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Question 1
Incorrect
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Which statement is true regarding anorexia nervosa?
Your Answer: If amenorrhoea is present a hormonal disorder needs to be excluded
Correct Answer: It is the most common cause of admissions to child and adolescent psychiatric wards
Explanation:Anorexia nervosa is an eating disorder characterized by an abnormally low body weight, an intense fear of gaining weight and a distorted perception of weight. People with anorexia place a high value on controlling their weight and shape, using extreme efforts that tend to significantly interfere with their lives.
The minimum level of severity is based, for adults, on current body mass index (BMI) (see below) or for
children and adolescents, on BMI percentile. The ranges below are derived from World Health
Organization categories for thinness in adults; for children and adolescents, corresponding BMI percentiles
should be used. The level of severity may be increased to reflect clinical symptoms, the degree of
functional disability, and the need for supervision.
Mild: BMI > 17 kg/m2
Moderate: BMI 16-16.99 kg/m2
Severe: BMI 15-15.99 kg/m2
Extreme: BMI < 15 kg/m2 Anorexia nervosa is more common in women than in men, with a female-to-male ratio of 10-20:1 in developed countries. The prognosis of anorexia nervosa is guarded. Morbidity rates range from 10-20%, with only 50% of patients making a complete recovery. Of the remaining 50%, 20% remain emaciated and 25% remain thin. The main change in the diagnosis of Anorexia Nervosa was to remove the criterion of amenorrhea (loss of menstrual cycle). Removing this criterion means that boys and men with Anorexia will finally be able to receive an appropriate diagnosis.
Similarly, girls and women who continue to have their period despite other symptoms associated with Anorexia, such as weight loss and food restriction, will now be eligible for a diagnosis of Anorexia. -
This question is part of the following fields:
- Psychiatry
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Question 2
Correct
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A 31-year-old female is admitted to the E.D complaining of severe abdominal pain. On examination, she is seen trembling and rolling around the trolley. She has previously been investigated for abdominal pain and no cause has been found. She states that she will commit suicide unless she is given morphine for the pain. Which condition is this is an example of?
Your Answer: Malingering
Explanation:Malingering is not considered a mental illness. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), malingering receives a V code as one of the other conditions that may be a focus of clinical attention. The DSM-5 describes malingering as the intentional production of false or grossly exaggerated physical or psychological problems. Motivation for malingering is usually external (e.g., avoiding military duty or work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs).
Malingering should be strongly suspected if any combination of the following factors is noted to be present: (1) medicolegal context of presentation; (2) marked discrepancy between the person’s claimed stress or disability and the objective findings; (3) lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen; and (4) the presence in the patient of antisocial personality disorder (ASPD).
This patient is be pretending to be sick in order to get morphine.
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This question is part of the following fields:
- Psychiatry
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Question 3
Incorrect
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A 62 year old man expresses to his doctor that he believes that his partner is being unfaithful. When asked if he has any evidence to prove that this is true, he says no. However, he appears to be distressed and believes that he is right. Which condition could this be a symptom of?
Your Answer: Capgras' delusion
Correct Answer: Othello's syndrome
Explanation:Othello syndrome (OS) is a type of paranoid delusional jealousy, characterized by the false absolute certainty of the infidelity of a partner, leading to preoccupation with a partner’s sexual unfaithfulness based on unfounded evidence. OS has been associated with psychiatric and neurological disorders including stroke, brain trauma, brain tumours, neurodegenerative disorders, encephalitis, multiple sclerosis, normal pressure hydrocephalus, endocrine disorders, and drugs.
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This question is part of the following fields:
- Psychiatry
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Question 4
Correct
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A prescription for Olanzapine is written for a 28 year old lady with a history of schizophrenia. Which adverse effect is she most likely to experience?
Your Answer: Weight gain
Explanation:Weight gain is an extremely common (5-40%) adverse effect of atypical antipsychotics such as olanzapine (dose dependent). Olanzapine causes orthostatic hypotension ≥20% of reported cases. Parkinsonism reactions occurs in 4% of people.
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This question is part of the following fields:
- Psychiatry
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Question 5
Correct
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Which of the following listed below is not a recognised feature of anorexia nervosa?
Your Answer: Reduced growth hormone levels
Explanation:Physiological abnormalities in anorexia include:
– Hypokalaemia – from diuretic or laxative use
– Low FSH, LH, oestrogens and testosterone – most consistent endocrine abnormality was low serum luteinizing and follicle stimulating hormone (LH and FSH) levels associated with depressed serum oestradiol levels.
– Raised cortisol and growth hormone
– Impaired glucose tolerance – lack of glucose precursors in the diet or low glycogen stores. Low blood glucose may also be due to impaired insulin clearance
– Hypercholesterolemia
– Hypercarotenaemia
– Low T3 -
This question is part of the following fields:
- Psychiatry
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Question 6
Incorrect
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A 26 year old male admits to you that he was sexually abused in his childhood. Which one of the following features is not a characteristic feature of post-traumatic stress disorder?
Your Answer: Avoidance
Correct Answer: Loss of inhibitions
Explanation:Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by stressful, frightening or distressing events.
PTSD is a lasting consequence of traumatic ordeals that cause intense fear, helplessness, or horror, such as a sexual or physical assault, the unexpected death of a loved one, an accident, war, or natural disaster. Families of victims can also develop PTSD, as can emergency personnel and rescue workers.
