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  • Question 1 - A 56 year-old man attends the out-patient clinic. He was started on fluoxetine...

    Incorrect

    • A 56 year-old man attends the out-patient clinic. He was started on fluoxetine eight weeks ago for depression and is now requesting to stop his medication as he feels so well. Your assessment indicates that he is now in remission. What should be recommended regarding his treatment?

      Your Answer: It should be continued for at least another 12 months

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

      Explanation:

      To minimize the likelihood of relapse, it is recommended to maintain treatment for at least 6 months after achieving remission. It is important to note that antidepressants are not habit-forming, and patients should be reassured of this fact.

      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 2 - According to Gottesman (1982), what is the risk of a parent developing schizophrenia...

    Correct

    • According to Gottesman (1982), what is the risk of a parent developing schizophrenia if they have an affected child?

      Your Answer: 6%

      Explanation:

      Schizophrenia: Understanding the Risk Factors

      Social class is a significant risk factor for schizophrenia, with people of lower socioeconomic status being more likely to develop the condition. Two hypotheses attempt to explain this relationship, one suggesting that environmental exposures common in lower social class conditions are responsible, while the other suggests that people with schizophrenia tend to drift towards the lower class due to their inability to compete for good jobs.

      While early studies suggested that schizophrenia was more common in black populations than in white, the current consensus is that there are no differences in rates of schizophrenia by race. However, there is evidence that rates are higher in migrant populations and ethnic minorities.

      Gender and age do not appear to be consistent risk factors for schizophrenia, with conflicting evidence on whether males of females are more likely to develop the condition. Marital status may also play a role, with females with schizophrenia being more likely to marry than males.

      Family history is a strong risk factor for schizophrenia, with the risk increasing significantly for close relatives of people with the condition. Season of birth and urban versus rural place of birth have also been shown to impact the risk of developing schizophrenia.

      Obstetric complications, particularly prenatal nutritional deprivation, brain injury, and influenza, have been identified as significant risk factors for schizophrenia. Understanding these risk factors can help identify individuals who may be at higher risk for developing the condition and inform preventative measures.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 3 - For what discovery did someone receive a Nobel Prize in 1949 regarding the...

    Incorrect

    • For what discovery did someone receive a Nobel Prize in 1949 regarding the therapeutic benefits of frontal leucotomy in specific psychoses?

      Your Answer: Meduna

      Correct Answer: Moniz

      Explanation:

      A Historical Note on the Development of Zimelidine, the First Selective Serotonin Reuptake Inhibitor

      In 1960s, evidence began to emerge suggesting a significant role of serotonin in depression. This led to the development of zimelidine, the first selective serotonin reuptake inhibitor (SSRI). Zimelidine was derived from pheniramine and was marketed in Europe in 1982. However, it was removed from the market in 1983 due to severe side effects such as hypersensitivity reactions and Guillain-Barre syndrome.

      Despite its short-lived availability, zimelidine paved the way for the development of other SSRIs such as fluoxetine, which was approved by the FDA in 1987 and launched in the US market in 1988 under the trade name Prozac. The development of SSRIs revolutionized the treatment of depression and other mood disorders, providing a safer and more effective alternative to earlier antidepressants such as the tricyclics and MAO inhibitors.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 4 - What is the first line treatment recommended by NICE for an adult with...

    Incorrect

    • What is the first line treatment recommended by NICE for an adult with OCD and moderate functional impairment?

      Your Answer: SSRI only

      Correct Answer: Choice of CBT of an SSRI

      Explanation:

      Individuals with OCD who experience moderate functional impairment should be presented with the option to choose between undergoing a course of SSRI medication of receiving more intensive CBT.

      Maudsley Guidelines

      First choice: SSRI of clomipramine (SSRI preferred due to tolerability issues with clomipramine)

      Second line:

      – SSRI + antipsychotic
      – Citalopram + clomipramine
      – Acetylcysteine + (SSRI of clomipramine)
      – Lamotrigine + SSRI
      – Topiramate + SSRI

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 5 - What demographic is most frequently targeted in homicides committed by individuals receiving mental...

    Incorrect

    • What demographic is most frequently targeted in homicides committed by individuals receiving mental health treatment?

      Your Answer: Child

      Correct Answer: Acquaintance

      Explanation:

      Homicide is a serious issue in the UK, with an average of 580 convictions each year. Shockingly, 11% of those convicted were patients under mental health services, although this figure has been decreasing. An independent review of mental health homicides found that 80% of perpetrators were male, with a mean age of 37. In most cases, the perpetrator knew the victim, with 33% being friends and 33% being partners. Illicit substances were used in 75% of cases, and 95% of perpetrators were in the community at the time of the offence. These findings highlight the need for continued efforts to prevent homicides and support those with mental health issues.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 6 - What is accurate about the management of eating disorders? ...

    Incorrect

    • What is accurate about the management of eating disorders?

      Your Answer: Bone mineral density scans should only be conducted on children with anorexia if they have evidence of fractures

      Correct Answer: People with an eating disorder who are vomiting should be encouraged to rinse with non-acid mouthwash after vomiting

      Explanation:

      Eating Disorders: NICE Guidelines

      Anorexia:
      For adults with anorexia nervosa, consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), of specialist supportive clinical management (SSCM). If these are not acceptable, contraindicated, of ineffective, consider eating-disorder-focused focal psychodynamic therapy (FPT). For children and young people, consider anorexia-nervosa-focused family therapy (FT-AN) of individual CBT-ED. Do not offer medication as the sole treatment.

      Bulimia:
      For adults, the first step is an evidence-based self-help programme. If this is not effective, consider individual CBT-ED. For children and young people, offer bulimia-nervosa-focused family therapy (FT-BN) of individual CBT-ED. Do not offer medication as the sole treatment.

      Binge Eating Disorder:
      The first step is a guided self-help programme. If this is not effective, offer group of individual CBT-ED. For children and young people, offer the same treatments recommended for adults. Do not offer medication as the sole treatment.

      Advice for those with eating disorders:
      Encourage people with an eating disorder who are vomiting to avoid brushing teeth immediately after vomiting, rinse with non-acid mouthwash, and avoid highly acidic foods and drinks. Advise against misusing laxatives of diuretics and excessive exercise.

