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  • Question 1 - A 25-year-old man has just been diagnosed with schizophrenia. His family is concerned...

    Correct

    • A 25-year-old man has just been diagnosed with schizophrenia. His family is concerned about the long-term outlook of the illness. What factor is linked to the poorest prognosis for poorly managed schizophrenia?

      Your Answer: Gradual onset

      Explanation:

      Schizophrenia with a gradual onset is indicative of a poor prognosis, whereas the other options suggest a better outcome. Although some studies have linked high intelligence with a higher risk of suicide, generally, individuals with higher intelligence have a more favorable prognosis for 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 2 - What is a true statement about obsessive compulsive disorder (obsessional neurosis)? ...

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    • What is a true statement about obsessive compulsive disorder (obsessional neurosis)?

      Your Answer: Patients have good insight

      Explanation:

      Obsessional Neurosis and Obsessional Compulsive Disorder

      Obsessional neurosis is a mental disorder characterized by repetitive rituals, irrational fears, and disturbing thoughts that are often not acted upon. Patients with this condition maintain their insight and are aware of their illness, which can lead to depression. On the other hand, obsessional compulsive disorder is a similar condition that typically starts in early adulthood and affects both sexes equally. Patients with this disorder often have above-average intelligence.

      It is important to note that Sigmund Freud’s theory that obsessive compulsive symptoms were caused by rigid toilet-training practices is no longer widely accepted. Despite this, the causes of these disorders are still not fully understood. However, treatment options such as cognitive-behavioral therapy and medication can help manage symptoms and improve the quality of life for those affected. these disorders and seeking appropriate treatment can make a significant difference in the lives of those who suffer from them.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 3 - A 21-year-old student has been diagnosed with schizophrenia.
    What is the most frequent type...

    Correct

    • A 21-year-old student has been diagnosed with schizophrenia.
      What is the most frequent type of hallucination experienced in schizophrenia?

      Your Answer: Auditory

      Explanation:

      Understanding the Characteristics of Psychosis: Types of Hallucinations

      Psychosis is a mental health condition that can manifest in various ways, including hallucinations. Hallucinations are sensory experiences that occur without any corresponding sensory stimulation. While they can occur in any sensory modality, auditory hallucinations are particularly common in patients with schizophrenia. However, it is important to note that the presence or absence of one symptom or type of symptom does not determine the psychiatric diagnosis.

      Visual hallucinations are more common in delirium or psychedelic drug intoxication than in schizophrenia. Olfactory and gustatory hallucinations are associated with partial complex seizures, while tactile hallucinations are characteristic of delirium tremens, a severe form of alcohol withdrawal.

      To aid in the diagnosis of schizophrenia, clinicians often use mnemonics. Negative symptoms, also known as type II schizophrenic symptoms, can be remembered with the acronym LESS. Diagnostic criteria for schizophrenia, in the absence of cerebral damage, intoxication, epilepsy, or mania, can be remembered with the acronym DEAD. Positive symptoms, also known as type I schizophrenic symptoms, can be remembered with the acronym THREAD.

      Overall, understanding the characteristics of different types of hallucinations can aid in the evaluation and diagnosis of psychotic patients. However, it is important to consider the overall spectrum of symptoms and the course of the disease when making a diagnosis.

      Understanding the Characteristics of Psychosis: Types of Hallucinations

    • This question is part of the following fields:

      • Psychiatry
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  • Question 4 - A 35-year-old woman presents to her general practitioner complaining of a backache that...

    Incorrect

    • A 35-year-old woman presents to her general practitioner complaining of a backache that has persisted for the last two weeks. The doctor diagnoses her with a muscle strain and recommends rest with paracetamol for pain as needed. The patient requested narcotic pain medicine, but the doctor refused to prescribe the drug because she thought a medicine of that strength was unnecessary. The patient left the examination room angrily and yelled at the reception staff on her way out.
      Which of the following defence mechanisms was the patient demonstrating?

      Your Answer: Projection

      Correct Answer: Displacement

      Explanation:

      Defense Mechanisms in Psychology

      Defense mechanisms are psychological strategies that individuals use to cope with stressful situations or emotions. These mechanisms can be conscious or unconscious and can be adaptive or maladaptive. Here are some common defense mechanisms:

      Displacement: This occurs when a person redirects their emotions or impulses from the original source to a neutral or innocent person or object.

      Projection: This is when a person attributes their own unacceptable thoughts or feelings to someone else.

      Denial: This is when a person refuses to accept reality or a diagnosis, often to avoid the pain or discomfort associated with it.

      Fixation: This is when a person becomes overly focused on a particular thought, idea, or object as a way of coping with stress.

      Splitting: This is a characteristic of borderline personality disorder, where a person sees others as either all good or all bad, and may switch between these views rapidly.

      Understanding these defense mechanisms can help individuals recognize when they are using them and work towards more adaptive coping strategies.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 5 - A 16-year-old boy is referred by his general practitioner (GP). He was brought...

    Correct

    • A 16-year-old boy is referred by his general practitioner (GP). He was brought in by his parents after he had attempted to set fire to his room. His parents reported that, over the past two months, they have noticed that the patient appears withdrawn and has been spending a lot of time in his room. He will not let anyone in his room and has also blocked the view from his windows using aluminium foil.
      At the clinic, he accused the GP of being one of the police agents sent to spy on him. He has also lost significant weight, and his parents report that his mood seems to be quite low on some days. The patient has no insight into his current condition and says that his room needs to be burnt down to destroy the surveillance devices installed by the police. The patient denies drug use, but his father confirms that he has once seen his son smoking what he suspected was an illicit drug in the backyard.
      The GP refers the patient to a psychiatric hospital, and the doctors there explain to the parents that it is in the patient’s best interests to be kept in hospital for assessment for a maximum of 28 days.
      Which of the following is the most appropriate Section to be used for this patient?