PTSD is diagnosed after a person experiences symptoms for at least one month following a traumatic event. However symptoms may not appear until several months or even years later. The disorder is characterized by three main types of symptoms:
-Re-experiencing the trauma through intrusive distressing recollections of the event, flashbacks, and nightmares.
-Emotional numbness and avoidance of places, people, and activities that are reminders of the trauma.
-Increased arousal such as difficulty sleeping and concentrating, feeling jumpy, and being easily irritated and angered.The goal of PTSD treatment is to reduce the emotional and physical symptoms, to improve daily functioning, and to help the person better cope with the event that triggered the disorder. Treatment for PTSD may involve psychotherapy (a type of counselling), medication, or both.
Certain antidepressant medications are used to treat PTSD and to control the feelings of anxiety and its associated symptoms including selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants. Mood stabilizers such are sometimes used.
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This question is part of the following fields:
- Psychiatry
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Question 7
Incorrect
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A 50-year-old male is brought to the emergency department following a suicide attempt. He was found at home with an empty bottle of paracetamol by his side. Still conscious, a history was obtained from him to assess his risk of further attempts. Which of the following is considered to be the strongest risk factor for successful suicide?
Your Answer: Being married
Correct Answer: Addiction to opiates
Explanation:Among the given options, an addiction to opiates is considered the strongest risk factor for committing suicide.
Other options:
Being a female – Being male is one of the most significant risk factors for suicide.
Being married – Having family support is an important protective factor for suicide.
Having five children – Having children at home is thought to be a protective factor.
Having never seen a general practitioner – Having a chronic mental or physical condition is however a risk factor for suicide.Risk factors of suicide:
There are several factors shown to be associated with an increased risk of suicide:
Male sex
History of deliberate self-harm
Alcohol or drug misuse
History of mental illness (depression, schizophrenia)
History of chronic disease
Advancing age
Unemployment or social isolation/living alone
Being unmarried, divorced or widowed
Previous attempt to commit suicide.Signs pointing towards suicidal intension:
Efforts to avoid discovery
Planning
Leaving a written note
Final acts such as sorting out finances
Violent methodProtective factors against suicide:
Family support
Having children at home
Religious belief -
This question is part of the following fields:
- Psychiatry
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Question 8
Correct
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An 12 year old girl is taken to the clinic for a review. Despite being normally fit and well and not visiting a doctor for the past four years, her father is concerned about her behaviour in the past week. The girl has expressed plans to run for president, is active with planning all through the night and seems overtly excited. When asked, she admits to smoking cannabis once a few months ago and has drank alcohol a few times in the past year. The last time she had alcohol was a week ago. Prior to her deterioration a few weeks ago her father describes her as a happy, well-adjusted, sociable girl. Which one of the following is the most likely diagnosis?
Your Answer: Mania
Explanation:Mania is a state of extreme physical and emotional elation. A person experiencing mania or a manic episode may present with the following symptoms:
-Elevated mood. The person feels extremely ‘high’, happy and full of energy; he or she may describe the experience as feeling on top of the world and invincible. The person may shift rapidly from an elevated,
happy mood to being angry and irritable if they perceive they have been obstructed.
-Increased energy and overactivity. The person may have great difficulty remaining still.
-Reduced need for sleep or food. The person may be too active to eat or sleep.
-Irritability. The person may become angry and irritated with those who disagree with or dismiss his or her sometimes unrealistic plans or ideas.
-Rapid thinking and speech. The person’s thoughts and speech are more rapid than usual.
-Grandiose plans and beliefs. It is quite common for a person in a hypomanic or manic state to believe that he or she is unusually talented or gifted or has special friends in power. For example, the person may believe that he or she is on a special mission from God.
-Lack of insight. A person in a hypomanic or manic state may understand that other people see his or her ideas and actions as inappropriate, reckless or irrational. However, he or she is unlikely to personally accept that the behaviour is inappropriate, due to a lack of insight.
– Distractibility. The person has difficulty maintaining attention and may not be able to filter out external stimuli.Careful assessment to rule out organic conditions is an important first step in the management of mania. Often hospitalisation is required for someone who is experiencing acute mania. Both mood-stabilising agents such as lithium carbonate or sodium valproate and an antipsychotic may be needed to treat psychotic symptoms, agitation, thought disorder and sleeping difficulties. Benzodiazepines may be useful to reduce hyperactivity. Treatment with lithium alone may have a relatively slow response rate (up to two weeks after a therapeutic blood level is established), so that adjunctive medication such as sodium valproate is usually required. Regular monitoring of blood levels for lithium and valproate is essential because of the potential for toxicity.
The symptoms of hypomania are similar to those of mania: elevated mood, inflated self-esteem, decreased need for sleep, etc. except that they don’t significantly impact a person’s daily function and never include any psychotic symptoms.
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This question is part of the following fields:
- Psychiatry
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Question 9
Correct
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A 25-year-old female is brought to the OPD by her husband. She has been refusing to go outside for the past 3 months, telling her husband she is afraid of catching avian flu. On exploring this further, she is concerned because of the high number of migrating birds that she can see in her garden. She reports that the presence of her husband's socks on the washing line in the garden alerted her to this. What is the most probable diagnosis?
Your Answer: Acute paranoid schizophrenia
Explanation:Based on the given clinical scenario, the most probable diagnosis in this patient is acute paranoid schizophrenia.
Schizophrenia is a functional psychotic disorder characterized by the presence of delusional beliefs, hallucinations, and disturbances in thought, perception, and behaviour.
