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Question 1
Correct
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A 67-year-old male who has been on long term chlorpromazine presents with repetitive eye blinking. He is concerned about the cause of this symptom and reports being unable to control it. He has no visual disturbance and is otherwise in good health. Upon examination, he has a normal facial and ocular appearance except for excessive rapid blinking. What is the probable reason for his symptoms?
Your Answer: Tardive dyskinesia
Explanation:The correct term for the condition described in the stem is tardive dyskinesia. This is a late onset side effect of conventional antipsychotics, such as chlorpromazine, which causes abnormal involuntary movements. Patients may exhibit symptoms such as lip-smacking, jaw pouting, chewing, or repetitive blinking. Unfortunately, this condition is often difficult to treat, but replacing the antipsychotic or trying tetrabenazine may provide some relief.
Parkinsonism is another potential side effect of conventional antipsychotics, but it presents with symptoms similar to Parkinson’s disease, such as tremors, blank facies, bradykinesia, and muscle rigidity. Dry eyes or Sjogren’s syndrome may cause eye twitching, but they are unlikely to cause repetitive blinking. Blepharospasm is a condition characterized by involuntary twitching or contraction of the eyelid, which may be caused by stress or fatigue. However, given the patient’s use of chlorpromazine, tardive dyskinesia is the most likely diagnosis.
Antipsychotics are a group of drugs used to treat schizophrenia, psychosis, mania, and agitation. They are divided into two categories: typical and atypical antipsychotics. The latter were developed to address the extrapyramidal side-effects associated with the first generation of typical antipsychotics. Typical antipsychotics work by blocking dopaminergic transmission in the mesolimbic pathways through dopamine D2 receptor antagonism. They are associated with extrapyramidal side-effects and hyperprolactinaemia, which are less common with atypical antipsychotics.
Extrapyramidal side-effects (EPSEs) are common with typical antipsychotics and include Parkinsonism, acute dystonia, sustained muscle contraction, akathisia, and tardive dyskinesia. The latter is a late onset of choreoathetoid movements that may be irreversible and occur in 40% of patients. The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients, including an increased risk of stroke and venous thromboembolism. Other side-effects include antimuscarinic effects, sedation, weight gain, raised prolactin, impaired glucose tolerance, neuroleptic malignant syndrome, reduced seizure threshold, and prolonged QT interval.
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This question is part of the following fields:
- Psychiatry
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Question 2
Incorrect
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A 58-year-old woman is brought to the psychiatric ward by her family due to concerns about her behavior. During your conversation with her, you observe that she speaks rapidly and does not allow you to interrupt her. She frequently changes the subject, but you can discern connections between them. What psychiatric disorder is most commonly associated with these symptoms?
Your Answer: Schizophrenia
Correct Answer: Bipolar disorder
Explanation:Mania is often characterized by flight of ideas, which is when a person speaks rapidly and jumps between different topics. This is a common symptom of bipolar disorder. It is important to differentiate flight of ideas from Knight’s move thinking, which is associated with schizophrenia. In flight of ideas, there are identifiable connections between the topics that the person jumps between, while in Knight’s move thinking, there are no apparent connections between the topics. This is referred to as loosening of association.
Thought disorders can manifest in various ways, including circumstantiality, tangentiality, neologisms, clang associations, word salad, Knight’s move thinking, flight of ideas, perseveration, and echolalia. Circumstantiality involves providing excessive and unnecessary detail when answering a question, but eventually returning to the original point. Tangentiality, on the other hand, refers to wandering from a topic without returning to it. Neologisms are newly formed words, often created by combining two existing words. Clang associations occur when ideas are related only by their similar sounds or rhymes. Word salad is a type of speech that is completely incoherent, with real words strung together into nonsensical sentences. Knight’s move thinking is a severe form of loosening of associations, characterized by unexpected and illogical leaps from one idea to another. Flight of ideas is a thought disorder that involves jumping from one topic to another, but with discernible links between them. Perseveration is the repetition of ideas or words despite attempts to change the topic. Finally, echolalia is the repetition of someone else’s speech, including the question that was asked.
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This question is part of the following fields:
- Psychiatry
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Question 3
Incorrect
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A 35-year-old woman is brought to the psychiatry clinic by her spouse. The spouse reports that the patient has been displaying abnormal behaviour, such as staying up all night, talking rapidly, excessive shopping, and claiming she will become a millionaire by investing in cryptocurrency.
The patient has a history of depression and is currently taking sertraline. During the mental state examination, the patient exhibits signs of overly familiar behaviour, pressured speech, and flight of ideas.
What is the best medication to treat this condition?Your Answer: Continue sertraline and add lithium
Correct Answer: Stop sertraline and start olanzapine
Explanation:When managing mania or hypomania in patients who are taking antidepressants, it may be necessary to discontinue the use of the antidepressant and initiate treatment with antipsychotic medication.
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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This question is part of the following fields:
- Psychiatry
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Question 4
Incorrect
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A 36-year-old woman presents to her doctor with complaints of struggling to maintain positive relationships with her coworkers. Upon further inquiry, it is revealed that the woman has a rigid value system and moral code, making it challenging for her to work with colleagues who have different beliefs and work practices. What personality disorder is most likely present in this patient?
Your Answer: Antisocial personality disorder
Correct Answer: Obsessive-compulsive personality disorder
Explanation:Patients with obsessive-compulsive personality disorder tend to be inflexible when it comes to morals, ethics, and values. They often have difficulty delegating tasks to others, as seen in this case. Other symptoms include an excessive focus on details, rules, lists, and order, as well as perfectionism that can interfere with completing tasks.
