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  • Question 1 - A 32-year-old woman presents to her GP with complaints of feeling extremely anxious,...

    Correct

    • A 32-year-old woman presents to her GP with complaints of feeling extremely anxious, avoiding going out, and experiencing disturbed sleep. Her symptoms have resulted in the breakdown of her relationship. She reports that her symptoms began to worsen after she was sexually assaulted 2 years ago. She experiences flashbacks of the assault when she is in a confined space with someone, even if there is no physical contact. The GP decides to refer her for cognitive behavioural therapy and the patient also expresses interest in trying medication. Which of the following medications would be recommended for the management of this patient?

      Your Answer: Venlafaxine

      Explanation:

      Medications for Post-Traumatic Stress Disorder (PTSD)

      Post-traumatic stress disorder (PTSD) is a mental health condition that can develop after experiencing or witnessing a traumatic event. Symptoms of PTSD include flashbacks, nightmares, avoidance, and hyperarousal. If drug treatment is necessary, selective serotonin reuptake inhibitors (SSRIs) or venlafaxine are recommended. Tricyclic antidepressants and benzodiazepines are not recommended due to their potential risks and lack of efficacy in treating PTSD. Antipsychotics may be considered in patients who do not respond to other treatments. It is important to regularly review and adjust medication treatment for PTSD.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 2 - A 67-year-old man presents to the hospital in a confused state. He is...

    Incorrect

    • A 67-year-old man presents to the hospital in a confused state. He is unable to explain his condition but insists that he was admitted for 10 days last month despite records showing his last admission to be 7 months ago. He cannot recall which secondary school he attended and, after being on the ward for a week, he does not recognize his primary doctor's face. The patient has a medical history of hypertension, ischemic stroke, and alcoholic liver disease.

      Upon examination, the patient has normal tone, upgoing plantar reflexes on the right, and a broad-based gait. There are bilateral cranial nerve 6 (CN 6) palsies associated with nystagmus.

      What is the probable diagnosis for this patient?

      Your Answer: Brain tumor

      Correct Answer: Korsakoff's syndrome

      Explanation:

      Korsakoff’s syndrome is a complication that can arise from Wernicke’s encephalopathy, and it is characterized by anterograde amnesia, retrograde amnesia, and confabulation. In this case, the patient displays confusion, ataxia, and ophthalmoplegia, as well as anterograde and retrograde amnesia with confabulation, which suggests that they have progressed to Korsakoff’s syndrome. Wernicke’s encephalopathy is caused by a deficiency in thiamine (vitamin B1), which is often due to chronic alcohol abuse or malnutrition. It presents with confusion, ataxia, and oculomotor dysfunction, which can lead to Korsakoff’s syndrome if left untreated. Brain tumors typically present with symptoms of increased intracranial pressure and focal neurological deficits, which are not present in this case. Lewy body dementia can be diagnosed if a patient with decreased cognition displays two or more of the following symptoms: parkinsonism, visual hallucinations, waxing-and-waning levels of consciousness, and rapid-eye-movement (REM) sleep behavior disorder. Transient global amnesia is a temporary condition that involves retrograde and anterograde amnesia following a stressful event, lasting between 2-8 hours but less than 24 hours. Based on the patient’s symptoms and history of alcohol abuse, Korsakoff’s syndrome is the most likely diagnosis.

      Understanding Korsakoff’s Syndrome

      Korsakoff’s syndrome is a memory disorder that is commonly observed in individuals who have a history of alcoholism. The condition is caused by a deficiency of thiamine, which leads to damage and bleeding in the mammillary bodies of the hypothalamus and the medial thalamus. Korsakoff’s syndrome often develops after untreated Wernicke’s encephalopathy.

      The symptoms of Korsakoff’s syndrome include anterograde amnesia, which is the inability to form new memories, and retrograde amnesia. Individuals with this condition may also experience confabulation, which is the production of fabricated or distorted memories to fill gaps in their recollection.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 3 - 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 4 - A 25-year-old basketball player undergoes an anterior cruciate ligament repair following an injury....