      Your Answer: Section 2

      Explanation:

      Understanding the Different Sections of the Mental Health Act

      The Mental Health Act provides legal frameworks for the assessment, treatment, and care of individuals with mental health illnesses. There are several sections under the Act that allow for patients to be detained in hospital for assessment or treatment. It is important to understand these sections and their limitations.

      Section 2 is used to keep a patient in hospital for assessment for up to 28 days. This section is used when a patient is at risk of harming themselves or others and there is a suspicion of a psychiatric illness or drug misuse.

      Section 5(2) allows doctors to keep a patient in hospital for at least 72 hours when Section 2 or 3 cannot be used. However, it cannot be extended, and arrangements should be made for Section 2 or 3 if the patient is to be kept longer in hospital.

      Section 4 is used in emergencies and allows for a patient to be kept in hospital for 72 hours. This section can be used by only one doctor when finding another doctor to use Section 5(2), 2 or 3 would cause delay, which is not in the patient’s best interests.

      Section 3 can be used to keep a patient in hospital for treatment for up to six months. The patient can also be discharged earlier if the doctor thinks the patient is well enough. However, if necessary, it can be extended for another six months, and then after that for one year for each renewal.

      Finally, Section 5(4) can be used by mental health or learning disability nurses to keep a patient in hospital for a maximum of six hours. This section is used when a doctor cannot be found for Section 5(2) to be used. However, it cannot be extended, and arrangements should be made for Section 2 or 3 if the patient is to be kept longer in hospital.

      It is important to note that these sections should only be used when necessary and in the best interests of the patient. The Mental Health Act also provides safeguards and rights for patients, including the right to appeal against detention.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 6 - A 42-year-old woman visits her General Practitioner (GP) on an emergency appointment due...

    Correct

    • A 42-year-old woman visits her General Practitioner (GP) on an emergency appointment due to her worsening anxiety state. She reveals to the GP that she has been experiencing this for several years and is now seeking treatment. What is the most effective approach for long-term management?

      Your Answer: Sertraline

      Explanation:

      Medications for Generalised Anxiety Disorder

      Generalised anxiety disorder can severely impact a patient’s daily life. Sertraline, a selective serotonin reuptake inhibitor (SSRI), is the recommended first-line treatment. However, caution must be taken when prescribing to young adults, those over 65, and patients on other medications due to potential side effects. Zopiclone, Haloperidol, and Diazepam are not appropriate treatments for this disorder and should be avoided. Amitriptyline, a tricyclic antidepressant, is not considered the best management for generalised anxiety disorder.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 7 - A 47-year-old woman presents complaining of ‘flashbacks’. Seven months earlier, she had been...

    Correct

    • A 47-year-old woman presents complaining of ‘flashbacks’. Seven months earlier, she had been standing at a bus stop when a car swerved off the road into the queue, killing instantly a child standing near to her. Every day she experiences intrusive images of the child’s face as it saw the car mount the curb. She has not been able to go to that part of town since the day and she has avoided taking the bus anywhere. She feels she is always on edge and jumps at the slightest noise around the house. She thinks things are getting worse, rather than better, and asks you whether there are any psychological treatments that might help her.
      Which one of the following approaches is indicated?

      Your Answer: Trauma-focused cognitive behavioural therapy (CBT)

      Explanation:

      Treatment Options for Post-Traumatic Stress Disorder: Focus on Trauma-Focused CBT

      Post-traumatic stress disorder (PTSD) is a delayed and/or prolonged response to a traumatic event that can cause distress in almost anyone. Symptoms include intrusive flashbacks, avoidance of trauma-related triggers, emotional numbness, and hypervigilance. Trauma-focused cognitive behavioural therapy (CBT) is the recommended first-line treatment for PTSD, according to the National Institute for Health and Care Excellence (NICE) in the United Kingdom. Other therapies, such as psychodynamic therapy, supportive therapy, and hypnotherapy, may be helpful but are not first-line approaches. Watchful waiting is only appropriate for mild symptoms present for less than a month. It is important to seek help for PTSD, and trauma-focused CBT is a proven effective treatment option.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 8 - A 25-year-old woman comes to her doctor's office seeking assistance for her anxiety....

    Incorrect

    • A 25-year-old woman comes to her doctor's office seeking assistance for her anxiety. She feels overwhelmed by her job, particularly when it comes to communicating with coworkers and superiors, as she is afraid of being criticized. In her personal life, she frequently worries about how her friends perceive her and often avoids socializing with them as a result. She admits to having low self-esteem and a negative self-image. What is the most appropriate diagnosis for her?

      Your Answer: Antisocial personality disorder

      Correct Answer: Avoidant personality disorder

      Explanation:

      Patients diagnosed with avoidant personality disorder exhibit a strong fear of criticism, rejection, ridicule, and being disliked. They tend to avoid social and occupational activities that involve significant interpersonal contact due to their fear of being criticized or rejected. These individuals have a negative self-image and are preoccupied with the idea that they are being criticized or rejected in social situations. Although they crave social contact, they tend to isolate themselves socially. This disorder is distinct from other personality disorders such as antisocial personality disorder, borderline personality disorder, and dependent personality disorder, which present with different symptoms and behaviors.

      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 9 - A 50-year-old man visits his GP in a state of distress. He recently...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 10 - A 27-year-old woman has been experiencing a pattern of tumultuous endings in all...

    Correct

    • A 27-year-old woman has been experiencing a pattern of tumultuous endings in all of her relationships. She confides in you that she seems to have a knack for choosing friends and romantic partners who ultimately reveal themselves to be awful people.
      What defense mechanism is most likely at play in this patient?

