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Question 1
Incorrect
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As a fourth-year medical student on placement in an acute psychiatric ward, I approached Peter, a patient with a history of schizophrenia, and asked him how many days he had been admitted to the ward.
Your Answer: Perseveration
Correct Answer: Circumstantiality
Explanation:Circumstantiality is the inability to provide a concise answer to a question, often due to excessive and unnecessary detail.
Thought disorders can manifest in various ways, including circumstantiality, tangentiality, neologisms, clang associations, word salad, Knight’s move thinking, flight of ideas, perseveration, and echolalia. Circumstantiality involves providing excessive and unnecessary detail when answering a question, but eventually returning to the original point. Tangentiality, on the other hand, refers to wandering from a topic without returning to it. Neologisms are newly formed words, often created by combining two existing words. Clang associations occur when ideas are related only by their similar sounds or rhymes. Word salad is a type of speech that is completely incoherent, with real words strung together into nonsensical sentences. Knight’s move thinking is a severe form of loosening of associations, characterized by unexpected and illogical leaps from one idea to another. Flight of ideas is a thought disorder that involves jumping from one topic to another, but with discernible links between them. Perseveration is the repetition of ideas or words despite attempts to change the topic. Finally, echolalia is the repetition of someone else’s speech, including the question that was asked.
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This question is part of the following fields:
- Psychiatry
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Question 2
Incorrect
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A 78-year-old woman complains of feeling down, having low energy, and losing interest in activities. She has been experiencing poor sleep for the past 2 weeks and has had no appetite. Her physician prescribes mirtazapine. What category of medications does mirtazapine fall under?
Your Answer:
Correct Answer: Noradrenergic and specific serotonergic antidepressants
Explanation:By blocking alpha2 adrenoreceptors, mirtazapine increases the release of neurotransmitters and functions as a noradrenergic and specific serotonergic antidepressant.
Mirtazapine: An Effective Antidepressant with Fewer Side Effects
Mirtazapine is an antidepressant medication that functions by blocking alpha2-adrenergic receptors, which leads to an increase in the release of neurotransmitters. Compared to other antidepressants, mirtazapine has fewer side effects and interactions, making it a suitable option for older individuals who may be more susceptible to adverse effects or are taking other medications.
Mirtazapine has two side effects that can be beneficial for older individuals who are experiencing insomnia and poor appetite. These side effects include sedation and an increased appetite. As a result, mirtazapine is typically taken in the evening to help with sleep and to stimulate appetite.
Overall, mirtazapine is an effective antidepressant that is well-tolerated by many individuals. Its unique side effects make it a valuable option for older individuals who may have difficulty sleeping or eating.
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This question is part of the following fields:
- Psychiatry
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Question 3
Incorrect
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A 20-year-old man presented to the psychiatry outpatients department with a sense of unsettling alteration in his personality. He expressed feeling peculiar, as if he is not his usual self. Despite being anxious and tense, he was unable to identify the exact nature of this change. What term best characterizes this sensation?
Your Answer:
Correct Answer: Depersonalisation
Explanation:Depersonalisation
Depersonalisation is a distressing experience where an individual feels disconnected from their own body and reality. It is often described as feeling like living in a dream or being in immediate danger of disappearing. Despite cognitive functioning remaining intact, the sufferer may interpret the experience as a sign of losing their mind. This can lead to the development of an autochthonous delusion, which arises spontaneously.
The delusional mood is a sense of unease that can be resolved when a delusional belief forms. Over valued ideas are also present in depersonalisation, but they are not held with the same level of fixity as delusional beliefs. Overall, depersonalisation can be a frightening and disturbing experience that can leave individuals feeling disconnected from themselves and their surroundings.
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This question is part of the following fields:
- Psychiatry
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Question 4
Incorrect
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A 35-year-old divorced man gives a history of moderately heavy drinking for 10 years. In the 2 years since his divorce, he has experienced disrupted sleep, fatigue, irritability and cynicism. He typically drinks excessively. For example, he consumes a case of beer in a weekend and now drinks before work.
