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  • Question 1 - What is a true statement about vigabatrin? ...

    Incorrect

    • What is a true statement about vigabatrin?

      Your Answer: The risk of visual loss is not dose related

      Correct Answer: Vision loss can worsen despite discontinuation

      Explanation:

      Vigabatrin has the potential to cause permanent visual field constriction, leading to tunnel vision and disability. It may also harm the central retina and reduce visual acuity. The risk of vision loss increases with higher doses and prolonged use. The onset of vision loss is unpredictable and can occur shortly after starting treatment of at any point during treatment, even after several months of years. Unfortunately, once vision loss is detected, it cannot be reversed.

      Antiepileptic drugs (AEDs) are commonly used for the treatment of epilepsy, but many of them also have mood stabilizing properties and are used for the prophylaxis and treatment of bipolar disorder. However, some AEDs carry product warnings for serious side effects such as hepatic failure, pancreatitis, thrombocytopenia, and skin reactions. Additionally, some AEDs have been associated with an increased risk of suicidal behavior and ideation.

      Behavioral side-effects associated with AEDs include depression, aberrant behaviors, and the development of worsening of irritability, impulsivity, anger, hostility, and aggression. Aggression can occur before, after, of in between seizures. Some AEDs are considered to carry a higher risk of aggression, including levetiracetam, perampanel, and topiramate. However, data on the specific risk of aggression for other AEDs is lacking of mixed. It is important for healthcare providers to carefully consider the potential risks and benefits of AEDs when prescribing them for patients with epilepsy of bipolar disorder.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 2 - A 20-year-old man presents to the emergency department with a two-week history of...

    Correct

    • A 20-year-old man presents to the emergency department with a two-week history of feeling 'on top of the world'. His girlfriend reports him being unusually irritable for the same period of time. He has only been having two hours of sleep each night for the past three nights but despite this says he feels full of energy. On examination he is extremely talkative, and his mood is liable. His girlfriend is concerned as for the past 24 hours he has been buying expensive items which they can't afford and do not need. He is admitted to a psychiatric ward for observation and continues to exhibit these signs for a further two days before he attempts to take his own life. His only psychiatric history is that of a moderate depressive illness six months ago which lasted two months.
      Which of the following do you most suspect?

      Your Answer: Bipolar I disorder

      Explanation:

      The individual exhibits symptoms of heightened mood and increased physical activity, indicating a possible episode of mania or hypomania. This presentation persists for a minimum of two weeks and necessitates hospitalization, meeting the criteria for a manic episode and thus a diagnosis of bipolar I disorder.

      Bipolar Disorder Diagnosis

      Bipolar and related disorders are mood disorders characterized by manic, mixed, of hypomanic episodes alternating with depressive episodes. The lifetime risk of suicide in individuals with bipolar disorder is estimated to be at least 15 times that of the general population. Under the ICD-11, there are three subtypes of bipolar disorder: Bipolar I, Bipolar II, and Cyclothymic disorder.

      Bipolar I disorder is diagnosed when an individual has a history of at least one manic of mixed episode. The typical course of the disorder is characterized by recurrent depressive and manic of mixed episodes. Onset of the first mood episode most often occurs during the late teen years, but onset of bipolar type I can occur at any time through the life cycle. The lifetime prevalence of bipolar I disorder is estimated to be around 2.1%.

      Bipolar II disorder is diagnosed when an individual has a history of at least one hypomanic episode and at least one depressive episode. The typical course of the disorder is characterized by recurrent depressive and hypomanic episodes. Onset of bipolar type II most often occurs during the mid-twenties. The number of lifetime episodes tends to be higher for bipolar II disorder than for major depressive disorder of bipolar I disorder.

      Cyclothymic disorder is diagnosed when an individual experiences mood instability over an extended period of time characterized by numerous hypomanic and depressive periods. The symptoms are present for more days than not, and there is no history of manic or mixed episodes. The course of cyclothymic disorder is often gradual and persistent, and onset commonly occurs during adolescence of early adulthood.

      Rapid cycling is not a subtype of bipolar disorder but instead is a qualifier. It is defined as the presence of at least four mood episodes in the previous 12 months that meet the criteria for a manic, hypomanic, of major depressive episode. Rapid cycling is associated with an increased risk of suicide and tends to be precipitated by stressors such as life events, alcohol abuse, use of antidepressants, and medical disorders.

      Overall, the diagnosis of bipolar disorder requires careful evaluation of an individual’s symptoms and history. Treatment typically involves a combination of medication and psychotherapy.

    • This question is part of the following fields:

      • General Adult Psychiatry
      5032.4
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  • Question 3 - A 35-year-old left-handed man suddenly experiences paralysis in his left hand, with no...

    Incorrect

    • A 35-year-old left-handed man suddenly experiences paralysis in his left hand, with no sensation from the wrist downwards. He had a fall while playing basketball two weeks ago, which was on his left side. He is currently undergoing psychodynamic psychotherapy with a forensic psychiatrist due to a personality disorder. He also has a history of criminal behavior, including strangling his 8-year-old daughter 10 years ago, for which he served time in prison. He lives alone and believes he has moved on from his past. What is the most likely diagnosis?

      Your Answer: Left median nerve palsy

      Correct Answer: Conversion disorder

      Explanation:

      The patient’s symptoms do not suggest a physical cause, as the median nerve does not affect all fingers, and there is no clear connection between the fall and the onset of symptoms. There is no apparent motive for the patient to feign illness of adopt a sick role. It is probable that the patient is experiencing a conversion disorder, with the symptoms arising unconsciously in the context of therapy. The fact that the symptoms are affecting the patient’s left hand is noteworthy, as this is the hand that may have been used in the act of strangulation.

    • This question is part of the following fields:

      • General Adult Psychiatry
      400.3
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  • Question 4 - What is a true statement about psychotic depression? ...

    Incorrect

    • What is a true statement about psychotic depression?

      Your Answer: It has an estimated community prevalence is 0.04%

      Correct Answer: It is classified by the ICD-11 and the DSM-5 as a subtype of depression

      Explanation:

      Psychotic Depression

      Psychotic depression is a type of depression that is characterized by the presence of delusions and/of hallucinations in addition to depressive symptoms. This condition is often accompanied by severe anhedonia, loss of interest, and psychomotor retardation. People with psychotic depression are tormented by hallucinations and delusions with typical themes of worthlessness, guilt, disease, of impending disaster. This condition affects approximately 14.7-18.5% of depressed patients and is estimated to affect around 0.4% of community adult samples, with a higher prevalence in the elderly community at around 1.4-3.0%. People with psychotic depression are at a higher risk of attempting and completing suicide than those with non-psychotic depression.

      Diagnosis

      Psychotic depression is currently classified as a subtype of depression in both the ICD-11 and the DSM-5. The main difference between the two is that in the ICD-11, the depressive episode must be moderate of severe to qualify for a diagnosis of depressive episode with psychotic symptoms, whereas in the DSM-5, the diagnosis can be applied to any severity of depressive illness.

      Treatment

      The recommended treatment for psychotic depression is tricyclics as first-line treatment, with antipsychotic augmentation. Second-line treatment includes SSRI/SNRI. Augmentation of antidepressant with olanzapine or quetiapine is recommended. The optimum dose and duration of antipsychotic augmentation are unknown. If one treatment is to be stopped during the maintenance phase, then this should be the antipsychotic. ECT should be considered where a rapid response is required of where other treatments have failed. According to NICE (ng222), combination treatment with antidepressant medication and antipsychotic medication (such as olanzapine or quetiapine) should be considered for people with depression with psychotic symptoms. If a person with depression with psychotic symptoms does not wish to take antipsychotic medication in addition to an antidepressant, then treat with an antidepressant alone.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 5 - What evidence indicates the presence of obsessive compulsive personality disorder? ...

    Correct

    • What evidence indicates the presence of obsessive compulsive personality disorder?

      Your Answer: Inability to discard worn out objects with no sentimental value

      Explanation:

      It is important to note that there is a significant difference between obsessive compulsive disorder and obsessive compulsive personality disorder.

      Personality Disorder (Obsessive Compulsive)

      Obsessive-compulsive personality disorder is characterized by a preoccupation with orderliness, perfectionism, and control, which can hinder flexibility and efficiency. This pattern typically emerges in early adulthood and can be present in various contexts. The estimated prevalence ranges from 2.1% to 7.9%, with males being diagnosed twice as often as females.

      The DSM-5 diagnosis requires the presence of four of more of the following criteria: preoccupation with details, rules, lists, order, organization, of agenda to the point that the key part of the activity is lost; perfectionism that hampers completing tasks; extreme dedication to work and efficiency to the elimination of spare time activities; meticulous, scrupulous, and rigid about etiquettes of morality, ethics, of values; inability to dispose of worn-out of insignificant things even when they have no sentimental meaning; unwillingness to delegate tasks of work with others except if they surrender to exactly their way of doing things; miserly spending style towards self and others; and rigidity and stubbornness.