      Your Answer: Splitting

      Explanation:

      Defense Mechanisms: Understanding How We Cope

      Defense mechanisms are psychological strategies that we use to protect ourselves from anxiety and emotional pain. These mechanisms are often unconscious and can be both adaptive and maladaptive. Here are some common defense mechanisms and their explanations:

      Splitting: This is a common defense mechanism in borderline personality disorder. It involves seeing people as either all good or all bad, and the inability to reconcile both good and bad traits in a person.

      Dissociation: This is an immature defense mechanism where one’s personal identity is temporarily modified to avoid distress. An extreme form is dissociative identity disorder.

      Identification: This is when someone models the behavior of a more powerful example. An example would be a victim of child abuse becoming a child abuser in adulthood.

      Sublimation: This is a mature defense mechanism where the person takes an unacceptable personality trait and uses it to drive a respectable work that does not conflict with their value system.

      Reaction formation: This is an immature defense mechanism where unacceptable emotions are repressed and replaced by their exact opposite. A classic example is a man with homoerotic desires championing anti-homosexual public policy.

      Understanding these defense mechanisms can help us recognize when we are using them and how they may be impacting our relationships and mental health.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 11 - A 25-year-old male is brought to the emergency department by his friends who...

    Correct

    • A 25-year-old male is brought to the emergency department by his friends who are concerned about his behavior. The patient's friends report that over the past few days the patient has hardly slept or eaten and is talking non-stop about a new business idea that he believes will make him a millionaire. He has also been spending a lot of money on his credit card and started making impulsive purchases. During the interview, the emergency department doctor observes that the patient is speaking rapidly and is difficult to interrupt. Despite the speed of his speech, the words themselves are coherent and follow a logical, albeit unusual, pattern of thought.

      What is the most appropriate term to describe the patient's abnormal speech pattern?

      Your Answer: Pressured speech

      Explanation:

      Mania and Related Speech Patterns

      Mania is a mental state characterized by elevated mood, energy, and activity levels. A patient presenting with decreased need for sleep, increased risk-taking behavior, and delusions of grandeur may be exhibiting symptoms of mania. One common speech pattern associated with mania is pressured speech, which is characterized by rapid speech that is difficult to interrupt.

      Other speech patterns that may be observed in patients with mania include clanging, echolalia, neologism, and word salad. Clanging refers to the use of rhyming words, while echolalia involves repeating what the examiner says. Neologism refers to the creation of new words, and word salad is a completely disorganized speech that is not understandable.

      It is important for healthcare professionals to recognize these speech patterns and other symptoms of mania in order to provide appropriate treatment and support for patients. By the characteristics of mania and related speech patterns, healthcare professionals can help patients manage their symptoms and improve their overall quality of life.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 12 - A 25-year-old man presents to the Emergency Department in a distressed state. He...

    Correct

    • A 25-year-old man presents to the Emergency Department in a distressed state. He says he hears voices telling him that he is worthless and that the people talking to him know what he is doing as they are listening to his thoughts via the television and radio. His friends who attend with him tell you that he has become withdrawn over the past few months and has been missing lectures. There is a history of cannabis use but nil else of note. When he talks to you, he appears to have constructed a number of new words to describe the machines used to listen to him.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 139 g/l 135–175 g/l
      White cell count (WCC) 6.1 × 109/l 4–11 × 109/l
      Platelets 294 × 109/l 150–400 × 109/l
      Sodium (Na+) 140 mmol/l 135–145 mmol/l
      Potassium (K+) 4.3 mmol/l 3.5–5.0 mmol/l
      Creatinine 100 μmol/l 50–120 µmol/l
      Alanine aminotransferase (ALT) 34 IU/l 5–30 IU/l
      Bilirubin 16 μmol/l 2–17 µmol/l
      Which of the following is the most likely diagnosis?

      Your Answer: Schizophrenia

      Explanation:

      Differential Diagnosis for Acute Psychosis

      Acute psychosis can have various underlying causes, and a thorough differential diagnosis is essential for appropriate management. Here is a brief overview of some of the possibilities for a patient who presents with auditory hallucinations, neologisms, and odd behavior.

      Schizophrenia: This is a primary psychotic disorder characterized by Schneider’s first-rank symptoms, which include auditory hallucinations, thought insertion/withdrawal/interruption, thought broadcasting, and delusions of control. Treatment typically involves antipsychotic medications.

      Delirium tremens: This is a severe form of alcohol withdrawal that can cause confusion, agitation, tremors, seizures, and autonomic instability. It usually occurs in people with a history of heavy alcohol use and requires urgent medical attention.

      Manic-depressive psychosis (bipolar disorder): This is a mood disorder that can involve episodes of elevated or irritable mood (mania or hypomania) and episodes of depressed mood. Psychotic symptoms may occur during manic or mixed episodes, but not necessarily during depressive episodes.

      Amphetamine abuse: Stimulant drugs like amphetamines can induce psychosis, which may resemble schizophrenia or other psychotic disorders. A history of drug use and toxicology screening can help identify this possibility.

      Subdural hematoma: This is a type of brain injury that can cause symptoms such as headache, confusion, drowsiness, and focal neurological deficits. It is less likely in the absence of a history of head trauma or abnormal findings on neurological examination, but imaging studies may be needed to rule it out.

      In summary, the differential diagnosis for acute psychosis includes various psychiatric and medical conditions that require different approaches to treatment and management. A comprehensive evaluation should consider the patient’s history, symptoms, physical and neurological examination, laboratory tests, and imaging studies as needed.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 13 - A 35-year-old homeless man is brought to the hospital as he reports seeing...

