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  • Question 1 - A 35-year-old teacher presents in a routine GP appointment feeling like everything is...

    Correct

    • A 35-year-old teacher presents in a routine GP appointment feeling like everything is falling apart. Despite this, she has never taken a day off work and has no history of mental illness. Her partner has noticed her cleaning the house more than usual and becoming irritated by the apparent lack of cleanliness at home. The patient is also becoming increasingly irritated with others' inability to perform tasks to her personal standards. She has a long-standing history of perfectionism and never spends her money on frivolous items. What is the probable diagnosis?

      Your Answer: Obsessive-compulsive personality

      Explanation:

      Individuals who exhibit obsessive-compulsive personality traits tend to be inflexible when it comes to their principles, beliefs, and standards, and frequently exhibit hesitancy in delegating tasks to others.

      Personality disorders are a set of personality traits that are maladaptive and interfere with normal functioning in life. It is estimated that around 1 in 20 people have a personality disorder, which are typically categorized into three clusters: Cluster A, which includes Odd or Eccentric disorders such as Paranoid, Schizoid, and Schizotypal; Cluster B, which includes Dramatic, Emotional, or Erratic disorders such as Antisocial, Borderline (Emotionally Unstable), Histrionic, and Narcissistic; and Cluster C, which includes Anxious and Fearful disorders such as Obsessive-Compulsive, Avoidant, and Dependent.

      Paranoid individuals exhibit hypersensitivity and an unforgiving attitude when insulted, a reluctance to confide in others, and a preoccupation with conspiratorial beliefs and hidden meanings. Schizoid individuals show indifference to praise and criticism, a preference for solitary activities, and emotional coldness. Schizotypal individuals exhibit odd beliefs and magical thinking, unusual perceptual disturbances, and inappropriate affect. Antisocial individuals fail to conform to social norms, deceive others, and exhibit impulsiveness, irritability, and aggressiveness. Borderline individuals exhibit unstable interpersonal relationships, impulsivity, and affective instability. Histrionic individuals exhibit inappropriate sexual seductiveness, a need to be the center of attention, and self-dramatization. Narcissistic individuals exhibit a grandiose sense of self-importance, lack of empathy, and excessive need for admiration. Obsessive-compulsive individuals are occupied with details, rules, and organization to the point of hampering completion of tasks. Avoidant individuals avoid interpersonal contact due to fears of criticism or rejection, while dependent individuals have difficulty making decisions without excessive reassurance from others.

      Personality disorders are difficult to treat, but a number of approaches have been shown to help patients, including psychological therapies such as dialectical behavior therapy and treatment of any coexisting psychiatric conditions.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 2 - A 26-year-old man presents to your clinic six months after he was assaulted...

    Incorrect

    • A 26-year-old man presents to your clinic six months after he was assaulted on his way home from work. He was mugged and punched in the stomach by his attacker before he fled. Six months later, the patient continues to have severe and incapacitating periumbilical pain where he was punched. He denies any gastrointestinal symptoms or any other issues. Previous investigations and imaging have been unremarkable for any underlying anatomical, neurological or vascular abnormality.
      What is the most appropriate description of the patient's current complaints during the clinic visit?

      Your Answer: Post-traumatic stress disorder (PTSD)

      Correct Answer: Pain disorder

      Explanation:

      Differentiating between Psychiatric Disorders: Pain Disorder, Conversion Disorder, Somatization Disorder, PTSD, and Acute Stress Disorder

      When evaluating a patient with unexplained physical symptoms, it is important to consider various psychiatric disorders that may be contributing to their presentation. In this case, the patient’s symptoms do not fit the criteria for somatization disorder, PTSD, or acute stress disorder. However, there are other disorders that should be considered.

      Pain disorder is characterized by intense, long-standing pain without a somatic explanation. The patient’s pain is out of proportion to the injury and is not explained by any underlying somatic pathology. This disorder is restricted to physical pain and does not include other somatic complaints.