Antisocial personality disorder is not applicable in this case. This disorder is characterized by aggressive and unlawful behavior, deception, and a lack of empathy.
Borderline personality disorder is also not applicable. This disorder is characterized by unstable self-image, unstable relationships, fear of abandonment, and chronic feelings of emptiness.
Paranoid personality disorder is not applicable. This disorder is characterized by a tendency to question the loyalty of friends, hypersensitivity to insult, and preoccupation with conspiracies and hidden meanings.
Narcissistic personality disorder is not applicable. This disorder is characterized by a grandiose sense of self-importance, lack of empathy, sense of entitlement, and preoccupation with fantasies of success, power, or beauty.
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.
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This question is part of the following fields:
- Psychiatry
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Question 5
Incorrect
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A 29-year-old woman presents with dry, eczematous hands. She reports being a very hygienic person, but since the onset of the COVID-19 pandemic, she has been washing her hands excessively - up to 60 times a day. She is aware that this is causing her skin to become dry and irritated, but her anxiety about contracting the virus is too great to stop. She works in a hospital and is worried about her colleagues noticing her frequent hand washing. You suspect she may have obsessive-compulsive disorder and decide to refer her to the community mental health team. What treatment options are likely to be offered to her?
Your Answer: Eye movement desensitisation and reprocessing (EMDR)
Correct Answer: Cognitive behavioural therapy
Explanation:Obsessive-compulsive disorder (OCD) is characterized by the presence of obsessions and/or compulsions that can cause significant functional impairment and distress. Risk factors include family history, age, pregnancy/postnatal period, and history of abuse, bullying, or neglect. Treatment options include low-intensity psychological treatments, SSRIs, and more intensive CBT (including ERP). Severe cases should be referred to the secondary care mental health team for assessment and may require combined treatment with an SSRI and CBT or clomipramine as an alternative. ERP involves exposing the patient to an anxiety-provoking situation and stopping them from engaging in their usual safety behavior. Treatment with SSRIs should continue for at least 12 months to prevent relapse and allow time for improvement.
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This question is part of the following fields:
- Psychiatry
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Question 6
Incorrect
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A 20-year-old woman is brought to your clinic by her parents due to concerns about her weight loss (her BMI has dropped from 21 to 18.5 in the past year). You have seen her before and have ruled out any physical causes for her weight loss. When you inquire about purging behaviors, such as self-induced vomiting, she becomes defensive, but you notice that her tooth enamel is eroded. She admits to feeling overweight and has been experiencing low mood for several months, finding little pleasure in anything except for when she indulges in too much chocolate and bread. However, she feels even more disgusted with herself afterwards. What is the most appropriate diagnosis for her condition?
Your Answer: Anorexia nervosa
Correct Answer: Bulimia nervosa
Explanation:Understanding Eating Disorders: Bulimia Nervosa and Anorexia Nervosa
Eating disorders are complex mental health conditions that can have serious physical and emotional consequences. Two common types of eating disorders are bulimia nervosa and anorexia nervosa.
Bulimia nervosa is characterized by episodes of binge eating, followed by purging behaviors such as vomiting, laxative abuse, or excessive exercise. People with bulimia often feel a loss of control during binge episodes and experience intense guilt afterwards. They may also engage in periods of dietary restraint and have a preoccupation with body weight and shape. Bulimia is more common in women and can cause dental problems, electrolyte imbalances, and other medical complications.
Anorexia nervosa involves deliberate weight loss to a low weight, often through restricted eating and excessive exercise. People with anorexia have a fear of gaining weight and a distorted body image, leading to a preoccupation with food and weight. Anorexia can cause severe malnutrition and medical complications such as osteoporosis, heart problems, and hormonal imbalances.
It is important to seek professional help if you or someone you know is struggling with an eating disorder. Treatment may involve therapy, medication, and nutritional counseling to address the physical and psychological aspects of the condition. With proper care, recovery from an eating disorder is possible.
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This question is part of the following fields:
- Psychiatry
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Question 7
Incorrect
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A 27-year-old woman presents with a 3-day history of inability to use her right arm. She has been staying with her mother for the past 5 days after experiencing domestic abuse from her husband. The patient reports feeling very stressed. She denies any history of trauma. On examination, there is normal tone and reflexes but 0/5 power in all muscle groups of the right upper limb. The affected arm falls to the patient's side when held above her face and released. What is the probable diagnosis?
Your Answer: Post traumatic stress disorder (PTSD)
Correct Answer: Conversion disorder
Explanation:The probable diagnosis for this patient is conversion disorder, which is a psychiatric condition that involves the loss of motor or sensory function and is often caused by stress. There is no evidence of neurological disease in the patient’s history or clinical findings. The condition is likely triggered by recent domestic abuse and stress. The patient also exhibits a positive drop-arm test, which is a controlled drop of the arm to prevent it from hitting the face, and is an unconscious manifestation of psychological stress.
Acute stress disorder is a condition that occurs after life-threatening experiences, such as abuse, and is characterized by symptoms of hyperarousal, re-experiencing of the traumatic event, avoidance of stimuli, and distress. However, it does not involve physical weakness. It typically lasts between 3 days and 1 month.
Post-traumatic stress disorder is another condition that occurs after life-threatening experiences, such as abuse, and has similar symptoms to acute stress disorder. However, it lasts longer than 1 month.
Patients with somatisation disorder have multiple bodily complaints that last for months to years and persistent anxiety about their symptoms. However, based on this patient’s history and physical findings, conversion disorder is the most likely diagnosis.