      Additional points:
      Do not offer physical therapy as part of treatment. Consider bone mineral density scans after 1 year of underweight in children and young people, of 2 years in adults. Do not routinely offer oral of transdermal oestrogen therapy to treat low bone mineral density in children of young people with anorexia nervosa. Consider transdermal 17-β-estradiol of bisphosphonates for women with anorexia nervosa.

      Note: These guidelines are taken from NICE guidelines 2017.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 7 - Which mood stabilizer is associated with causing visual field defects? ...

    Incorrect

    • Which mood stabilizer is associated with causing visual field defects?

      Your Answer: Lamotrigine

      Correct Answer: Vigabatrin

      Explanation:

      Vigabatrin and its Impact on Visual Field Defects

      Vigabatrin is a medication that is known to cause visual field constriction in approximately 30% of its users. Although most cases are asymptomatic, the drug affects the peripheral fields and does not impair central visual acuity. Unfortunately, the effects of vigabatrin on the visual field appear to be irreversible of only partially reversible, even after discontinuation of the medication.

      This medication is commonly used to treat epilepsy and other seizure disorders, but its potential impact on vision should be carefully considered before prescribing it to patients. Vigabatrin-induced visual field defects can have a significant impact on a patient’s quality of life, and healthcare providers should monitor patients closely for any signs of visual impairment while taking this medication.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 8 - You are provided with a set of blood test outcomes that show serum...

    Correct

    • You are provided with a set of blood test outcomes that show serum levels for different medications. Which of the following falls outside the typical range for an elderly patient?

      Your Answer: Lithium - 1.3 mmol/L

      Explanation:

      Here are some possible ways to rewrite the given optimal therapeutic ranges:

      – The recommended therapeutic levels for olanzapine are between 20 and 40 nanograms per milliliter (ng/mL).
      – To achieve optimal treatment outcomes, clozapine levels should be maintained within the range of 350 to 500 ng/mL.
      – The therapeutic window for quetiapine spans from 100 to 1000 ng/mL, depending on the patient’s condition and response.
      – Valproate therapy is typically effective when the serum concentration falls between 50 and 100 micrograms per milliliter (mcg/mL).

      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.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 9 - According to Klerman's bipolar subtypes, what term is used to describe a state...

    Incorrect

    • According to Klerman's bipolar subtypes, what term is used to describe a state of mania without depression?

      Your Answer: Bipolar I

      Correct Answer: Bipolar VI

      Explanation:

      Bipolar Disorder: Historical Subtypes

      Bipolar disorder is a complex mental illness that has been classified into several subtypes over the years. The most widely recognized subtypes are Bipolar I, Bipolar II, and Cyclothymia. However, there have been other classification systems proposed by experts in the field.

      In 1981, Gerald Klerman proposed a classification system that included Bipolar I, Bipolar II, Bipolar III, Bipolar IV, Bipolar V, and Bipolar VI. This system was later expanded by Akiskal in 1999, who added more subtypes such as Bipolar I 1/2, Bipolar II 1/2, and Bipolar III 1/2.

      Bipolar I is characterized by full-blown mania, while Bipolar II is characterized by hypomania with depression. Cyclothymia is a milder form of bipolar disorder that involves cycling between hypomania and mild depression.

      Other subtypes include Bipolar III, which is associated with hypomania of mania precipitated by antidepressant drugs, and Bipolar IV, which is characterized by hyperthymic depression. Bipolar V is associated with depressed patients who have a family history of bipolar illness, while Bipolar VI is characterized by mania without depression (unipolar mania).

      Overall, the classification of bipolar disorder subtypes has evolved over time, and different experts have proposed different systems. However, the most widely recognized subtypes are still Bipolar I, Bipolar II, and Cyclothymia.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 10 - How should the norclozapine ratios be interpreted in therapeutic drug monitoring of clozapine?...

    Incorrect

    • How should the norclozapine ratios be interpreted in therapeutic drug monitoring of clozapine?

      Your Answer: High ratios are expected in fast metabolisers of clozapine

      Correct Answer: Levels taken less than 11 hours after the last dose are likely to result in high ratios

      Explanation:

      It is important to take clozapine levels as trough samples, which means they should be taken 11-13 hours after the last dose. Samples taken outside of this time frame may produce inaccurate results. If the levels are taken too early (before 11 hours), the clozapine levels may be artificially high, resulting in high ratios. Conversely, if the levels are taken too late (after 11 hours), the clozapine levels may be artificially low, resulting in low ratios.

      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 11 - What is an example of a neurovegetative symptom? ...

    Incorrect

    • What is an example of a neurovegetative symptom?

      Your Answer: Low mood

      Correct Answer: Insomnia

      Explanation:

      Symptoms related to inadequate performance of the autonomic nervous system, such as difficulties with sleep, exhaustion, and reduced energy levels, are referred to as neurovegetative symptoms.

      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 12 - At the beginning of the CATIE study, what was the proportion of patients...

    Incorrect

    • At the beginning of the CATIE study, what was the proportion of patients diagnosed with metabolic syndrome?

      Your Answer: 10%

      Correct Answer: 40%

      Explanation:

      The information provided is valuable because the CATIE study was conducted in a real-world setting, making the estimate potentially applicable to the UK.

      CATIE Study: Comparing Antipsychotic Medications for Schizophrenia Treatment

      The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Study, funded by the National Institute of Mental Health (NIMH), was a nationwide clinical trial that aimed to compare the effectiveness of older and newer antipsychotic medications used to treat schizophrenia. It is the largest, longest, and most comprehensive independent trial ever conducted to examine existing therapies for schizophrenia. The study consisted of two phases.

      Phase I of CATIE compared four newer antipsychotic medications to one another and an older medication. Participants were followed for 18 months to evaluate longer-term patient outcomes. The study involved over 1400 participants and was conducted at various treatment sites, representative of real-life settings where patients receive care. The results from CATIE are applicable to a wide range of people with schizophrenia in the United States.