      Conversion disorder, on the other hand, presents as a neurological deficit in the absence of a somatic cause. Patients are usually unconcerned about the symptom, unlike this patient. It usually follows a psychosocial stressor.

      Somatization disorder refers to patients with a constellation of physical complaints that are not explained by a somatic process. This would include odd distributions of pain, numbness, GI upset, headache, nausea, vomiting, shortness of breath, palpitations, etc. However, this patient is fixated on a particular disease and does not fit the criteria for somatization.

      PTSD presents with persistent re-experiencing of the trauma, nightmares, flashbacks, intense fear, avoidant behaviour and/or increased arousal. Symptoms must persist for at least 1 month and impair his quality of life. There are no clear signs of PTSD in this patient.

      Acute stress disorder is an anxiety condition precipitated by an acute stress that resolves within a month. This is well beyond the window for acute stress, and it does not fit the symptomatology of acute stress.

      In conclusion, it is important to consider various psychiatric disorders when evaluating a patient with unexplained physical symptoms. By ruling out certain disorders, a proper diagnosis and treatment plan can be established.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 3 - A 29-year-old man is admitted to a psychiatry ward from the emergency department....

    Incorrect

    • A 29-year-old man is admitted to a psychiatry ward from the emergency department. He was brought by a concerned family member who was worried by his recent behaviour. He had been engaging in large amounts of shopping, spending nearly every night at the mall and hardly sleeping. When asked if he understands the risks of overspending, he is convinced that nothing can go wrong. He struggles to focus on the topic and begins rambling about buying various different items that are sure to make him happy. A diagnosis of a manic episode is made and he is stabilised on treatment with quetiapine. Subsequently it is decided to initiate lithium to maintain his mood.
      When should his serum lithium levels next be monitored?

      Your Answer: 1 week - 6 hours after last dose

      Correct Answer: 1 week - 12 hours after last dose

      Explanation:

      To prevent future manic episodes, this patient with an acute manic episode can be prescribed lithium as a prophylactic mood stabilizer. When starting or changing the dose of lithium, weekly monitoring of lithium levels is necessary, with samples taken 12 hours after the last dose. After treatment is established, monitoring frequency can be reduced to every 3 months, with samples still taken 12 hours after the last dose. Additionally, U&E and TFTs should be monitored every 6 months after starting treatment.

      Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in treatment-resistant depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. The mechanism of action is not fully understood, but it is believed to interfere with inositol triphosphate and cAMP formation. Adverse effects may include nausea, vomiting, diarrhea, fine tremors, nephrotoxicity, thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, hyperparathyroidism, and hypercalcemia.

      Monitoring of patients taking lithium is crucial to prevent adverse effects and ensure therapeutic levels. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until levels are stable. Once established, lithium levels should be checked every three months. Thyroid and renal function should be monitored every six months. Patients should be provided with an information booklet, alert card, and record book to ensure proper management of their medication. Inadequate monitoring of patients taking lithium is common, and guidelines have been issued to address this issue.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 4 - A 30-year-old man visits his GP for a medication review. He began taking...

    Correct

    • A 30-year-old man visits his GP for a medication review. He began taking citalopram four months ago to treat his depression, and he now feels that his symptoms have significantly improved. He believes that he has returned to his usual self and no longer requires the antidepressant medication. What advice should the GP provide to minimize the risk of relapse?

      Your Answer: Continue citalopram for 6 more months

      Explanation:

      Antidepressant medication should be continued for a minimum of 6 months after symptoms have remitted to reduce the risk of relapse. Therefore, the correct course of action is to continue treatment for 6 more months from the point of remission. Continuing for only 2 or 3 more months would not meet the recommended duration of treatment. Gradually reducing doses over 4 weeks is a suitable approach for weaning off SSRIs, but it should only be done after the 6-month period of treatment. Stopping citalopram abruptly is not safe and could lead to discontinuation syndrome or a relapse of depression.

      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.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 5 - A 35-year-old divorced man gives a history of moderately heavy drinking for 10...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 6 - A 47-year-old man visits his General Practitioner with worsening anxiety. He describes one...