    Correct

    • A 25-year-old basketball player undergoes an anterior cruciate ligament repair following an injury. He is advised by his medical team that he will need an extended period of rest and physiotherapy before he resumes competitive basketball. Following the surgery, he says he feels better and discharges himself. He later goes out with his friends and tells them that he will be back on the court next week.

      What type of coping is this?

      Your Answer: Avoidance

      Explanation:

      Coping Mechanisms: Understanding Different Approaches to Dealing with Stress

      When faced with stress, individuals often employ coping mechanisms to manage their emotions and reactions. Here are some common coping mechanisms and their definitions:

      Avoidance: This coping mechanism involves denying the existence of a stressor and continuing with one’s usual behavior without making any changes. It is often used when the stressor is too overwhelming to deal with immediately.

      Appraisal: Appraisal involves assessing past events and experiences to make decisions for future arrangements. This coping mechanism can help individuals feel more in control of their situation.

      Projection: Projection is when an individual attributes unwanted thoughts and feelings onto someone else. This can be a way to avoid dealing with one’s own emotions.

      Problem-focused: This coping mechanism involves identifying the causes of a stressor and taking action to reduce or eliminate it. It is a proactive approach to dealing with stress.

      Emotion-focused: Emotion-focused coping involves managing the emotions that a stressor creates. This can involve using drugs or other methods to regulate one’s emotional response.

      Understanding these coping mechanisms can help individuals choose the most effective approach for dealing with stress in their lives.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 5 - A 60-year-old man is admitted from the angiography suite after the cardiologist discovered...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 6 - A 32-year-old man is referred by his general practitioner (GP) for counselling. He...

    Correct

    • A 32-year-old man is referred by his general practitioner (GP) for counselling. He describes being incredibly happy with his long-time girlfriend, describing how they have been together for 10 years. They go out shopping together, own a successful business together, frequently host parties and are very outgoing and popular. But when his partner brings up marriage, he convulses with fear. ‘I know it’s ridiculous, but I really think if we get married, everything will suddenly be terrible.’
      Which of the following best describes this patient?

      Your Answer: Gamophobia

      Explanation:

      Different Types of Phobias and Anxiety Disorders

      Phobias and anxiety disorders are common mental health conditions that affect many people. Here are some examples of different types of phobias and anxiety disorders:

      Gamophobia: This is a specific phobia of getting married. It is commonly seen in patients in committed long-term relationships who are terrified of formalizing the relationship in marriage.

      Agoraphobia: This is a fear of being out in public. It is a fear of being in situations where escape might be difficult or that help would not be available in case of any accident.

      Algophobia: This is a fear of pain.

      Acrophobia: This is a fear of heights.

      Generalized Anxiety Disorder: This is a condition where a person experiences excessive and persistent worry and anxiety about everyday situations. However, this disorder is inconsistent with a patient who is outgoing and comfortable in public.

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      • Psychiatry
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  • Question 7 - A 78-year-old man comes to see you, struggling to cope after his wife...

    Incorrect

    • A 78-year-old man comes to see you, struggling to cope after his wife passed away suddenly 5 months ago. He appears sad and spends most of the appointment looking down, but answers your questions. He expresses concern that he may be losing his mind because he has started seeing his wife sitting in her old chair and sometimes talks to her when he is alone. He confirms that he can hear her voice responding to him. He says he mostly talks to her while cooking in the kitchen or when he is alone at night. Despite these experiences, he knows that what he sees and hears is not real. He reports occasional memory loss and some abdominal pain due to his irritable bowel syndrome, but is otherwise healthy. He has no history of psychiatric conditions in himself or his family. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Normal grief reaction

      Explanation:

      Pseudohallucinations may be a normal part of the grieving process, and differ from true hallucinations in that the individual is aware that what they are experiencing is not real. While pseudohallucinations can be distressing, they are not considered pathological unless accompanied by urinary symptoms, which would require further investigation. The patient in question displays low mood and avoids eye contact, but responds well to questioning and is able to prepare food independently. While depression with psychotic features can involve true hallucinations, there are no other symptoms to suggest this diagnosis. Lewy-body dementia, which can cause visual hallucinations, Parkinsonian features, and cognitive impairment, is not a likely explanation for this patient’s symptoms. Abnormal grief reactions are typically defined as persisting for at least six months after the loss.