      The medications were comparably effective, but high rates of discontinuation were observed due to intolerable side-effects of failure to adequately control symptoms. Olanzapine was slightly better than the other drugs but was associated with significant weight gain as a side-effect. Surprisingly, the older, less expensive medication (perphenazine) used in the study generally performed as well as the four newer medications. Movement side effects primarily associated with the older medications were not seen more frequently with perphenazine than with the newer drugs.

      Phase II of CATIE sought to provide guidance on which antipsychotic to try next if the first failed due to ineffectiveness of intolerability. Participants who discontinued their first antipsychotic medication because of inadequate management of symptoms were encouraged to enter the efficacy (clozapine) pathway, while those who discontinued their first treatment because of intolerable side effects were encouraged to enter the tolerability (ziprasidone) pathway. Clozapine was remarkably effective and was substantially better than all the other atypical medications.

      The CATIE study also looked at the risk of metabolic syndrome (MS) using the US National Cholesterol Education Program Adult Treatment Panel criteria. The prevalence of MS at baseline in the CATIE group was 40.9%, with female patients being three times as likely to have MS compared to matched controls and male patients being twice as likely.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 13 - A teenager presents with a three-year history of feeling sad for most of...

    Incorrect

    • A teenager presents with a three-year history of feeling sad for most of the day for approximately 2-3 weeks every month. Low mood is accompanied by reduced concentration and mild insomnia. They deny alterations in appetite, low self-worth, and any marked loss of interest of pleasure. They deny that their condition has ever been more severe than this. They report brief periods of feeling okay in between these episodes of low mood. There is no evidence of any history of elevated mood states, and they are otherwise fit and well with no issues of substance misuse. They claim to function reasonably well but emphasise that this requires significant effort when they are feeling down.
      Which of the following ICD-11 diagnosis is most suggested by this description?:

      Your Answer: Single depressive episode

      Correct Answer: Dysthymic disorder

      Explanation:

      Based on the patient report, it appears that they are experiencing symptoms consistent with Dysthymic Disorder. There is no indication that they have experienced a depressive episode that meets the criteria for a diagnosis of either single of recurrent depression. Additionally, there is no evidence of extended periods without symptoms, which would exclude a diagnosis of Dysthymic Disorder. The absence of elevated mood suggests that neither Cyclothymic Disorder nor Bipolar Disorder Type I of II are likely diagnoses.

      Depression is diagnosed using different criteria in the ICD-11 and DSM-5. The ICD-11 recognizes single depressive episodes, recurrent depressive disorder, dysthymic disorder, and mixed depressive and anxiety disorder. The DSM-5 recognizes disruptive mood dysregulation disorder, major depressive disorder, persistent depressive disorder, and premenstrual dysphoric disorder.

      For a diagnosis of a single depressive episode, the ICD-11 requires the presence of at least five characteristic symptoms occurring most of the day, nearly every day during a period lasting at least 2 weeks. The DSM-5 requires the presence of at least five symptoms during the same 2-week period, with at least one of the symptoms being either depressed mood of loss of interest of pleasure.

      Recurrent depressive disorder is characterized by a history of at least two depressive episodes separated by at least several months without significant mood disturbance, according to the ICD-11. The DSM-5 requires at least two episodes with an interval of at least 2 consecutive months between separate episodes in which criteria are not met for a major depressive episode.

      Dysthymic disorder is diagnosed when a person experiences persistent depressed mood lasting 2 years of more, according to the ICD-11. The DSM-5 requires depressed mood for most of the day, for more days than not, for at least 2 years, along with the presence of two or more additional symptoms.

      Mixed depressive and anxiety disorder is recognized as a separate code in the ICD-11, while the DSM-5 uses the ‘with anxious distress’ qualifier. The ICD-11 requires the presence of both depressive and anxiety symptoms for most of the time during a period of 2 weeks of more, while the DSM-5 requires the presence of both depressive and anxious symptoms during the same 2-week period.

      Overall, the criteria for diagnosing depression vary between the ICD-11 and DSM-5, but both require the presence of characteristic symptoms that cause significant distress of impairment in functioning.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 14 - Which of the following factors does not increase the risk of developing tardive...

    Correct

    • Which of the following factors does not increase the risk of developing tardive dyskinesia?

      Your Answer: Male gender

      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 15 - Which of the following factors does not contribute to a higher likelihood of...

    Correct

    • Which of the following factors does not contribute to a higher likelihood of developing PTSD?

      Your Answer: Male gender

      Explanation:

      The likelihood of developing PTSD is greater for females. Additionally, experiencing significant distress and dissociation during the initial traumatic event are also linked to the development of PTSD.

      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 16 - As per NICE guidelines, what is the recommended time frame for a clinic...

    Incorrect

    • As per NICE guidelines, what is the recommended time frame for a clinic review of a 25 year-old man who has been started on an SSRI for his first episode of depression?

      Your Answer: 24 hours

      Correct Answer: 1 week

      Explanation:

      It is recommended that individuals who are under 30 years of age of are at an increased risk of suicide and have started taking antidepressants should be monitored closely and seen for follow-up appointments. This is particularly important in the early stages of treatment when there may be a higher prevalence of suicidal thoughts.

      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 17 - A 28 year old woman discloses that her 4 month old daughter passed...

    Incorrect

    • A 28 year old woman discloses that her 4 month old daughter passed away from sudden infant death syndrome 2 years ago. Since then, she has developed a heightened sense of protectiveness towards her family. She engages in repetitive checking behaviors and experiences distress, anxiety, and agitation when unable to do so. Although she recognizes that her checking behavior is unhelpful, she struggles to resist it. What is the most suitable form of psychological intervention for her?

      Your Answer: Cognitive restructuring

      Correct Answer: Exposure and response prevention

      Explanation:

      Maudsley Guidelines

      First choice: SSRI of clomipramine (SSRI preferred due to tolerability issues with clomipramine)

      Second line:

      – SSRI + antipsychotic
      – Citalopram + clomipramine
      – Acetylcysteine + (SSRI of clomipramine)
      – Lamotrigine + SSRI
      – Topiramate + SSRI

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 18 - What is the most probable biomarker to be increased in an individual diagnosed...