Given the patient’s normal tone and reflexes and the absence of trauma to the neck or spine, it is highly unlikely that a spinal cord lesion is causing total arm paralysis.
Psychiatric Terms for Unexplained Symptoms
There are various psychiatric terms used to describe patients who exhibit symptoms for which no organic cause can be found. One such disorder is somatisation disorder, which involves the presence of multiple physical symptoms for at least two years, and the patient’s refusal to accept reassurance or negative test results. Another disorder is illness anxiety disorder, which is characterized by a persistent belief in the presence of an underlying serious disease, such as cancer, despite negative test results.
Conversion disorder is another condition that involves the loss of motor or sensory function, and the patient does not consciously feign the symptoms or seek material gain. Patients with this disorder may be indifferent to their apparent disorder, a phenomenon known as la belle indifference. Dissociative disorder, on the other hand, involves the process of ‘separating off’ certain memories from normal consciousness, and may manifest as amnesia, fugue, or stupor. Dissociative identity disorder (DID) is the most severe form of dissociative disorder and was previously known as multiple personality disorder.
Factitious disorder, also known as Munchausen’s syndrome, involves the intentional production of physical or psychological symptoms. Finally, malingering is the fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain. Understanding these psychiatric terms can help healthcare professionals better diagnose and treat patients with unexplained symptoms.
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This question is part of the following fields:
- Psychiatry
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Question 8
Incorrect
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A 25-year-old woman returns to your clinic complaining of constant feelings of sadness, loss of appetite, insomnia, and a lack of enjoyment in anything. Despite making lifestyle changes and setting small goals, she still feels hopeless and requests medication. You decide to prescribe sertraline. What drug should be avoided in patients taking an SSRI?
Your Answer: Amiodarone
Correct Answer: Sumatriptan
Explanation:Patients who are taking a SSRI should not use triptans.
Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.
The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.
When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.
When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.
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This question is part of the following fields:
- Psychiatry
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Question 9
Correct
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A 32-year-old woman presents to her GP with complaints of feeling extremely anxious, avoiding going out, and experiencing disturbed sleep. Her symptoms have resulted in the breakdown of her relationship. She reports that her symptoms began to worsen after she was sexually assaulted 2 years ago. She experiences flashbacks of the assault when she is in a confined space with someone, even if there is no physical contact. The GP decides to refer her for cognitive behavioural therapy and the patient also expresses interest in trying medication. Which of the following medications would be recommended for the management of this patient?
Your Answer: Venlafaxine
Explanation:Medications for Post-Traumatic Stress Disorder (PTSD)
Post-traumatic stress disorder (PTSD) is a mental health condition that can develop after experiencing or witnessing a traumatic event. Symptoms of PTSD include flashbacks, nightmares, avoidance, and hyperarousal. If drug treatment is necessary, selective serotonin reuptake inhibitors (SSRIs) or venlafaxine are recommended. Tricyclic antidepressants and benzodiazepines are not recommended due to their potential risks and lack of efficacy in treating PTSD. Antipsychotics may be considered in patients who do not respond to other treatments. It is important to regularly review and adjust medication treatment for PTSD.
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This question is part of the following fields:
- Psychiatry
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Question 10
Incorrect
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A 47-year-old male comes to the GP with concerns about his difficulty falling asleep. He believes that he may be suffering from chronic insomnia, which he has read about online.
The patient reports that he has attempted various methods to help him sleep, such as meditation and taking a warm bath before bed. However, he feels that he has too many thoughts racing through his mind and cannot seem to turn them off. This occurs at least three times a week and has persisted for the past month.
What indication would suggest that this individual has misdiagnosed himself?Your Answer: Chronic insomnia must be associated with other features, such as sleep apnoea
Correct Answer: The duration of insomnia is too brief; it must be over 3 months
Explanation:If a person experiences difficulty falling asleep or staying asleep for at least three nights per week, they may be diagnosed with chronic insomnia after three months. This form of insomnia can occur alone or together with other sleep disturbances. The diagnosis of chronic insomnia is not limited by age and can be made in patients of any age.
Insomnia: Causes, Diagnosis, and Management
Insomnia is a common problem reported in primary care, often associated with other physical and mental health complaints. It is defined as difficulty initiating or maintaining sleep, or early-morning awakening that leads to dissatisfaction with sleep quantity or quality, despite adequate time and opportunity for sleep, resulting in impaired daytime functioning. Insomnia may be acute or chronic, with chronic insomnia diagnosed if a person has trouble falling asleep or staying asleep at least three nights per week for 3 months or longer.
Patients with insomnia typically present with decreased daytime functioning, decreased periods of sleep, or increased accidents due to poor concentration. It is important to identify the cause of insomnia, as management can differ. Risk factors for insomnia include female gender, increased age, lower educational attainment, unemployment, economic inactivity, widowed/divorced/separated status, alcohol and substance abuse, stimulant usage, poor sleep hygiene, chronic pain, chronic illness, and psychiatric illness.
Diagnosis is primarily made through patient interview, looking for the presence of risk factors. Sleep diaries and actigraphy may aid diagnosis, while polysomnography is not routinely indicated. Short-term management of insomnia involves identifying potential causes, advising good sleep hygiene, and considering the use of hypnotic drugs only if daytime impairment is severe. The recommended hypnotics for treating insomnia are short-acting benzodiazepines or non-benzodiazepines, with the lowest effective dose used for the shortest period possible. Diazepam may be useful if insomnia is linked to daytime anxiety. It is important to review after 2 weeks and consider referral for cognitive behavioural therapy (CBT). Other sedative drugs are not recommended for managing insomnia.
