, which involves mania and depression, and type II, which involves hypomania and depression.

      Mania and hypomania both refer to abnormally elevated mood or irritability, but mania is more severe and can include psychotic symptoms for 7 days or more. Hypomania, on the other hand, involves decreased or increased function for 4 days or more. The presence of psychotic symptoms suggests mania.

      Management of bipolar disorder may involve psychological interventions specifically designed for the condition, as well as medication. Lithium is the mood stabilizer of choice, but valproate can also be used. Antipsychotic therapy, such as olanzapine or haloperidol, may be used to manage mania/hypomania, while fluoxetine is the antidepressant of choice for depression. It is important to address any co-morbidities, as there is an increased risk of diabetes, cardiovascular disease, and COPD in individuals with bipolar disorder.

      If symptoms suggest hypomania, routine referral to the community mental health team (CMHT) is recommended. However, if there are features of mania or severe depression, an urgent referral to the CMHT should be made. Understanding bipolar disorder and its management is crucial for healthcare professionals to provide appropriate care and support for individuals with this condition.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 41 - A 38-year-old teacher has called for the pest controller for the third time...

    Correct

    • A 38-year-old teacher has called for the pest controller for the third time in the past month. She is worried that her house is infested with rats and she frequently checks under the beds and around the property for any signs of the infestation. She mentions that she saw a therapist in her early twenties for obsessive hand washing and underwent a brief period of cognitive behavioural therapy.
      Upon physical examination, there are no abnormalities found. However, upon further questioning, she admits to feeling compelled to check for rats and is constantly anxious about cleanliness.
      What is the most probable diagnosis?

      Your Answer: Obsessive-compulsive disorder (OCD)

      Explanation:

      Differentiating OCD from other mental health conditions

      Obsessive-compulsive disorder (OCD) is characterized by repetitive cycles of ritualistic behavior. It is important to differentiate OCD from other mental health conditions such as schizophrenia, anxiety, bipolar disease, and depression. Cognitive behavioral therapy and exposure response prevention are the mainstays of therapy for OCD, along with medication. Features consistent with schizophrenia, anxiety, bipolar disease, and depression are absent in OCD. Understanding the differences between these conditions is crucial in providing appropriate treatment.

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      • Psychiatry
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  • Question 42 - According to the Mental Health Act (1983), which section should be used to...

    Incorrect

    • According to the Mental Health Act (1983), which section should be used to detain a teenage patient, already in hospital, who is suffering from acute psychosis and is attempting to leave the hospital against medical advice?

      Your Answer: Section 135

      Correct Answer: Section 5.2

      Explanation:

      Mental Health Act Sections and Their Purposes

      The Mental Health Act includes several sections that outline the circumstances under which a person can be detained for mental health treatment. These sections serve different purposes and have varying time limits for detention.

      Section 5.2 allows for the detention of a patient who is already in the hospital for up to 72 hours. Section 5.4 allows a senior nurse to detain a patient for up to 6 hours without a doctor present.

      Section 3 applies to patients with a known mental disorder who require detention for treatment. This section allows for admission for up to 6 months.

      Section 2 applies to patients with an uncertain diagnosis who require detention for assessment. This section allows for detention for no longer than 28 days.

      Section 135 is a police warrant that allows for the removal of a patient from private property to a place of safety.

      Section 136 allows for the removal of a person with a mental illness from the community to a place of safety for further assessment. This can be a special suite in Accident & Emergency, a local psychiatry hospital, or a police station if specific criteria are met.

      Understanding these sections of the Mental Health Act is important for ensuring that individuals receive appropriate care and treatment for their mental health needs.

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      • Psychiatry
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  • Question 43 - What is a true statement about obsessive compulsive disorder (obsessional neurosis)? ...

    Correct

    • What is a true statement about obsessive compulsive disorder (obsessional neurosis)?