    Incorrect

    • A 35-year-old homeless man is brought to the hospital as he reports seeing an 'ocean of bees' surrounding him. He is unable to provide a detailed medical history due to his extreme anxiety and confusion, constantly yelling about the 'deafening buzzing.' His heart rate is 140 beats per minute and his breathing rate is 23 breaths per minute. Reviewing his records, it is noted that he has been admitted to the emergency department multiple times due to alcohol intoxication.

      What is the initial treatment for his condition?

      Your Answer: Haloperidol

      Correct Answer: Chlordiazepoxide

      Explanation:

      Chlordiazepoxide or diazepam are administered to manage delirium tremens/alcohol withdrawal.

      When a patient experiences delirium tremens due to alcohol withdrawal after dependency, chlordiazepoxide or diazepam are commonly prescribed. This condition often leads to the manifestation of visual and auditory hallucinations. While haloperidol can be beneficial in calming the patient, the primary treatment for delirium tremens is administering 10-30 mg of chlordiazepoxide four times daily.

      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.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 14 - A 45-year-old man with a history of schizophrenia no longer reports hallucinations or...

    Correct

    • A 45-year-old man with a history of schizophrenia no longer reports hallucinations or delusions. However, he spends many hours doing nothing, has trouble reading a book or watching a film and rarely speaks spontaneously or fluently. His grooming is poor and he is socially withdrawn.
      What is a positron emission tomography (PET) scan most likely to show?

      Your Answer: Hypoactivity of the prefrontal lobes, enlarged cerebral ventricles

      Explanation:

      Brain Function and Psychiatric Disorders: PET Scan Findings

      Major psychiatric syndromes, such as schizophrenia, mania, and depression, involve alterations in sensory processing, volitional behavior, environmental adaptation, and regulation of strong emotions. PET scans have shown that hypoactivity of the prefrontal lobes and enlarged cerebral ventricles are most likely to be associated with schizophrenia. On the other hand, hyperactivity of the prefrontal lobes is linked to obsessive-compulsive disorder (OCD). The prefrontal cortex plays a crucial role in planning, temporal sequencing, abstract thought, problem-solving, motility, attention, and the modulation of emotion. Lesions of these pathways impair pursuit of goal-oriented activity. PET scans have also revealed decreased metabolic activity in the temporal lobes in some patients with schizophrenia. However, increased occipital lobe activity is not likely to be seen on PET scans. Additionally, symmetrical enlargement of cerebral ventricles is a well-validated finding in patients suffering from schizophrenia.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 15 - A 30-year-old woman visits her General Practitioner (GP) with complaints of insomnia. She...

    Correct

    • A 30-year-old woman visits her General Practitioner (GP) with complaints of insomnia. She reports feeling persistently anxious and unable to cease worrying about everything. The GP suspects she may have an anxiety disorder.
      What is the most effective tool to use in making a diagnosis?

      Your Answer: Generalised Anxiety Disorder Questionnaire (GAD-7)

      Explanation:

      Common Screening Tools for Mental Health Conditions

      There are several screening tools used in healthcare settings to identify and monitor mental health conditions. These tools help healthcare professionals assess the severity of symptoms and determine appropriate treatment plans. Here are some commonly used screening tools:

      1. Generalised Anxiety Disorder Questionnaire (GAD-7): This questionnaire consists of seven questions and is used to screen for generalised anxiety disorder. It measures the severity of symptoms as mild, moderate, or severe.

      2. Alcohol Use Disorders Identification Test (AUDIT): The AUDIT is a screening tool used to identify signs of harmful drinking and dependence on alcohol.

      3. Mini-Mental State Examination (MMSE): The MMSE is a questionnaire consisting of 30 questions used to identify cognitive impairment. It is commonly used to screen for dementia.

      4. Modified Single-Answer Screening Question (M SASQ): The M SASQ is a single-question alcohol-harm assessment tool designed for use in Emergency Departments. It identifies high-risk drinkers based on their frequency of consuming six or more units (if female, or eight or more if male) on a single occasion in the last year.

      5. Patient Health Questionnaire (PHQ-9): The PHQ-9 is used in primary care to monitor the severity of depression and the response to treatment. It uses each of the nine Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria for a diagnosis of depression and scores each domain depending on how often the patient experiences these symptoms.

      These screening tools are valuable resources for healthcare professionals to identify and monitor mental health conditions. By using these tools, healthcare professionals can provide appropriate treatment and support to their patients.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 16 - A 28-year-old female patient complains of experiencing difficulty sleeping for the past six...

    Correct

    • A 28-year-old female patient complains of experiencing difficulty sleeping for the past six months. She frequently stays awake at night due to worrying about work and family-related stressors. These episodes of anxiety are often accompanied by chest tightness and palpitations. Despite trying mindfulness, sleep hygiene, and reducing caffeine intake, she has not experienced significant improvement and is now considering medication. What would be the most suitable medication to prescribe?

      Your Answer: Sertraline

      Explanation:

      Sertraline is the recommended first-line medication for generalised anxiety disorder (GAD). This is because the patient has already tried non-pharmacological measures with little benefit. Diazepam, a benzodiazepine, is not recommended due to the risk of tolerance and addiction. Duloxetine, a serotonin-norepinephrine reuptake inhibitor (SNRI), is not first-line but may be considered if the patient does not respond to sertraline. Mirtazapine, a noradrenergic and specific serotonergic antidepressant (NaSSA), is not generally recommended for GAD.

      Anxiety is a common disorder that can manifest in various ways. According to NICE, the primary feature is excessive worry about multiple events associated with heightened tension. It is crucial to consider potential physical causes when diagnosing anxiety disorders, such as hyperthyroidism, cardiac disease, and medication-induced anxiety. Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants, and caffeine.