In summary, insomnia is a common problem that can significantly impact a person’s daily functioning. It is important to identify the cause of insomnia and manage it appropriately, with short-term management involving good sleep hygiene and the cautious use of hypnotic drugs. Referral for CBT may also be considered.
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This question is part of the following fields:
- Psychiatry
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Question 11
Correct
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A 25-year-old female has been discharged from hospital after being diagnosed with schizophrenia. She is now being seen in the GP clinic and is concerned about her prognosis. Prior to her illness, she was a high-functioning accountant. Her symptoms began gradually and mainly involved auditory hallucinations and persecutory delusions, which are currently under control. What factor in her case suggests a poor prognosis?
Your Answer: Gradual onset of symptoms
Explanation:The gradual onset of schizophrenia is associated with a worse long-term outcome, making it a poor prognostic indicator for this patient. However, her gender (being female) and good pre-illness functioning are both positive prognostic indicators. Additionally, her predominant positive symptoms (auditory hallucinations and delusions) suggest a better prognosis compared to predominant negative symptoms. Lastly, being diagnosed at a younger age (such as in her teens) would have resulted in a poorer prognosis.
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.
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This question is part of the following fields:
- Psychiatry
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Question 12
Incorrect
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A 32-year-old man with a diagnosis of bipolar disorder is brought in by police under section 136 of the mental health act. His psychiatrist has recently adjusted his medication. He was found dancing in the middle of a busy street claiming to be the king of the world.
Upon assessment, he appears elated, his speech is rapid and he appears easily distracted. He believes he has been chosen by a higher power to save the world from destruction and hasn't slept for days as a result.
The patient is sectioned and admitted to the mental health ward.
What is the most appropriate course of action?Your Answer: Start olanzapine
Correct Answer: Stop sertraline and start olanzapine
Explanation:When managing mania or hypomania in patients who are taking antidepressants, it may be necessary to discontinue the use of the antidepressant and initiate treatment with antipsychotic medication.
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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This question is part of the following fields:
- Psychiatry
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Question 13
Incorrect
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A 27-year-old man is brought to the emergency department by police after being found naked in the street and shouting about the government's plan to infect the population with a virus through the water supply. He is not known to secondary care services and a drug screen is negative. The psychiatry liaison team admits him under Section 2 of the Mental Health Act for assessment of a first psychosis. What is the most significant risk factor for this patient's condition?
Your Answer: Prolonged cannabis use
Correct Answer: Uncle with schizophrenia
Explanation:The most significant risk factor for psychotic disorders is a person’s family history.
Understanding the Epidemiology of Schizophrenia
Schizophrenia is a psychotic disorder that affects a significant portion of the population. The strongest risk factor for developing this condition is having a family history of the disorder. Individuals with a parent who has schizophrenia have a relative risk of 7.5. Additionally, monozygotic twins have a 50% chance of developing schizophrenia, while siblings have a 10% chance. In contrast, individuals without relatives with schizophrenia have a 1% chance of developing the disorder.
Aside from family history, other factors can increase the risk of developing schizophrenia. Black Caribbean ethnicity has a relative risk of 5.4, while migration and living in an urban environment have relative risks of 2.9 and 2.4, respectively. Cannabis use also increases the risk of developing schizophrenia, with a relative risk of 1.4.
Understanding the epidemiology of schizophrenia is crucial in identifying individuals who may be at risk of developing the disorder. By recognizing these risk factors, healthcare professionals can provide early interventions and support to prevent or manage the onset of schizophrenia.
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This question is part of the following fields:
- Psychiatry
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Question 14
Correct
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A 28-year-old man has been admitted to the psychiatric ward under section 2 of the mental health act for suspected first-episode psychosis. During his mental state examination, burns are observed on his arms and he claims that insects are burrowing into his skin. He suggests that the burns are caused by bleach. The evaluating psychiatrist could not detect any insects, and when questioned, the patient became agitated and insisted that his skin was infested. What is the most probable disorder being described?
Your Answer: Delusional parasitosis
Explanation:The patient in the scenario is experiencing delusional parasitosis, a psychiatric disorder characterized by a fixed, false belief that one is infested by parasites or ‘bugs’. This delusion can lead to extreme measures to try to eradicate the perceived infestation. Delusional parasitosis is also known as Ekbom syndrome. Capgras delusion, Cotard’s delusion, and formication are not applicable in this case.
Understanding Delusional Parasitosis
Delusional parasitosis is a condition that is not commonly known but can be debilitating for those who suffer from it. It is characterized by a persistent and false belief that one is infested with bugs, parasites, mites, bacteria, or fungus. This delusion can occur on its own or in conjunction with other psychiatric conditions. Despite the delusion, patients may still be able to function normally in other aspects of their lives.
In simpler terms, delusional parasitosis is a rare condition where a person believes they have bugs or other organisms living on or inside their body, even though there is no evidence to support this belief. This can cause significant distress and anxiety for the individual, and they may go to great lengths to try and rid themselves of the perceived infestation. It is important for those who suspect they may be suffering from delusional parasitosis to seek professional help, as treatment can greatly improve their quality of life.
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This question is part of the following fields:
- Psychiatry
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Question 15
Incorrect
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A 35-year-old male comes to your clinic at the suggestion of his partner. He has been experiencing hyperarousal to loud noises and difficulty concentrating at work since his stay in the ICU 4 weeks ago. His partner believes he may have acute stress disorder, but you diagnose him with PTSD and discuss treatment options. He asks you to explain the difference between the two to his partner. You explain that while the presentation is similar, the main difference is temporal.