    Correct

    • A 47-year-old man visits his General Practitioner with worsening anxiety. He describes one of his symptoms as feeling severely nauseous and even vomiting every time he smells a particular perfume. What theory of learning explains this?

      Your Answer: Classical conditioning

      Explanation:

      Types of Learning and Conditioning in Psychology

      Classical conditioning, latent inhibition, habituation, operant conditioning, and tolerance are all types of learning and conditioning in psychology.

      Classical conditioning involves learning through association, where an unfamiliar stimulus becomes associated with a conditioned response through repetitive exposure.

      Latent inhibition refers to the slower acquisition of meaning or response to a familiar stimulus compared to a new stimulus.

      Habituation is the decrease in responsiveness to a stimulus with repeated exposure.

      Operant conditioning involves learning through positive or negative reinforcement, where a voluntary response is followed by a reinforcing stimulus.

      Tolerance is the reduced response to a drug over time, requiring a higher concentration to achieve the desired effect.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 7 - A 72-year-old woman, widowed for 5 years, presents with insomnia, anhedonia, frequent tearfulness...

    Incorrect

    • A 72-year-old woman, widowed for 5 years, presents with insomnia, anhedonia, frequent tearfulness when discussing her late husband, and weight loss. She reports experiencing various nonspecific physical symptoms and expresses concerns about the return of breast cancer that was previously treated. She denies any substance abuse and denies having suicidal thoughts but admits that she would feel relieved if she were to pass away. What is the most suitable form of psychotherapy/treatment for this patient?

      Your Answer: Cognitive behavioural therapy (CBT)

      Correct Answer: Interpersonal therapy

      Explanation:

      Choosing the Right Therapy for a Patient with Depression and Grief

      When a patient’s grief persists beyond the usual two years of acute distress and leads to depression, it’s important to choose the right therapy. In this case, interpersonal therapy for depression is the most likely form of treatment, as it offers a protocol specifically for resolving depression after loss and is compatible with antidepressant medication. However, if the patient were suicidal, more aggressive intervention would be necessary.

      A breast cancer support group is not an appropriate resource for this patient, as her concern about cancer is a form of depressive somatic preoccupation and should not be the main focus of her treatment. Psychoanalytic psychotherapy may be helpful if there are deep-rooted problems that do not respond well to interpersonal therapy, but it can be time-consuming and costly.

      While cognitive behavioural therapy (CBT) is helpful in depression, it may not be the best option when there is a key trigger such as loss that needs specific intervention. Immediate hospitalisation is not necessary in this case, as the patient is not contemplating suicide.

      Overall, choosing the right therapy for a patient with depression and grief requires careful consideration of the patient’s specific needs and circumstances.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 8 - A 60-year-old female with depression is seen by her psychiatrist. She reports that...

    Correct

    • A 60-year-old female with depression is seen by her psychiatrist. She reports that her antidepressants are not improving her depressed mood. She expresses a sense of detachment from her surroundings, including her loved ones.
      What is the most appropriate term to describe the patient's abnormality?

      Your Answer: Derealisation

      Explanation:

      Derealisation

      Derealisation is a phenomenon where an individual experiences a sense of detachment from their surroundings, leading them to believe that the world around them is not real. It is different from depersonalisation, which is a feeling of detachment from oneself. While depression may cause symptoms such as anhedonia, nihilistic delusions, and reduced affect display, these are not necessarily present in someone experiencing derealisation.

      In summary, derealisation is a dissociative experience that can make an individual feel as though their environment is not real. It is important to note that this is a distinct experience from depersonalisation and may occur without other symptoms commonly associated with depression.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 9 - A 35-year-old woman is experiencing a low mood after being laid off from...

    Incorrect

    • A 35-year-old woman is experiencing a low mood after being laid off from her job. She struggles to fall asleep at night and has difficulty getting out of bed in the morning. She has little desire to socialize with her friends or spend time with her family. She is consumed with anxiety about her future and has lost weight due to a decreased appetite.

      What are the primary symptoms of a depressive episode that she is experiencing?