    Incorrect

    • What is the most probable biomarker to be increased in an individual diagnosed with anorexia nervosa?

      Your Answer: Thiamine

      Correct Answer: Creatinine kinase

      Explanation:

      In individuals with anorexia, the majority of their blood test results are typically below normal levels, with the exception of growth hormone, cholesterol, and cortisol.

      Eating Disorders: Lab Findings and Medical Complications

      Eating disorders can lead to a range of medical complications, including renal failure, peripheral edema, sinus bradycardia, QT-prolongation, pericardial effusion, and slowed GI motility. Other complications include constipation, cathartic colon, esophageal esophagitis, hair loss, and dental erosion. Blood abnormalities are also common in patients with eating disorders, including hyponatremia, hypokalemia, hypophosphatemia, and hypoglycemia. Additionally, patients may experience leucopenia, anemia, low albumin, elevated liver enzymes, and vitamin deficiencies. These complications can cause significant morbidity and mortality in patients with eating disorders. It is important for healthcare providers to monitor patients for these complications and provide appropriate treatment.

    • This question is part of the following fields:

      • General Adult Psychiatry
      15.7
      Seconds
  • Question 19 - Among the given options, which delusion is the least probable to be observed...

    Incorrect

    • Among the given options, which delusion is the least probable to be observed during a manic episode?

      Your Answer: Belief that people find them irresistible

      Correct Answer: Belief that people are inserting thoughts into their minds

      Explanation:

      Mood congruent delusions are commonly observed in affective disorders such as depression and bipolar disorder, whereas mood incongruent delusions are more typical of schizophrenia. In mania, psychotic experiences are often consistent with the individual’s mood, which is known as mood congruent. Conversely, mood incongruent psychotic experiences are either unrelated to mood of in opposition to the prevailing mood.

      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 20 - What is the first-line recommendation by the MARSIPAN group for managing agitation in...

    Incorrect

    • What is the first-line recommendation by the MARSIPAN group for managing agitation in patients with anorexia nervosa?

      Your Answer: Quetiapine

      Correct Answer: Lorazepam

      Explanation:

      In cases where patients with anorexia nervosa require medical intervention for agitation, benzodiazepines are recommended in small doses. It is advised to avoid antipsychotics due to their potential for adverse cardiac events, which can be particularly risky for this patient group. However, antipsychotics such as olanzapine and quetiapine may have a role in managing anorexia by promoting weight gain and reducing intrusive thoughts. The focus of the question is on the use of antipsychotics for agitation in anorexia nervosa.

      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 21 - What changes in the blood profile are anticipated in a patient diagnosed with...

    Incorrect

    • What changes in the blood profile are anticipated in a patient diagnosed with bulimia nervosa?

      Your Answer: Hypoglycemia

      Correct Answer: Hypokalaemia

      Explanation:

      Eating Disorders: Lab Findings and Medical Complications

      Eating disorders can lead to a range of medical complications, including renal failure, peripheral edema, sinus bradycardia, QT-prolongation, pericardial effusion, and slowed GI motility. Other complications include constipation, cathartic colon, esophageal esophagitis, hair loss, and dental erosion. Blood abnormalities are also common in patients with eating disorders, including hyponatremia, hypokalemia, hypophosphatemia, and hypoglycemia. Additionally, patients may experience leucopenia, anemia, low albumin, elevated liver enzymes, and vitamin deficiencies. These complications can cause significant morbidity and mortality in patients with eating disorders. It is important for healthcare providers to monitor patients for these complications and provide appropriate treatment.

    • This question is part of the following fields:

      • General Adult Psychiatry
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      Seconds
  • Question 22 - What is the recommended alternative for bipolar disorder prophylaxis when lithium and valproate...

    Incorrect

    • What is the recommended alternative for bipolar disorder prophylaxis when lithium and valproate are not viable options, according to NICE?

      Your Answer: Aripiprazole

      Correct Answer: Olanzapine

      Explanation:

      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.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 23 - What is the visual assessment that must be conducted before starting therapy and...

    Incorrect

    • What is the visual assessment that must be conducted before starting therapy and every 3 months thereafter until treatment is stopped?

      Your Answer: Topiramate

      Correct Answer: Vigabatrin

      Explanation:

      The use of Vigabatrin may lead to permanent visual field constriction in both eyes, causing tunnel vision and potential disability. Additionally, it may harm the central retina and result in reduced visual acuity.

      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
      8.7
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  • Question 24 - A 25-year-old marathon runner who is currently training for a regional race requests...

    Incorrect

    • A 25-year-old marathon runner who is currently training for a regional race requests to meet with the team physician due to an unusual sensation in her legs. She reports feeling a numbness below her knee. Upon examination, the physician observes sensory loss below the left knee in a non-dermatomal distribution. After conducting further investigations, which all come back normal, the physician concludes that the symptoms are not consistent with neurological disease. During a discussion with the patient's parents, the physician learns that the patient recently lost her sister in a tragic accident. Despite this, the patient appears strangely indifferent to her symptoms. What is the most likely diagnosis at this point?

      Your Answer: Body integrity dysphoria

      Correct Answer: Dissociative neurological symptom disorder

      Explanation:

      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.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 25 - Who is responsible for introducing eye movement desensitisation and reprocessing? ...

    Incorrect

    • Who is responsible for introducing eye movement desensitisation and reprocessing?

      Your Answer: Anthony Ryle

      Correct Answer: Francine Shapiro

      Explanation:

      EMDR: A Trauma-Focused Therapy for PTSD

      EMDR, of eye movement desensitisation and reprocessing, is a therapy developed by Francine Shapiro in the 1980s that focuses on processing traumatic memories. While the exact way it works is not fully understood, it involves reliving traumatic memories while experiencing bilateral alternating stimulation, often through a light source. EMDR is recommended by the NICE Guidelines as a treatment for PTSD, along with trauma-focused cognitive-behavioral therapy.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 26 - At low doses, which medications are purported to have an antidepressant effect? ...

    Correct

    • At low doses, which medications are purported to have an antidepressant effect?