At what point after the event can you confirm a diagnosis of PTSD?Your Answer: 2 weeks
Correct Answer: 4 weeks
Explanation:Acute stress disorder is characterized by an acute stress reaction that occurs within four weeks of a traumatic event, while PTSD is diagnosed after four weeks have passed. Symptoms presented within two weeks would suggest acute stress disorder. Both acute stress disorder and PTSD share similar features, including re-experiencing, avoidance, hyperarousal, and emotional numbing. Re-experiencing symptoms may include flashbacks, nightmares, and repetitive and distressing intrusive images. Avoidance symptoms may involve avoiding people, situations, or circumstances associated with the traumatic event. Hyperarousal symptoms may include hypervigilance for threat, exaggerated startle response, sleep problems, irritability, and difficulty concentrating. Emotional numbing may result in a lack of ability to experience feelings and feeling detached.
Acute stress disorder is a condition that occurs within the first four weeks after a person has experienced a traumatic event, such as a life-threatening situation or sexual assault. It is characterized by symptoms such as intrusive thoughts, dissociation, negative mood, avoidance, and arousal. These symptoms can include flashbacks, nightmares, feeling disconnected from reality, and being hypervigilant.
To manage acute stress disorder, trauma-focused cognitive-behavioral therapy (CBT) is typically the first-line treatment. This type of therapy helps individuals process their traumatic experiences and develop coping strategies. In some cases, benzodiazepines may be used to alleviate acute symptoms such as agitation and sleep disturbance. However, caution must be taken when using these medications due to their addictive potential and potential negative impact on adaptation. Overall, early intervention and appropriate treatment can help individuals recover from acute stress disorder and prevent the development of more chronic conditions such as PTSD.
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This question is part of the following fields:
- Psychiatry
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Question 16
Correct
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A 25-year-old woman comes to the emergency department with suicidal ideation after a fight with her partner. She has a history of relationship problems and frequently argues with loved ones. She denies having any paranoid thoughts or unusual beliefs but reports hearing a voice in her head that describes her negative thoughts. Upon examination, you observe several superficial scars on her forearms. There is no evidence of delusions or abnormal speech. What is the most probable diagnosis?
Your Answer: Borderline personality disorder
Explanation:The correct answer is borderline personality disorder, which is characterized by a history of self-harm and intense relationships that alternate between idealization and devaluation. Symptoms also include mood swings and the possibility of paranoid thoughts and hallucinations.
Paranoid personality disorder is not the correct answer, as it primarily involves difficulty trusting others and interpreting situations as threatening. While the patient in question does exhibit some paranoia, their other symptoms are more indicative of borderline personality disorder.
Schizoid personality disorder is also not the correct answer, as it involves difficulty forming close relationships and a preference for solitude. The patient in question has close relationships with others.
Schizophrenia is not the correct answer either, as it primarily involves delusions, hallucinations, and disordered thinking.
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.
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This question is part of the following fields:
- Psychiatry
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Question 17
Correct
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A 50-year-old man has been hospitalized following an overdose. What is the most significant indicator of an increased likelihood of future suicide?
Your Answer: Making plans before the overdose to avoid discovery
Explanation:Factors indicating high risk of suicide
The concealment of an overdose indicates a serious intent to complete suicide, more so than other options. However, a previous history of overdoses does not necessarily imply a more serious intent. Other factors that may suggest a higher risk of suicide include being male, elderly, and having a mental illness.
According to the Assessment of Suicide Risk clinical guide, protective factors against suicide include religious beliefs, social support, and being responsible for children. While being responsible for children is an important point to note in the management plan for a suicidal patient, it is not a factor that indicates a high risk of suicide.
It is crucial to identify the factors that suggest a high risk of suicide in order to provide appropriate care and management for the patient. However, it is also important to consider the patient’s wider circumstances and any protective factors that may be present. By taking a comprehensive approach, healthcare professionals can provide the best possible care for patients at risk of suicide.
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This question is part of the following fields:
- Psychiatry
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Question 18
Incorrect
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A 35-year-old female comes to your clinic with concerns that her husband is cheating on her. They have been married for 10 years and have always been faithful to each other. She is a stay-at-home mom and her husband works long hours. You wonder about the likelihood of her claims being true.
What is the medical term for this type of delusional jealousy?Your Answer: Fregoli syndrome
Correct Answer: Othello syndrome
Explanation:Othello syndrome is a condition characterized by delusional jealousy, where individuals believe that their partner is being unfaithful. This belief can stem from a variety of underlying conditions, including affective states, schizophrenia, or personality disorders. Patients with Othello syndrome may become fixated on finding evidence of their partner’s infidelity, even when none exists. In extreme cases, this can lead to violent behavior.
Understanding Othello’s Syndrome
Othello’s syndrome is a condition characterized by extreme jealousy and suspicion that one’s partner is being unfaithful, even in the absence of any concrete evidence. This type of pathological jealousy can lead to socially unacceptable behavior, such as stalking, accusations, and even violence. People with Othello’s syndrome may become obsessed with their partner’s every move, constantly checking their phone, email, and social media accounts for signs of infidelity. They may also isolate themselves from friends and family, becoming increasingly paranoid and controlling.
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This question is part of the following fields:
- Psychiatry
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Question 19
Incorrect
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A 7-year-old boy and his mother die in a car crash. Following these deaths, the boy’s 16-year-old brother starts playing with the dead boy’s toys.