      NICE recommends a step-wise approach for managing generalised anxiety disorder (GAD). This includes education about GAD and active monitoring, low-intensity psychological interventions, high-intensity psychological interventions or drug treatment, and highly specialist input. Sertraline is the first-line SSRI for drug treatment, and if it is ineffective, an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI) such as duloxetine or venlafaxine may be offered. If the patient cannot tolerate SSRIs or SNRIs, pregabalin may be considered. For patients under 30 years old, NICE recommends warning them of the increased risk of suicidal thinking and self-harm and weekly follow-up for the first month.

      The management of panic disorder also follows a stepwise approach, including recognition and diagnosis, treatment in primary care, review and consideration of alternative treatments, review and referral to specialist mental health services, and care in specialist mental health services. NICE recommends either cognitive behavioural therapy or drug treatment in primary care. SSRIs are the first-line drug treatment, and if contraindicated or no response after 12 weeks, imipramine or clomipramine should be offered.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 17 - A 26-year-old man comes for his scheduled psychiatry visit after being prescribed Risperidone...

    Incorrect

    • A 26-year-old man comes for his scheduled psychiatry visit after being prescribed Risperidone for his recent diagnosis of schizophrenia. Although he has been stable since starting this medication, he reports experiencing milky discharge from both nipples and inquires about alternative medications that can manage his schizophrenia without causing this side effect. What would be the most suitable medication to consider as an alternative?

      Your Answer: Olanzapine

      Correct Answer: Aripiprazole

      Explanation:

      Aripiprazole is the most suitable medication to try for this patient as it has the least side effects among atypical antipsychotics, especially in terms of prolactin elevation. This is important as the patient’s nipple discharge is likely caused by high prolactin levels. Chlorpromazine, a typical antipsychotic, is not recommended as it has a higher risk of extrapyramidal side effects. Clozapine, another atypical antipsychotic, is not appropriate for this patient as it is only used for treatment-resistant schizophrenia and requires two other antipsychotics to be trialled first. Haloperidol, a typical antipsychotic, is also not recommended due to its higher risk of extrapyramidal side effects.

      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 18 - A 35-year-old man is brought to his GP by his partner who is...

    Incorrect

    • A 35-year-old man is brought to his GP by his partner who is concerned he may have developed bipolar disorder over the last few months.
      The man experiences periods of elevated mood, where he spends a lot of money and sleeps very little. He denies having any delusions of grandeur. These episodes usually last for a few days, and he has never put himself or others in danger.
      The man also has episodes of severe depression, where he feels suicidal, loses interest in his hobbies, and sleeps excessively. He is referred to a psychiatrist for further evaluation.
      What is the most probable diagnosis?

      Your Answer: Type 1 bipolar disorder

      Correct Answer: Type 2 bipolar disorder

      Explanation:

      The woman’s alternating episodes of hypomania and severe depression suggest that she has type 2 bipolar disorder. There are no indications of an anxiety disorder, and the severity of her symptoms is not consistent with cyclothymia. Major depressive disorder is also not a likely diagnosis, as she experiences ‘highs’ consistent with hypomania. Type 1 bipolar disorder is also unlikely, as her ‘high’ periods are more in line with hypomania rather than full-blown mania.

      Understanding Bipolar Disorder

      Bipolar disorder is a mental health condition that is characterized by alternating periods of mania/hypomania and depression. It typically develops in the late teen years and has a lifetime prevalence of 2%. There are two recognized types of bipolar disorder: type I, which involves mania and depression, and type II, which involves hypomania and depression.

      Mania and hypomania both refer to abnormally elevated mood or irritability, but mania is more severe and can include psychotic symptoms for 7 days or more. Hypomania, on the other hand, involves decreased or increased function for 4 days or more. The presence of psychotic symptoms suggests mania.

      Management of bipolar disorder may involve psychological interventions specifically designed for the condition, as well as medication. Lithium is the mood stabilizer of choice, but valproate can also be used. Antipsychotic therapy, such as olanzapine or haloperidol, may be used to manage mania/hypomania, while fluoxetine is the antidepressant of choice for depression. It is important to address any co-morbidities, as there is an increased risk of diabetes, cardiovascular disease, and COPD in individuals with bipolar disorder.

      If symptoms suggest hypomania, routine referral to the community mental health team (CMHT) is recommended. However, if there are features of mania or severe depression, an urgent referral to the CMHT should be made. Understanding bipolar disorder and its management is crucial for healthcare professionals to provide appropriate care and support for individuals with this condition.

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      • Psychiatry
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  • Question 19 - Following the 2011 NICE guidelines for managing panic disorder, what is the most...

    Incorrect

    • Following the 2011 NICE guidelines for managing panic disorder, what is the most suitable initial drug therapy for treating the condition in younger patients?

      Your Answer: Propranolol

      Correct Answer: Selective serotonin reuptake inhibitor

      Explanation:

      Anxiety is a common disorder that can manifest in various ways. According to NICE, the primary feature is excessive worry about multiple events associated with heightened tension. It is crucial to consider potential physical causes when diagnosing anxiety disorders, such as hyperthyroidism, cardiac disease, and medication-induced anxiety. Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants, and caffeine.

      NICE recommends a step-wise approach for managing generalised anxiety disorder (GAD). This includes education about GAD and active monitoring, low-intensity psychological interventions, high-intensity psychological interventions or drug treatment, and highly specialist input. Sertraline is the first-line SSRI for drug treatment, and if it is ineffective, an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI) such as duloxetine or venlafaxine may be offered. If the patient cannot tolerate SSRIs or SNRIs, pregabalin may be considered. For patients under 30 years old, NICE recommends warning them of the increased risk of suicidal thinking and self-harm and weekly follow-up for the first month.