      Your Answer: Depressed mood, disturbed sleep and diminished appetite

      Correct Answer: Depressed mood, anergia and anhedonia

      Explanation:

      Understanding the Symptoms of Depression

      Depression is a mental health condition that affects millions of people worldwide. It is characterized by a persistent feeling of sadness, hopelessness, and despair. The three core symptoms of depression are depressed mood, anhedonia, and anergia. To receive a diagnosis of depression, a person must have at least two of these core symptoms, as well as other non-core symptoms such as reduced concentration, disturbed sleep, and diminished appetite.

      While disturbed sleep and diminished appetite are common symptoms of depression, they are not considered core symptoms. On the other hand, overactivity and grandiose ideation are not typical symptoms of depression, as patients with depression usually have reduced activity and negative thoughts.

      Reduced self-esteem and self-confidence are also common in depression, but they are not considered core symptoms. In severe cases of depression, patients may experience catatonia and paranoid ideation, as well as other psychotic symptoms such as hallucinations and delusions.

      It is important to recognize the symptoms of depression and seek help if you or someone you know is struggling with this condition. With proper treatment, including therapy and medication, many people with depression can recover and lead fulfilling lives.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 10 - Sarah is a 20-year-old woman who has just started her first year at...

    Correct

    • Sarah is a 20-year-old woman who has just started her first year at university. She is described by others as quite a reserved character. She has one friend but prefers solitary activities and has few interests. Sarah has never had a boyfriend and does not seem to be interested in companionship. When she is praised or criticised by others, she remains indifferent to their comments. There is no history of low mood or hallucinations.

      What is the most probable diagnosis for Sarah's condition?

      Your Answer: Schizoid personality disorder

      Explanation:

      Schizoid personality disorder exhibits similar negative symptoms to those seen in schizophrenia. This disorder is characterized by a lack of enjoyment in activities, emotional detachment, difficulty expressing emotions, indifference to praise or criticism, a preference for solitary activities, excessive introspection, a lack of close relationships, and a disregard for social norms. John displays more than three of these traits, indicating a possible diagnosis of schizoid personality disorder. Avoidant personality disorder is characterized by feelings of inadequacy and social inhibition, while borderline personality disorder involves mood swings and impulsive behavior. Histrionic personality disorder is marked by attention-seeking behavior and exaggerated emotions.

      Personality disorders are a set of personality traits that are maladaptive and interfere with normal functioning in life. It is estimated that around 1 in 20 people have a personality disorder, which are typically categorized into three clusters: Cluster A, which includes Odd or Eccentric disorders such as Paranoid, Schizoid, and Schizotypal; Cluster B, which includes Dramatic, Emotional, or Erratic disorders such as Antisocial, Borderline (Emotionally Unstable), Histrionic, and Narcissistic; and Cluster C, which includes Anxious and Fearful disorders such as Obsessive-Compulsive, Avoidant, and Dependent.

      Paranoid individuals exhibit hypersensitivity and an unforgiving attitude when insulted, a reluctance to confide in others, and a preoccupation with conspiratorial beliefs and hidden meanings. Schizoid individuals show indifference to praise and criticism, a preference for solitary activities, and emotional coldness. Schizotypal individuals exhibit odd beliefs and magical thinking, unusual perceptual disturbances, and inappropriate affect. Antisocial individuals fail to conform to social norms, deceive others, and exhibit impulsiveness, irritability, and aggressiveness. Borderline individuals exhibit unstable interpersonal relationships, impulsivity, and affective instability. Histrionic individuals exhibit inappropriate sexual seductiveness, a need to be the center of attention, and self-dramatization. Narcissistic individuals exhibit a grandiose sense of self-importance, lack of empathy, and excessive need for admiration. Obsessive-compulsive individuals are occupied with details, rules, and organization to the point of hampering completion of tasks. Avoidant individuals avoid interpersonal contact due to fears of criticism or rejection, while dependent individuals have difficulty making decisions without excessive reassurance from others.