Clinical features:
Schneider’s first-rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions:Auditory hallucinations of a specific type:
Two or more voices discussing the patient in the third person
Thought echo
Voices commenting on the patient’s behaviourThought disorder:
Thought insertion
Thought withdrawal
Thought broadcastingPassivity phenomena:
Bodily sensations being controlled by external influence
Actions/impulses/feelings – experiences which are imposed on the Individual or influenced by othersOther features of schizophrenia include
Impaired insight (a feature of all psychoses)
Incongruity/blunting of affect (inappropriate emotion for circumstances)
Decreased speech
Neologisms: made-up words
Catatonia
Negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation).Treatment:
For the initial treatment of acute psychosis, it is recommended to commence an oral second-generation antipsychotics such as aripiprazole, olanzapine, risperidone, quetiapine, etc.
Once the acute phase is controlled, switching to a depot preparation like aripiprazole, paliperidone, zuclopenthixol, fluphenazine, haloperidol, pipotiazine, or risperidone is recommended.
Cognitive-behavioural therapy (CBT) and the use of art and drama therapies help counteract the negative symptoms of the disease, improve insight, and assist relapse prevention.
Clozapine is used in case of treatment resistance. -
This question is part of the following fields:
- Psychiatry
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Question 10
Incorrect
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A 30-year-old female in her second week post delivery presents for review with her husband. He is worried due to her depressed mood and her poor interaction with the baby. He describes her mood three days ago being much different. She was talking in a rapid and incoherent fashion about the future. The mother denies any hallucinations but states that her child has been brought into a 'very bad world'. What is the most appropriate treatment for this patient?
Your Answer: Cognitive behavioural therapy
Correct Answer: Arrange urgent admission
Explanation:The given clinical scenario warrants urgent admission and psychiatric evaluation as the mother seems to be suffering from puerperal psychosis.
Post-partum mental health problems can range from the ‘baby-blues’ to puerperal psychosis.
The Edinburgh Postnatal Depression Scale may be used to screen for depression:
A 10-item questionnaire, with a maximum score of 30
indicates how the mother has felt over the previous week
score > 13 indicates a ‘depressive illness of varying severity’
sensitivity and specificity > 90%. It includes a question about self-harmPostpartum psychosis has a complex multifactorial origin. Risk factors include a history of bipolar disorder, history of postpartum psychosis in a previous pregnancy, a family history of psychosis or bipolar disorder, a history of schizoaffective disorder or schizophrenia and discontinuation of psychiatric medications during pregnancy.
Incidence rate: 2.6 per 1000 births.
Onset usually within the first 2-3 weeks following birth
Symptoms of puerperal psychosis include confusion, lack of touch with reality, disorganized thought pattern and behaviour, odd effect, sleep disturbances, delusions, paranoia, appetite disturbances, a noticeable change in the level of functioning from baseline, hallucinations and suicidal or homicidal ideation.
The safety of the patient and new-born is of utmost importance, and thus, immediate hospitalization is warranted if there is a risk of harm to either one.
Cognitive-behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe – whilst they are secreted in breast milk it is not thought to be harmful to the infant
There is around a 20% risk of recurrence following future pregnancies -
This question is part of the following fields:
- Psychiatry
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Question 11
Correct
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A 40 year old man who has a 12 year history of bipolar disorder is placed on Lithium. How often should his Lithium levels be checked once a stable dose has been achieved?
Your Answer: Every 3 months
Explanation:Lithium acts by:
– I inhibiting postsynaptic D2 receptor super sensitivity
– Altering cation transport in nerve and muscle cells and influencing reuptake of serotonin or norepinephrine
– Inhibiting phosphatidylinositol cycle second messenger systemsThe NICE guidelines for depression and bipolar disorder both recommend Lithium as an effective treatment; patients who take lithium should have regular blood tests to monitor the amount of lithium in their blood (every 3 months), and to make sure the lithium has not caused any problems with their kidneys or thyroid (every 6 months).
Lithium adverse effects include:
– Leucocytosis (most patients) which is when the white cells are above the normal range in the blood.
– Polyuria/polydipsia (30-50%)
– Dry mouth (20-50%)
– Hand tremor (45% initially, 10% after 1 year of treatment)
– Confusion (40%)
– Decreased memory (40%)
– Headache (40%)
– Muscle weakness (30% initially, 1% after 1 year of treatment)
– Electrocardiographic (ECG) changes (20-30%)
– Nausea, vomiting, diarrhoea (10-30% initially, 1-10% after 1-2 years of treatment)
– Hyperreflexia (15%)
– Muscle twitch (15%)
– Vertigo (15%) -
This question is part of the following fields:
- Psychiatry
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Question 12
Correct
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A 22-year-old, thin drama student presents with weakness and muscle cramps. She has a past medical history of reflux and bronchial asthma, for which she takes lansoprazole 30mg once daily, inhaled salbutamol PRN, and a once-daily inhaled corticosteroid. She reports feeling stressed lately as she has a leading role in a significant stage production due to open in one week. Her heart rate is 87 bpm, blood pressure 103/71mmHg, respiratory rate 13/min. Her blood results are: pH: 7.46 Na+: 138 mmol/L, K+: 2.8 mmol/L, Chloride: 93 mmol/L, Magnesium: 0.61 mmol/L, What is the most likely aetiology for her symptoms?