Which is the most appropriate initial form of psychotherapy?Your Answer:
Correct Answer: Self-help group
Explanation:Different Forms of Therapy for Alcohol Dependence: Pros and Cons
Alcohol dependence is a serious issue that requires professional intervention. There are various forms of therapy available for individuals struggling with alcohol abuse. Here are some of the most common types of therapy and their pros and cons:
1. Self-help group: Alcoholics Anonymous (AA) and similar self-help programs are free, widely available, and confidential. The diversity of membership, vast experience with alcohol among participants, and flexibility of meeting times provide therapeutic advantages. However, the lack of accountability and wide variation in quality among different groups can be a disadvantage.
2. Interpersonal psychotherapy and antidepressants: Interpersonal psychotherapy deals with specific circumstances thought to contribute to depression, including losses, social transitions, role disputes, and unsatisfactory interpersonal relations. Antidepressants are only considered after a month of abstinence. However, this form of therapy may not be suitable for everyone.
3. Cognitive behavioural therapy (CBT): CBT may be useful for addressing underlying reasons for alcohol abuse in the long run. However, first-line support for patients with addiction is self-help groups such as AA.
4. Structural family therapy: This form of treatment is developed for helping families in which a child shows psychiatric symptoms, behaviour problems, or unstable chronic illness. However, it may not be suitable for patients with isolated alcoholism or fractured families.
5. Psychoanalytic psychotherapy: This therapy posits that therapeutic change requires making early experiences conscious and their influence explicit. However, it may not be suitable for everyone and may require a longer time commitment.
In conclusion, there are various forms of therapy available for individuals struggling with alcohol dependence. It is important to consider the pros and cons of each type of therapy and choose the one that is most suitable for the individual’s needs.
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This question is part of the following fields:
- Psychiatry
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Question 5
Incorrect
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Sarah is a 30-year-old teacher who has been referred to the mental health team with suspected bipolar disorder. The psychiatrist has confirmed the diagnosis and prescribed lithium, which has stabilized her condition. They have requested that you take over the monitoring of her medication levels. When you call Sarah to advise her on when to have her lithium levels checked, she cannot recall the specific timing related to her medication. How would you recommend that her medication levels be monitored?
Your Answer:
Correct Answer: Blood test 12 hours post dose every 3 months
Explanation:According to NICE, lithium levels should be checked one week after starting treatment, one week after any dose changes, and weekly until stable levels are achieved. Once stable levels are reached, lithium levels should be checked every 3 months, with the sample taken 12 hours after the dose. It is important to note that a trough level taken immediately before a dose is only applicable for certain medications, such as twice-daily clozapine.
Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in treatment-resistant depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. The mechanism of action is not fully understood, but it is believed to interfere with inositol triphosphate and cAMP formation. Adverse effects may include nausea, vomiting, diarrhea, fine tremors, nephrotoxicity, thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, hyperparathyroidism, and hypercalcemia.
Monitoring of patients taking lithium is crucial to prevent adverse effects and ensure therapeutic levels. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until levels are stable. Once established, lithium levels should be checked every three months. Thyroid and renal function should be monitored every six months. Patients should be provided with an information booklet, alert card, and record book to ensure proper management of their medication. Inadequate monitoring of patients taking lithium is common, and guidelines have been issued to address this issue.
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This question is part of the following fields:
- Psychiatry
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Question 6
Incorrect
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A 29-year-old man presented to the hospital, accompanied by the police after having had a fight in a casino. The casino manager called the police when the man refused to leave after he had spent almost 24 hours gambling. The patient ran out of money and was harassing other clients, trying to borrow money from them and telling them that he will return it after he had won and invested the prize money. The patient has no known next of kin and refuses to engage with the attending doctor. He threatens to assault the medical staff and is eventually put under urgent mental health Section 4. A review of his medical notes reveals that the only medication on which he has been is lithium for a known psychiatric illness, but he has not been in touch with his general practitioner for the past two months.