      Your Answer: Patients have good insight

      Explanation:

      Obsessional Neurosis and Obsessional Compulsive Disorder

      Obsessional neurosis is a mental disorder characterized by repetitive rituals, irrational fears, and disturbing thoughts that are often not acted upon. Patients with this condition maintain their insight and are aware of their illness, which can lead to depression. On the other hand, obsessional compulsive disorder is a similar condition that typically starts in early adulthood and affects both sexes equally. Patients with this disorder often have above-average intelligence.

      It is important to note that Sigmund Freud’s theory that obsessive compulsive symptoms were caused by rigid toilet-training practices is no longer widely accepted. Despite this, the causes of these disorders are still not fully understood. However, treatment options such as cognitive-behavioral therapy and medication can help manage symptoms and improve the quality of life for those affected. these disorders and seeking appropriate treatment can make a significant difference in the lives of those who suffer from them.

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      • Psychiatry
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  • Question 44 - Sophie is a 25-year-old woman who was diagnosed with generalised anxiety disorder 8...

    Incorrect

    • Sophie is a 25-year-old woman who was diagnosed with generalised anxiety disorder 8 months ago. She has been taking sertraline for 5 months but feels that her symptoms have not improved much. Sophie wants to switch to a different medication. What is the most suitable drug to start?

      Your Answer: Bupropion

      Correct Answer: Venlafaxine

      Explanation:

      If sertraline, a first-line SSRI, is ineffective or not well-tolerated for treating GAD, alternative options include trying a different SSRI like paroxetine or escitalopram, or an SNRI like duloxetine or venlafaxine. In Maxine’s case, since sertraline did not work, venlafaxine, an SNRI, would be a suitable option. Bupropion is primarily used for smoking cessation but may be considered off-label for depression treatment if other options fail. Mirtazapine is a NaSSA used for depression, not GAD. Pregabalin can be used if SSRIs or SNRIs are not suitable, and propranolol can help with acute anxiety symptoms but is not a specific treatment for GAD.

      Anxiety is a common disorder that can manifest in various ways. According to NICE, the primary feature is excessive worry about multiple events associated with heightened tension. It is crucial to consider potential physical causes when diagnosing anxiety disorders, such as hyperthyroidism, cardiac disease, and medication-induced anxiety. Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants, and caffeine.

      NICE recommends a step-wise approach for managing generalised anxiety disorder (GAD). This includes education about GAD and active monitoring, low-intensity psychological interventions, high-intensity psychological interventions or drug treatment, and highly specialist input. Sertraline is the first-line SSRI for drug treatment, and if it is ineffective, an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI) such as duloxetine or venlafaxine may be offered. If the patient cannot tolerate SSRIs or SNRIs, pregabalin may be considered. For patients under 30 years old, NICE recommends warning them of the increased risk of suicidal thinking and self-harm and weekly follow-up for the first month.

      The management of panic disorder also follows a stepwise approach, including recognition and diagnosis, treatment in primary care, review and consideration of alternative treatments, review and referral to specialist mental health services, and care in specialist mental health services. NICE recommends either cognitive behavioural therapy or drug treatment in primary care. SSRIs are the first-line drug treatment, and if contraindicated or no response after 12 weeks, imipramine or clomipramine should be offered.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 45 - A 35-year-old unemployed man visits his GP seeking assistance with his heroin addiction....

    Correct

    • A 35-year-old unemployed man visits his GP seeking assistance with his heroin addiction. He has been using heroin for more than a year after a friend suggested trying the drug after a night out. As a result, he has frequently used heroin. He has lost his job, ended his long-term relationship, and is currently sleeping on his friend's couch.

      A few months ago, he attempted to quit because he wanted to turn his life around, but he found the withdrawal symptoms too difficult to handle and ended up using heroin again. He is eager to try and quit drugs, but he feels he cannot do it without some form of assistance.

      Which of the following can be used for substitution therapy in opioid-dependent patients?

      Your Answer: Methadone

      Explanation:

      Medications for Opioid Dependence and Withdrawal

      Opioid dependence can be treated with medications under medical supervision. Methadone and buprenorphine are two options that can be used to substitute for illicit opioids. Buprenorphine should be given when the patient is experiencing withdrawal symptoms. Benzodiazepines like lorazepam and diazepam are used to treat withdrawal symptoms but not as a substitute for opioids. Lofexidine is also used to treat withdrawal symptoms. Naltrexone, an opioid antagonist, can be used to sustain abstinence in consenting patients.