Your Answer: Bulimia
Explanation:The most probable diagnosis considering hypochloraemia and the mild metabolic alkalosis as well as the history of GERD (requiring a high dose of PPI to control) would be bulimia.
Other options:
Diuretic abuse tends to give a hypochloraemic acidosis.
Gitelman syndrome also fits the diagnosis but, it is very rare compared to bulimia.
Inhaled steroid use and stress would not be responsible for such marked electrolyte derangement.Other potential signs of bulimia nervosa would be parotid gland swelling and dental enamel erosion induced by regular vomiting.
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This question is part of the following fields:
- Psychiatry
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Question 13
Correct
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A 56-year-old male was admitted to the in-patient psychiatric unit last night. He is a poor historian, answering most questions minimally and stating he does not need to be here as he is deceased, and hospitals should be for living patients. What is the type of delusion in this patient and what is it commonly associated with?
Your Answer: Cotard syndrome and Major Depressive Disorder
Explanation:The most probable diagnosis of this patient is Cotard syndrome with major depressive disorder.
Cotard syndrome is a rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary. Cotard syndrome is often associated with severe depression and psychotic disorders (like schizophrenia).
Other delusional syndromes:
– Othello syndrome is a delusional belief that a patients partner is committing infidelity despite no evidence of this. It can often result in violence and controlling behaviour.
– De Clerambault syndrome (otherwise known as erotomania), is where a patient believes that a person of higher social or professional standing is in love with them. Often this presents with people who believe celebrities are in love with them.
– Capgras syndrome is characterised by a person believing their friend or relative had been replaced by an exact double.
– Couvade syndrome is also known as ‘sympathetic pregnancy’. It affects fathers, particularly during the first and third trimesters of pregnancy, who suffer the somatic features of pregnancy.
– Ekbom syndrome is also known as delusional parasitosis and is the belief that they are infected with parasites or have ‘bugs’ under their skin. This can vary from the classic psychosis symptoms in narcotic use where the user can ‘see’ bugs crawling under their skin or can be a patient who believes that they are infested with snakes. -
This question is part of the following fields:
- Psychiatry
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Question 14
Correct
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Which of the following would suggest an increase risk of suicide in a patient with a history of depression?
Your Answer: History of arm cutting
Explanation:Risk factors specific to depression:
-Family history of mental disorder.
-History of previous suicide attempts (this includes self-harm).
-Severe depression.
-Anxiety.
-Feelings of hopelessness.
-Personality disorder.
-Alcohol abuse and/or drug abuse.
-Male gender.Protective Factors for Suicide.
Protective factors buffer individuals from suicidal thoughts and behaviour. To date, protective factors have not been studied as extensively or rigorously as risk factors. Identifying and understanding protective factors are, however, equally as important as researching risk factors.Protective Factors:
-Effective clinical care for mental, physical, and substance abuse disorders
-Easy access to a variety of clinical interventions and support for help seeking
-Family and community support (connectedness)
-Support from ongoing medical and mental health care relationships
-Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes
-Cultural and religious beliefs that discourage suicide and support instincts for self-preservation -
This question is part of the following fields:
- Psychiatry
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Question 15
Incorrect
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A young man complains that he feels paralysed and is unable to move when he wakes up and less often when he is falling asleep. He complains of having hallucinations and sees other strangers in the room. His anxiety has also increased with these episodes. What is his likely diagnosis?
Your Answer: Night terrors
Correct Answer: Sleep paralysis
Explanation:Sleep paralysis is a temporary inability to move or speak that occurs when you’re waking up or falling asleep. Paralysis is often accompanied by hallucinations
REM is a stage of sleep when the brain is very active and dreams often occur. The body is unable to move, apart from the eyes and muscles used in breathing, possibly to stop the person from acting out the dreams and hurting himself.
It’s not clear why REM sleep can sometimes occur while one is awake, but it has been associated with:
-not getting enough sleep (sleep deprivation or insomnia)
-irregular sleeping patterns – for example, because of shift work or jet lag
-narcolepsy – a long-term condition that causes a person to suddenly fall asleep at inappropriate times
-a family history of sleep paralysis
-sleeping on one’s back -
This question is part of the following fields:
- Psychiatry
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Question 16
Incorrect
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A 46 year old woman with a history of depression visits the clinic for a review. She was started on Fluoxetine 7 weeks earlier and is requesting that this medication be stopped because she feels well. What recommendation would you give with regards to the treatment?
Your Answer: It should be continued for at least another 6 weeks
Correct Answer: It should be continued for at least another 6 months
Explanation:Depressive disorders require long-term treatment with antidepressants, psychotherapy, or both. The goal of antidepressant therapy is complete remission of symptoms and return to normal daily functioning. Studies have shown that achieving remission and continuing antidepressant therapy long after the acute symptoms remit can protect against the relapse or recurrence of the psychiatric episode. Many patients, however, inadvertently or intentionally skip doses of their antidepressant, and even discontinue it, if their symptoms improve or if they experience side effects. Antidepressant discontinuation may increase the risk of relapse or precipitate certain distressing symptoms such as gastrointestinal complaints, dizziness, flu-like symptoms, equilibrium disturbances, and sleep disorders.
Pharmacologic therapy should be continued long enough to sustain remission and avoid relapses and recurrences. Recurrence refers to a return of depression at a time beyond the expected duration of the index episode (> 9 months after remission). This means that physicians and patients alike should not be too eager to discontinue medication prematurely. An interval of 6 months has been thought to be the usual duration of antidepressant therapy. New recommendations, however, suggest that treatment should continue for up to 9 months after symptoms have resolved (continuation phase) to prevent relapse and for longer to help prevent recurrence (maintenance phase).