This would most likely be an example of which of the following defence mechanisms?Your Answer: Reaction formation
Correct Answer: Identification
Explanation:Defense Mechanisms: Coping Strategies for Unconscious Thoughts and Emotions
Defense mechanisms are unconscious coping strategies that individuals use to protect themselves from anxiety, guilt, and other negative emotions. These mechanisms can be helpful in reducing the impact of stressful situations, but they can also lead to maladaptive behaviors if used excessively. Here are some common defense mechanisms:
Identification: This mechanism involves adopting the characteristics or activities of another person to reduce the pain of separation or loss. For example, a child may imitate a favorite teacher to cope with the absence of a parent.
Rationalization: This mechanism involves offering a false but acceptable explanation for behavior to avoid feelings of guilt or shame. For example, a student who fails an exam may blame the teacher for not providing enough study materials.
Denial: This mechanism involves behaving as if one does not know something that they should reasonably be expected to know. For example, a person with a drinking problem may deny that they have a problem despite evidence to the contrary.
Reaction Formation: This mechanism involves adopting behavior that is opposite to one’s true feelings. For example, a person who is attracted to someone they consider inappropriate may express disgust or hostility towards that person.
Sublimation: This mechanism involves directing unacceptable impulses into acceptable outlets. For example, a person with aggressive tendencies may channel their energy into sports or other physical activities.
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This question is part of the following fields:
- Psychiatry
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Question 20
Incorrect
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A 50-year-old man with schizophrenia who is on chlorpromazine experiences a bilateral resting tremor. Which side effect of antipsychotic medication does this exemplify?
Your Answer: Tardive dyskinesia
Correct Answer: Parkinsonism
Explanation:Antipsychotics are a group of drugs used to treat schizophrenia, psychosis, mania, and agitation. They are divided into two categories: typical and atypical antipsychotics. The latter were developed to address the extrapyramidal side-effects associated with the first generation of typical antipsychotics. Typical antipsychotics work by blocking dopaminergic transmission in the mesolimbic pathways through dopamine D2 receptor antagonism. They are associated with extrapyramidal side-effects and hyperprolactinaemia, which are less common with atypical antipsychotics.
Extrapyramidal side-effects (EPSEs) are common with typical antipsychotics and include Parkinsonism, acute dystonia, sustained muscle contraction, akathisia, and tardive dyskinesia. The latter is a late onset of choreoathetoid movements that may be irreversible and occur in 40% of patients. The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients, including an increased risk of stroke and venous thromboembolism. Other side-effects include antimuscarinic effects, sedation, weight gain, raised prolactin, impaired glucose tolerance, neuroleptic malignant syndrome, reduced seizure threshold, and prolonged QT interval.
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This question is part of the following fields:
- Psychiatry
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Question 21
Correct
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A 40-year-old woman was admitted to the psychiatric ward with paranoid delusions, auditory hallucinations and violent behaviour. There was no past medical history. She was diagnosed with schizophrenia and given intramuscular haloperidol regularly. Four days later, she became febrile and confused. The haloperidol was stopped, but 2 days later, she developed marked rigidity, sweating and drowsiness. She had a variable blood pressure and pulse rate. Creatine phosphokinase was markedly raised.
What is the most likely diagnosis?Your Answer: Neuroleptic malignant syndrome
Explanation:Understanding Neuroleptic Malignant Syndrome: A Potentially Life-Threatening Reaction to Neuroleptic Medication
Neuroleptic malignant syndrome (NMS) is a rare but serious reaction to neuroleptic medication. It is characterized by hyperpyrexia (high fever), autonomic dysfunction, rigidity, altered consciousness, and elevated creatine phosphokinase levels. Treatment involves stopping the neuroleptic medication and cooling the patient. Medications such as bromocriptine, dantrolene, and benzodiazepines may also be used.
It is important to note that other conditions, such as cerebral abscess, meningitis, and phaeochromocytoma, do not typically present with the same symptoms as NMS. Serotonin syndrome, while similar, usually presents with different symptoms such as disseminated intravascular coagulation, renal failure, tachycardia, hypertension, and tachypnea.
If you or someone you know is taking neuroleptic medication and experiences symptoms of NMS, seek medical attention immediately. Early recognition and treatment can be life-saving.
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This question is part of the following fields:
- Psychiatry
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Question 22
Correct
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A 38-year-old teacher has called for the pest controller for the third time in the past month. She is worried that her house is infested with rats and she frequently checks under the beds and around the property for any signs of the infestation. She mentions that she saw a therapist in her early twenties for obsessive hand washing and underwent a brief period of cognitive behavioural therapy.
Upon physical examination, there are no abnormalities found. However, upon further questioning, she admits to feeling compelled to check for rats and is constantly anxious about cleanliness.
What is the most probable diagnosis?Your Answer: Obsessive-compulsive disorder (OCD)
Explanation:Differentiating OCD from other mental health conditions
Obsessive-compulsive disorder (OCD) is characterized by repetitive cycles of ritualistic behavior. It is important to differentiate OCD from other mental health conditions such as schizophrenia, anxiety, bipolar disease, and depression. Cognitive behavioral therapy and exposure response prevention are the mainstays of therapy for OCD, along with medication. Features consistent with schizophrenia, anxiety, bipolar disease, and depression are absent in OCD. Understanding the differences between these conditions is crucial in providing appropriate treatment.
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This question is part of the following fields:
- Psychiatry
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Question 23
Incorrect
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A 29-year-old man is admitted to a medical ward for treatment of an abscess in his leg. He has a history of intravenous heroin use and reports that he is beginning to experience symptoms of opioid withdrawal. What is the most appropriate course of action for this patient?