      Your Answer: Flupentixol

      Explanation:

      Flupentixol as an Antidepressant

      Flupentixol is a conventional antipsychotic medication that works by strongly blocking D1 and D2 receptors, as well as having some weak antagonistic effects on 5-HT2A receptors. It is commonly used as an antidepressant at doses ranging from 0.5 to 3 mg per day. The British National Formulary (BNF) has approved flupentixol for the treatment of depression. In the 13th edition of the Maudsley Prescribing Guidelines, intramuscular flupentixol is recommended as an alternative route of administration for patients who are unable of unwilling to take oral antidepressants.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 27 - After a hospitalization for mania, a female patient with a history of hepatitis...

    Incorrect

    • After a hospitalization for mania, a female patient with a history of hepatitis C presents with abnormal liver function. Which medication would be appropriate for long-term management of her mania?

      Your Answer: Risperidone

      Correct Answer: Lithium

      Explanation:

      Hepatic Impairment: Recommended Drugs

      Patients with hepatic impairment may experience reduced ability to metabolize drugs, toxicity, enhanced dose-related side effects, reduced ability to synthesize plasma proteins, and elevated levels of drugs subject to first-pass metabolism due to reduced hepatic blood flow. The Maudsley Guidelines 14th Ed recommends the following drugs for patients with hepatic impairment:

      Antipsychotics: Paliperidone (if depot required), Amisulpride, Sulpiride

      Antidepressants: Sertraline, Citalopram, Paroxetine, Vortioxetine (avoid TCA and MAOI)

      Mood stabilizers: Lithium

      Sedatives: Lorazepam, Oxazepam, Temazepam, Zopiclone 3.75mg (with care)

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 28 - Which antiepileptic medication has the most substantial evidence linking it to aggression when...

    Incorrect

    • Which antiepileptic medication has the most substantial evidence linking it to aggression when utilized in the treatment of epilepsy?

      Your Answer: Phenobarbital

      Correct Answer: Perampanel

      Explanation:

      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
      13
      Seconds
  • Question 29 - What is the most frequently observed symptom in children diagnosed with bodily distress...

    Correct

    • What is the most frequently observed symptom in children diagnosed with bodily distress disorder?

      Your Answer: Abdominal pain

      Explanation:

      According to ICD-11, the bodily symptoms that are most frequently reported by children and adolescents are gastrointestinal symptoms that occur repeatedly (such as abdominal pain and nausea), fatigue, headaches, and musculoskeletal pain. Typically, children tend to experience one recurring symptom rather than multiple bodily symptoms.

      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.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 30 - How should acute mania be managed? ...

    Incorrect

    • How should acute mania be managed?

      Your Answer: Carbamazepine

      Correct Answer: Valproate

      Explanation:

      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.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 31 - A manic adolescent who has already had 3 manic episodes in the past...

    Incorrect

    • A manic adolescent who has already had 3 manic episodes in the past 10 months is admitted to hospital for treatment. He is currently taking both lithium and valproate at maximum dose. Which of the following would be appropriate as an augmentation agent?

      Your Answer: Tranylcypromine

      Correct Answer: Quetiapine

      Explanation:

      If a patient is experiencing mania, it is important to avoid administering antidepressants such as dosulepin, moclobemide, and tranylcypromine as they may exacerbate the condition. Instead, the Maudsley recommends the use of quetiapine and other appropriate medications.

      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.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 32 - What is a true statement about Cotard's syndrome? ...

    Incorrect

    • What is a true statement about Cotard's syndrome?

      Your Answer: It is more common in males than females

      Correct Answer: It is most commonly associated with depression

      Explanation:

      Cotard’s syndrome is a delusion where an individual believes they do not exist of have lost their blood, internal organs, of soul. It is commonly seen in depression, schizophrenia, and bipolar disorder, and can also occur after trauma. The condition is more prevalent in females and the elderly.

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      • General Adult Psychiatry
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  • Question 33 - What strategies are effective in managing obsessive compulsive disorder? ...

    Incorrect

    • What strategies are effective in managing obsessive compulsive disorder?

      Your Answer: Client centred psychotherapy

      Correct Answer: Exposure and response prevention

      Explanation:

      Maudsley Guidelines

      First choice: SSRI of clomipramine (SSRI preferred due to tolerability issues with clomipramine)

      Second line:

      – SSRI + antipsychotic
      – Citalopram + clomipramine
      – Acetylcysteine + (SSRI of clomipramine)
      – Lamotrigine + SSRI
      – Topiramate + SSRI

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 34 - What is the difference between rapid cycling and non-rapid cycling bipolar disorder? ...

    Incorrect

    • What is the difference between rapid cycling and non-rapid cycling bipolar disorder?

      Your Answer: Rapid cycling is more common in those with a positive family history

      Correct Answer: Rapid cycling is more common in women

      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.

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      • General Adult Psychiatry
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  • Question 35 - What is the term used to refer to a psychotic episode that is...

    Incorrect

    • What is the term used to refer to a psychotic episode that is brief and lasts for less than 3 months?

      Your Answer: Paraphrenia

      Correct Answer: Bouffée délirante

      Explanation:

      The term Bouffée délirante is a distinct and historical French diagnosis used to describe a brief episode of psychosis characterized by sudden and severe psychotic symptoms that fully resolve. The oneiroid state refers to a dreamy mental state. Latent schizophrenia is an outdated term that was previously used to describe individuals with borderline, schizoid, and schizotypal personality disorders.

      – 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 36 - A 45-year-old man presents with a high fever of 39.5°C. He reports a...

    Incorrect

    • A 45-year-old man presents with a high fever of 39.5°C. He reports a stiff neck and complains of a severe headache. He quickly becomes confused and there is evidence that he is experiencing hallucinations related to taste and smell.

      He has a history of being in good health, but had a pacemaker implanted at the age of 30. He has not traveled outside of the country recently. The medical team has requested your assistance as the consulting psychiatrist.

      What is the most probable diagnosis?

      Your Answer: Bacterial meningitis

      Correct Answer: Herpes simplex virus (HSV) encephalitis

      Explanation:

      The patient’s symptoms indicate possible HSV encephalitis, with specific damage to the temporal and orbitofrontal regions causing hallucinations, loss of smell, and significant memory problems. Immediate treatment with acyclovir and dexamethasone is necessary, and referral for decompression may be necessary depending on the severity of the condition.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 37 - What is the most frequently observed co-existing condition in individuals with borderline personality...