      Personality disorders are difficult to treat, but a number of approaches have been shown to help patients, including psychological therapies such as dialectical behavior therapy and treatment of any coexisting psychiatric conditions.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 11 - A 22-year old woman comes to see her GP, seeking medication for opioid...

    Correct

    • A 22-year old woman comes to see her GP, seeking medication for opioid withdrawal. She explains that she has been using heroin for the past six months since losing her job as a store manager. She informs the GP that she has decided to quit using heroin and has not taken any for the past three days. She reports experiencing severe withdrawal symptoms that have been affecting her daily life and asks if there is anything that can be prescribed to alleviate her symptoms.
      What are the observable indications of opioid withdrawal?

      Your Answer: Dilated pupils, yawning, rhinorrhoea, epiphora

      Explanation:

      Identifying Objective Signs of Opioid Withdrawal and Intoxication

      It is crucial to recognize objective signs of opioid withdrawal and intoxication to prevent fatal outcomes. In psychiatric settings, individuals may falsely claim withdrawal to obtain opioid medications. Objective signs of withdrawal include epiphora, rhinorrhoea, agitation, perspiration, piloerection, tachycardia, vomiting, shivering, yawning, and dilated pupils. Pinpoint pupils, yawning, and galactorrhoea are indicative of opiate intoxication. Respiratory depression is a feature of opioid intoxication, along with pinpoint pupils and bradycardia. Opioid intoxication can also cause pulmonary oedema, stupor, pallor, severe respiratory depression, and nausea. By recognizing these objective signs, healthcare professionals can accurately diagnose and treat opioid withdrawal and intoxication.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 12 - A 78-year-old, frail elderly man on the geriatric ward is experiencing difficulty sleeping...

    Correct

    • A 78-year-old, frail elderly man on the geriatric ward is experiencing difficulty sleeping and asks for medication to aid his insomnia. The doctor prescribes a brief course of zopiclone.
      What is one of the potential hazards linked to the use of zopiclone in older adults?

      Your Answer: Increased risk of falls

      Explanation:

      Elderly patients taking zopiclone are at an increased risk of falling due to its mode of action on GABA-containing receptors, which enhances the effects of GABA. This is similar to benzodiazepines. Zopiclone can cause adverse effects such as agitation, constipation, dry mouth, dizziness, and decreased muscle tone. However, diarrhea is not a known side effect. Withdrawal from zopiclone may lead to convulsions, tremors, and hyperventilation.

      Understanding Z Drugs and Their Adverse Effects

      Z drugs are a class of medications that have similar effects to benzodiazepines, but they differ in their chemical structure. These drugs work by acting on the α2-subunit of the GABA receptor. There are three groups of Z drugs: imidazopyridines, cyclopyrrolones, and pyrazolopyrimidines. Examples of these drugs include zolpidem, zopiclone, and zaleplon.

      Despite their effectiveness in treating sleep disorders, Z drugs have adverse effects that are similar to benzodiazepines. One of the most significant risks associated with these drugs is an increased risk of falls in the elderly. Therefore, it is essential to use these medications with caution, especially in older adults. It is also important to follow the prescribed dosage and not to mix them with other medications or alcohol. By understanding the potential risks and benefits of Z drugs, patients can make informed decisions about their use and work with their healthcare providers to manage any adverse effects.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 13 - A 21-year-old man is brought to the psychiatrist by his father. He expresses...

    Correct

    • A 21-year-old man is brought to the psychiatrist by his father. He expresses concern for his son's mental health, as he has noticed him talking to himself frequently over the past 6 months. The patient is hesitant to speak with the psychiatrist and insists that his father stay in the room with him. During the psychiatric evaluation, it is revealed that the patient has been hearing a voice in his head for the past year, but denies any thoughts of self-harm or harm to others. The psychiatrist recommends a referral for further treatment, which causes the father to become emotional and question if he did something wrong as a parent. Which factor from the patient's history is a poor prognostic indicator for his condition?