      Understanding Pseudohallucinations

      Pseudohallucinations are false sensory perceptions that occur in the absence of external stimuli, but with the awareness that they are not real. While not officially recognized in the ICD 10 or DSM-5, there is a general consensus among specialists about their definition. Some argue that it is more helpful to view hallucinations on a spectrum, from mild sensory disturbances to full-blown hallucinations, to avoid misdiagnosis or mistreatment.

      One example of a pseudohallucination is a hypnagogic hallucination, which occurs during the transition from wakefulness to sleep. These vivid auditory or visual experiences are fleeting and can happen to anyone. It is important to reassure patients that these experiences are normal and do not necessarily indicate the development of a mental illness.

      Pseudohallucinations are particularly common in people who are grieving. Understanding the nature of these experiences can help healthcare professionals provide appropriate support and reassurance to those who may be struggling with them. By acknowledging the reality of pseudohallucinations and their potential impact on mental health, we can better equip ourselves to provide compassionate care to those who need it.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 8 - A 35-year-old male comes to your clinic at the suggestion of his partner....

    Incorrect

    • A 35-year-old male comes to your clinic at the suggestion of his partner. He has been experiencing hyperarousal to loud noises and difficulty concentrating at work since his stay in the ICU 4 weeks ago. His partner believes he may have acute stress disorder, but you diagnose him with PTSD and discuss treatment options. He asks you to explain the difference between the two to his partner. You explain that while the presentation is similar, the main difference is temporal.

      At what point after the event can you confirm a diagnosis of PTSD?

      Your Answer:

      Correct Answer: 4 weeks

      Explanation:

      Acute stress disorder is characterized by an acute stress reaction that occurs within four weeks of a traumatic event, while PTSD is diagnosed after four weeks have passed. Symptoms presented within two weeks would suggest acute stress disorder. Both acute stress disorder and PTSD share similar features, including re-experiencing, avoidance, hyperarousal, and emotional numbing. Re-experiencing symptoms may include flashbacks, nightmares, and repetitive and distressing intrusive images. Avoidance symptoms may involve avoiding people, situations, or circumstances associated with the traumatic event. Hyperarousal symptoms may include hypervigilance for threat, exaggerated startle response, sleep problems, irritability, and difficulty concentrating. Emotional numbing may result in a lack of ability to experience feelings and feeling detached.

      Acute stress disorder is a condition that occurs within the first four weeks after a person has experienced a traumatic event, such as a life-threatening situation or sexual assault. It is characterized by symptoms such as intrusive thoughts, dissociation, negative mood, avoidance, and arousal. These symptoms can include flashbacks, nightmares, feeling disconnected from reality, and being hypervigilant.

      To manage acute stress disorder, trauma-focused cognitive-behavioral therapy (CBT) is typically the first-line treatment. This type of therapy helps individuals process their traumatic experiences and develop coping strategies. In some cases, benzodiazepines may be used to alleviate acute symptoms such as agitation and sleep disturbance. However, caution must be taken when using these medications due to their addictive potential and potential negative impact on adaptation. Overall, early intervention and appropriate treatment can help individuals recover from acute stress disorder and prevent the development of more chronic conditions such as PTSD.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 9 - A 20-year-old man presented to the psychiatry outpatients department with a sense of...

    Incorrect

    • A 20-year-old man presented to the psychiatry outpatients department with a sense of unsettling alteration in his personality. He expressed feeling peculiar, as if he is not his usual self. Despite being anxious and tense, he was unable to identify the exact nature of this change. What term best characterizes this sensation?