      The ICD-11 abolished all categories of personality disorder except for a general description of personality disorder, which can be further specified as “mild,” “moderate,” of “severe.” The anankastic trait domain is characterized by a narrow focus on one’s rigid standard of perfection and of right and wrong, and on controlling one’s own and others’ behavior and controlling situations to ensure conformity to these standards. Common manifestations of anankastic include perfectionism and emotional and behavioral constraint.

      Differential diagnosis includes OCD, hoarding disorder, narcissistic personality disorder, antisocial personality disorder, and schizoid personality disorder. OCD is distinguished by the presence of true obsessions and compulsions, while hoarding disorder should be considered when hoarding is extreme. Narcissistic personality disorder individuals are more likely to believe that they have achieved perfection, while those with obsessive-compulsive personality disorder are usually self-critical. Antisocial personality disorder individuals lack generosity but will indulge themselves, while those with obsessive-compulsive personality disorder adopt a miserly spending style toward both self and others. Schizoid personality disorder is characterized by a fundamental lack of capacity for intimacy, while in obsessive-compulsive personality disorder, this stems from discomfort with emotions and excessive devotion to work.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 6 - What is the DSM-5's definition of 'gender dysphoria'? ...

    Incorrect

    • What is the DSM-5's definition of 'gender dysphoria'?

      Your Answer: To achieve a diagnosis there must be evidence of incongruence between the experienced and assigned gender prior to puberty

      Correct Answer: To meet the diagnostic threshold the condition must be associated with significant distress

      Explanation:

      The main requirement is a mismatch between an individual’s biological sex and their gender identity, which causes significant distress.

      Gender identity is the person’s identification of lived role in society, which is separate from their biological sex. Gender can include non-binary and pangender identities, and cisgender refers to people whose gender is congruent with their biological sex. Gender identity is not the same as sexual preference, which is covered by separate diagnostic categories. The ICD-11 has redefined gender identity-related health, replacing diagnostic categories like “transsexualism” and “gender identity disorder of children” with “gender incongruence of adolescence and adulthood” and “gender incongruence of childhood”, respectively. The DSM-5 uses the term ‘gender dysphoria’ to cover the whole range of gender identity disorders, which is characterized by a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, and associated with clinically significant distress of impairment in social, occupational, of other important areas of functioning.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 7 - What is the recommended antidepressant for an individual with epilepsy who experiences symptoms...

    Correct

    • What is the recommended antidepressant for an individual with epilepsy who experiences symptoms of depression?

      Your Answer: Citalopram

      Explanation:

      SSRIs, such as citalopram, are generally considered safe for individuals with epilepsy. However, when prescribing SSRIs to those with epilepsy, it is preferable to choose options that have a low likelihood of interacting with antiepileptic medications. Typically, citalopram or escitalopram are the preferred options, followed by sertraline.

      Psychotropics and Seizure Threshold in People with Epilepsy

      People with epilepsy are at an increased risk for various mental health conditions, including depression, anxiety, psychosis, and suicide. It is important to note that the link between epilepsy and mental illness is bidirectional, as patients with mental health conditions also have an increased risk of developing new-onset epilepsy. Psychotropic drugs are often necessary for people with epilepsy, but they can reduce the seizure threshold and increase the risk of seizures. The following tables provide guidance on the seizure risk associated with different classes of antidepressants, antipsychotics, and ADHD medications. It is important to use caution and carefully consider the risks and benefits of these medications when treating people with epilepsy.

    • This question is part of the following fields:

      • General Adult Psychiatry
      1171.5
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  • Question 8 - What are the accurate statements about the endocrine complications observed in individuals with...

    Incorrect

    • What are the accurate statements about the endocrine complications observed in individuals with anorexia nervosa?

      Your Answer: Insulin-like growth factor-1 is raised due to elevated growth hormone levels

      Correct Answer: Severe hypoglycemia can indicate infection

      Explanation:

      – Severe hypoglycemia can indicate infection and can be fatal
      – Triiodothyronine levels are usually low
      – Hypercortisolaemia does not result in Cushingoid features
      – Primary and secondary amenorrhoea are common
      – Insulin-like growth factor-1 is reduced

      Anorexia is a serious mental health condition that can have severe physical complications. These complications can affect various systems in the body, including the cardiac, skeletal, hematologic, reproductive, metabolic, gastrointestinal, CNS, and dermatological systems. Some of the recognized physical complications of anorexia nervosa include bradycardia, hypotension, osteoporosis, anemia, amenorrhea, hypothyroidism, delayed gastric emptying, cerebral atrophy, and lanugo.

      The Royal College of Psychiatrists has issued advice on managing sick patients with anorexia nervosa, recommending hospital admission for those with high-risk items. These items include a BMI of less than 13, a pulse rate of less than 40 bpm, a SUSS test score of less than 2, a sodium level of less than 130 mmol/L, a potassium level of less than 3 mmol/L, a serum glucose level of less than 3 mmol/L, and a QTc interval of more than 450 ms. The SUSS test involves assessing the patient’s ability to sit up and squat without using their hands. A rating of 0 indicates complete inability to rise, while a rating of 3 indicates the ability to rise without difficulty. Proper management and treatment of anorexia nervosa are crucial to prevent of manage these physical complications.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 9 - What is a true statement about the NICE Guidelines for depression? ...

    Correct

    • What is a true statement about the NICE Guidelines for depression?

      Your Answer: If an antidepressant is indicated, an SSRI is recommended

      Explanation:

      Depression Treatment Guidelines by NICE

      The National Institute for Health and Care Excellence (NICE) provides guidelines for the treatment of depression. The following are some general recommendations:

      – Selective serotonin reuptake inhibitors (SSRIs) are preferred when prescribing antidepressants.
      – Antidepressants are not the first-line treatment for mild depression.
      – After remission, continue antidepressant treatment for at least six months.
      – Continue treatment for at least two years if at high risk of relapse of have a history of severe or prolonged episodes of inadequate response.
      – Use a stepped care approach to depression treatment, starting at the appropriate level based on the severity of depression.

      The stepped care approach involves the following steps:

      – Step 1: Assessment, support, psychoeducation, active monitoring, and referral for further assessment and interventions.
      – Step 2: Low-intensity psychosocial interventions, psychological interventions, medication, and referral for further assessment and interventions.
      – Step 3: Medication, high-intensity psychological interventions, combined treatments, collaborative care, and referral for further assessment and interventions.
      – Step 4: Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care.

      Individual guided self-help programs based on cognitive-behavioral therapy (CBT) principles should be supported by a trained practitioner and last 9 to 12 weeks. Physical activity programs should consist of three sessions per week of moderate duration over 10 to 14 weeks.

      NICE advises against using antidepressants routinely to treat persistent subthreshold depressive symptoms of mild depression. However, they may be considered for people with a past history of moderate or severe depression, initial presentation of subthreshold depressive symptoms that have been present for a long period, of subthreshold depressive symptoms of mild depression that persist after other interventions.

      NICE recommends a combination of antidepressant medication and a high-intensity psychological intervention (CBT of interpersonal therapy) for people with moderate of severe depression. Augmentation of antidepressants with lithium, antipsychotics, of other antidepressants may be appropriate, but benzodiazepines, buspirone, carbamazepine, lamotrigine, of valproate should not be routinely used.

      When considering different antidepressants, venlafaxine is associated with a greater risk of death from overdose compared to other equally effective antidepressants. Tricyclic antidepressants (TCAs) except for lofepramine are associated with the greatest risk in overdose. Higher doses of venlafaxine may exacerbate cardiac arrhythmias, and venlafaxine and duloxetine may exacerbate hypertension. TCAs may cause postural hypotension and arrhythmias, and mianserin requires hematological monitoring in elderly people.

      The review frequency depends on the age and suicide risk of the patient. If the patient is over 30 and has no suicide risk, see them after two weeks and then at intervals of 2-4 weeks for the first three months. If the patient is under 30 and has a suicide risk, see them after one week.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 10 - What is the most prevalent mental disorder observed in individuals with multiple sclerosis?...

    Correct

    • What is the most prevalent mental disorder observed in individuals with multiple sclerosis?

      Your Answer: Depression

      Explanation:

      Psychiatric Consequences of Multiple Sclerosis

      Multiple sclerosis (MS) is a neurological disorder that affects individuals between the ages of 20 and 40. It is characterized by multiple demyelinating lesions in the optic nerves, cerebellum, brainstem, and spinal cord. MS presents with diverse neurological signs, including optic neuritis, internuclear ophthalmoplegia, and ocular motor cranial neuropathy.

      Depression is the most common psychiatric condition seen in MS, with a lifetime prevalence of 25-50%. The symptoms of depression in people with MS tend to be different from those without MS. The preferred diagnostic indicators for depression in MS include pervasive mood change, diurnal mood variation, suicidal ideation, functional change not related to physical disability, and pessimistic of negative patterns of thinking. Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for depression in patients with MS.