      Your Answer: Pre-morbid social withdrawal

      Explanation:

      Schizophrenia is more likely to be diagnosed if the patient presents with Schneider’s first-rank symptoms, such as auditory hallucinations, which are characteristic of the condition. However, the presence of auditory hallucinations alone does not indicate a poor prognosis. A poor prognosis is associated with pre-morbid social withdrawal, low IQ, family history of schizophrenia, gradual onset of symptoms, and lack of an obvious precipitant. There is no known link between a family history of an eating disorder and a poor prognosis in schizophrenia.

      Schizophrenia is a mental disorder that can have varying prognosis depending on certain factors. Some indicators associated with a poor prognosis include a strong family history of the disorder, a gradual onset of symptoms, a low IQ, a prodromal phase of social withdrawal, and a lack of an obvious precipitant. These factors can contribute to a more severe and chronic course of the illness, making it more difficult to manage and treat. It is important for individuals with schizophrenia and their loved ones to be aware of these indicators and seek appropriate treatment and support.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 14 - As an F2 in psychiatry, you come across the notes of a 27-year-old...

    Correct

    • As an F2 in psychiatry, you come across the notes of a 27-year-old man who is noted to prefer solitude, has never been in a romantic relationship, and has no desire for one. He also displays minimal interest in engaging in sexual activities with others. Despite performing well at work, he places little importance on feedback from his colleagues. Based on this information, which personality disorder is most likely present in this individual?

      Your Answer: Schizoid

      Explanation:

      Schizoid personality disorder is characterized by a preference for solitude, a lack of interest in close relationships, and a low libido. It is important to note that while asexuality is recognized as part of the LGBTQ+ spectrum, it is not included in the diagnostic criteria for this disorder. The DSM-5 and ICD-10 both list a lack of desire for close relationships, a preference for solitary activities, and a limited capacity for expressing emotions as key features of schizoid personality disorder. Individuals with this disorder may also appear indifferent to praise or criticism, lack close friends or confidants, and exhibit emotional detachment or flattened affectivity. In contrast, borderline personality disorder is characterized by emotional instability in relationships, including sudden mood swings, rages, self-harming behaviors, and intense jealousy. Dependent personality disorder involves a reliance on others for reassurance and decision-making.

      Personality disorders are a set of personality traits that are maladaptive and interfere with normal functioning in life. It is estimated that around 1 in 20 people have a personality disorder, which are typically categorized into three clusters: Cluster A, which includes Odd or Eccentric disorders such as Paranoid, Schizoid, and Schizotypal; Cluster B, which includes Dramatic, Emotional, or Erratic disorders such as Antisocial, Borderline (Emotionally Unstable), Histrionic, and Narcissistic; and Cluster C, which includes Anxious and Fearful disorders such as Obsessive-Compulsive, Avoidant, and Dependent.

      Paranoid individuals exhibit hypersensitivity and an unforgiving attitude when insulted, a reluctance to confide in others, and a preoccupation with conspiratorial beliefs and hidden meanings. Schizoid individuals show indifference to praise and criticism, a preference for solitary activities, and emotional coldness. Schizotypal individuals exhibit odd beliefs and magical thinking, unusual perceptual disturbances, and inappropriate affect. Antisocial individuals fail to conform to social norms, deceive others, and exhibit impulsiveness, irritability, and aggressiveness. Borderline individuals exhibit unstable interpersonal relationships, impulsivity, and affective instability. Histrionic individuals exhibit inappropriate sexual seductiveness, a need to be the center of attention, and self-dramatization. Narcissistic individuals exhibit a grandiose sense of self-importance, lack of empathy, and excessive need for admiration. Obsessive-compulsive individuals are occupied with details, rules, and organization to the point of hampering completion of tasks. Avoidant individuals avoid interpersonal contact due to fears of criticism or rejection, while dependent individuals have difficulty making decisions without excessive reassurance from others.

      Personality disorders are difficult to treat, but a number of approaches have been shown to help patients, including psychological therapies such as dialectical behavior therapy and treatment of any coexisting psychiatric conditions.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 15 - A 35-year-old woman has been diagnosed with paranoid schizophrenia and prescribed clozapine for...