SSRI discontinuation symptoms are similar to those of the TCAs, with dizziness, gastrointestinal symptoms, and sleep disorders common. Anecdotal reports have included complaints of “electric shock–like” sensations, flashes, and “withdrawal buzz.” The type and severity of the symptoms correlate with the relative affinities of the agents for the serotonin reuptake sites and with secondary effects on other neurotransmitters; with SRIs that also affect cholinergic systems, the symptoms possibly correlate with cholinergic rebound.
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This question is part of the following fields:
- Psychiatry
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Question 17
Incorrect
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Which of the following symptoms are more indicative of mania than hypomania?
Your Answer: Predominately elevated mood
Correct Answer: Delusions of grandeur
Explanation:The delusion of grandeur is more indicative of mania than hypomania.
While criteria (e.g. ICD-10, DSM-5) vary regarding the diagnosis between hypomania and mania, the consistent difference between mania and hypomania is the presence of psychotic symptoms.Hypomania vs. mania:
The presence of psychotic symptoms such as delusions of grandeur
auditory hallucinations point towards mania rather than hypomania/The following symptoms are common to both hypomania and mania
Mood:
Predominately elevated
IrritableSpeech and thought:
Pressured
Flight of ideas
Poor attentionBehaviour
Insomnia
Loss of inhibitions: sexual promiscuity, overspending, risk-taking
increased appetite -
This question is part of the following fields:
- Psychiatry
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Question 18
Correct
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A 28 year old woman is reviewed after giving birth one week ago. She complains about having difficulty sleeping and feeling anxious and tearful. She is also concerned about her mood because this is her first pregnancy and she is miserable. She is also not breast feeding. She has no history of any mental health disorder. What is the most appropriate approach to manage this patient?
Your Answer: Explanation and reassurance
Explanation:Most new moms experience postpartum baby blues after childbirth, which commonly include mood swings, crying spells, anxiety and difficulty sleeping. Baby blues typically begin within the first two to three days after delivery, and may last for up to two weeks.
Signs and symptoms of baby blues may include:
Mood swings
Anxiety
Sadness
Irritability
Feeling overwhelmed
Crying
Reduced concentration
Appetite problems
Trouble sleepingThe exact cause of the “baby blues” is unknown at this time. It is thought to be related to the hormone changes that occur during pregnancy and again after a baby is born. These hormonal changes may produce chemical changes in the brain that result in depression.
Although the experience of baby blues is unpleasant, the condition usually subsides within two weeks without treatment. All the mom needs is reassurance and help with the baby and household chores. -
This question is part of the following fields:
- Psychiatry
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Question 19
Incorrect
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A 57 year old man is reviewed and discovered to be dependent on Temazepam which was prescribed for him as a hypnotic. He wants to end his addiction and requests help. What is the most appropriate strategy?
Your Answer: Switch to the equivalent zopiclone dose then slowly withdraw over the next 2 weeks
Correct Answer: Switch to the equivalent diazepam dose then slowly withdraw over the next 2 months
Explanation:Temazepam is a medication that is often prescribed for the treatment of short-term insomnia. It belongs to the benzodiazepine family of drugs and is classed as intermediate-acting, meaning that it can take between six and twenty-four hours for the drug to take effect.
Although it is known that shorter-acting benzodiazepines are more harmful and more likely to cause addiction, temazepam is, nevertheless, a highly addictive drug. It should not be taken for longer than four weeks.
-Adverse effects associated with the use of benzodiazepine hypnotics (to which the elderly are most vulnerable) include confusion, over sedation, increased risks of falls and consequent fractures
-Withdrawal from a benzodiazepine hypnotic must be agreed between the clinician and the patient – patients should never be forced or threatened. The risks of continued benzodiazepine use should be explained. An agreed schedule for reduction of and gradual withdrawal from the benzodiazepine hypnotic should also be agreed. This will involve substitution of the hypnotic with a long-acting benzodiazepine (e.g. diazepam) and a subsequent gradual reduction in dose of the substituted benzodiazepine -the substituted benzodiazepine can then be withdrawn in steps of about one-eighth to one-tenth every fortnight
Example: withdrawal schedule for patient on temazepam 20mg nocte
week 1 – temazepam 10mg, diazepam 5mg
week 2 – stop temazepam, diazepam 10mg
week 4 – diazepam 9mg
week 6 – diazepam 8mg
continue reducing dose of diazepam by 1mg every fortnight – tapering of dose may be slower if necessary -
This question is part of the following fields:
- Psychiatry
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Question 20
Incorrect
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A 76-year-old male presents with recurrent episodes of hallucinations. He often sees faces smaller than normal or other objects out of proportion. He says he knows they're not real. His past medical history includes macular degeneration and an episode of depression 15 years ago following the death of his wife. Neurological examination is unremarkable. What is the most probable diagnosis?
Your Answer: Psychotic depression
Correct Answer: Charles-Bonnet syndrome
Explanation:The most probable diagnosis in the given scenario would be Charles-Bonnet syndrome.
Charles-Bonnet syndrome (CBS) is characterized by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally against a background of visual impairment (although visual impairment is not mandatory for a diagnosis). Insight is usually preserved. This must occur in the absence of any other significant neuropsychiatric disturbance.