      Suicide is common in MS, with recognized risk factors including male gender, young age at onset of illness, current of previous history of depression, social isolation, and substance misuse. Mania is more common in people with MS, and mood stabilizers are recommended for treatment. Pathological laughing and crying, defined as uncontrollable laughing and/of crying without the associated affect, occurs in approximately 10% of cases of MS. Emotional lability, defined as an excessive emotional response to a minor stimulus, is also common in MS and can be treated with amitriptyline and SSRIs.

      The majority of cases of neuropsychiatric side effects from corticosteroids fit an affective profile of mania and/of depression. Psychotic symptoms, particularly hallucinations, are present in up to half of these cases. Glatiramer acetate has not been associated with neuropsychiatric side-effects. The data regarding the risk of mood symptoms related to interferon use is conflicting.

      In conclusion, MS has significant psychiatric consequences, including depression, suicide, mania, pathological laughing and crying, emotional lability, and neuropsychiatric side effects from treatment. Early recognition and treatment of these psychiatric symptoms are essential for improving the quality of life of individuals with MS.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 11 - How does the suicide rate in patients with epilepsy compare to the general...

    Incorrect

    • How does the suicide rate in patients with epilepsy compare to the general population?

      Your Answer: Not significantly different

      Correct Answer: 3 times higher

      Explanation:

      Suicide Risk in Epilepsy

      Several studies have shown that individuals with epilepsy have an increased risk of suicide. A large study published in the Lancet in 2007 found that individuals with epilepsy were three times more likely to commit suicide compared to those without epilepsy. This risk remained high even after excluding those with a history of psychiatric disease and adjusting for socioeconomic factors.

      The highest risk of suicide was found in individuals with epilepsy and comorbid psychiatric disease, with a risk of 13.7 times higher than controls. The risk of suicide was also highest during the first six months after diagnosis, especially in those with a history of comorbid psychiatric disease.

      These findings highlight the importance of addressing mental health concerns in individuals with epilepsy, particularly during the early stages of diagnosis. Healthcare providers should be aware of the increased risk of suicide in this population and provide appropriate support and resources to prevent suicide.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 12 - Can you rephrase the question to ask for a definition of macrosomia? ...

    Correct

    • Can you rephrase the question to ask for a definition of macrosomia?

      Your Answer: Macrosomia

      Explanation:

      Risks to Children of Mothers with Eating Disorders

      Children of mothers with eating disorders are at risk of various complications, including premature birth, increased perinatal mortality, cleft lip and cleft palate, epilepsy, developmental delays, abnormal growth, food fussiness, feeding difficulties, low birth weight, microcephaly, and low APGAR scores. Previous exam questions have focused on low APGAR scores.

      Eating disorders in pregnancy can also lead to associated complications, such as inadequate of excessive weight gain, hyperemesis gravidarum, hypotension (in anorexia) of hypertension (in bulimia), syncope/presyncope from cardiac arrhythmias and electrolyte disturbances, anemia (in anorexia), pregnancy termination (spontaneous of therapeutic), small for term infant, stillbirth, breech pregnancy, pre-eclampsia, cesarean section, post-episiotomy suture tearing, vaginal bleeding, increased rate of perinatal difficulties, postpartum depression risk, cardiac changes, and refeeding syndrome (occurs primarily in patients who are aggressively refed).

    • This question is part of the following fields:

      • General Adult Psychiatry
      16
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  • Question 13 - You have been asked to assess a 60-year-old female at the cardiac unit...

    Correct

    • You have been asked to assess a 60-year-old female at the cardiac unit of the local general hospital. She suffered a myocardial (MI) infarction three weeks ago and has been recovering well physically.
      The medical team are concerned that she is experiencing frequent crying spells. You observe evidence of low mood, anhedonia and sleep disturbance.
      The woman feels hopeless about the future and has fleeting thoughts of suicide. She has a history of depression which responded well to antidepressant treatment.
      Which antidepressant would you recommend based on its demonstrated safety post-myocardial infarction?

      Your Answer: Sertraline

      Explanation:

      According to a study published in JAMA, sertraline is a safe and effective treatment for depression in patients who have recently experienced a myocardial infarction (MI) of unstable angina. The study found that sertraline not only has antidepressant effects but also inhibits platelet aggregation. This suggests that sertraline may have additional benefits for patients with cardiovascular disease. For more information, refer to Glassman et al.’s study in JAMA.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 14 - What is the prognosis for individuals diagnosed with anorexia nervosa? ...

    Correct

    • What is the prognosis for individuals diagnosed with anorexia nervosa?

      Your Answer: About half will have recovered within 30 years

      Explanation:

      Anorexia Prognosis

      The long-term outcomes of anorexia are difficult to determine due to high drop-out rates from follow-up. However, one study found that over a 29 year period, half of patients recovered completely, a third recovered partially, 20% had a chronic eating disorder, and 5% died. Factors associated with a poor prognosis include a long duration of hospital care, psychiatric comorbidity, being adopted, growing up in a one-parent household, and having a young mother. Other factors that have been found to contribute to a poor prognosis include lower minimum weight, poor family relationships, failed treatment, late age of onset, and social problems.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 15 - What is true about the 2014 Adult Psychiatric Morbidity Survey? ...

    Correct

    • What is true about the 2014 Adult Psychiatric Morbidity Survey?

      Your Answer: People in prisons were not included in the sample

      Explanation:

      The APMS has a significant drawback in that it solely relies on household data and does not incorporate data from institutions like prisons.

      Adult Psychiatric Morbidity Survey

      The Adult Psychiatric Morbidity Survey (APMS), also known as the National Psychiatric Morbidity Survey, is conducted every 7 years to monitor the prevalence of mental illness and access to treatment in the general population of England. The survey obtains a stratified random sample representative of the population living in private households by using postcodes. The information is gathered through questionnaires and interviews to screen for a range of mental disorders and risk factors. However, the survey does not collect data on individuals under the age of 16. The study does not include people living in institutional settings such as prisons of care homes, of those who are homeless of living in temporary housing.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 16 - What is the closest estimate of the average ratio between clozapine and norclozapine?...

    Correct

    • What is the closest estimate of the average ratio between clozapine and norclozapine?

      Your Answer: 1.3

      Explanation:

      Clozapine is an effective antipsychotic drug used in the management of treatment-resistant schizophrenia (TRS). It was reintroduced in the 1990s with mandatory blood monitoring due to the risk of agranulocyte

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 17 - What statement accurately describes the STAR*D trial? ...

    Incorrect

    • What statement accurately describes the STAR*D trial?

      Your Answer: It excluded those with a history of psychosis

      Correct Answer: It was a pragmatic trial

      Explanation:

      STAR*D Study

      The STAR*D trial, conducted in the USA, aimed to evaluate the effectiveness of treatments for major depressive disorder in real-world patients. The study involved four levels of treatment, with patients starting at level 1 and progressing to the next level if they did not respond. The outcome measure used was remission, and the study entry criteria were broadly defined to ensure results could be generalized to a wide range of patients.

      A total of 4,041 patients were enrolled in the first level of treatment, making STAR*D the largest prospective clinical trial of depression ever conducted. In level 1, one-third of participants achieved remission, and a further 10-15% responded but not to the point of remission. If treatment with an initial SSRI fails, then one in four patients who choose to switch to another medication will enter remission, regardless of whether the second medication is an SSRI of a medication of a different class. If patients choose to add a medication instead, one in three will get better.

      Overall, the STAR*D study provides valuable insights into the effectiveness of different treatments for major depressive disorder and highlights the importance of considering alternative treatments if initial treatment fails.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 18 - What factor is the most probable cause of tardive dyskinesia? ...

    Correct

    • What factor is the most probable cause of tardive dyskinesia?

      Your Answer: Haloperidol

      Explanation:

      Tardive Dyskinesia: Symptoms, Causes, Risk Factors, and Management

      Tardive dyskinesia (TD) is a condition that affects the face, limbs, and trunk of individuals who have been on neuroleptics for months to years. The movements fluctuate over time, increase with emotional arousal, decrease with relaxation, and disappear with sleep. The cause of TD remains theoretical, but the postsynaptic dopamine (D2) receptor supersensitivity hypothesis is the most persistent. Other hypotheses include the presynaptic dopaminergic/noradrenergic hyperactivity hypothesis, the cholinergic interneuron burnout hypothesis, the excitatory/oxidative stress hypothesis, and the synaptic plasticity hypothesis. Risk factors for TD include advancing age, female sex, ethnicity, longer illness duration, intellectual disability and brain damage, negative symptoms in schizophrenia, mood disorders, diabetes, smoking, alcohol and substance misuse, FGA vs SGA treatment, higher antipsychotic dose, anticholinergic co-treatment, and akathisia.

      Management options for TD include stopping any anticholinergic, reducing antipsychotic dose, changing to an antipsychotic with lower propensity for TD, and using tetrabenazine, vitamin E, of amantadine as add-on options. Clozapine is the antipsychotic most likely to be associated with resolution of symptoms. Vesicular monoamine transporter type 2 (VMAT2) inhibitors are agents that cause a depletion of neuroactive peptides such as dopamine in nerve terminals and are used to treat chorea due to neurodegenerative diseases of dyskinesias due to neuroleptic medications (tardive dyskinesia).