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      • Psychiatry
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  • Question 46 - A 16-year-old male comes in for a psychiatric check-up for his depression and...

    Incorrect

    • A 16-year-old male comes in for a psychiatric check-up for his depression and reports frequently losing his train of thought, attributing it to the government stealing his ideas. What is the symptom he is displaying?

      Your Answer: Ideas of reference

      Correct Answer: Thought withdrawal

      Explanation:

      Schizophrenia is a mental disorder that is characterized by various symptoms. Schneider’s first rank symptoms are divided into four categories: auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions. Auditory hallucinations can include hearing two or more voices discussing the patient in the third person, thought echo, or voices commenting on the patient’s behavior. Thought disorders can involve thought insertion, thought withdrawal, or thought broadcasting. Passivity phenomena can include bodily sensations being controlled by external influence or actions/impulses/feelings that are imposed on the individual or influenced by others. Delusional perceptions involve a two-stage process where a normal object is perceived, and then there is a sudden intense delusional insight into the object’s meaning for the patient.

      Other features of schizophrenia include impaired insight, incongruity/blunting of affect (inappropriate emotion for circumstances), decreased speech, neologisms (made-up words), catatonia, and negative symptoms such as incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), and avolition (poor motivation). It is important to note that schizophrenia can manifest differently in each individual, and not all symptoms may be present.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 47 - A 42-year-old woman visits her General Practitioner (GP) on an emergency appointment due...

    Correct

    • A 42-year-old woman visits her General Practitioner (GP) on an emergency appointment due to her worsening anxiety state. She reveals to the GP that she has been experiencing this for several years and is now seeking treatment. What is the most effective approach for long-term management?

      Your Answer: Sertraline

      Explanation:

      Medications for Generalised Anxiety Disorder

      Generalised anxiety disorder can severely impact a patient’s daily life. Sertraline, a selective serotonin reuptake inhibitor (SSRI), is the recommended first-line treatment. However, caution must be taken when prescribing to young adults, those over 65, and patients on other medications due to potential side effects. Zopiclone, Haloperidol, and Diazepam are not appropriate treatments for this disorder and should be avoided. Amitriptyline, a tricyclic antidepressant, is not considered the best management for generalised anxiety disorder.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 48 - A 36-year-old man with a known history of severe depression has been in...

    Incorrect

    • A 36-year-old man with a known history of severe depression has been in hospital for the past year. He was diagnosed with depression at the age of 23 and has been on antidepressants since. He has had multiple self-harm and suicide attempts in the past. For the past year, he has been receiving treatment in hospital and has been making some progress with regard to his mental health. He is not happy to be in hospital, but the doctors thought that it was in his best interests to keep him in hospital for treatment. He has been under a Section which allowed him to be kept in hospital for six months. At the end of the first six months, the doctors applied for a second time for him to be kept for another six months, as they feel he is not yet fit for discharge.
      For how long can the relevant Section be renewed for this patient for the third time?

      Your Answer: Six months

      Correct Answer: One year

      Explanation:

      Understanding the Time Limits of Mental Health Detention in the UK

      In the UK, mental health detention is governed by specific time limits depending on the type of detention and the purpose of the detention. Here are some of the key time limits to be aware of:

      – Section 2: This is the Section used for assessment, and a patient can be kept in hospital for a maximum of 28 days under this Section. It cannot be extended.
      – Section 3: This is the Section used for treatment, and a patient can be detained for up to six months initially. The Section can be renewed for another six months, and then for one year at a time. Treatment without consent can be given for the first three months, and then only with the approval of an ‘approved second-opinion doctor’ for the next three months.
      – Two years: While a patient can be kept in hospital for up to two years for treatment, Section 3 cannot be renewed for two years at a time. The patient can also be discharged earlier if the doctor thinks the patient is well enough.
      – Six months: This is the time for which an initial Section 3 can be applied for and the time for which it can be renewed for a second time. For a third time and onwards, Section 3 can be renewed for one year each time, but the patient can be discharged earlier if doctors think it is not necessary for the patient to be under Section anymore.