Risk factors include:
Advanced age
Peripheral visual impairment
Social isolation
Sensory deprivation
Early cognitive impairmentCBS is equally distributed between sexes and does not show any familial predisposition. The most common ophthalmological conditions associated with this syndrome are age-related macular degeneration, followed by glaucoma and cataract.
Well-formed complex visual hallucinations are thought to occur in 10-30 percent of individuals with severe visual impairment. The prevalence of CBS in visually impaired people is thought to be between 11 and 15 percent.
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This question is part of the following fields:
- Psychiatry
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Question 21
Correct
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An elderly woman is taken to the clinic by her husband because she has been complaining about seeing ghosts in their house. She no longer wants to enter in the house. You wonder if this might be Charles-Bonnet syndrome. Which of the following risk factors may pre-dispose this woman to Charles-Bonnet syndrome?
Your Answer: Peripheral visual impairment
Explanation:Charles Bonnet syndrome (CBS) involves visual hallucinations due to eye disease, usually associated with a sharp decline in vision. The phenomenon is seen in patients with moderate or severe visual impairment. It can occur spontaneously as the vision declines or it may be precipitated, in predisposed individuals, by concurrent illness such as infections elsewhere in the body.
It is not clear why CBS develops or why some individuals appear to be predisposed to it. It is particularly noted in patients with advanced macular degeneration. It has been suggested that reduced or absent stimulation of the visual system leads to increased excitability of the visual cortex (deafferentation hypothesis). This release phenomenon is compared to phantom limb symptoms after amputation.
CBS is much more common in older patients because conditions causing marked visual loss are more common in older people. However, it can occur at any age and has been described in children.
The prevalence is hard to assess due to considerable under-reporting, perhaps because patients frequently fear that it is a sign of mental illness or dementia. However, it is thought to occur in:
About 10-15% of patients with moderate visual loss.
Possibly up to 50% of people with severe visual loss.
Presentation:
The nature of the hallucination depends on the part of the brain that is activated. The hallucinations may be black and white or in colour. They may involve grids/brickwork/lattice patterns but are typically much more complex:The hallucinations are always outside the body.
The hallucinations are purely visual – other senses are not involved.
The hallucinations have no personal meaning to the patient.
Hallucinations may last seconds, minutes or hours.
CBS tends to occur in a ‘state of quiet restfulness’. This may be after a meal or when listening to the radio (but not when dozing off).
Symptoms also have a tendency to occur in dim lighting conditions.
Patients may report high levels of distress, with some patients reporting anger, anxiety and even fear associated with the hallucinations. -
This question is part of the following fields:
- Psychiatry
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Question 22
Incorrect
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A patient is started on imipramine for depression. Which combination of side-effects is most likely to be associated with the intake of this class of antidepressants?
Your Answer: Dry mouth + urinary frequency
Correct Answer: Blurred vision + dry mouth
Explanation:Blurring of vision and dry mouth are antimuscarinic side-effects that are more common with imipramine than other types of tricyclic antidepressants.
Tricyclic antidepressants (TCAs) are used less commonly now for depression due to their side-effects and toxicity in overdose. They are however used widely in the treatment of neuropathic pain, where smaller doses are typically required.
Mechanism of action: Tricyclic antidepressants impose their therapeutic effects by inhibiting presynaptic reuptake of norepinephrine and serotonin in the central nervous system (this, may give rise to seizures).
Common side-effects:
Drowsiness
Dry mouth
Blurred vision
Constipation
Urinary retentionLow-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headaches (both tension and migraine).
Lofepramine has a lower incidence of toxicity in overdose
Amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose. -
This question is part of the following fields:
- Psychiatry
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Question 23
Incorrect
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A 28-year-old man visits the clinic and demands a CT scan of his stomach. He states it is 'obvious' he has cancer despite previous negative investigations. Which disorder is this an example of?
Your Answer: Conversion disorder
Correct Answer: Hypochondrial disorder
Explanation:Illness anxiety disorder (IAD) is a recent term for what used to be diagnosed as hypochondriasis, or hypochondrial disorder. People diagnosed with IAD strongly believe they have a serious or life-threatening illness despite having no, or only mild, symptoms.
Symptoms of IAD may include:
-Excessive worry over having or getting a serious illness.
-Physical symptoms are not present or if present, only mild. If another illness is present, or there is a high risk for developing an illness, the person’s concern is out of proportion.
-High level of anxiety and alarm over personal health status.
-Excessive health-related behaviours (e.g., repeatedly checking body for signs of illness) or shows abnormal avoidance (e.g., avoiding doctors’ appointments and hospitals).
-Fear of illness is present for at least six months (but the specific disease that is feared may change over that time).
-Fear of illness is not due to another mental disorder. -
This question is part of the following fields:
- Psychiatry
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Question 24
Incorrect
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A 43 year old ex-marine who has a history of post-traumatic stress disorder visits the office for a review. He is reluctant to try cognitive behavioural therapy. Which medication could be useful in this patient?
Your Answer: Fluoxetine
Correct Answer: Mirtazapine
Explanation:Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by stressful, frightening or distressing events.
PTSD is a lasting consequence of traumatic ordeals that cause intense fear, helplessness, or horror, such as a sexual or physical assault, the unexpected death of a loved one, an accident, war, or natural disaster. Families of victims can also develop PTSD, as can emergency personnel and rescue workers.