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 19 - What is accurate about the haematological issues associated with anorexia nervosa? ...

    Incorrect

    • What is accurate about the haematological issues associated with anorexia nervosa?

      Your Answer: Anaemia is seen in approximately 5% of patients with anorexia

      Correct Answer: Plasma volume depletion can mask an anaemia

      Explanation:

      Anorexia is a serious mental health condition that can have severe physical complications. These complications can affect various systems in the body, including the cardiac, skeletal, hematologic, reproductive, metabolic, gastrointestinal, CNS, and dermatological systems. Some of the recognized physical complications of anorexia nervosa include bradycardia, hypotension, osteoporosis, anemia, amenorrhea, hypothyroidism, delayed gastric emptying, cerebral atrophy, and lanugo.

      The Royal College of Psychiatrists has issued advice on managing sick patients with anorexia nervosa, recommending hospital admission for those with high-risk items. These items include a BMI of less than 13, a pulse rate of less than 40 bpm, a SUSS test score of less than 2, a sodium level of less than 130 mmol/L, a potassium level of less than 3 mmol/L, a serum glucose level of less than 3 mmol/L, and a QTc interval of more than 450 ms. The SUSS test involves assessing the patient’s ability to sit up and squat without using their hands. A rating of 0 indicates complete inability to rise, while a rating of 3 indicates the ability to rise without difficulty. Proper management and treatment of anorexia nervosa are crucial to prevent of manage these physical complications.

    • This question is part of the following fields:

      • General Adult Psychiatry
      31.6
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  • Question 20 - What symptom is commonly observed in individuals with bipolar disorder and psychosis? ...

    Incorrect

    • What symptom is commonly observed in individuals with bipolar disorder and psychosis?

      Your Answer: Persecutory delusions

      Correct Answer: Prominent affective symptoms and mood congruent delusions

      Explanation:

      Bipolar Disorder Diagnosis

      Bipolar and related disorders are mood disorders characterized by manic, mixed, of hypomanic episodes alternating with depressive episodes. The lifetime risk of suicide in individuals with bipolar disorder is estimated to be at least 15 times that of the general population. Under the ICD-11, there are three subtypes of bipolar disorder: Bipolar I, Bipolar II, and Cyclothymic disorder.

      Bipolar I disorder is diagnosed when an individual has a history of at least one manic of mixed episode. The typical course of the disorder is characterized by recurrent depressive and manic of mixed episodes. Onset of the first mood episode most often occurs during the late teen years, but onset of bipolar type I can occur at any time through the life cycle. The lifetime prevalence of bipolar I disorder is estimated to be around 2.1%.

      Bipolar II disorder is diagnosed when an individual has a history of at least one hypomanic episode and at least one depressive episode. The typical course of the disorder is characterized by recurrent depressive and hypomanic episodes. Onset of bipolar type II most often occurs during the mid-twenties. The number of lifetime episodes tends to be higher for bipolar II disorder than for major depressive disorder of bipolar I disorder.

      Cyclothymic disorder is diagnosed when an individual experiences mood instability over an extended period of time characterized by numerous hypomanic and depressive periods. The symptoms are present for more days than not, and there is no history of manic or mixed episodes. The course of cyclothymic disorder is often gradual and persistent, and onset commonly occurs during adolescence of early adulthood.

      Rapid cycling is not a subtype of bipolar disorder but instead is a qualifier. It is defined as the presence of at least four mood episodes in the previous 12 months that meet the criteria for a manic, hypomanic, of major depressive episode. Rapid cycling is associated with an increased risk of suicide and tends to be precipitated by stressors such as life events, alcohol abuse, use of antidepressants, and medical disorders.

      Overall, the diagnosis of bipolar disorder requires careful evaluation of an individual’s symptoms and history. Treatment typically involves a combination of medication and psychotherapy.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 21 - Which statement about St John's Wort is incorrect? ...

    Incorrect

    • Which statement about St John's Wort is incorrect?

      Your Answer: Adverse effects in trials is similar to placebo

      Correct Answer: Causes inhibition of the P450 system

      Explanation:

      St John’s Wort is recognized as a substance that stimulates the P450 system.

      Herbal Remedies for Depression and Anxiety

      Depression can be treated with Hypericum perforatum (St John’s Wort), which has been found to be more effective than placebo and as effective as standard antidepressants. However, its use is not advised due to uncertainty about appropriate doses, variation in preparations, and potential interactions with other drugs. St John’s Wort can cause serotonin syndrome and decrease levels of drugs such as warfarin and ciclosporin. The effectiveness of the combined oral contraceptive pill may also be reduced.

      Anxiety can be reduced with Piper methysticum (kava), but it cannot be recommended for clinical use due to its association with hepatotoxicity.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 22 - What is the time frame after paracetamol ingestion in which paracetamol levels are...

    Incorrect

    • What is the time frame after paracetamol ingestion in which paracetamol levels are used to determine the appropriate treatment with acetylcysteine in cases of overdose?

      Your Answer: 4-8 hours

      Correct Answer: 4-24 hours

      Explanation:

      The treatment nomogram for acetylcysteine is applicable for a duration of 4-24 hours, but it is important to note that the reliability of the levels decreases beyond 15 hours, as indicated by the dotted line. It is recommended to consider administering acetylcysteine to patients who have overdosed within 24 hours, even if their plasma paracetamol levels are below the treatment threshold on the graph, provided that biochemical tests indicate acute liver injury.

      Self-Harm and its Management

      Self-harm refers to intentional acts of self-poisoning of self-injury. It is prevalent among younger people, with an estimated 10% of girls and 3% of boys aged 15-16 years having self-harmed in the previous year. Risk factors for non-fatal repetition of self-harm include previous self-harm, personality disorder, hopelessness, history of psychiatric treatment, schizophrenia, alcohol abuse/dependence, and drug abuse/dependence. Suicide following an act of self-harm is more likely in those with previous episodes of self-harm, suicidal intent, poor physical health, and male gender.

      Risk assessment tools are not recommended for predicting future suicide of repetition of self-harm. The recommended interventions for self-harm include 4-10 sessions of CBT specifically structured for people who self-harm and considering DBT for adolescents with significant emotional dysregulation. Drug treatment as a specific intervention to reduce self-harm should not be offered.

      In the management of ingestion, activated charcoal can help if used early, while emetics and cathartics should not be used. Gastric lavage should generally not be used unless recommended by TOXBASE. Paracetamol is involved in 30-40% of acute presentations with poisoning. Intravenous acetylcysteine is the treatment of choice, and pseudo-allergic reactions are relatively common. Naloxone is used as an antidote for opioid overdose, while flumazenil can help reduce the need for admission to intensive care in benzodiazepine overdose.

      For superficial uncomplicated skin lacerations of 5 cm of less in length, tissue adhesive of skin closure strips could be used as a first-line treatment option. All children who self-harm should be admitted for an overnight stay at a pediatric ward.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 23 - What is the purpose of using the DAI and MARS scales for assessment?...

    Correct

    • What is the purpose of using the DAI and MARS scales for assessment?

      Your Answer: Compliance with medication

      Explanation:

      Non-Compliance

      Studies have shown that adherence rates in patients with psychosis who are treated with antipsychotics can range from 25% to 75%. Shockingly, approximately 90% of those who are non-compliant admit to doing so intentionally (Maudsley 12th edition). After being discharged from the hospital, the expected non-compliance rate in individuals with schizophrenia is as follows (Maudsley 12th Edition): 25% at ten days, 50% at one year, and 75% at two years. The Drug Attitude Inventory (DAI) is a useful tool for assessing a patient’s attitude towards medication and predicting compliance. Other scales that can be used include the Rating of Medication Influences Scale (ROMI), the Beliefs about Medication Questionnaire, and the Medication Adherence Rating Scale (MARS).

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 24 - What is a licensed treatment for PTSD? ...

    Incorrect

    • What is a licensed treatment for PTSD?

      Your Answer: Fluoxetine

      Correct Answer: Sertraline

      Explanation:

      While NICE recommends mirtazapine for the treatment of PTSD, its license only permits its use for major depression.

      Antidepressants (Licensed Indications)

      The following table outlines the specific licensed indications for antidepressants in adults, as per the Maudsley Guidelines and the British National Formulary. It is important to note that all antidepressants are indicated for depression.

      – Nocturnal enuresis in children: Amitriptyline, Imipramine, Nortriptyline
      – Phobic and obsessional states: Clomipramine
      – Adjunctive treatment of cataplexy associated with narcolepsy: Clomipramine
      – Panic disorder and agoraphobia: Citalopram, Escitalopram, Sertraline, Paroxetine, Venlafaxine
      – Social anxiety/phobia: Escitalopram, Paroxetine, Sertraline, Moclobemide, Venlafaxine
      – Generalised anxiety disorder: Escitalopram, Paroxetine, Duloxetine, Venlafaxine
      – OCD: Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, Clomipramine
      – Bulimia nervosa: Fluoxetine
      – PTSD: Paroxetine, Sertraline

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 25 - What is a correct statement about the epidemiological catchment area study? ...