    Incorrect

    • What is the most frequently observed co-existing condition in individuals with borderline personality disorder?

      Your Answer: Post-traumatic stress disorder

      Correct Answer: Major depression

      Explanation:

      Personality Disorder (Borderline)

      History and Terminology

      The term borderline personality disorder originated from early 20th-century theories that the disorder was on the border between neurosis and psychosis. The term borderline was coined by Adolph Stern in 1938. Subsequent attempts to define the condition include Otto Kernberg’s borderline personality organization, which identified key elements such as ego weakness, primitive defense mechanisms, identity diffusion, and unstable reality testing.

      Features

      The DSM-5 and ICD-11 both define borderline personality disorder as a pervasive pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity. Symptoms include efforts to avoid abandonment, unstable relationships, impulsivity, suicidal behavior, affective instability, chronic feelings of emptiness, difficulty controlling temper, and transient dissociative symptoms.

      Abuse

      Childhood abuse and neglect are extremely common among borderline patients, with up to 87% having suffered some form of trauma. The effect of abuse seems to depend on the stage of psychological development at which it takes place.

      comorbidity

      Borderline PD patients are more likely to receive a diagnosis of major depressive disorder, bipolar disorder, panic disorder, PTSD, OCD, eating disorders, and somatoform disorders.

      Psychological Therapy

      Dialectical Behavioral Therapy (DBT), Mentalization-Based Treatment (MBT), Schema-Focused Therapy (SFT), and Transference-Focused Psychotherapy (TFP) are the main psychological treatments for BPD. DBT is the most well-known and widely available, while MBT focuses on improving mentalization, SFT generates structural changes to a patient’s personality, and TFP examines dysfunctional interpersonal dynamics that emerge in interactions with the therapist in the transference.

      NICE Guidelines

      The NICE guidelines on BPD offer very little recommendations. They do not recommend medication for treatment of the core symptoms. Regarding psychological therapies, they make reference to DBT and MBT being effective but add that the evidence base is too small to draw firm conclusions. They do specifically say Do not use brief psychotherapeutic interventions (of less than 3 months’ duration) specifically for borderline personality disorder of for the individual symptoms of the disorder.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 38 - A 15-year-old boy is brought for review. He is normally fit and well...

    Incorrect

    • A 15-year-old boy is brought for review. He is normally fit and well and hasn't seen a doctor for over five years. His mother has been increasingly concerned about his behaviour in the past few weeks. She describes him staying up late at night, talking quickly and being very irritable. Yesterday he told his mother he was planning to 'take-over' the company meeting and give 'constructive criticism' to his bosses in front of the other employees. He feels many of his colleagues are 'underperforming' and need to be 'retaught' their jobs by him. He admits to trying cannabis once around six months ago and has drunk alcohol 'a few times' in the past year, the last time being two weeks ago. Prior to his deterioration a few weeks ago his mother describes him as a happy, well-adjusted, sociable young man.
      Which one of the following is the most likely diagnosis?

      Your Answer: Psychotic depression

      Correct Answer: Mania

      Explanation:

      It is highly improbable for him to experience issues related to cannabis and alcohol use, considering the significant amount of time that has passed since he last consumed those substances.

      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.

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      • General Adult Psychiatry
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  • Question 39 - What is the expected response rate to clozapine for individuals with treatment resistant...

    Incorrect

    • What is the expected response rate to clozapine for individuals with treatment resistant schizophrenia?

      Your Answer: 10%

      Correct Answer: 60%

      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 40 - Which of the options below provides the weakest evidence for a diagnosis of...

    Incorrect

    • Which of the options below provides the weakest evidence for a diagnosis of narcissistic personality disorder?

      Your Answer: Exaggerates achievements

      Correct Answer: Has robust self-esteem

      Explanation:

      Narcissistic personality disorder typically involves a very delicate sense of self-esteem.

      Personality Disorder (Narcissistic)

      Narcissistic personality disorder is a mental illness characterized by individuals having an exaggerated sense of their own importance, an intense need for excessive attention and admiration, troubled relationships, and a lack of empathy towards others. The DSM-5 diagnostic manual outlines the criteria for this disorder, which includes a pervasive pattern of grandiosity, a need for admiration, and a lack of empathy. To be diagnosed with this disorder, an individual must exhibit at least five of the following traits: a grandiose sense of self-importance, preoccupation with fantasies of unlimited success, belief in being special and unique, excessive admiration requirements, a sense of entitlement, interpersonal exploitation, lack of empathy, envy towards others, and arrogant of haughty behaviors. While the previous version of the ICD included narcissistic personality disorder, the ICD-11 does not have a specific reference to this condition, but it can be coded under the category of general personality disorder.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 41 - Out of the options provided, which one is the least probable cause of...

    Correct

    • Out of the options provided, which one is the least probable cause of postural hypotension?

      Your Answer: Aripiprazole

      Explanation:

      Antipsychotics: Common Side Effects and Relative Adverse Effects

      Antipsychotics are medications used to treat various mental health conditions, including schizophrenia and bipolar disorder. However, they can also cause side effects that can be bothersome of even serious. The most common side effects of antipsychotics are listed in the table below, which includes the adverse effects associated with their receptor activity.

      Antidopaminergic effects: These effects are related to the medication’s ability to block dopamine receptors in the brain. They can cause galactorrhoea, gynecomastia, menstrual disturbance, lowered sperm count, reduced libido, Parkinsonism, dystonia, akathisia, and tardive dyskinesia.

      Anticholinergic effects: These effects are related to the medication’s ability to block acetylcholine receptors in the brain. They can cause dry mouth, blurred vision, urinary retention, and constipation.

      Antiadrenergic effects: These effects are related to the medication’s ability to block adrenaline receptors in the body. They can cause postural hypotension and ejaculatory failure.

      Histaminergic effects: These effects are related to the medication’s ability to block histamine receptors in the brain. They can cause drowsiness.