      Your Answer:

      Correct Answer: Depersonalisation

      Explanation:

      Depersonalisation

      Depersonalisation is a distressing experience where an individual feels disconnected from their own body and reality. It is often described as feeling like living in a dream or being in immediate danger of disappearing. Despite cognitive functioning remaining intact, the sufferer may interpret the experience as a sign of losing their mind. This can lead to the development of an autochthonous delusion, which arises spontaneously.

      The delusional mood is a sense of unease that can be resolved when a delusional belief forms. Over valued ideas are also present in depersonalisation, but they are not held with the same level of fixity as delusional beliefs. Overall, depersonalisation can be a frightening and disturbing experience that can leave individuals feeling disconnected from themselves and their surroundings.

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      • Psychiatry
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  • Question 10 - Electroconvulsive Therapy (ECT) is recommended by NICE for which clinical conditions? ...

    Incorrect

    • Electroconvulsive Therapy (ECT) is recommended by NICE for which clinical conditions?

      Your Answer:

      Correct Answer: In a catatonic patient

      Explanation:

      Electroconvulsive therapy (ECT) should only be considered as a treatment option for individuals with severe major depressive disorder that is potentially life-threatening, and where other treatments have been ineffective. It is also recommended for those experiencing catatonia or a prolonged/severe manic episode.

      Electroconvulsive therapy (ECT) is a viable treatment option for patients who suffer from severe depression that does not respond to medication, such as catatonia, or those who experience psychotic symptoms. The only absolute contraindication for ECT is when a patient has raised intracranial pressure.

      Short-term side effects of ECT include headaches, nausea, short-term memory impairment, memory loss of events prior to the therapy, and cardiac arrhythmia. However, these side effects are typically temporary and resolve quickly.

      Long-term side effects of ECT are less common, but some patients have reported impaired memory. It is important to note that the benefits of ECT often outweigh the potential risks, and it can be a life-changing treatment for those who have not found relief from other forms of therapy.

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      • Psychiatry
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  • Question 11 - A 25-year-old male is brought to the emergency department by his friends who...

    Incorrect

    • A 25-year-old male is brought to the emergency department by his friends who are concerned about his behavior. The patient's friends report that over the past few days the patient has hardly slept or eaten and is talking non-stop about a new business idea that he believes will make him a millionaire. He has also been spending a lot of money on his credit card and started making impulsive purchases. During the interview, the emergency department doctor observes that the patient is speaking rapidly and is difficult to interrupt. Despite the speed of his speech, the words themselves are coherent and follow a logical, albeit unusual, pattern of thought.

      What is the most appropriate term to describe the patient's abnormal speech pattern?

      Your Answer:

      Correct Answer: Pressured speech

      Explanation:

      Mania and Related Speech Patterns

      Mania is a mental state characterized by elevated mood, energy, and activity levels. A patient presenting with decreased need for sleep, increased risk-taking behavior, and delusions of grandeur may be exhibiting symptoms of mania. One common speech pattern associated with mania is pressured speech, which is characterized by rapid speech that is difficult to interrupt.

      Other speech patterns that may be observed in patients with mania include clanging, echolalia, neologism, and word salad. Clanging refers to the use of rhyming words, while echolalia involves repeating what the examiner says. Neologism refers to the creation of new words, and word salad is a completely disorganized speech that is not understandable.

      It is important for healthcare professionals to recognize these speech patterns and other symptoms of mania in order to provide appropriate treatment and support for patients. By the characteristics of mania and related speech patterns, healthcare professionals can help patients manage their symptoms and improve their overall quality of life.

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      • Psychiatry
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  • Question 12 - A 28-year-old woman comes to her General Practitioner (GP) with her partner, concerned...

    Incorrect

    • A 28-year-old woman comes to her General Practitioner (GP) with her partner, concerned about her recent behavior. She has been having trouble sleeping for the past week and has been very active at night, working tirelessly on her new art project, which she believes will be a groundbreaking masterpiece. When questioned further, she admits to feeling very energetic and has been spending a lot of money on new materials for her project. Her partner is worried that this may be a recurrence of her known psychiatric condition. She is currently taking olanzapine and was recently started on fluoxetine for low mood six weeks ago. She has no significant family history. The couple has been actively trying to conceive for the past six months.