    Correct

    • What is a correct statement about the epidemiological catchment area study?

      Your Answer: The survey instrument used was the Diagnostic Interview Schedule

      Explanation:

      The DIS was the survey instrument used in the Epidemiological Catchment Area Study, which was conducted in the United States.

      Epidemiological Catchment Area Study: A Landmark Community-Based Survey

      The Epidemiological Catchment Area Study (ECA) was a significant survey conducted in five US communities from 1980-1985. The study included 20,000 participants, with 3000 community residents and 500 residents of institutions sampled in each site. The Diagnostic Interview Schedule (DIS) was used to conduct two interviews over a year with each participant.

      However, the DIS diagnosis of schizophrenia was not consistent with psychiatrists’ classification, with only 20% of cases identified by the DIS in the Baltimore ECA site matching the psychiatrist’s diagnosis. Despite this, the ECA produced valuable findings, including a lifetime prevalence rate of 32.3% for any disorder, 16.4% for substance misuse disorder, 14.6% for anxiety disorder, 8.3% for affective disorder, 1.5% for schizophrenia and schizophreniform disorder, and 0.1% for somatization disorder.

      The ECA also found that phobia had a one-month prevalence of 12.5%, generalized anxiety and depression had a prevalence of 8.5%, obsessive-compulsive disorder had a prevalence of 2.5%, and panic had a prevalence of 1.6%. Overall, the ECA was a landmark community-based survey that provided valuable insights into the prevalence of mental disorders in the US.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 26 - What is the estimated percentage of women who go through temporary periods of...

    Correct

    • What is the estimated percentage of women who go through temporary periods of emotional instability after giving birth?

      Your Answer: 40

      Explanation:

      Perinatal Depression, Baby Blues, and Postpartum Depression

      Perinatal depression, also known as postpartum depression, is a common mood disorder experienced by new mothers after childbirth. The term baby blues is used to describe the emotional lability that some mothers experience during the first week after childbirth, which usually resolves by day 10 without treatment. The prevalence of baby blues is around 40%. Postpartum depression, on the other hand, refers to depression that occurs after childbirth. While neither DSM-5 nor ICD-11 specifically mention postpartum depression, both diagnostic systems offer categories that encompass depression during pregnancy of in the weeks following delivery. The prevalence of postpartum depression is approximately 10-15%.

      Various factors have been shown to increase the risk of postnatal depression, including youth, marital and family conflict, lack of social support, anxiety and depression during pregnancy, substance misuse, previous pregnancy loss, ambivalence about the current pregnancy, and frequent antenatal admissions to a maternity hospital. However, obstetric factors such as length of labor, assisted delivery, of separation of the mother from the baby in the Special Care Baby Unit do not seem to influence the development of postnatal depression. Additionally, social class does not appear to be associated with postnatal depression.

      Puerperal psychosis, along with severe depression, is thought to be mainly caused by biological factors, while psychosocial factors are most important in the milder postnatal depressive illnesses.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 27 - A stable postpartum patient, with a history of depression, has just given birth....

    Correct

    • A stable postpartum patient, with a history of depression, has just given birth. She asks for your advice about breastfeeding. She has been stable on her current antidepressant medication for several years, although had multiple episodes of depression in the past.
      Which of the following prescribed medications would lead you to advise against breastfeeding?

      Your Answer: Clozapine

      Explanation:

      In the scenario described, the patient has treatment-resistant schizophrenia and is currently stable. Therefore, it may not be necessary to change their antipsychotic medication, as the benefits of continuing their current medication may outweigh the potential risks to the baby if they choose to breastfeed. However, it is important to consider the specific medication being taken and consult with a healthcare professional to determine the best course of action.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 28 - What is the association between the use of ipecac and patients with eating...

    Correct

    • What is the association between the use of ipecac and patients with eating disorders?

      Your Answer: Cardiomyopathy

      Explanation:

      Bulimia, a disorder characterized by inducing vomiting, is a serious health concern. One method used to induce vomiting is through the use of syrup of ipecac, which contains emetine, a toxic alkaloid that irritates the stomach and causes vomiting. While it may produce vomiting within 15-30 minutes, it is not always effective. Unfortunately, nearly 8% of women with eating disorders experiment with ipecac, and 1-2% use it frequently. This is concerning because ipecac is associated with serious cardiac toxicity, including cardiomyopathy and left ventricular dysfunction. Elevated serum amylase levels are a strong indication that a patient has recently been vomiting. It is important to seek professional help for bulimia and avoid using dangerous methods like ipecac to induce vomiting.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 29 - A 33-year-old woman who is eight months pregnant is referred to you by...

    Correct

    • A 33-year-old woman who is eight months pregnant is referred to you by the obstetrics team at the local hospital. She has previously received treatment from a private eating disorders service.

      The obstetrics team are concerned about the well-being of the fetus as her BMI is 15.5 and she is restricting her eating. She seems to have overvalued ideas of being overweight and a fear of fatness.

      You share the obstetric team's concern.

      What is the most probable outcome for this baby?

      Your Answer: Have a low APGAR score

      Explanation:

      Infants born to mothers with anorexia nervosa have significantly lower APGAR scores and birth weights compared to infants born to healthy women. Additionally, mothers with anorexia nervosa have higher rates of caesarean delivery, postnatal complications, and postpartum depression.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 30 - A 45-year-old man had a single episode of mania that was managed with...

    Incorrect

    • A 45-year-old man had a single episode of mania that was managed with medication during a two-week stay in a psychiatric facility. He is currently adhering to his medication regimen without any negative side effects and has gained full awareness of his condition. He is curious about when he will be able to resume driving.

      Your Answer: After a period of one month of remaining stable and well

      Correct Answer: After a period of three months of remaining stable and well

      Explanation:

      Individuals with psychiatric illness may inquire about the criteria for being able to continue driving. Following an acute episode of uncomplicated mania of psychosis, a period of three months of stability is necessary before resuming driving.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 31 - Which statement accurately describes the diagnosis of PTSD according to the ICD-11 criteria?...

    Correct

    • Which statement accurately describes the diagnosis of PTSD according to the ICD-11 criteria?

      Your Answer: The traumatic event must be of a degree that would considered horrific in nature

      Explanation:

      The ICD-11 requires that the traumatic event be of an extremely threatening of horrific nature, which can be experienced directly of indirectly. There is no specific timeframe for when symptoms must occur after the event. To diagnose PTSD, three core elements must be present: re-experiencing the traumatic event, deliberate avoidance of reminders, and persistent perceptions of heightened current threat. Flashbacks can range from mild to severe, with mild flashbacks involving a brief sense of the event occurring again and severe flashbacks resulting in a complete loss of awareness of present surroundings.

      Stress disorders, such as Post Traumatic Stress Disorder (PTSD), are emotional reactions to traumatic events. The diagnosis of PTSD requires exposure to an extremely threatening of horrific event, followed by the development of a characteristic syndrome lasting for at least several weeks, consisting of re-experiencing the traumatic event, deliberate avoidance of reminders likely to produce re-experiencing, and persistent perceptions of heightened current threat. Additional clinical features may include general dysphoria, dissociative symptoms, somatic complaints, suicidal ideation and behaviour, social withdrawal, excessive alcohol of drug use, anxiety symptoms, and obsessions of compulsions. The emotional experience of individuals with PTSD commonly includes anger, shame, sadness, humiliation, of guilt. The onset of PTSD symptoms can occur at any time during the lifespan following exposure to a traumatic event, and the symptoms and course of PTSD can vary significantly over time and individuals. Key differentials include acute stress reaction, adjustment disorder, and complex PTSD. Management of PTSD includes trauma-focused cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and supported trauma-focused computerized CBT interventions. Drug treatments, including benzodiazepines, are not recommended for the prevention of treatment of PTSD in adults, but venlafaxine of a selective serotonin reuptake inhibitor (SSRI) may be considered for adults with a diagnosis of PTSD if the person has a preference for drug treatment. Antipsychotics such as risperidone may be considered in addition if disabling symptoms and behaviors are present and have not responded to other treatments. Psychological debriefing is not recommended for the prevention of treatment of PTSD. For children and young people, individual trauma-focused CBT interventions of EMDR may be considered, but drug treatments are not recommended.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 32 - Which of the following drugs is not recommended by NICE for the treatment...

    Incorrect

    • Which of the following drugs is not recommended by NICE for the treatment of PTSD in adults?

      Your Answer: Venlafaxine

      Correct Answer: Amitriptyline

      Explanation:

      There are various treatment options available for PTSD, including the use of selective serotonin reuptake inhibitors (SSRIs) and venlafaxine.