    Correct

    • A 35-year-old woman has been diagnosed with paranoid schizophrenia and prescribed clozapine for the past three months. She is due for a review appointment and has had regular blood tests. What is the primary abnormality she is at risk for?

      Your Answer: Decreased leukocytes

      Explanation:

      Monitoring of FBC is crucial in patients taking clozapine due to the potential life-threatening side effect of agranulocytosis/neutropenia. This condition is characterized by a significant decrease in white blood cell count, particularly neutrophils. Therefore, a decrease in leukocytes will be observed in the blood test results. Clozapine is commonly used in the treatment of schizophrenia that is resistant to other therapies.

      Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.

      Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 16 - A 32-year-old with a long standing history of schizophrenia presents to the emergency...

    Incorrect

    • A 32-year-old with a long standing history of schizophrenia presents to the emergency department in status epilepticus. After receiving treatment, he informs the physician that he has been experiencing frequent seizures lately.
      Which medication is the most probable cause of his seizures?

      Your Answer: Haloperidol

      Correct Answer: Clozapine

      Explanation:

      Seizures are more likely to occur with the use of clozapine due to its ability to lower the seizure threshold. This is a known side-effect of the atypical antipsychotic, which is commonly prescribed for treatment resistant schizophrenia.

      Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.

      Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.

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      • Psychiatry
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  • Question 17 - A 26-year-old man is admitted to your psychiatric ward in a state of...

    Correct

    • A 26-year-old man is admitted to your psychiatric ward in a state of distress saying that he knows for certain that his colleagues are plotting to have him dismissed from work. He says they are spreading malicious rumours about his sexuality and, with the help of the CIA, have bugged his office. In the first week of his admission, he is observed to be responding to unseen stimuli when alone in his room. His family state that he is a lovely lad who never gets into any trouble with drink or drugs. They are very worried because in the last 3 months he has told them he can hear people talking about him to each other when he lies in bed at night. He has no significant medical history.
      Which one of the following courses of action would be most appropriate?

      Your Answer: Commence olanzapine with lorazepam and procyclidine as required

      Explanation:

      Treatment Options for Schizophrenia

      Schizophrenia is a serious mental disorder that requires prompt treatment. The following are some treatment options for schizophrenia:

      Commence Olanzapine with Lorazepam and Procyclidine as Required
      Olanzapine is an atypical anti-psychotic that carries a lower risk of extrapyramidal side-effects. However, it is appropriate to prescribe anticholinergic medication such as procyclidine to reduce the risk further. The anti-psychotic action of olanzapine may take up to 10 days to begin, so short-acting benzodiazepines such as lorazepam may be prescribed for sedation.

      Do Not Just Observe with Sedation as Required
      Observing with sedation is not a definitive treatment for schizophrenia. It is essential to commence anti-psychotic medication promptly.

      Commence Chlorpromazine
      Chlorpromazine is a typical anti-psychotic that carries a higher risk of extrapyramidal side-effects. Therefore, atypical anti-psychotics are usually preferred as first-line treatment.

      Commence Clozapine
      Clozapine is the most effective medication for treatment-resistant schizophrenia. However, it carries a small risk of serious complications such as fatal agranulocytosis, myocarditis or cardiomyopathy, and pulmonary embolus. Therefore, it is usually reserved for patients who have not responded to two anti-psychotics given at an appropriate dose for 6-8 weeks.

      Commence Chlorpromazine with Lorazepam and Procyclidine as Required
      Chlorpromazine is a typical anti-psychotic that carries a higher risk of extrapyramidal side-effects. Therefore, it is appropriate to prescribe anticholinergic medication such as procyclidine to reduce the risk. Short-acting benzodiazepines such as lorazepam may also be prescribed for sedation.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 18 - Sarah is a 30-year-old teacher who has been referred to the mental health...

    Incorrect

    • 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: Blood test 12 hours post dose every month

      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.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 19 - A 60-year-old man is admitted from the angiography suite after the cardiologist discovered...