      What is the most appropriate next step in managing this patient?

      Your Answer:

      Correct Answer: Stop the fluoxetine

      Explanation:

      Managing Mania in Bipolar Disorder: Treatment Options

      When a patient with bipolar disorder develops mania while on an antidepressant and antipsychotic, it is important to adjust their medication regimen. According to NICE guideline CG185, the first step is to stop the antidepressant. In this case, the patient was on olanzapine and fluoxetine, so the fluoxetine should be discontinued.

      While lithium is a first-line mood stabilizer for bipolar disorder, it is contraindicated in this patient as she is trying to conceive. Instead, the patient could be switched from olanzapine to quetiapine, another antipsychotic that is similar in effectiveness.

      It is important not to stop both the antipsychotic and antidepressant, as this could worsen the patient’s condition. By adjusting the medication regimen, the patient can be effectively managed during a manic episode.

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      • Psychiatry
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  • Question 13 - A 29-year-old man experiences a sudden emergence of auditory hallucinations describing his actions....

    Incorrect

    • A 29-year-old man experiences a sudden emergence of auditory hallucinations describing his actions. He also firmly believes that he has been chosen by a divine entity as a prophet, which contradicts his religious convictions. During the mental state examination, the patient exhibits tangentiality and clanging. After a fortnight, the patient's symptoms disappear entirely. The patient had a history of depression during his late adolescence, but no prior comparable incidents. What disorder did this patient have?

      Your Answer:

      Correct Answer: Brief psychotic disorder

      Explanation:

      The patient experienced psychosis, including hallucinations, delusions, and thought disorganisation. The correct diagnosis is brief psychotic disorder, which refers to a short-lived episode of psychosis followed by a return to normal functioning. Bipolar affective disorder is an incorrect diagnosis as there are no signs of manic episodes. Drug abuse is also an unlikely cause as there is no evidence of drug use in the patient’s history. Schizoaffective disorder is also an incorrect diagnosis as it involves both psychotic and mood symptoms occurring together, which is not the case for this patient.

      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.

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      • Psychiatry
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  • Question 14 - A 28-year-old woman is brought to the Emergency Department after taking an overdose...

    Incorrect

    • A 28-year-old woman is brought to the Emergency Department after taking an overdose of paracetamol due to a recent breakup with her partner. She expresses remorse for her actions, denies any suicidal thoughts, and requests to be discharged. Her parents and a friend arrive at the hospital soon after. Paracetamol levels at 4 hours are below the treatment limit.
      What should be the next course of action in managing her case?

      Your Answer:

      Correct Answer: Arrange review by mental health liaison team prior to discharge

      Explanation:

      Importance of Mental Health Liaison Team Review Prior to Discharge for Paracetamol Overdose Patients

      Paracetamol overdose is a common presentation of self-harm in emergency departments. While medical management is crucial, patients may also require mental health support. A hospital-based mental health liaison team can provide advice on discharge and arrange follow-up if necessary. Discharging a patient without follow-up increases the risk of further self-harm. However, temporary compulsory detention under the Mental Health Act is not appropriate for low-risk patients. Prescribing N-acetyl-L-cysteine is unnecessary if the paracetamol levels are below treatment threshold. Emergency admission to an inpatient psychiatric unit is only necessary for high-risk patients. Therefore, mental health liaison team review prior to discharge is crucial for appropriate management of paracetamol overdose patients.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 15 - A teenager has been referred because of bizarre behaviour at school. His teachers...

    Incorrect

    • A teenager has been referred because of bizarre behaviour at school. His teachers have reported that he alternates between very passive and very aggressive behaviours. At times, he cries and withdraws from sight when he thinks he is being slighted in some manner. At other times, he yells wildly and fights over the smallest of infractions. Upon further examination, you discover that the patient has been the victim of significant abuse at home.
      Which one of the following defence mechanisms is he likely employing?