Your Answer: Ask her how much heroin she uses per day and give her a dose of methadone syrup equivalent to this
Correct Answer: Give her 60 mg of codeine phosphate and wait 30 minutes to determine its effect
Explanation:Managing Acute Opioid Withdrawal in Heroin Users
Managing acute opioid withdrawal in patients who are actively using heroin can be challenging. However, a good way to manage this is by titrating codeine to effect. Codeine can be given in doses of 30-60 mg and repeated every 30 minutes until the symptoms begin to subside. It is important to note that most trusts will have a local policy on this matter.
If a patient normally takes methadone, it is crucial to contact their dispensing pharmacy to confirm their dose before administering codeine. Codeine can be used in the meantime to alleviate symptoms of opioid withdrawal. By following this approach, healthcare professionals can effectively manage acute opioid withdrawal in heroin users.
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This question is part of the following fields:
- Psychiatry
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Question 24
Correct
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Sarah is a 38-year-old female who was diagnosed with post-traumatic stress disorder (PTSD) following a car accident two years ago. Similar to Steven, Sarah has been experiencing difficulty with sleep since the accident. She frequently wakes up in the middle of the night due to nightmares and struggles to fall back asleep. This has been affecting her daily life as she no longer has the energy to keep up with her young children.
Sarah has undergone several sessions of cognitive behavioural therapy (CBT), but unfortunately, she has not seen any significant improvement in her symptoms.
What would be the appropriate medication to manage Sarah's condition?Your Answer: Venlafaxine
Explanation:If CBT or EMDR therapy prove ineffective in treating PTSD, the recommended first-line drug treatments are venlafaxine or a SSRI. Tricyclic antidepressants like amitriptyline may also be used under the supervision of a mental health specialist, but they are not currently part of NICE guidance. Diazepam and zopiclone are only recommended for short-term management of severe symptoms or acute exacerbations of insomnia, and do not address the underlying cause of PTSD. Risperidone may be considered for patients with disabling symptoms or behaviors that have not responded to other treatments.
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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This question is part of the following fields:
- Psychiatry
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Question 25
Incorrect
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A 27-year-old is brought to the on-call psychiatry team at a hospital after being found wandering aimlessly on the streets. The patient had a breakdown in a local convenience store where they were caught stealing cigarettes and had a violent outburst when confronted by the store clerk. When asked about their behavior, they state that they do not care about the consequences of their actions and that they have stolen many times before. They also admit to enjoying hurting others in the past and have a history of animal cruelty. Although they report self-harming in the past, there are no visible scars.
Which of the following characteristics would be more indicative of a diagnosis of antisocial personality disorder rather than borderline personality disorder?Your Answer: Concurrently low mood
Correct Answer: Male gender
Explanation:Men are more commonly affected by antisocial personality disorder, while borderline personality disorder is more frequently diagnosed in young women. However, there can be some overlap in the symptoms of both disorders, such as impulsivity. Borderline personality disorder is characterized by unstable emotions, fluctuating self-image, and recurrent thoughts of self-harm or suicide. On the other hand, antisocial personality disorder is marked by a repeated failure to follow social norms or rules, reckless behavior that endangers oneself and others, and a lack of remorse for these actions. If there are persistent mood changes or psychotic symptoms present, it may indicate a different primary diagnosis than a personality disorder.
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.
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This question is part of the following fields:
- Psychiatry
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Question 26
Correct
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A 32-year-old woman has come to her doctor for a medication review. She was diagnosed with bipolar disorder 10 months ago and has been taking olanzapine 10 mg once daily and lithium carbonate 600mg twice daily. While her psychological symptoms have improved, she has been feeling more fatigued in the past few weeks. Additionally, she has noticed a decrease in appetite and has experienced bouts of constipation. What is the most probable cause of her symptoms?
Your Answer: Hypothyroidism due to lithium toxicity
Explanation:Chronic lithium toxicity is the leading cause of hypothyroidism, which is the most common endocrine disorder. The onset of this condition typically occurs within 6 to 18 months of starting lithium treatment, although the exact mechanism by which lithium inhibits thyroid hormone release is not well understood. While olanzapine does not cause hypothyroidism or hypercalcemia, lithium is not associated with hypoadrenalism. Although undertreatment of bipolar disorder can lead to a depressive episode, the patient in this case has experienced an improvement in mood and the emergence of new somatic symptoms, making hypothyroidism due to lithium toxicity a more probable diagnosis.
Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in treatment-resistant depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. The mechanism of action is not fully understood, but it is believed to interfere with inositol triphosphate and cAMP formation. Adverse effects may include nausea, vomiting, diarrhea, fine tremors, nephrotoxicity, thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, hyperparathyroidism, and hypercalcemia.
Monitoring of patients taking lithium is crucial to prevent adverse effects and ensure therapeutic levels. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until levels are stable. Once established, lithium levels should be checked every three months. Thyroid and renal function should be monitored every six months. Patients should be provided with an information booklet, alert card, and record book to ensure proper management of their medication. Inadequate monitoring of patients taking lithium is common, and guidelines have been issued to address this issue.
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This question is part of the following fields:
- Psychiatry
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Question 27
Correct
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A 20-year-old man with moderate learning difficulty visits your clinic with his father. His father complains that he has trouble sleeping at night and frequently wakes up, disrupting his own sleep and causing him to be excessively drowsy during the day. He frequently takes a nap in the late afternoon, which is impacting his ability to participate in local community services. They have already attempted conventional sleep hygiene recommendations. Given the history of learning difficulty, what would be the most appropriate medication to assist with his sleep problems?