      The management of panic disorder also follows a stepwise approach, including recognition and diagnosis, treatment in primary care, review and consideration of alternative treatments, review and referral to specialist mental health services, and care in specialist mental health services. NICE recommends either cognitive behavioural therapy or drug treatment in primary care. SSRIs are the first-line drug treatment, and if contraindicated or no response after 12 weeks, imipramine or clomipramine should be offered.

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  • Question 20 - A 30-year-old man visits his doctor six weeks after being diagnosed with generalised...

    Correct

    • A 30-year-old man visits his doctor six weeks after being diagnosed with generalised anxiety disorder (GAD). Despite undergoing cognitive behavioural therapy for a few sessions, his symptoms continue to significantly impact his daily routine. He inquires about the possibility of taking medication for his anxiety.
      What is the primary drug class used to treat GAD?

      Your Answer: Selective serotonin reuptake inhibitor (SSRI)

      Explanation:

      The first-line pharmacological treatment for GAD, according to NICE, is selective serotonin reuptake inhibitors (SSRIs) like sertraline. Benzodiazepines should only be used for a short period during a crisis due to their association with dependence and tolerance. If SSRIs or SNRIs cannot be tolerated, pregabalin may be considered as a third-line treatment. SNRIs like venlafaxine or paroxetine are recommended as a second-line treatment. Tricyclic antidepressants are not recommended for GAD but may be effective for panic disorder, although caution should be taken in patients with a history of self-harm or suicidal ideation due to their toxicity in overdose.

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      • Psychiatry
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  • Question 21 - A 50-year-old woman arrives at the emergency department complaining of palpitations, dizziness, and...

    Correct

    • A 50-year-old woman arrives at the emergency department complaining of palpitations, dizziness, and lightheadedness. Upon conducting an ECG, torsades de pointes is observed. Which medication is the most probable cause of the cardiac anomaly?

      Your Answer: Citalopram

      Explanation:

      Citalopram, an SSRI used to treat major depressive disorder, has been identified as the most likely to cause QT prolongation and torsades de pointes. In 2011, the MHRA issued a warning against its use in patients with long-QT syndrome. While fluoxetine and sertraline can also cause prolonged QT, citalopram is more frequently associated with this side effect. Gentamicin, a bactericidal antibiotic, does not appear to cause QT prolongation or torsades de pointes. Although sertraline is another SSRI that can cause prolonged QT, citalopram remains the most concerning in this regard.

      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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  • Question 22 - A mental state examination is conducted on a 30-year-old individual. When asked about...

    Incorrect

    • A mental state examination is conducted on a 30-year-old individual. When asked about their activities during the week, they begin discussing their job, then transition to their passion for writing, followed by reminiscing about their favorite literature teacher from school, and finally discussing the death of their childhood dog and how it relates to their current writing project. Although their speech is at a normal pace, they never fully answer the question about their recent activities. What can be said about this individual's behavior?

      Your Answer: Flight of ideas

      Correct Answer: Tangentiality

      Explanation:

      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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  • Question 23 - A 56-year-old man without medical history is beginning treatment with tranylcypromine for his...

    Incorrect

    • A 56-year-old man without medical history is beginning treatment with tranylcypromine for his depression. What foods should he be cautioned against consuming?

      Your Answer: Cranberries

      Correct Answer: Cheese

      Explanation:

      To prevent a hypertensive crisis, individuals taking monoamine oxidase inhibitors (MAOIs) should steer clear of tyramine-containing foods, such as cheese. Other foods have not been found to have an interaction with MAOIs.

      Monoamine Oxidase Inhibitors and their Adverse Effects

      Monoamine oxidase inhibitors are drugs that inhibit the enzyme monoamine oxidase, which is responsible for the breakdown of neurotransmitters such as serotonin and noradrenaline in the presynaptic cell. Non-selective monoamine oxidase inhibitors, such as tranylcypromine and phenelzine, are used in the treatment of atypical depression and other psychiatric disorders. However, they are not commonly used due to their adverse effects.

      One of the main adverse effects of non-selective monoamine oxidase inhibitors is hypertensive reactions when consuming tyramine-containing foods such as cheese, pickled herring, Bovril, Oxo, Marmite, and broad beans. This is because monoamine oxidase normally breaks down tyramine, but when inhibited by the drug, tyramine can accumulate and cause a sudden increase in blood pressure. Therefore, patients taking non-selective monoamine oxidase inhibitors must adhere to a strict diet that avoids these foods.

      Another adverse effect of non-selective monoamine oxidase inhibitors is anticholinergic effects, which can cause dry mouth, blurred vision, constipation, and urinary retention. These effects are due to the inhibition of the enzyme acetylcholinesterase, which breaks down the neurotransmitter acetylcholine. As a result, acetylcholine levels increase and can lead to these side effects.

      In conclusion, while non-selective monoamine oxidase inhibitors can be effective in treating certain psychiatric disorders, they are not commonly used due to their adverse effects. Patients taking these drugs must adhere to a strict diet and be monitored for potential side effects.

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  • Question 24 - A 26-year-old male comes to his doctor's office at the request of his...

    Correct

    • A 26-year-old male comes to his doctor's office at the request of his friends. Upon examination, he discloses that he thinks everyone can hear his thoughts, as if he were a radio station, and that he hears voices commenting on his actions. The doctor observes that he has a blunted affect, alogia, and avolition. Additionally, the doctor notes that the patient repeats the final word of any inquiry posed to him.

      What term describes this phenomenon?

      Your Answer: Echolalia

      Explanation:

      Echolalia is when someone repeats the speech of another person, including any questions asked. This is often seen in individuals with schizophrenia, particularly catatonic schizophrenia, which is characterized by negative symptoms such as a lack of emotional expression, poverty of speech, and poor motivation. The patient in question exhibits two of Schneider’s first-rank symptoms: thought broadcasting and third-person auditory hallucinations, and is therefore diagnosable with schizophrenia. Copropraxia refers to the involuntary performance of obscene or forbidden gestures or inappropriate touching, while echopraxia involves the meaningless repetition or imitation of others’ movements. Finally, a neologism is a word that has been made up.