      Your Answer:

      Correct Answer: Dissociation

      Explanation:

      Understanding Ego Defense Mechanisms: Dissociation, Sublimation, Identification, Reaction Formation, and Splitting

      Ego defense mechanisms are psychological strategies that individuals use to cope with stressful situations. These mechanisms can be either mature or immature, depending on their effectiveness and adaptability. Here are some examples of common ego defense mechanisms and how they manifest in individuals:

      Dissociation: This is an immature defense mechanism where a person temporarily modifies their personal identity to avoid distress. For instance, a victim of abuse may develop multiple personalities to cope with the trauma.

      Sublimation: This is a mature defense mechanism where a person takes an unacceptable personality trait and channels it into a respectable work that aligns with their values. For example, a person with aggressive tendencies may become a successful athlete.

      Identification: This is when a person models the behavior of a more powerful figure. For instance, a victim of child abuse may become a child abuser in adulthood.

      Reaction Formation: This is an immature defense mechanism where a person represses unacceptable emotions and replaces them with their exact opposite. For example, a man with homoerotic desires may champion anti-homosexual public policy.

      Splitting: This is an immature defense mechanism where a person is unable to reconcile both good and bad traits in a given person and sees people as either all good or all bad.

      Understanding these defense mechanisms can help individuals recognize and address maladaptive coping strategies and work towards healthier ways of dealing with stress.

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      • Psychiatry
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  • Question 16 - A 50-year-old male with a past of alcohol addiction comes in with ataxia,...

    Incorrect

    • A 50-year-old male with a past of alcohol addiction comes in with ataxia, confusion, and nystagmus. During the examination, a weakness in the sixth cranial nerve is observed.

      What is the probable diagnosis?

      Your Answer:

      Correct Answer: Wernicke encephalopathy

      Explanation:

      Neurological Disorders Associated with Alcoholism

      Wernicke encephalopathy is a neurological disorder that occurs due to a deficiency in vitamin B-1, which is essential for carbohydrate metabolism. Alcohol consumption interferes with the absorption of thiamine, leading to a deficiency. Chronic liver disease also reduces the activation of thiamine pyrophosphate and the liver’s capacity to store thiamine. The symptoms of Wernicke encephalopathy include ataxia, confusion, and ocular abnormalities.

      de Clerambault’s syndrome is a delusional disorder where the sufferer believes that someone of higher social or professional standing is in love with them. Delirium tremens is a condition that occurs due to alcohol withdrawal and is characterized by confusion, hallucinations, and autonomic disturbance. The symptoms of delirium tremens usually peak 48-72 hours after stopping alcohol.

      Korsakoff’s psychosis is a type of dementia that occurs as a result of untreated Wernicke’s encephalopathy. The main symptom of Korsakoff’s psychosis is confabulation, where the sufferer creates false memories to fill gaps in their memory. These neurological disorders are commonly associated with alcoholism and can have severe consequences if left untreated.

      Neurological Disorders Associated with Alcoholism

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      • Psychiatry
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  • Question 17 - In clozapine-treated patients, what is the treatment for hypersalivation? ...

    Incorrect

    • In clozapine-treated patients, what is the treatment for hypersalivation?

      Your Answer:

      Correct Answer: Hyoscine

      Explanation:

      Treatment for Clozapine-Induced Hypersalivation: Hyoscine and Other Options

      Hypersalivation, or excessive saliva production, is a common side effect of clozapine treatment. While it usually subsides over time, it can be distressing for patients and may even pose a risk of aspiration pneumonia. Limited trial data exists on treatments for clozapine-induced hypersalivation, but hyoscine, a type of anticholinergic medication, is commonly used. Other options include pirenzepine and benzhexol. It’s important to note that procyclidine is typically used for acute dystonia, not hypersalivation, and medications like propranolol, risperidone, and lorazepam are not indicated for this side effect.

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      • Psychiatry
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  • Question 18 - A 25-year-old man presents to the Emergency Department in a distressed state. He...