      The Maudsley Guidelines provide a rough guide to the relative adverse effects of different antipsychotics. The table below summarizes their findings, with +++ indicating a high incidence of adverse effects, ++ indicating a moderate incidence, + indicating a low incidence, and – indicating a very low incidence.

      Drug Sedation Weight gain Diabetes EPSE Anticholinergic Postural Hypotension Prolactin elevation
      Amisulpride – + + + – – +++
      Aripiprazole – +/- – +/- – – –
      Asenapine + + +/- +/- – – +/-
      Clozapine +++ +++ +++ – +++ +++ –
      Flupentixol + ++ + ++ ++ + +++
      Fluphenazine + + + +++ ++ + +++
      Haloperidol + + +/- +++ + + +++
      Olanzapine ++ +++ +++ +/- + + +
      Paliperidone + ++ + + + ++ +++
      Pimozide + + – + + + +++
      Quetiapine ++ ++ ++ – + ++ –
      Risperidone + ++ + + + ++ +++
      Zuclopenthixol ++ ++ + ++ ++ + +++

      Overall, it is important to discuss the potential side effects of antipsychotics with a healthcare provider and to monitor for any adverse effects while taking these medications.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 42 - What is the most probable condition of a patient referred by cardiologists who...

    Incorrect

    • What is the most probable condition of a patient referred by cardiologists who persists in believing that he has heart disease despite multiple normal tests and reassurances from several cardiologists?

      Your Answer: Conversion disorder

      Correct Answer: Hypochondriacal disorder

      Explanation:

      There is often confusion between hypochondriasis and somatisation disorder, which have been renamed illness anxiety disorder and somatic symptom disorder in the DSM-5. Hypochondriasis involves a preoccupation with a specific condition, while somatisation disorder is characterized by a focus on symptoms rather than a particular illness.

      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.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 43 - Which country has the highest rate of 'any psychiatric disorder' according to the...

    Incorrect

    • Which country has the highest rate of 'any psychiatric disorder' according to the World Mental Health Survey Initiative?

      Your Answer: Italy

      Correct Answer: United states

      Explanation:

      World Mental Health Survey Initiative: Variations in Prevalence of Mental Disorders Across Countries

      The World Mental Health Survey Initiative aims to gather accurate cross-national information on the prevalence and correlates of mental, substance, and behavioural disorders. The initiative includes nationally of regionally representative surveys in 28 countries, with a total sample size of over 154,000. All interviews are conducted face-to-face by trained lay interviewers using the WMH-CIDI, a fully structured diagnostic interview.

      As of 2009, data from 17 countries and 70,000 respondents have been returned. The main findings show that the US has the highest prevalence of any disorder, with anxiety disorder being the most common condition, followed by mood disorder. However, there is significant variation in prevalence between countries. These findings highlight the importance of understanding the cultural and societal factors that contribute to the prevalence of mental disorders in different regions.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 44 - According to Gottesman (1982), what is the risk of a child developing schizophrenia...

    Incorrect

    • According to Gottesman (1982), what is the risk of a child developing schizophrenia if they have an affected parent?

      Your Answer: 75%

      Correct Answer: 13%

      Explanation:

      Schizophrenia: Understanding the Risk Factors

      Social class is a significant risk factor for schizophrenia, with people of lower socioeconomic status being more likely to develop the condition. Two hypotheses attempt to explain this relationship, one suggesting that environmental exposures common in lower social class conditions are responsible, while the other suggests that people with schizophrenia tend to drift towards the lower class due to their inability to compete for good jobs.

      While early studies suggested that schizophrenia was more common in black populations than in white, the current consensus is that there are no differences in rates of schizophrenia by race. However, there is evidence that rates are higher in migrant populations and ethnic minorities.

      Gender and age do not appear to be consistent risk factors for schizophrenia, with conflicting evidence on whether males of females are more likely to develop the condition. Marital status may also play a role, with females with schizophrenia being more likely to marry than males.

      Family history is a strong risk factor for schizophrenia, with the risk increasing significantly for close relatives of people with the condition. Season of birth and urban versus rural place of birth have also been shown to impact the risk of developing schizophrenia.

      Obstetric complications, particularly prenatal nutritional deprivation, brain injury, and influenza, have been identified as significant risk factors for schizophrenia. Understanding these risk factors can help identify individuals who may be at higher risk for developing the condition and inform preventative measures.

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      • General Adult Psychiatry
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  • Question 45 - Which country's data is excluded from the World Mental Health Survey Initiative? ...

    Correct

    • Which country's data is excluded from the World Mental Health Survey Initiative?

      Your Answer: England

      Explanation:

      World Mental Health Survey Initiative: Variations in Prevalence of Mental Disorders Across Countries

      The World Mental Health Survey Initiative aims to gather accurate cross-national information on the prevalence and correlates of mental, substance, and behavioural disorders. The initiative includes nationally of regionally representative surveys in 28 countries, with a total sample size of over 154,000. All interviews are conducted face-to-face by trained lay interviewers using the WMH-CIDI, a fully structured diagnostic interview.

      As of 2009, data from 17 countries and 70,000 respondents have been returned. The main findings show that the US has the highest prevalence of any disorder, with anxiety disorder being the most common condition, followed by mood disorder. However, there is significant variation in prevalence between countries. These findings highlight the importance of understanding the cultural and societal factors that contribute to the prevalence of mental disorders in different regions.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 46 - What is the estimated rate of puerperal psychosis in the UK? ...

    Incorrect

    • What is the estimated rate of puerperal psychosis in the UK?

      Your Answer: 1 in 5000

      Correct Answer: 1 in 500

      Explanation:

      Puerperal Psychosis: Incidence, Risk Factors, and Treatment

      Postpartum psychosis is a subtype of bipolar disorder with an incidence of 1-2 in 1000 pregnancies. It typically occurs rapidly between day 2 and day 14 following delivery, with almost all cases occurring within 8 weeks of delivery. Risk factors for puerperal psychosis include a past history of puerperal psychosis, pre-existing psychotic illness (especially affective psychosis) requiring hospital admission, and a family history of affective psychosis in first of second degree relatives. However, factors such as twin pregnancy, breastfeeding, single parenthood, and stillbirth have not been shown to be associated with an increased risk. Treatment for puerperal psychosis is similar to that for psychosis in general, but special consideration must be given to potential issues if the mother is breastfeeding.