      Stress disorders, such as Post Traumatic Stress Disorder (PTSD), are emotional reactions to traumatic events. The diagnosis of PTSD requires exposure to an extremely threatening of horrific event, followed by the development of a characteristic syndrome lasting for at least several weeks, consisting of re-experiencing the traumatic event, deliberate avoidance of reminders likely to produce re-experiencing, and persistent perceptions of heightened current threat. Additional clinical features may include general dysphoria, dissociative symptoms, somatic complaints, suicidal ideation and behaviour, social withdrawal, excessive alcohol of drug use, anxiety symptoms, and obsessions of compulsions. The emotional experience of individuals with PTSD commonly includes anger, shame, sadness, humiliation, of guilt. The onset of PTSD symptoms can occur at any time during the lifespan following exposure to a traumatic event, and the symptoms and course of PTSD can vary significantly over time and individuals. Key differentials include acute stress reaction, adjustment disorder, and complex PTSD. Management of PTSD includes trauma-focused cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and supported trauma-focused computerized CBT interventions. Drug treatments, including benzodiazepines, are not recommended for the prevention of treatment of PTSD in adults, but venlafaxine of a selective serotonin reuptake inhibitor (SSRI) may be considered for adults with a diagnosis of PTSD if the person has a preference for drug treatment. Antipsychotics such as risperidone may be considered in addition if disabling symptoms and behaviors are present and have not responded to other treatments. Psychological debriefing is not recommended for the prevention of treatment of PTSD. For children and young people, individual trauma-focused CBT interventions of EMDR may be considered, but drug treatments are not recommended.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 33 - What is the approximate percentage of individuals in the UK who have engaged...

    Incorrect

    • What is the approximate percentage of individuals in the UK who have engaged in self-harm at some point in their lives?

      Your Answer: 33%

      Correct Answer: 6%

      Explanation:

      Self-Harm and its Management

      Self-harm refers to intentional acts of self-poisoning of self-injury. It is prevalent among younger people, with an estimated 10% of girls and 3% of boys aged 15-16 years having self-harmed in the previous year. Risk factors for non-fatal repetition of self-harm include previous self-harm, personality disorder, hopelessness, history of psychiatric treatment, schizophrenia, alcohol abuse/dependence, and drug abuse/dependence. Suicide following an act of self-harm is more likely in those with previous episodes of self-harm, suicidal intent, poor physical health, and male gender.

      Risk assessment tools are not recommended for predicting future suicide of repetition of self-harm. The recommended interventions for self-harm include 4-10 sessions of CBT specifically structured for people who self-harm and considering DBT for adolescents with significant emotional dysregulation. Drug treatment as a specific intervention to reduce self-harm should not be offered.

      In the management of ingestion, activated charcoal can help if used early, while emetics and cathartics should not be used. Gastric lavage should generally not be used unless recommended by TOXBASE. Paracetamol is involved in 30-40% of acute presentations with poisoning. Intravenous acetylcysteine is the treatment of choice, and pseudo-allergic reactions are relatively common. Naloxone is used as an antidote for opioid overdose, while flumazenil can help reduce the need for admission to intensive care in benzodiazepine overdose.

      For superficial uncomplicated skin lacerations of 5 cm of less in length, tissue adhesive of skin closure strips could be used as a first-line treatment option. All children who self-harm should be admitted for an overnight stay at a pediatric ward.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 34 - In which situations might lower doses of clozapine be necessary? ...

    Correct

    • In which situations might lower doses of clozapine be necessary?

      Your Answer: Female patients

      Explanation:

      Clozapine is an effective antipsychotic drug used in the management of treatment-resistant schizophrenia (TRS). It was reintroduced in the 1990s with mandatory blood monitoring due to the risk of agranulocyte

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 35 - With which condition are raised liver function tests most commonly associated? ...

    Correct

    • With which condition are raised liver function tests most commonly associated?

      Your Answer: Valproate

      Explanation:

      Biochemical Changes Associated with Psychotropic Drugs

      Psychotropic drugs can have incidental biochemical of haematological effects that need to be identified and monitored. The evidence for many of these changes is limited to case reports of information supplied by manufacturers. The Maudsley Guidelines 14th Edition summarises the important changes to be aware of.

      One important parameter to monitor is ALT, a liver enzyme. Agents that can raise ALT levels include clozapine, haloperidol, olanzapine, quetiapine, chlorpromazine, mirtazapine, moclobemide, SSRIs, carbamazepine, lamotrigine, and valproate. On the other hand, vigabatrin can lower ALT levels.

      Another liver enzyme to monitor is ALP. Haloperidol, clozapine, olanzapine, duloxetine, sertraline, and carbamazepine can raise ALP levels, while buprenorphine and zolpidem (rarely) can lower them.

      AST levels are often associated with ALT levels. Trifluoperazine and vigabatrin can raise AST levels, while agents that raise ALT levels can also raise AST levels.

      TSH levels, which are associated with thyroid function, can be affected by aripiprazole, carbamazepine, lithium, quetiapine, rivastigmine, sertraline, and valproate (slightly). Moclobemide can lower TSH levels.

      Thyroxine levels can be affected by dexamphetamine, moclobemide, lithium (which can raise of lower levels), aripiprazole (rarely), and quetiapine (rarely).

      Overall, it is important to monitor these biochemical changes when prescribing psychotropic drugs to ensure the safety and well-being of patients.

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      • General Adult Psychiatry
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  • Question 36 - After a deliberate self-harm episode, what is the estimated risk of suicide for...

    Incorrect

    • After a deliberate self-harm episode, what is the estimated risk of suicide for a 24-year-old man in the next 12 months?

      Your Answer: 14%

      Correct Answer: 0.50%

      Explanation:

      Suicide Rates Following Self-Harm

      Most individuals who engage in self-harm do not go on to commit suicide, which makes risk assessment challenging. A study conducted in the UK in 2015 by Hawton found that 0.5% of individuals died by suicide in the first year following self-harm, with a higher rate among males (0.82%) than females (0.27%). Over the two-year period following self-harm, 1.6% died by suicide, with more occurrences in the second year. Interestingly, a study by Murphy in 2012 found that the rate of suicide following self-harm was higher in the elderly (those over 60), with a rate of 1.5 suicides in the first 12 months. The only significant risk factor for suicide following self-harm in this study was the use of a violent method in the initial episode.

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      • General Adult Psychiatry
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  • Question 37 - What is the recommended minimum dose of olanzapine for a patient experiencing a...

    Correct

    • What is the recommended minimum dose of olanzapine for a patient experiencing a relapse of schizophrenia?

      Your Answer: 7.5 mg

      Explanation:

      Antipsychotics: Minimum Effective Doses

      The Maudsley Guidelines provide a table of minimum effective oral doses for antipsychotics in schizophrenia. The following doses are recommended for first episode and relapse (multi-episode) cases:

      – Chlorpromazine: 200mg (first episode) and 300mg (relapse)
      – Haloperidol: 2mg (first episode) and 4mg (relapse)
      – Sulpiride: 400mg (first episode) and 800mg (relapse)
      – Trifluoperazine: 10mg (first episode) and 15mg (relapse)
      – Amisulpride: 300mg (first episode) and 400mg (relapse)
      – Aripiprazole: 10mg (first episode and relapse)
      – Olanzapine: 5mg (first episode) and 7.5mg (relapse)
      – Quetiapine: 150mg (first episode) and 300mg (relapse)
      – Risperidone: 2mg (first episode) and 4mg (relapse)

      The minimum effective doses may vary depending on individual patient factors and response to treatment. It is important to consult with a healthcare professional before making any changes to medication dosages.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 38 - A teenage patient with schizophrenia has been prescribed olanzapine and amisulpride, two different...

    Correct

    • A teenage patient with schizophrenia has been prescribed olanzapine and amisulpride, two different oral atypical antipsychotics. The patient's healthcare team suspects non-compliance as the patient continues to display positive and negative symptoms. What would be the most suitable course of action for the patient's management?

      Your Answer: Switch to an intramuscular antipsychotic

      Explanation:

      Consider administering clozapine via the intramuscular route in cases where patients are noncompliant with oral medications, provided that two different antipsychotics (at least one of which is an atypical) have been tried at effective doses and with adequate compliance.

      Clozapine is an effective antipsychotic drug used in the management of treatment-resistant schizophrenia (TRS). It was reintroduced in the 1990s with mandatory blood monitoring due to the risk of agranulocyte

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      • General Adult Psychiatry
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  • Question 39 - What is the duration requirement for psychotic symptoms to be classified as an...

    Incorrect

    • What is the duration requirement for psychotic symptoms to be classified as an acute and transient psychotic disorder?