    Incorrect

    • A 25-year-old man presents to the Emergency Department in a distressed state. He says he hears voices telling him that he is worthless and that the people talking to him know what he is doing as they are listening to his thoughts via the television and radio. His friends who attend with him tell you that he has become withdrawn over the past few months and has been missing lectures. There is a history of cannabis use but nil else of note. When he talks to you, he appears to have constructed a number of new words to describe the machines used to listen to him.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 139 g/l 135–175 g/l
      White cell count (WCC) 6.1 × 109/l 4–11 × 109/l
      Platelets 294 × 109/l 150–400 × 109/l
      Sodium (Na+) 140 mmol/l 135–145 mmol/l
      Potassium (K+) 4.3 mmol/l 3.5–5.0 mmol/l
      Creatinine 100 μmol/l 50–120 µmol/l
      Alanine aminotransferase (ALT) 34 IU/l 5–30 IU/l
      Bilirubin 16 μmol/l 2–17 µmol/l
      Which of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Schizophrenia

      Explanation:

      Differential Diagnosis for Acute Psychosis

      Acute psychosis can have various underlying causes, and a thorough differential diagnosis is essential for appropriate management. Here is a brief overview of some of the possibilities for a patient who presents with auditory hallucinations, neologisms, and odd behavior.

      Schizophrenia: This is a primary psychotic disorder characterized by Schneider’s first-rank symptoms, which include auditory hallucinations, thought insertion/withdrawal/interruption, thought broadcasting, and delusions of control. Treatment typically involves antipsychotic medications.

      Delirium tremens: This is a severe form of alcohol withdrawal that can cause confusion, agitation, tremors, seizures, and autonomic instability. It usually occurs in people with a history of heavy alcohol use and requires urgent medical attention.

      Manic-depressive psychosis (bipolar disorder): This is a mood disorder that can involve episodes of elevated or irritable mood (mania or hypomania) and episodes of depressed mood. Psychotic symptoms may occur during manic or mixed episodes, but not necessarily during depressive episodes.

      Amphetamine abuse: Stimulant drugs like amphetamines can induce psychosis, which may resemble schizophrenia or other psychotic disorders. A history of drug use and toxicology screening can help identify this possibility.

      Subdural hematoma: This is a type of brain injury that can cause symptoms such as headache, confusion, drowsiness, and focal neurological deficits. It is less likely in the absence of a history of head trauma or abnormal findings on neurological examination, but imaging studies may be needed to rule it out.

      In summary, the differential diagnosis for acute psychosis includes various psychiatric and medical conditions that require different approaches to treatment and management. A comprehensive evaluation should consider the patient’s history, symptoms, physical and neurological examination, laboratory tests, and imaging studies as needed.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 19 - A 32-year-old woman with schizophrenia has been under the care of mental health...

    Incorrect

    • A 32-year-old woman with schizophrenia has been under the care of mental health services for a few years with a fluctuating pattern of illness. Her consultant, in collaboration with the patient’s Community Psychiatric Nurse (CPN), decides to initiate clozapine treatment. As a component of the prescription, she is registered into the Clozapine Monitoring Service scheme.
      What is the primary rationale for her registration?

      Your Answer:

      Correct Answer: To monitor the white cell count

      Explanation:

      The Importance of Monitoring White Cell Count in Patients on Clozapine Therapy

      Schizophrenia is commonly treated with anti-psychotic medications, including typical and atypical agents. Clozapine, an atypical anti-psychotic, is often prescribed for patients who do not respond to other medications. While effective, clozapine carries a risk of agranulocytosis, a condition characterized by a lowered white blood cell count that increases the risk of infection. To mitigate this risk, patients on clozapine therapy must be enrolled in a monitoring program that includes regular blood tests to check their white cell count. This monitoring is crucial for patient safety and should be a top priority for healthcare providers.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 20 - A 42-year-old woman is seen in the clinic after a recent visit to...

    Incorrect

    • 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:

      Correct 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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Psychiatry (4/6) 67%
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