PTSD is diagnosed after a person experiences symptoms for at least one month following a traumatic event. However symptoms may not appear until several months or even years later. The disorder is characterized by three main types of symptoms:
-Re-experiencing the trauma through intrusive distressing recollections of the event, flashbacks, and nightmares.
-Emotional numbness and avoidance of places, people, and activities that are reminders of the trauma.
-Increased arousal such as difficulty sleeping and concentrating, feeling jumpy, and being easily irritated and angered.The goal of PTSD treatment is to reduce the emotional and physical symptoms, to improve daily functioning, and to help the person better cope with the event that triggered the disorder. Treatment for PTSD may involve psychotherapy (a type of counselling), medication, or both.
Eye Movement Desensitization and Reprocessing (EMDR) therapy was initially developed in 1987 for the treatment of posttraumatic stress disorder (PTSD) and is guided by the Adaptive Information Processing model. EMDR is an individual therapy typically delivered one to two times per week for a total of 6-12 sessions, although some people benefit from fewer sessions. Sessions can be conducted on consecutive days.
Drug treatments (paroxetine, mirtazapine, amitriptyline or phenelzine) should be considered for the treatment of PTSD when a sufferer expresses a preference to not engage in trauma-focused psychological treatment.
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This question is part of the following fields:
- Psychiatry
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Question 25
Incorrect
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A 30 year old male is reviewed following treatment using cognitive behaviour therapy for bulimia. He thinks there has been no improvement in his condition and is interested in using pharmacological therapy. Which of the following is most suitable?
Your Answer: Low-dose citalopram
Correct Answer: High-dose fluoxetine
Explanation:Bulimia nervosa is a serious, potentially life-threatening eating disorder characterized by a cycle of bingeing and compensatory behaviours such as self-induced vomiting designed to undo or compensate for the effects of binge eating.
According to the DSM-5, the official diagnostic criteria for bulimia nervosa are:
Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).
Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months.
Self-evaluation is unduly influenced by body shape and weight.
The disturbance does not occur exclusively during episodes of anorexia nervosa.Antidepressants as a group – particularly selective serotonin reuptake inhibitors (SSRIs) – are the mainstay of pharmacotherapy for bulimia nervosa. These may be helpful for patients with substantial concurrent symptoms of depression, anxiety, obsessions, or certain impulse disorder symptoms. They may be particularly good for patients who have not benefited from or had suboptimal response to suitable psychosocial therapy or who have a chronic, difficult course in combination with other treatments.
Food and Drug Administration (FDA) approved treatments
Fluoxetine (Prozac): Initial dose 20 mg/d with advance over 1–2 weeks to 60 mg/d in the morning as tolerated. Some patients may need to begin at a lower dose if side effects are intolerable. A maximum dose of 80 mg/d may be used in some cases. -
This question is part of the following fields:
- Psychiatry
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Question 26
Correct
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A 36 year old female who has been suffering from depression for the past 5 years was recently admitted to the psychiatric intensive care unit. She is currently being managed on Sertraline. In clinic she was observed to be sitting in a fixed position for several hours, awake but unable to move. What would be an appropriate treatment for this patient?
Your Answer: ECT
Explanation:Catatonia is a state of apparent unresponsiveness to external stimuli and apparent inability to move normally in a person who is apparently awake. Catatonia can be acute and occur in severely ill patients with underlying psychiatric or other medical disorders.
A history of behavioural responses to others usually includes the presence of the following:
– Mutism (absence of speech)
– Negativism (performing actions contrary to the commands of the examiner)
– Echopraxia (repeating the movements of others)
– Echolalia (repeating the words of others)
– Waxy flexibility (slight, even resistance to positioning by examiner)
– Withdrawal (absence of responses to the environment).In the presence of a catatonic state, both first and second generation antipsychotics (SGA) may contribute to maintaining or worsening the catatonic state and increase the risk of developing NMS (neuroleptic malignant syndrome).
Electroconvulsive therapy (ECT) is effective in all forms of catatonia, even after pharmacotherapy with benzodiazepines has failed. Response rate ranges from 80% to 100% and results superior to those of any other therapy in psychiatry. ECT should be considered first-line treatment in patients with malignant catatonia, neuroleptic malignant syndrome, delirious mania or severe catatonic excitement, and in general in all catatonic patients that are refractory or partially responsive to benzodiazepines. Early intervention with ECT is encouraged to avoid undue deterioration of the patient’s medical condition.
Electroconvulsive therapy (ECT) is a procedure, done under general anaesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can quickly reverse symptoms of certain mental health conditions.
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This question is part of the following fields:
- Psychiatry
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Question 27
Incorrect
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Which selective serotonin reuptake inhibitors listed below has the highest incidence of discontinuation symptoms?
Your Answer: Escitalopram
Correct Answer: Paroxetine
Explanation:A couple of papers written by the same authors indicate that children and adolescents taking an SSRI definitely experience discontinuation reactions that can be mild, moderate or severe when the medication is stopped suddenly or high doses are reduced substantially. Among the SSRIs paroxetine seems to be the worst offender and fluoxetine the least while sertraline and fluvoxamine tend to be intermediate. The rate of discontinuation syndrome varies with the particular SSRI involved. It is generally quoted as 25% but is higher for SSRIs with shorter half-lives. Paroxetine has been associated with more frequent discontinuation symptoms than the other SSRIs.
The use of fluoxetine with its long half-life appears safer in this respect than paroxetine and venlafaxine causing the most concerns.