      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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      • Psychiatry
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  • Question 25 - A 25-year-old woman comes to her doctor with concerning symptoms. Ten weeks ago,...

    Incorrect

    • A 25-year-old woman comes to her doctor with concerning symptoms. Ten weeks ago, she was in a serious car accident. Despite being physically fine, she has been experiencing flashbacks, heightened alertness when crossing the street, and difficulty concentrating at work. What characteristic would most strongly support the probable diagnosis?

      Your Answer: Paranoid ideation

      Correct Answer: Emotional detachment

      Explanation:

      One of the common features of PTSD is emotional detachment, where patients may feel numb and unable to fully experience their emotions. Other symptoms include re-experiencing traumatic events through flashbacks and nightmares, avoiding people or situations, and hyperarousal such as hypervigilance and sleep problems. Delusional beliefs are not typically associated with PTSD, and excessive sleep and nystagmus are not common symptoms. However, there is a link between eyes and PTSD, as eye movement desensitisation and reprocessing therapy is a common treatment for the disorder.

      Understanding Post-Traumatic Stress Disorder (PTSD)

      Post-traumatic stress disorder (PTSD) is a mental health condition that can develop in individuals of any age following a traumatic event. This can include experiences such as natural disasters, accidents, or even childhood abuse. PTSD is characterized by a range of symptoms, including re-experiencing the traumatic event through flashbacks or nightmares, avoidance of situations or people associated with the event, hyperarousal, emotional numbing, depression, and even substance abuse.

      Effective management of PTSD involves a range of interventions, depending on the severity of the symptoms. Single-session interventions are not recommended, and watchful waiting may be used for mild symptoms lasting less than four weeks. Military personnel have access to treatment provided by the armed forces, while trauma-focused cognitive behavioral therapy (CBT) or eye movement desensitization and reprocessing (EMDR) therapy may be used in more severe cases.

      It is important to note that drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used, venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline, should be tried. In severe cases, NICE recommends that risperidone may be used. Overall, understanding the symptoms and effective management of PTSD is crucial in supporting individuals who have experienced traumatic events.

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  • Question 26 - A 28-year-old woman experiences chest pain following an argument with her 16-year-old daughter....

    Incorrect

    • A 28-year-old woman experiences chest pain following an argument with her 16-year-old daughter. She is brought to your clinic for evaluation. Upon examination, she appears anxious and is hyperventilating. She exhibits tenderness to light pressure on the front of her chest, but her oxygen saturation is 99% while breathing room air. An ECG reveals no abnormalities. What is the most suitable course of action for this patient?

      Your Answer: Check troponin and send with routine samples. Plan to repeat ECG in two hours. Explain that you think that there is probably nothing serious going on, but you want to make sure that she has not had a heart attack.

      Correct Answer: Explain that she has had a panic attack and that her symptoms are a consequence of this. Help her to control her breathing rate, and say that you think everything will settle down and she will be able to go home.

      Explanation:

      The causes of septic shock are important to understand in order to provide appropriate treatment and improve patient outcomes. Septic shock can cause fever, hypotension, and renal failure, as well as tachypnea due to metabolic acidosis. However, it is crucial to rule out other conditions such as hyperosmolar hyperglycemic state or diabetic ketoacidosis, which have different symptoms and diagnostic criteria.

      While metformin can contribute to acidosis, it is unlikely to be the primary cause in this case. Diabetic patients may be prone to renal tubular acidosis, but this is not likely to be the cause of an acute presentation. Instead, a type IV renal tubular acidosis, characterized by hyporeninaemic hypoaldosteronism, may be a more likely association.

      Overall, it is crucial to carefully evaluate patients with septic shock and consider all possible causes of their symptoms. By ruling out other conditions and identifying the underlying cause of the acidosis, healthcare providers can provide targeted treatment and improve patient outcomes. Further research and education on septic shock and its causes can also help to improve diagnosis and treatment in the future.

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  • Question 27 - A 32-year-old man visits his General Practitioner (GP) for an annual mental health...

    Correct

    • A 32-year-old man visits his General Practitioner (GP) for an annual mental health review. He was diagnosed with schizophrenia eight years ago. He has been on medication since diagnosis and takes this daily without any side-effects. He has regular contact with the community mental health team. He is working part-time as a shop assistant, which he enjoys. He has a good appetite, sleeps well and exercises regularly.

      What is true regarding the treatment of schizophrenia in a 32-year-old man who has been diagnosed with the condition for eight years and is currently on medication without any side-effects, has regular contact with the community mental health team, works part-time, and has good appetite, sleep, and exercise habits?

      Your Answer: People with a first episode of psychosis should be offered oral antipsychotic treatment, along with psychological interventions

      Explanation:

      Mythbusting: Common Misconceptions About Schizophrenia Treatment

      1. Oral antipsychotic treatment and psychological interventions should be offered to those with a first episode of psychosis.
      2. Patients with schizophrenia should remain under the care of a psychiatrist lifelong, but can be eligible for shared care with a GP after 12 months of stability.
      3. An ECG is only necessary before starting antipsychotic medication in certain circumstances.
      4. Before starting any oral antipsychotic medication, various health factors need to be checked in all patients.
      5. The choice of antipsychotic medication should be made on an individual basis, taking into account potential side-effects.
      6. Early intervention in psychosis services should be accessed urgently for anyone presenting with a first episode of psychosis. Antipsychotic medication should not be initiated in primary care without the advice of a psychiatrist.

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  • Question 28 - A 32-year-old man comes to you seeking help as he feels like he...