      Your Answer: 48 hours

      Correct Answer: 3 months

      Explanation:

      – Schizophrenia and other primary psychotic disorders are characterized by impairments in reality testing and alterations in behavior.
      – Schizophrenia is a chronic mental health disorder with symptoms including delusions, hallucinations, disorganized speech of behavior, and impaired cognitive ability.
      – The essential features of schizophrenia include persistent delusions, persistent hallucinations, disorganized thinking, experiences of influence, passivity of control, negative symptoms, grossly disorganized behavior, and psychomotor disturbances.
      – Schizoaffective disorder is diagnosed when all diagnostic requirements for schizophrenia are met concurrently with mood symptoms that meet the diagnostic requirements of a moderate or severe depressive episode, a manic episode, of a mixed episode.
      – Schizotypal disorder is an enduring pattern of unusual speech, perceptions, beliefs, and behaviors that are not of sufficient intensity of duration to meet the diagnostic requirements of schizophrenia, schizoaffective disorder, of delusional disorder.
      – Acute and transient psychotic disorder is characterized by an acute onset of psychotic symptoms, which can include delusions, hallucinations, disorganized thinking, of experiences of influence, passivity of control, that emerge without a prodrome, progressing from a non-psychotic state to a clearly psychotic state within 2 weeks.
      – Delusional disorder is diagnosed when there is a presence of a delusion of set of related delusions, typically persisting for at least 3 months and often much longer, in the absence of a depressive, manic, of mixed episode.

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      • General Adult Psychiatry
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  • Question 40 - What measures should be taken to address erratic compliance in individuals with bipolar...

    Incorrect

    • What measures should be taken to address erratic compliance in individuals with bipolar disorder?

      Your Answer: Olanzapine

      Correct Answer: Lithium

      Explanation:

      Patients who are likely to have poor compliance should avoid intermittent treatment with lithium as it can exacerbate the natural progression of bipolar disorder, according to the Maudsley 13th Edition.

      Bipolar Disorder: Diagnosis and Management

      Bipolar disorder is a lifelong condition characterized by episodes of mania or hypomania and episodes of depressed mood. The peak age of onset is 15-19 years, and the lifetime prevalence of bipolar I disorders is estimated to be around 2.1%. The diagnosis of bipolar disorder is based on the presence of manic or hypomanic episodes, which are characterized by elevated of expansive mood, rapid speech, and increased activity of energy. Psychotic symptoms, such as delusions and hallucinations, may also be present.

      Bipolar depression differs from unipolar depression in several ways, including more rapid onset, more frequent episodes, and shorter duration. Rapid cycling is a qualifier that can be applied to bipolar I of bipolar II disorder and is defined as the presence of at least four mood episodes in the previous 12 months that meet the criteria for a manic, hypomanic, of major depressive episode.

      The management of bipolar disorder involves acute and long-term interventions. Acute management of mania or hypomania may involve stopping antidepressants and offering antipsychotics of mood stabilizers. Long-term management may involve psychological interventions and pharmacological treatments such as lithium, valproate, of olanzapine.

      It is important to note that valproate should not be offered to women of girls of childbearing potential for long-term bipolar disorder unless other options are ineffective of not tolerated and a pregnancy prevention program is in place. Aripiprazole is recommended as an option for treating moderate to severe manic episodes in adolescents with bipolar I disorder.

      Overall, the diagnosis and management of bipolar disorder require a comprehensive approach that takes into account the individual’s symptoms, history, and preferences.

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      • General Adult Psychiatry
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  • Question 41 - A client who has recently been diagnosed with schizophrenia asks for information regarding...

    Correct

    • A client who has recently been diagnosed with schizophrenia asks for information regarding their prognosis. What factor has been consistently linked to a poor prognosis in schizophrenia?

      Your Answer: Younger age of onset

      Explanation:

      Schizophrenia Epidemiology

      Prevalence:
      – In England, the estimated annual prevalence for psychotic disorders (mostly schizophrenia) is around 0.4%.
      – Internationally, the estimated annual prevalence for psychotic disorders is around 0.33%.
      – The estimated lifetime prevalence for psychotic disorders in England is approximately 0.63% at age 43, consistent with the typically reported 1% prevalence over the life course.
      – Internationally, the estimated lifetime prevalence for psychotic disorders is around 0.48%.

      Incidence:
      – In England, the pooled incidence rate for non-affective psychosis (mostly schizophrenia) is estimated to be 15.2 per 100,000 years.
      – Internationally, the incidence of schizophrenia is about 0.20/1000/year.

      Gender:
      – The male to female ratio is 1:1.

      Course and Prognosis:
      – Long-term follow-up studies suggest that after 5 years of illness, one quarter of people with schizophrenia recover completely, and for most people, the condition gradually improves over their lifetime.
      – Schizophrenia has a worse prognosis with onset in childhood of adolescence than with onset in adult life.
      – Younger age of onset predicts a worse outcome.
      – Failure to comply with treatment is a strong predictor of relapse.
      – Over a 2-year period, one-third of patients with schizophrenia showed a benign course, and two-thirds either relapsed of failed to recover.
      – People with schizophrenia have a 2-3 fold increased risk of premature death.

      Winter Births:
      – Winter births are associated with an increased risk of schizophrenia.

      Urbanicity:
      – There is a higher incidence of schizophrenia associated with urbanicity.

      Migration:
      – There is a higher incidence of schizophrenia associated with migration.

      Class:
      – There is a higher prevalence of schizophrenia among lower socioeconomic classes.

      Learning Disability:
      – Prevalence rates for schizophrenia in people with learning disabilities are approximately three times greater than for the general population.

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      • General Adult Psychiatry
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  • Question 42 - What is a true statement about bodily distress disorder? ...

    Incorrect

    • What is a true statement about bodily distress disorder?

      Your Answer: The individual's beliefs that symptoms might reflect serious underlying physical illness are held with delusional intensity

      Correct Answer: Prevalence is higher in females

      Explanation:

      Children experience a particular symptom more frequently than adults do.

      Somatoform and dissociative disorders are two groups of psychiatric disorders that are characterized by physical symptoms and disruptions in the normal integration of identity, sensations, perceptions, affects, thoughts, memories, control over bodily movements, of behavior. Somatoform disorders are characterized by physical symptoms that are presumed to have a psychiatric origin, while dissociative disorders are characterized by the loss of integration between memories, identity, immediate sensations, and control of bodily movements. The ICD-11 lists two main types of somatoform disorders: bodily distress disorder and body integrity dysphoria. Dissociative disorders include dissociative neurological symptom disorder, dissociative amnesia, trance disorder, possession trance disorder, dissociative identity disorder, partial dissociative identity disorder, depersonalization-derealization disorder, and other specified dissociative disorders. The symptoms of these disorders result in significant impairment in personal, family, social, educational, occupational, of other important areas of functioning. Diagnosis of these disorders involves a thorough evaluation of the individual’s symptoms and medical history, as well as ruling out other possible causes of the symptoms.

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      • General Adult Psychiatry
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  • Question 43 - Based on the NICE Guidelines, which factor is linked to a greater likelihood...

    Correct

    • Based on the NICE Guidelines, which factor is linked to a greater likelihood of experiencing discontinuation symptoms?

      Your Answer: Paroxetine

      Explanation:

      According to NICE, paroxetine has a greater likelihood of causing discontinuation symptoms compared to other SSRIs.

      Depression Treatment Guidelines by NICE

      The National Institute for Health and Care Excellence (NICE) provides guidelines for the treatment of depression. The following are some general recommendations:

      – Selective serotonin reuptake inhibitors (SSRIs) are preferred when prescribing antidepressants.
      – Antidepressants are not the first-line treatment for mild depression.
      – After remission, continue antidepressant treatment for at least six months.
      – Continue treatment for at least two years if at high risk of relapse of have a history of severe or prolonged episodes of inadequate response.
      – Use a stepped care approach to depression treatment, starting at the appropriate level based on the severity of depression.

      The stepped care approach involves the following steps:

      – Step 1: Assessment, support, psychoeducation, active monitoring, and referral for further assessment and interventions.
      – Step 2: Low-intensity psychosocial interventions, psychological interventions, medication, and referral for further assessment and interventions.
      – Step 3: Medication, high-intensity psychological interventions, combined treatments, collaborative care, and referral for further assessment and interventions.
      – Step 4: Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care.

      Individual guided self-help programs based on cognitive-behavioral therapy (CBT) principles should be supported by a trained practitioner and last 9 to 12 weeks. Physical activity programs should consist of three sessions per week of moderate duration over 10 to 14 weeks.

      NICE advises against using antidepressants routinely to treat persistent subthreshold depressive symptoms of mild depression. However, they may be considered for people with a past history of moderate or severe depression, initial presentation of subthreshold depressive symptoms that have been present for a long period, of subthreshold depressive symptoms of mild depression that persist after other interventions.

      NICE recommends a combination of antidepressant medication and a high-intensity psychological intervention (CBT of interpersonal therapy) for people with moderate of severe depression. Augmentation of antidepressants with lithium, antipsychotics, of other antidepressants may be appropriate, but benzodiazepines, buspirone, carbamazepine, lamotrigine, of valproate should not be routinely used.