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      • General Adult Psychiatry
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  • Question 47 - What potential adverse effect on the neonate may be linked to the use...

    Incorrect

    • What potential adverse effect on the neonate may be linked to the use of SSRIs after 20 weeks of gestation?

      Your Answer: Jaundice

      Correct Answer: Persistent pulmonary hypertension

      Explanation:

      According to the 13th edition of Maudsley, taking SSRIs after 20 weeks of pregnancy may be linked to a higher chance of persistent pulmonary hypertension in newborns. However, the risk is relatively low and may only be present if the exposure occurs in late pregnancy. It’s important to note that this increased risk is based on comparisons with the general population, not women who have depression, for whom the risk is unknown.

      Paroxetine Use During Pregnancy: Is it Safe?

      Prescribing medication during pregnancy and breastfeeding is challenging due to the potential risks to the fetus of baby. No psychotropic medication has a UK marketing authorization specifically for pregnant of breastfeeding women. Women are encouraged to breastfeed unless they are taking carbamazepine, clozapine, of lithium. The risk of spontaneous major malformation is 2-3%, with drugs accounting for approximately 5% of all abnormalities. Valproate and carbamazepine are associated with an increased risk of neural tube defects, and lithium is associated with cardiac malformations. Benzodiazepines are associated with oral clefts and floppy baby syndrome. Antidepressants have been linked to preterm delivery and congenital malformation, but most findings have been inconsistent. TCAs have been used widely without apparent detriment to the fetus, but their use in the third trimester is known to produce neonatal withdrawal effects. Sertraline appears to result in the least placental exposure among SSRIs. MAOIs should be avoided in pregnancy due to a suspected increased risk of congenital malformations and hypertensive crisis. If a pregnant woman is stable on an antipsychotic and likely to relapse without medication, she should continue the antipsychotic. Depot antipsychotics should not be offered to pregnant of breastfeeding women unless they have a history of non-adherence with oral medication. The Maudsley Guidelines suggest specific drugs for use during pregnancy and breastfeeding. NICE CG192 recommends high-intensity psychological interventions for moderate to severe depression and anxiety disorders. Antipsychotics are recommended for pregnant women with mania of psychosis who are not taking psychotropic medication. Promethazine is recommended for insomnia.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 48 - A man who has recently turned 60 and is still taking medication for...

    Incorrect

    • A man who has recently turned 60 and is still taking medication for hypertension develops mania. He fails to respond to olanzapine. Considering the fact that he is taking medication for hypertension, which of the following is the most appropriate next step?

      Your Answer:

      Correct Answer: Quetiapine

      Explanation:

      Paroxetine Use During Pregnancy: Is it Safe?

      Prescribing medication during pregnancy and breastfeeding is challenging due to the potential risks to the fetus of baby. No psychotropic medication has a UK marketing authorization specifically for pregnant of breastfeeding women. Women are encouraged to breastfeed unless they are taking carbamazepine, clozapine, of lithium. The risk of spontaneous major malformation is 2-3%, with drugs accounting for approximately 5% of all abnormalities. Valproate and carbamazepine are associated with an increased risk of neural tube defects, and lithium is associated with cardiac malformations. Benzodiazepines are associated with oral clefts and floppy baby syndrome. Antidepressants have been linked to preterm delivery and congenital malformation, but most findings have been inconsistent. TCAs have been used widely without apparent detriment to the fetus, but their use in the third trimester is known to produce neonatal withdrawal effects. Sertraline appears to result in the least placental exposure among SSRIs. MAOIs should be avoided in pregnancy due to a suspected increased risk of congenital malformations and hypertensive crisis. If a pregnant woman is stable on an antipsychotic and likely to relapse without medication, she should continue the antipsychotic. Depot antipsychotics should not be offered to pregnant of breastfeeding women unless they have a history of non-adherence with oral medication. The Maudsley Guidelines suggest specific drugs for use during pregnancy and breastfeeding. NICE CG192 recommends high-intensity psychological interventions for moderate to severe depression and anxiety disorders. Antipsychotics are recommended for pregnant women with mania of psychosis who are not taking psychotropic medication. Promethazine is recommended for insomnia.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 49 - Which symptom is not included in the somatic syndrome of depression? ...

    Incorrect

    • Which symptom is not included in the somatic syndrome of depression?

      Your Answer:

      Correct Answer: Low mood

      Explanation:

      Anhedonia is commonly regarded as a psychological manifestation of depression.

      Depression (Biological Symptoms)

      Depression can be classified into biological (physical) of psychological symptoms. The terms used to describe biological symptoms include somatic, vital, melancholic, and endogenomorphic. These terms are used interchangeably in exams, so it is important to be familiar with them.

      Biological symptoms of depression include decreased appetite, weight loss, lack of emotional reactivity, anhedonia, early morning waking, depression worse in the mornings, psychomotor changes (retardation and agitation), fatigue, reduced libido, constipation, and insomnia.

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      • General Adult Psychiatry
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  • Question 50 - A 14-year-old, child assigned female at birth who identifies as male presents for...

    Incorrect

    • A 14-year-old, child assigned female at birth who identifies as male presents for a consultation due to concerns about recent onset of low mood. Around fourth grade, he began expressing interest in wearing boys clothing, and in the last few years, he has been stating that he wants to be a boy. He now goes by his chosen name and uses he/him pronouns at school and at home, although his parents are still struggling to use these pronouns and name. He is out to his teachers and most of the kids at school, and most are supportive. The patient becomes very upset, aggressive, and angry when people use the wrong name of pronoun, and he has had some fights at school in these situations.

      Which ICD-11 diagnosis is appropriate for this patient?

      Your Answer:

      Correct Answer: Gender incongruence

      Explanation:

      The DSM-5 uses the term Gender Dysphoria, but the correct diagnosis would be Gender Incongruence.

      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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SESSION STATS - PERFORMANCE PER SPECIALTY

General Adult Psychiatry (32/47) 68%
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