    Incorrect

    • A 60-year-old man is admitted from the angiography suite after the cardiologist discovered severe triple vessel disease. He awaits transfer to a tertiary hospital for a coronary artery bypass graft. After 48 hours of admission, you receive a call to see him as he has become confused, sweaty, tremulous, and agitated.

      Upon reviewing his record, you note a history of asthma, variceal bleed, and cirrhosis secondary to alcohol excess. His observations show a pyrexia at 37.9ºC, heart rate of 105 bpm, and blood pressure 175/98 mmHg. What would be the most appropriate immediate intervention given the likely diagnosis?

      Your Answer: Pabrinex

      Correct Answer: Chlordiazepoxide

      Explanation:

      Chlordiazepoxide or diazepam are effective treatments for delirium tremens and alcohol withdrawal. Symptoms of alcohol withdrawal can include confusion, agitation, tremors, hallucinations, and autonomic dysfunction such as high blood pressure, sweating, and fever.

      Chlordiazepoxide is the most appropriate answer for this scenario. While confusion, sweating, and agitation can be signs of infection, the patient’s alcohol history suggests that delirium tremens is the more likely diagnosis. IV antibiotics would not address the primary issue of alcohol withdrawal. The patient’s high blood pressure also suggests that infection is not the cause of their symptoms.

      Intravenous hydration may be necessary if the patient is experiencing excessive fluid loss due to sweating, but it would not be the best treatment for alcohol withdrawal in this case.

      Alcohol withdrawal occurs when an individual who has been consuming alcohol chronically suddenly stops or reduces their intake. Chronic alcohol consumption enhances the inhibitory effects of GABA in the central nervous system, similar to benzodiazepines, and inhibits NMDA-type glutamate receptors. However, alcohol withdrawal leads to the opposite effect, resulting in decreased inhibitory GABA and increased NMDA glutamate transmission. Symptoms of alcohol withdrawal typically start at 6-12 hours and include tremors, sweating, tachycardia, and anxiety. Seizures are most likely to occur at 36 hours, while delirium tremens, which includes coarse tremors, confusion, delusions, auditory and visual hallucinations, fever, and tachycardia, peak at 48-72 hours.

      Patients with a history of complex withdrawals from alcohol, such as delirium tremens, seizures, or blackouts, should be admitted to the hospital for monitoring until their withdrawals stabilize. The first-line treatment for alcohol withdrawal is long-acting benzodiazepines, such as chlordiazepoxide or diazepam, which are typically given as part of a reducing dose protocol. Lorazepam may be preferable in patients with hepatic failure. Carbamazepine is also effective in treating alcohol withdrawal, while phenytoin is said to be less effective in treating alcohol withdrawal seizures.

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      • Psychiatry
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  • Question 20 - A 35-year-old man presents to a psychiatrist after his wife demands he sees...

    Correct

    • A 35-year-old man presents to a psychiatrist after his wife demands he sees someone to manage his ‘endless nagging’. He has no interest in being here. He reports that his wife is always frustrating him because she simply will not do things the right way. He cites frequent eruptions over how to load the dishwasher properly and how his wife continues to load it improperly. When asked what happens if she loads it her way, the patient describes feeling frustrated that it is not loaded the right way and expressing his frustration to his wife. When asked what he hopes to get out of this visit, the patient wants to learn if there are better ways of effectively communicating the right way to do things.

      Which of the following is most likely?

      Your Answer: Obsessive-compulsive personality disorder (OCPD)

      Explanation:

      The patient’s behavior of being fixated on the right way to load a dishwasher could be indicative of either obsessive-compulsive personality disorder (OCPD) or obsessive-compulsive disorder (OCD). The key difference between the two is whether or not the individual experiences distress over their obsession. In this case, the patient does not seem to experience any distress and instead wants to control how his wife loads the dishwasher. This suggests OCPD rather than OCD. Histrionic personality disorder, antisocial personality disorder, and narcissistic personality disorder are not as applicable to this situation.

    • This question is part of the following fields:

      • Psychiatry
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Psychiatry (13/20) 65%
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