Your Answer: Melatonin
Explanation:Medication Options for Sleep Disturbance in Patients with Learning Disabilities
Patients with learning disabilities often experience chronic sleep-wake cycle disruption, leading to insomnia. Melatonin has been found to be effective in regulating natural sleep-wake cycles and treating insomnia in these patients. However, it is not licensed for use in individuals under 55 years old and should only be prescribed by a psychiatrist with expertise in sleep disturbance in learning disability.
Other medications, such as zopiclone, diazepam, promethazine, and trazodone, can also be used for insomnia. Zopiclone is helpful for patients with trouble falling asleep, while diazepam can be used for anxiety and sedation but may lead to dependence. Promethazine is useful for maintaining sleep, particularly in cases of agitation or insomnia. Trazodone, on the other hand, is an antidepressant medication with sedating properties and is typically used for patients with depression and sleep disturbance.
However, given the history of learning disability in the stem, melatonin would be the most appropriate medication to trial in this patient. It is important to consult with a psychiatrist with expertise in sleep disturbance in learning disability to determine the best course of treatment.
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This question is part of the following fields:
- Psychiatry
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Question 28
Incorrect
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A 50-year-old woman comes to you complaining of experiencing electric shock sensations and dizziness in her arms and legs for the past three days. She has a medical history of chronic pain, depression, and schizophrenia. When you inquire about her medications and drug use, she seems hesitant to provide a clear answer. What could be the probable reason behind her symptoms?
Your Answer: Opiate withdrawal
Correct Answer: SSRI discontinuation syndrome
Explanation:If someone suddenly stops or reduces their use of SSRIs, they may experience symptoms of SSRI discontinuation syndrome, including dizziness, electric shock sensations, and anxiety. It is possible that this woman has decided to stop taking her antidepressants. Symptoms of alcohol withdrawal typically include anxiety, tremors, and sweating. Neuroleptic malignant syndrome is a rare reaction that can occur with antipsychotic use and may present with fever, confusion, and muscle rigidity. Opiate withdrawal may cause anxiety, sweating, and gastrointestinal symptoms such as diarrhea and vomiting.
Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.
The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.
When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.
When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.
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This question is part of the following fields:
- Psychiatry
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Question 29
Incorrect
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A 49-year-old male with schizophrenia is being evaluated by his psychiatrist. According to his family, he has become increasingly apathetic and neglectful of his personal hygiene and household chores. When asked about his behavior, he responds with statements such as it doesn't matter and why bother? What symptom of schizophrenia is this patient exhibiting?
Your Answer: Anhedonia
Correct Answer: Apathy
Explanation:Common Symptoms of Schizophrenia
Schizophrenia is a mental disorder that affects a person’s ability to think, feel, and behave clearly. It is characterized by a range of symptoms, including apathy, affective flattening, alogia, anhedonia, and catatonia. Apathy is a feeling of indifference and lack of interest in things that would normally be enjoyable or important. Affective flattening refers to a reduced range of emotional expression, making it difficult for the person to express their feelings appropriately. Alogia is a lack of spontaneous speech, making it difficult for the person to communicate effectively. Anhedonia is the inability to experience pleasure from activities that were once enjoyable. Finally, catatonia is a disturbance in motor function, which can cause the person to become unresponsive to their environment.
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This question is part of the following fields:
- Psychiatry
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Question 30
Incorrect
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A 72-year-old female visits her GP due to concerns about memory loss. She has been experiencing forgetfulness and absent-mindedness for the past three weeks. She cannot recall conversations that occurred earlier in the day and has forgotten to lock her front door. Additionally, she has been feeling fatigued and has lost interest in her usual activities, such as going out for walks. Living alone, she is worried about the potential risks associated with her memory loss. Although initially appearing cheerful, she becomes emotional and starts crying while discussing her symptoms. The following blood test result is obtained: TSH 2 mU/L. What is the most probable cause of her presentation?
Your Answer: Lewy body dementia
Correct Answer: Depression
Explanation:Depression and dementia can be distinguished based on their respective characteristics. Depression typically has a short history and a sudden onset, which can cause memory loss due to lack of concentration. Other symptoms include fatigue and loss of interest in usual activities. Hypothyroidism can be ruled out if TSH levels are normal. On the other hand, dementia progresses slowly and patients may not notice the symptoms themselves. It is usually others who notice the symptoms, and memory loss is not a concern for patients with dementia. Finally, there is no indication of bipolar disorder as there is no history of manic episodes.
Differentiating between Depression and Dementia
Depression and dementia are two conditions that can have similar symptoms, making it difficult to distinguish between the two. However, there are certain factors that can suggest a diagnosis of depression over dementia.
One of the key factors is the duration and onset of symptoms. Depression often has a short history and a rapid onset, whereas dementia tends to develop slowly over time. Additionally, biological symptoms such as weight loss and sleep disturbance are more commonly associated with depression than dementia.
Patients with depression may also express concern about their memory, but they are often reluctant to take tests and may be disappointed with the results. In contrast, patients with dementia may not be aware of their memory loss or may not express concern about it.
The mini-mental test score can also be variable in patients with depression, whereas in dementia, there is typically a global memory loss, particularly in recent memory.
In summary, while depression and dementia can have overlapping symptoms, careful consideration of the duration and onset of symptoms, biological symptoms, patient concerns, and cognitive testing can help differentiate between the two conditions.
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This question is part of the following fields:
- Psychiatry
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