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Question 1
Correct
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A 28-year-old patient presents to her doctor with symptoms of low mood and anhedonia. She has previously undergone cognitive behavioural therapy and art therapy, but with limited success. The doctor prescribes citalopram and refers her for additional talk therapy.
What medication should be avoided while taking citalopram?Your Answer: Rasagiline
Explanation:Combining SSRIs and MAOIs is not recommended due to the potential danger of developing serotonin syndrome.
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 2
Incorrect
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A 28-year-old new mum is seen by the midwife three days post-giving birth. She is tearful, has lost her appetite and worries she is a bad mother. Her midwife reassures her that this is most likely postpartum blues or ‘baby blues’.
What is the incidence of this condition in new mothers?Your Answer: 95-100%
Correct Answer: 50-75%
Explanation:Understanding Postpartum Mood Disorders: From Baby Blues to Postpartum Psychosis
Postpartum mood disorders are common among new mothers, but they can range from mild and transient to severe and potentially life-threatening. The most common form of postpartum mood disorder is postpartum blues, which affects an estimated 50-75% of mothers in the days following childbirth. Symptoms include crying, fatigue, anxiety, irritability, and labile mood, and typically last from hours to a few days. Postpartum blues is thought to be caused by hormonal changes in the body after labor and can be managed with supportive, non-pharmacological measures.
Postpartum depression is a more serious condition that can occur up to a year after birth and affects 10-15% of pregnancies. It is similar to major depression and requires screening by midwives and at the 6-week postnatal check. The Edinburgh Postnatal Depression Scale (EPDS) is a screening questionnaire used to identify women with postnatal depression, and it is important to follow up with mothers who may be depressed on a regular basis.
Postpartum psychosis is a rare but very serious mental health condition that usually develops in the days or weeks following childbirth and affects 0.1-0.5% of mothers. Symptoms may include mania, severe depression, hallucinations, abnormal behavior, and delusions. It is a medical emergency and typically requires inpatient psychiatric treatment.
Understanding the different types of postpartum mood disorders and their symptoms is crucial for healthcare providers to provide appropriate support and treatment for new mothers.
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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 49-year-old man is brought to the emergency department after being found wandering the streets in an agitated state. His medical history includes hepatic steatosis, hypertension, and asthma, and he regularly takes amlodipine and Symbicort. He drinks up to 1 liter of vodka daily and has smoked for 30 years. He has not been seen by his family for 2-3 days before these events. His vital signs are heart rate 111 beats per minute, blood pressure 170/94 mmHg, respiratory rate 23 /min, oxygen saturations 97% on air, and temperature 37.2ºC. He is tremulous, diaphoretic, and agitated. Shortly after examination, he has a self-terminating seizure lasting 30 seconds. Blood tests and a CT head are performed, with the latter being reported as normal. What is the best medication choice to prevent further seizures?
Your Answer: Intravenous levetiracetam
Correct Answer: Oral chlordiazepoxide
Explanation:Chlordiazepoxide is the preferred medication for treating delirium tremens and alcohol withdrawal, not diazepam. Symptoms of minor alcohol withdrawal, such as tremors, anxiety, and headaches, typically appear 6-12 hours after alcohol cessation and can progress to alcoholic hallucinosis, withdrawal seizures, and delirium tremens. Delirium tremens and alcohol withdrawal seizures are treated with chlordiazepoxide as the first-line medication. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score is used to manage alcohol withdrawal in hospital, with benzodiazepines being administered based on the score. Intravenous glucose, intravenous hypertonic saline, and intravenous levetiracetam are not appropriate treatments for delirium tremens and alcohol withdrawal.
Alcohol withdrawal occurs when an individual who has been consuming alcohol chronically suddenly stops or reduces their intake. Chronic alcohol consumption enhances the inhibitory effects of GABA in the central nervous system, similar to benzodiazepines, and inhibits NMDA-type glutamate receptors. However, alcohol withdrawal leads to the opposite effect, resulting in decreased inhibitory GABA and increased NMDA glutamate transmission. Symptoms of alcohol withdrawal typically start at 6-12 hours and include tremors, sweating, tachycardia, and anxiety. Seizures are most likely to occur at 36 hours, while delirium tremens, which includes coarse tremors, confusion, delusions, auditory and visual hallucinations, fever, and tachycardia, peak at 48-72 hours.
Patients with a history of complex withdrawals from alcohol, such as delirium tremens, seizures, or blackouts, should be admitted to the hospital for monitoring until their withdrawals stabilize. The first-line treatment for alcohol withdrawal is long-acting benzodiazepines, such as chlordiazepoxide or diazepam, which are typically given as part of a reducing dose protocol. Lorazepam may be preferable in patients with hepatic failure. Carbamazepine is also effective in treating alcohol withdrawal, while phenytoin is said to be less effective in treating alcohol withdrawal seizures.