      Understanding these time limits is important for both patients and healthcare professionals involved in mental health detention in the UK.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 49 - A 32-year-old woman has come to her doctor for a medication review. She...

    Incorrect

    • A 32-year-old woman has come to her doctor for a medication review. She was diagnosed with bipolar disorder 10 months ago and has been taking olanzapine 10 mg once daily and lithium carbonate 600mg twice daily. While her psychological symptoms have improved, she has been feeling more fatigued in the past few weeks. Additionally, she has noticed a decrease in appetite and has experienced bouts of constipation. What is the most probable cause of her symptoms?

      Your Answer: Hypercalcaemia due to olanzapine toxicity

      Correct Answer: Hypothyroidism due to lithium toxicity

      Explanation:

      Chronic lithium toxicity is the leading cause of hypothyroidism, which is the most common endocrine disorder. The onset of this condition typically occurs within 6 to 18 months of starting lithium treatment, although the exact mechanism by which lithium inhibits thyroid hormone release is not well understood. While olanzapine does not cause hypothyroidism or hypercalcemia, lithium is not associated with hypoadrenalism. Although undertreatment of bipolar disorder can lead to a depressive episode, the patient in this case has experienced an improvement in mood and the emergence of new somatic symptoms, making hypothyroidism due to lithium toxicity a more probable diagnosis.

      Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in treatment-resistant depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. The mechanism of action is not fully understood, but it is believed to interfere with inositol triphosphate and cAMP formation. Adverse effects may include nausea, vomiting, diarrhea, fine tremors, nephrotoxicity, thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, hyperparathyroidism, and hypercalcemia.

      Monitoring of patients taking lithium is crucial to prevent adverse effects and ensure therapeutic levels. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until levels are stable. Once established, lithium levels should be checked every three months. Thyroid and renal function should be monitored every six months. Patients should be provided with an information booklet, alert card, and record book to ensure proper management of their medication. Inadequate monitoring of patients taking lithium is common, and guidelines have been issued to address this issue.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 50 - A 25-year-old woman with schizophrenia visits you with her caregiver on a Monday...

    Incorrect

    • A 25-year-old woman with schizophrenia visits you with her caregiver on a Monday morning. She informs you that she was out of town over the weekend and misplaced her prescribed clozapine, which she takes at a dosage of 200 mg in the morning and 400 mg at night. She hasn't taken any since Friday evening and seems to be experiencing psychotic symptoms. Her caregiver mentions that this is the first time she has ever lost her medication.
      What course of action should you take?

      Your Answer: Restart clozapine at 150 mg mane, 300 mg nocte

      Correct Answer: Restart clozapine at the starting dose of 12.5 mg daily

      Explanation:

      Managing Non-Compliance with Clozapine in Schizophrenia Patients

      When a patient with schizophrenia on clozapine misses their medication for more than 48 hours, it is important to manage the situation appropriately. Restarting clozapine at the starting dose of 12.5 mg daily is recommended, even if the patient has been on a higher dose previously. However, the titration upwards can be more rapid than for a clozapine-naive patient.

      Stopping the clozapine prescription completely is not advisable, as the patient needs to be on treatment for their schizophrenia, and clozapine is often the treatment of choice for those who are resistant to other anti-psychotic medications. Restarting clozapine at a higher dose than the starting dose is also not recommended.

      Switching to a depo form of anti-psychotic medication may be considered if non-compliance is a recurring issue, but it should be a decision made in consultation with the patient, their family, and their healthcare team. However, switching to a depo after one incidence of non-compliance may be an overreaction, especially as it would require a change of medication.

      In summary, managing non-compliance with clozapine in schizophrenia patients requires careful consideration of the patient’s individual circumstances and consultation with their healthcare team. Restarting clozapine at the starting dose is the recommended course of action, and switching to a depo form of medication should be considered only after careful discussion.

    • This question is part of the following fields:

      • Psychiatry
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