What is the best course of action for managing this patient?Your Answer:
Correct Answer: Check the lithium levels and consider adding olanzapine
Explanation:Management of Bipolar Depression with Mania or Hypomania
According to the latest NICE guideline CG85, patients with bipolar depression presenting with mania or hypomania should have their lithium levels checked and consider adding an antipsychotic such as haloperidol, olanzapine, quetiapine or risperidone. Therefore, checking the lithium levels and considering adding olanzapine is the correct answer in this case.
Stopping lithium without checking the levels first is not recommended as it is a mood stabiliser and may be required for the patient. Starting haloperidol or risperidone without checking the lithium levels is also not recommended as the doctor must consider the patient’s lithium levels before adding an antipsychotic.
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This question is part of the following fields:
- Psychiatry
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Question 7
Incorrect
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A 28-year-old man comes to see his doctor complaining of feeling down for the past two weeks. He has been having nightmares and difficulty sleeping. These symptoms started after he was violently robbed outside of his workplace. He has been avoiding going to work and often feels disconnected from reality.
What is the most probable diagnosis for this patient?Your Answer:
Correct Answer: Acute stress disorder
Explanation:Acute stress disorder is a type of acute stress reaction that occurs within the first 4 weeks after a person experiences a traumatic event, such as a life-threatening situation or sexual assault. It is different from PTSD, which is diagnosed after 4 weeks. The symptoms of acute stress disorder are similar to PTSD, including intrusive thoughts, dissociation, negative mood, avoidance, and arousal. Generalized anxiety disorder, panic disorder, and phobic disorder are not the same as acute stress disorder and have their own distinct characteristics.
Acute stress disorder is a condition that occurs within the first four weeks after a person has experienced a traumatic event, such as a life-threatening situation or sexual assault. It is characterized by symptoms such as intrusive thoughts, dissociation, negative mood, avoidance, and arousal. These symptoms can include flashbacks, nightmares, feeling disconnected from reality, and being hypervigilant.
To manage acute stress disorder, trauma-focused cognitive-behavioral therapy (CBT) is typically the first-line treatment. This type of therapy helps individuals process their traumatic experiences and develop coping strategies. In some cases, benzodiazepines may be used to alleviate acute symptoms such as agitation and sleep disturbance. However, caution must be taken when using these medications due to their addictive potential and potential negative impact on adaptation. Overall, early intervention and appropriate treatment can help individuals recover from acute stress disorder and prevent the development of more chronic conditions such as PTSD.
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This question is part of the following fields:
- Psychiatry
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Question 8
Incorrect
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A 25-year-old female presents to the emergency department with palpitations. Her ECG reveals first-degree heart block, tall P-waves, and flattened T-waves. Upon arterial blood gas analysis, her results are as follows: pH 7.55 (normal range 7.35-7.45), HCO3- 30 mmol/L (normal range 22-26 mmol/L), pCO2 5.8kPa (normal range 4.5-6kPa), p02 11kPa (normal range 10-14kPa), and Chloride 85mmol/L (normal range 95-108mmol/L). What is the underlying cause of her presentation?
Your Answer:
Correct Answer: Bulimia nervosa
Explanation:The palpitations experienced by this patient are likely due to hypokalaemia, as indicated by their ECG. The ABG results reveal a metabolic alkalosis, with low chloride levels suggesting that the cause is likely due to prolonged vomiting resulting in the loss of hydrochloric acid from the stomach. This could also explain the hypokalaemia observed on the ECG. The absence of acute nausea and vomiting suggests that this may be a chronic issue, possibly indicating bulimia nervosa as the underlying condition, unless there is a previous medical history that could account for persistent vomiting.