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This question is part of the following fields:
- Psychiatry
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Question 4
Incorrect
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A 21-year-old woman is admitted to the psychiatric ward. She has been awake for 4 days and is convinced that she will become the next big pop star by recording 3 albums simultaneously. When asked about her emotions, she immediately talks about her music projects, providing intricate details about each album, her plans for distribution, and her future as a famous musician. She then mentions that her mood has been fantastic because of these topics. When the conversation shifts, she continues to respond in a similar fashion. What term best describes this patient's presentation?
Your Answer: Flight of ideas
Correct Answer: Circumstantiality
Explanation:Circumstantiality is the appropriate term to describe this patient’s response. They provide excessive and unnecessary detail before eventually answering the question about their mood. Flight of ideas, Knight’s move, and perseveration are not applicable in this case as the patient eventually returns to the original topic and follows along with subsequent topic changes.
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 5
Incorrect
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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 clozapine
Correct 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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This question is part of the following fields:
- Psychiatry
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Question 6
Correct
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A 30-year-old bipolar woman has been readmitted to the hospital after attempting to harm herself. She is currently stable. What form of psychotherapy would be most appropriate in this case?
Your Answer: Cognitive behavioural therapy
Explanation:Psychotherapy Options for Schizophrenia
There are several psychotherapy options available for individuals with schizophrenia. Cognitive behavioural therapy (CBT) is a structured, goal-directed, problem-focused, and time-limited therapy that combines principles of both behavioural and cognitive therapy. It focuses on the environment, behaviour, and cognition simultaneously. Brief psychodynamic psychotherapy primarily relies on insight, bringing unconscious or unclear material into awareness, and linking past and present experiences to address the patient’s difficulties. Interpersonal therapy is derived partially from a psychodynamic perspective and focuses primarily on the patient’s interpersonal relationships. It is fairly non-directive and addresses issues such as grief, role transitions, interpersonal role disputes, and interpersonal deficits as they relate to the patient’s current symptoms.
Family therapy is another option that helps family members learn about the disorder, solve problems, and cope more constructively with the patient’s illness. There is evidence that family interventions can reduce relapse rates in schizophrenia. Systemic desensitisation is an exposure-based behavioural treatment that utilises gradual, systematic, repeated exposure to the feared object or situation to allow patients with anxiety disorders to become desensitised to the feared stimulus.
The decision between CBT and family therapy would be highly influenced by patient preference. However, if only CBT is presented as an option, it would be the appropriate choice. It is important to consider the different psychotherapy options available and choose the one that best suits the patient’s needs and preferences.
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This question is part of the following fields:
- Psychiatry
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Question 7
Incorrect
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Samantha is a 35-year-old female who is receiving treatment for bipolar disorder on the psychiatric ward. She has been taking lithium for the past 3 weeks and the doctor needs to check if her levels have stabilised by taking bloods. Samantha's last dose of lithium was at 9am this morning and it is currently 12pm. What is the appropriate time for the doctor to take her bloods?
Your Answer: In 12 hours
Correct Answer: In 9 hours
Explanation:Lithium levels should be checked 12 hours after the last dose, ideally in the evening before bloods are taken the following morning. Taking the sample too soon or too late can lead to incorrect dosing adjustments.
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 8
Incorrect
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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: Borderline 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.
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This question is part of the following fields:
- Psychiatry
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Question 9
Incorrect
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A 21-year-old student has been diagnosed with schizophrenia.
What is the most frequent type of hallucination experienced in schizophrenia?Your Answer: Visual
Correct 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
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This question is part of the following fields:
- Psychiatry
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Question 10
Incorrect
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Which statement about the causation and dynamics of schizophrenia is accurate?
Your Answer: Heavy cannabis use does not increase the risk of developing schizophrenia
Correct Answer: Schizophrenia is commoner in individuals not in stable relationships
Explanation:Schizophrenia Risk Factors
Schizophrenia is a mental disorder that affects a person’s ability to think, feel, and behave clearly. The risk of developing schizophrenia is influenced by various factors, including heavy cannabis use, marital status, socioeconomic status, and genetics.
According to the Swedish conscript study, heavy cannabis users have a sevenfold increase in the risk of developing schizophrenia. However, it is unclear whether cannabis use directly causes schizophrenia or if there are other underlying factors at play.
Marital status also appears to be a factor in schizophrenia risk, with unmarried and divorced individuals being twice as likely to develop the disorder compared to married or widowed individuals. This may be due to the alienating effects of schizophrenia rather than any causal relationship with being single.
Additionally, people with schizophrenia are more likely to be in the lowest socioeconomic groups. While poverty may not directly cause schizophrenia, it may increase the risk of exposure to biological factors or social stressors that could trigger the illness in susceptible individuals.
Finally, genetics also play a significant role in schizophrenia risk, with monozygotic twins having a 50% concordance rate and 10% of offspring being affected. This suggests a strong inheritance component to the disorder.
Overall, while the exact causes of schizophrenia are not fully understood, it is clear that multiple factors contribute to its development.