    Correct

    • A 32-year-old man comes to you seeking help as he feels like he is not himself lately. He has been struggling since his divorce 8 months ago. For the past 5 weeks, he has been experiencing low moods for most of the day, particularly in the mornings when he wakes up early. He has lost interest in his usual hobbies, including going to the gym. He has not been to any of his regular workout classes. He has had thoughts of taking a bottle of pills to end it all, but he knows he won't do it because he has a supportive family. He has no significant medical or psychiatric history.

      Which of the following treatments would be the most appropriate?

      Your Answer: Fluoxetine

      Explanation:

      Treatment Options for Depression: Choosing the Right Antidepressant

      Depression is a serious mental health condition that requires a comprehensive treatment plan. Antidepressants are often prescribed as part of this plan, along with high-intensity psychological interventions like cognitive behavioural therapy (CBT). However, not all antidepressants are created equal. Here are some of the most commonly used antidepressants and their indications:

      Fluoxetine: This selective serotonin reuptake inhibitor (SSRI) is the most suitable first-line treatment for depression due to its efficacy, patient acceptability, and lower toxicity in overdose.

      Imipramine: This tricyclic antidepressant is not usually used as a first-line treatment for depression but has a role in nocturnal enuresis.

      Lithium: While lithium has antidepressant properties, it is not a first-line treatment for unipolar depression due to its side-effects and the need for blood monitoring. It is commonly used in the treatment of bipolar affective disorder.

      Electroconvulsive therapy (ECT): ECT is reserved for more severe depression where there is an immediate risk to life or where other treatments have been ineffective.

      Phenelzine: This monoamine oxidase inhibitor (MAOI) is not commonly used as a first-line treatment for depression but is helpful in treatment-resistant depression.

      It’s important to work closely with a healthcare professional to determine the best treatment plan for your individual needs. Antidepressants may take several weeks to take effect, and patients should be aware of potential side-effects and the importance of adhering to their medication regimen.

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  • Question 29 - Sophie, a 22-year-old student, presents to her GP with a history of low...

    Correct

    • Sophie, a 22-year-old student, presents to her GP with a history of low mood lasting several months. She is struggling with her university studies due to poor concentration and constant fatigue. Despite waking up early every morning, she finds it difficult to fall back asleep. Sophie no longer enjoys spending time with her loved ones and feels hopeless about her future. She has sought medical attention as her symptoms are significantly impacting her academic performance.

      Sophie denies having any suicidal thoughts, and there is no evidence of psychotic features during the examination. She is in good health and denies any alcohol or drug use. Sophie is eager to begin treatment for her symptoms. What would be the most appropriate course of action?

      Your Answer: A trial of fluoxetine

      Explanation:

      Lucy is exhibiting symptoms typical of moderate/severe depression, including low mood, fatigue, anhedonia, difficulty concentrating, poor sleep, and feelings of hopelessness. According to NICE guidelines, the recommended first-line treatment for this level of depression is a combination of antidepressants and high-intensity psychological therapy, such as cognitive behavioural therapy or interpersonal therapy. As such, starting fluoxetine (an SSRI) would be the most appropriate course of action. Tricyclic antidepressants like amitriptyline are not recommended due to their potential side effects and overdose risk. Low-intensity psychological interventions like individual guided self-help are also not suitable for moderate/severe depression. While Lucy is not currently a risk to herself or others and is willing to try treatment in the community, urgent mental health review is not necessary. Given the severity of her symptoms and her desire for active treatment, watchful waiting is not recommended.

      In 2022, NICE updated its guidelines on managing depression and now classifies it as either less severe or more severe based on a patient’s PHQ-9 score. For less severe depression, NICE recommends discussing treatment options with patients and considering the least intrusive and resource-intensive treatment first. Antidepressant medication should not be routinely offered as first-line treatment unless it is the patient’s preference. Treatment options for less severe depression include guided self-help, group cognitive behavioral therapy, group behavioral activation, individual CBT or BA, group exercise, group mindfulness and meditation, interpersonal psychotherapy, SSRIs, counseling, and short-term psychodynamic psychotherapy. For more severe depression, NICE recommends a shared decision-making approach and suggests a combination of individual CBT and an antidepressant as the preferred treatment option. Other treatment options for more severe depression include individual CBT or BA, antidepressant medication, individual problem-solving, counseling, short-term psychodynamic psychotherapy, interpersonal psychotherapy, guided self-help, and group exercise.

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  • Question 30 - A 28-year-old male patient visits the psychiatric clinic for a routine check-up. He...

    Correct

    • A 28-year-old male patient visits the psychiatric clinic for a routine check-up. He reports experiencing weight gain, erectile dysfunction, and gynaecomastia. The patient was diagnosed with schizophrenia a year ago and has been struggling to find a suitable medication despite being compliant. He expresses concern that his partner is becoming increasingly frustrated with his lack of sexual interest, which is affecting their relationship. What is the most appropriate management option for this case?

      Your Answer: Switch to aripiprazole

      Explanation:

      The best course of action for this patient, who has been diagnosed with schizophrenia and is experiencing side effects such as gynaecomastia, loss of libido and erectile dysfunction, is to switch to aripiprazole. This medication has the most tolerable side effect profile of the atypical antipsychotics, particularly when it comes to prolactin elevation, which is likely causing the patient’s current symptoms. It is important to find a medication that reduces side effects, and aripiprazole has been shown to do so. Options such as once-monthly intramuscular antipsychotic depo injections are more suitable for patients who struggle with compliance, which is not the case for this patient. Switching to clozapine or haloperidol would not be appropriate due to their respective side effect profiles.

      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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SESSION STATS - PERFORMANCE PER SPECIALTY

Psychiatry (20/30) 67%
Passmed