      When considering different antidepressants, venlafaxine is associated with a greater risk of death from overdose compared to other equally effective antidepressants. Tricyclic antidepressants (TCAs) except for lofepramine are associated with the greatest risk in overdose. Higher doses of venlafaxine may exacerbate cardiac arrhythmias, and venlafaxine and duloxetine may exacerbate hypertension. TCAs may cause postural hypotension and arrhythmias, and mianserin requires hematological monitoring in elderly people.

      The review frequency depends on the age and suicide risk of the patient. If the patient is over 30 and has no suicide risk, see them after two weeks and then at intervals of 2-4 weeks for the first three months. If the patient is under 30 and has a suicide risk, see them after one week.

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      • General Adult Psychiatry
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  • Question 44 - Among the adverse effects linked to clozapine, which one is least likely to...

    Incorrect

    • Among the adverse effects linked to clozapine, which one is least likely to increase in severity with higher doses?

      Your Answer: Constipation

      Correct Answer: Agranulocytosis

      Explanation:

      There is no association between the risk of agranulocytosis and either the dose of plasma concentration of clozapine, according to Bishara (2014).

      Clozapine is an effective antipsychotic drug used in the management of treatment-resistant schizophrenia (TRS). It was reintroduced in the 1990s with mandatory blood monitoring due to the risk of agranulocyte

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      • General Adult Psychiatry
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  • Question 45 - Which statement accurately describes the evidence supporting the use of lithium? ...

    Correct

    • Which statement accurately describes the evidence supporting the use of lithium?

      Your Answer: Lithium has been shown to be an effective augmentation agent for people with unipolar depression

      Explanation:

      Lithium – Clinical Usage

      Lithium is primarily used as a prophylactic agent for bipolar disorder, where it reduces the severity and number of relapses. It is also effective as an augmentation agent in unipolar depression and for treating aggressive and self-mutilating behavior, steroid-induced psychosis, and to raise WCC in people using clozapine.

      Before prescribing lithium, renal, cardiac, and thyroid function should be checked, along with a Full Blood Count (FBC) and BMI. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.

      Once daily administration is preferred, and various preparations are available. Abrupt discontinuation of lithium increases the risk of relapse, and if lithium is to be discontinued, the dose should be reduced gradually over a period of at least 4 weeks.

      Inadequate monitoring of patients taking lithium is common, and it is often an exam hot topic. Lithium salts have a narrow therapeutic/toxic ratio, and samples should ideally be taken 12 hours after the dose. The target range for prophylaxis is 0.6–0.75 mmol/L.

      Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI and neuro symptoms.

      The severity of toxicity can be assessed using the AMDISEN rating scale.

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      • General Adult Psychiatry
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  • Question 46 - Which of the following is an atypical characteristic of paranoid personality disorder? ...

    Correct

    • Which of the following is an atypical characteristic of paranoid personality disorder?

      Your Answer: Indifference to praise and criticism

      Explanation:

      Paranoid Personality Disorder is a type of personality disorder where individuals have a deep-seated distrust and suspicion of others, often interpreting their actions as malevolent. This disorder is characterized by a pattern of negative interpretations of others’ words, actions, and intentions, leading to a reluctance to confide in others and holding grudges for long periods of time. The DSM-5 criteria for this disorder include at least four of the following symptoms: unfounded suspicions of exploitation, harm, of deception by others, preoccupation with doubts about the loyalty of trustworthiness of friends of associates, reluctance to confide in others due to fear of malicious use of information, reading negative meanings into benign remarks of events, persistent grudges, perceiving attacks on one’s character of reputation that are not apparent to others and reacting angrily of counterattacking, and recurrent suspicions of infidelity in a partner without justification. The ICD-11 does not have a specific category for paranoid personality disorder but covers many of its features under the negative affectivity qualifier under the element of mistrustfulness.

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      • General Adult Psychiatry
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  • Question 47 - Which of the options below is not a valid means of supporting a...

    Correct

    • Which of the options below is not a valid means of supporting a diagnosis of obsessive compulsive personality disorder?

      Your Answer: Views self as inferior to others

      Explanation:

      It is important to note that while individuals with obsessive personality disorder may experience feelings of inferiority, this is not a defining characteristic of the disorder. In contrast, a diagnosis of avoidant personality disorder may be more appropriate for individuals who consistently view themselves as inferior to others.

      Personality Disorder (Obsessive Compulsive)

      Obsessive-compulsive personality disorder is characterized by a preoccupation with orderliness, perfectionism, and control, which can hinder flexibility and efficiency. This pattern typically emerges in early adulthood and can be present in various contexts. The estimated prevalence ranges from 2.1% to 7.9%, with males being diagnosed twice as often as females.

      The DSM-5 diagnosis requires the presence of four of more of the following criteria: preoccupation with details, rules, lists, order, organization, of agenda to the point that the key part of the activity is lost; perfectionism that hampers completing tasks; extreme dedication to work and efficiency to the elimination of spare time activities; meticulous, scrupulous, and rigid about etiquettes of morality, ethics, of values; inability to dispose of worn-out of insignificant things even when they have no sentimental meaning; unwillingness to delegate tasks of work with others except if they surrender to exactly their way of doing things; miserly spending style towards self and others; and rigidity and stubbornness.

      The ICD-11 abolished all categories of personality disorder except for a general description of personality disorder, which can be further specified as “mild,” “moderate,” of “severe.” The anankastic trait domain is characterized by a narrow focus on one’s rigid standard of perfection and of right and wrong, and on controlling one’s own and others’ behavior and controlling situations to ensure conformity to these standards. Common manifestations of anankastic include perfectionism and emotional and behavioral constraint.

      Differential diagnosis includes OCD, hoarding disorder, narcissistic personality disorder, antisocial personality disorder, and schizoid personality disorder. OCD is distinguished by the presence of true obsessions and compulsions, while hoarding disorder should be considered when hoarding is extreme. Narcissistic personality disorder individuals are more likely to believe that they have achieved perfection, while those with obsessive-compulsive personality disorder are usually self-critical. Antisocial personality disorder individuals lack generosity but will indulge themselves, while those with obsessive-compulsive personality disorder adopt a miserly spending style toward both self and others. Schizoid personality disorder is characterized by a fundamental lack of capacity for intimacy, while in obsessive-compulsive personality disorder, this stems from discomfort with emotions and excessive devotion to work.

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      • General Adult Psychiatry
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  • Question 48 - A middle-aged woman experiences a sudden loss of vision after witnessing her husband...

    Correct

    • A middle-aged woman experiences a sudden loss of vision after witnessing her husband get knocked down by a car. No medical cause can be found to explain this. She is surprisingly unconcerned by her symptoms.
      Select the most likely diagnosis:

      Your Answer: Dissociative neurological symptom disorder

      Explanation:

      The apparent disregard for her visual impairment is indicative of La belle indifference, a common characteristic of conversion disorder. Based on this presentation, a possible diagnosis according to the ICD-11 would be dissociative neurological symptom disorder with accompanying visual disturbances.

      Somatoform and dissociative disorders are two groups of psychiatric disorders that are characterized by physical symptoms and disruptions in the normal integration of identity, sensations, perceptions, affects, thoughts, memories, control over bodily movements, of behavior. Somatoform disorders are characterized by physical symptoms that are presumed to have a psychiatric origin, while dissociative disorders are characterized by the loss of integration between memories, identity, immediate sensations, and control of bodily movements. The ICD-11 lists two main types of somatoform disorders: bodily distress disorder and body integrity dysphoria. Dissociative disorders include dissociative neurological symptom disorder, dissociative amnesia, trance disorder, possession trance disorder, dissociative identity disorder, partial dissociative identity disorder, depersonalization-derealization disorder, and other specified dissociative disorders. The symptoms of these disorders result in significant impairment in personal, family, social, educational, occupational, of other important areas of functioning. Diagnosis of these disorders involves a thorough evaluation of the individual’s symptoms and medical history, as well as ruling out other possible causes of the symptoms.

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      • General Adult Psychiatry
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  • Question 49 - What drug has been proven through placebo controlled RCT evidence to effectively manage...

    Correct

    • What drug has been proven through placebo controlled RCT evidence to effectively manage hypersalivation caused by the use of clozapine?

      Your Answer: Hyoscine

      Explanation:

      Clozapine is an effective antipsychotic drug used in the management of treatment-resistant schizophrenia (TRS). It was reintroduced in the 1990s with mandatory blood monitoring due to the risk of agranulocyte

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      • General Adult Psychiatry
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  • Question 50 - What is the most effective treatment for premenstrual dysphoric disorder? ...

    Correct

    • What is the most effective treatment for premenstrual dysphoric disorder?

      Your Answer: Fluoxetine

      Explanation:

      There is currently no evidence to support the use of vitamin supplements for the treatment of premenstrual dysphoric disorder. However, lifestyle changes such as regular exercise, a healthy diet, and stress reduction techniques may be helpful in managing symptoms. It is important to consult with a healthcare provider to determine the best course of treatment for individual cases of PMDD.

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      • General Adult Psychiatry
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SESSION STATS - PERFORMANCE PER SPECIALTY

General Adult Psychiatry (30/50) 60%
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