Paroxetine has the shortest half-life with 21 hours of all listed SSRIs and as such it would be expected to have a higher incidence or severity (greater number of symptoms) and fluoxetine would have the least since it has a half life of 96 hours. Citalopram has a half-life of 35 hours while escitalopram has a half-life of 30 hours.
The most common symptoms reported are: dizziness, light-headedness, drowsiness, poor concentration, nausea, headache and fatigue.
Another common symptom in adults is paraesthesia described as burning, tingling, numbness or electric shock feelings usually in the upper half of the body or proximal lower limbs. -
This question is part of the following fields:
- Psychiatry
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Question 28
Incorrect
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A 49 year old man states that he is feeling down and has not been sleeping well. An assessment is done using a validated symptom measure which indicates that he is moderately depressed. He is currently taking Ramipril, Simvastatin and Aspirin for ischaemic heart disease. What is the most appropriate course of action?
Your Answer: Start sertraline
Correct Answer: Start sertraline + lansoprazole
Explanation:Results of a randomized trial confirm that the antidepressant sertraline can be used safely in patients with recent MI or unstable angina and is effective in relieving depression in these patients.
There are theoretical reasons for believing that selective serotonin reuptake inhibitors (SSRIs), widely used to treat depression, might increase the risk of gastrointestinal bleeding. Gastroprotective drugs are advocated for high risk patients taking non-steroidal anti-inflammatory drugs, another class of drug that causes gastrointestinal bleeding.
Serotonin is released from platelets in response to vascular injury and promotes vasoconstriction and a change in the shape of the platelets that leads to aggregation. Platelets cannot themselves synthesise serotonin. SSRIs inhibit the serotonin transporter, which is responsible for the uptake of serotonin into platelets. It could thus be predicted that SSRIs would deplete platelet serotonin, leading to a reduced ability to form clots and a subsequent increase in the risk of bleeding.
The well established association between nonsteroidal anti-inflammatory drugs and upper gastrointestinal bleeding is estimated to result in 700-2000 deaths/year in the UK. This has led to the recommendation that patients in high risk groups should receive gastroprotection in the form of an H2 antagonist, proton pump inhibitor (lansoprazole), or misoprostol.
Proton pump inhibitors have been shown to reduce endoscopically diagnosed mucosal damage and heal ulcers induced by non-steroidal anti-inflammatory drugs but not to reduce the incidence of severe gastrointestinal bleeds.
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This question is part of the following fields:
- Psychiatry
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Question 29
Correct
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A 55-year-old female inpatient in a psychiatric hospital has stopped eating or drinking as she believes she is dead and does not require food anymore. Which syndrome is characteristic of this finding?
Your Answer: Cotard syndrome
Explanation:The most probable diagnosis of this patient is Cotard syndrome.
Cotard syndrome is a rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary. Cotard syndrome is often associated with severe depression and psychotic disorders.
Other delusional syndromes:
– Othello syndrome is a delusional belief that a patients partner is committing infidelity despite no evidence of this. It can often result in violence and controlling behaviour.
– De Clerambault syndrome (otherwise known as erotomania), is where a patient believes that a person of higher social or professional standing is in love with them. Often this presents with people who believe celebrities are in love with them.
– Capgras syndrome is characterised by a person believing their friend or relative had been replaced by an exact double.
– Couvade syndrome is also known as ‘sympathetic pregnancy’. It affects fathers, particularly during the first and third trimesters of pregnancy, who suffer the somatic features of pregnancy.
– Ekbom syndrome is also known as delusional parasitosis and is the belief that they are infected with parasites or have ‘bugs’ under their skin. This can vary from the classic psychosis symptoms in narcotic use where the user can ‘see’ bugs crawling under their skin or can be a patient who believes that they are infested with snakes. -
This question is part of the following fields:
- Psychiatry
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Question 30
Incorrect
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Which among the following is most likely to be beneficial to a patient with schizophrenia?
Your Answer: Adherence therapy
Correct Answer: Cognitive behavioural therapy
Explanation:Among the given options, cognitive-behavioural therapy is the most likely to benefit a patient with schizophrenia.
Schizophrenia is a functional psychotic disorder characterized by the presence of delusional beliefs, hallucinations, and disturbances in thought, perception, and behaviour.
Clinical features:
Schneider’s first-rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions:Auditory hallucinations of a specific type:
Two or more voices discussing the patient in the third person
Thought echo
Voices commenting on the patient’s behaviourThought disorder:
Thought insertion
Thought withdrawal
Thought broadcastingPassivity phenomena:
Bodily sensations being controlled by external influence
Actions/impulses/feelings – experiences which are imposed on the Individual or influenced by othersOther features of schizophrenia include
Impaired insight (a feature of all psychoses)
Incongruity/blunting of affect (inappropriate emotion for circumstances)
Decreased speech
Neologisms: made-up words
Catatonia
Negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation).Treatment:
For the initial treatment of acute psychosis, it is recommended to commence an oral second-generation antipsychotics such as aripiprazole, olanzapine, risperidone, quetiapine, etc.
Once the acute phase is controlled, switching to a depot preparation like aripiprazole, paliperidone, zuclopenthixol, fluphenazine, haloperidol, pipotiazine, or risperidone is recommended.
Cognitive-behavioural therapy (CBT) and the use of art and drama therapies help counteract the negative symptoms of the disease, improve insight, and assist relapse prevention.
Clozapine is used in case of treatment resistance. -
This question is part of the following fields:
- Psychiatry
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