Bulimia Nervosa: An Eating Disorder Characterized by Binge Eating and Purging
Bulimia nervosa is a type of eating disorder that involves recurrent episodes of binge eating followed by purging behaviors such as self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise. The DSM 5 diagnostic criteria for bulimia nervosa include recurrent episodes of binge eating, a sense of lack of control over eating during the episode, and recurrent inappropriate compensatory behaviors to prevent weight gain. These behaviors occur at least once a week for three months and are accompanied by an undue influence of body shape and weight on self-evaluation.
Management of bulimia nervosa involves referral for specialist care and the use of bulimia-nervosa-focused guided self-help or individual eating-disorder-focused cognitive behavioral therapy (CBT-ED). Children should be offered bulimia-nervosa-focused family therapy (FT-BN). While pharmacological treatments have a limited role, a trial of high-dose fluoxetine is currently licensed for bulimia. It is important to seek appropriate care for bulimia nervosa to prevent the physical and psychological consequences of this eating disorder.
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This question is part of the following fields:
- Psychiatry
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Question 9
Incorrect
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A 67-year-old Indigenous male with a lengthy history of heavy alcohol use is hospitalized after experiencing a seizure upon stopping alcohol consumption. The physician observes that the patient is experiencing memory difficulties, as evidenced by his detailed recollection of events from the previous day in the hospital that are completely different from what actually occurred. The patient does not appear to have any intention of deceiving the doctor.
What is the most appropriate term to describe the patient's abnormality?Your Answer:
Correct Answer: Confabulation
Explanation:Common Terms in Psychiatry
Confabulation is the act of unintentionally reporting false memories that seem plausible. This can occur in individuals with Alzheimer’s disease or Korsakoff syndrome. Concrete thinking is a type of thinking where a person has difficulty thinking abstractly and may interpret proverbs literally. Hallucinations are sensory experiences that are not caused by external stimuli. Thought blocking is when a person suddenly stops their train of thought. Thought insertion is a delusion where a person believes that their thoughts are being placed in their mind by an external force.
These terms are commonly used in psychiatry to describe various symptoms and conditions. It is important to understand their meanings in order to properly diagnose and treat patients. Confabulation and concrete thinking may be indicative of cognitive impairment, while hallucinations and delusions may be symptoms of a psychotic disorder. Thought blocking may occur in individuals with schizophrenia, while thought insertion may be a symptom of delusional disorder. By these terms, healthcare professionals can provide better care for their patients.
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This question is part of the following fields:
- Psychiatry
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Question 10
Incorrect
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A 50-year-old man visits his GP in a state of distress. He recently returned from a vacation and forgot to renew his prescriptions, resulting in him not taking his medications for the past week. The patient is currently experiencing general discomfort, nausea, and excessive diarrhea. Upon conducting a thorough examination and reviewing his medical history, the GP suspects that his symptoms are due to the discontinuation of one of his medications. The patient has a medical history of depression, gout, hypothyroidism, and type two diabetes mellitus. He also occasionally uses zopiclone to treat his insomnia. Which medication withdrawal is likely causing the patient's symptoms?
Your Answer:
Correct Answer: Paroxetine
Explanation:SSRI discontinuation syndrome can cause gastrointestinal side-effects such as diarrhoea, with paroxetine having a particularly high risk of such symptoms. Withdrawal of SSRIs should be done gradually over several weeks to reduce the incidence of discontinuation symptoms. Colchicine, a gout medication, is associated with gastrointestinal side effects but does not cause significant symptoms upon withdrawal. Levothyroxine withdrawal does not cause any particular symptoms, but stopping long-term use can lead to hypothyroidism symptoms such as constipation. Metformin withdrawal does not cause acute symptoms, but stopping long-term use can worsen diabetic control, and diarrhoea is a side effect of metformin treatment.
Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.
The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.
When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.
When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.
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This question is part of the following fields:
- Psychiatry
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