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This question is part of the following fields:
- Psychiatry
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Question 11
Incorrect
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A 32-year-old with a long standing history of schizophrenia presents to the emergency department in status epilepticus. After receiving treatment, he informs the physician that he has been experiencing frequent seizures lately.
Which medication is the most probable cause of his seizures?Your Answer: Haloperidol
Correct Answer: Clozapine
Explanation:Seizures are more likely to occur with the use of clozapine due to its ability to lower the seizure threshold. This is a known side-effect of the atypical antipsychotic, which is commonly prescribed for treatment resistant schizophrenia.
Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.
Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.
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This question is part of the following fields:
- Psychiatry
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Question 12
Correct
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A 17-year-old male student spontaneously disrobed while watching a film. He saw wavy lines on the screen and then reported a brief episode of mental blankness, followed soon after by a headache and extreme fatigue.
What is the most likely diagnosis?Your Answer: Partial complex seizure or Focal Impaired Awareness epilepsy
Explanation:Neuropsychiatric Syndromes and Seizure Disorders: Understanding the Differences
Seizure disorders can be complex and varied, with different symptoms and causes. One type of seizure disorder is the partial complex seizure (PCS), which is confined to the limbic structures of the brain. Symptoms of PCS can include visual distortions and disruptions of cognitive function. Patients may also experience intense dysphoria, anxiety, or rage during or after a seizure. However, organised, directed violent behaviour is not typical of a seizure.
Another type of seizure disorder is the generalised tonic-clonic epilepsy, which can cause a loss of consciousness and convulsions. Inhibition-type behaviour is not typical of this disorder, and there is no history of tonic-clonic seizure activity.
Schizophreniform disorder is a condition that involves schizophrenic symptoms of short duration. Patients with repeated focal seizures may exhibit personality changes that closely resemble chronic schizophrenia, such as passivity, unusual sexual behaviour, anhedonia, obsessiveness, religiosity, and psychosis.
Migraine behavioural syndrome can involve visual auras, but it is unlikely to involve bizarre behaviour such as inappropriate disrobing. Finally, exhibitionism involves attracting attention to oneself, such as compulsive exposure of genitals in public.
Understanding the differences between these neuropsychiatric syndromes and seizure disorders is important for accurate diagnosis and treatment.
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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 30-year-old male is brought to the emergency department by his friends as they are concerned that he is talking and behaving oddly.
When asked about the health of his parents he responded that Yesterday I went to visit my father. He was on the roof cleaning the gutters. This seems like a dangerous activity, as there is a high risk of falling and causing an injury. Still, we are all at risk of injuries a lot of the time, for example when driving our cars. We could also cause injuries to ourselves simply by tripping and falling. I think you are at greater risk of falling if your house is poorly lit, you have trip hazards such as loose cables and if your reflexes or depth perception are impaired, for example, when you are intoxicated. When I saw my father yesterday he seemed well and he has no current medical conditions.
What is the best term to describe the abnormality of speech that the patient is demonstrating?Your Answer: Echolalia
Correct Answer: Circumstantiality
Explanation:– Circumstantiality: vague speech that wanders off topic before returning to answer the question
– Clanging: using words that sound similar instead of their meaning
– Echolalia: repeating what the examiner says
– Neologism: creating new words
– Perseveration: repeating a word or activity too much -
This question is part of the following fields:
- Psychiatry
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Question 14
Incorrect
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A 29-year-old man experiences a sudden emergence of auditory hallucinations describing his actions. He also firmly believes that he has been chosen by a divine entity as a prophet, which contradicts his religious convictions. During the mental state examination, the patient exhibits tangentiality and clanging. After a fortnight, the patient's symptoms disappear entirely. The patient had a history of depression during his late adolescence, but no prior comparable incidents. What disorder did this patient have?
Your Answer: Bipolar affective disorder
Correct Answer: Brief psychotic disorder
Explanation:The patient experienced psychosis, including hallucinations, delusions, and thought disorganisation. The correct diagnosis is brief psychotic disorder, which refers to a short-lived episode of psychosis followed by a return to normal functioning. Bipolar affective disorder is an incorrect diagnosis as there are no signs of manic episodes. Drug abuse is also an unlikely cause as there is no evidence of drug use in the patient’s history. Schizoaffective disorder is also an incorrect diagnosis as it involves both psychotic and mood symptoms occurring together, which is not the case for this patient.
Understanding Psychosis
Psychosis is a term used to describe a person’s experience of perceiving things differently from those around them. This can manifest in various ways, including hallucinations, delusions, thought disorganization, alogia, tangentiality, clanging, and word salad. Associated features may include agitation/aggression, neurocognitive impairment, depression, and thoughts of self-harm. Psychotic symptoms can occur in a range of conditions, such as schizophrenia, depression, bipolar disorder, puerperal psychosis, brief psychotic disorder, neurological conditions, and drug use. The peak age of first-episode psychosis is around 15-30 years.
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This question is part of the following fields:
- Psychiatry
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Question 15
Incorrect
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Electroconvulsive Therapy (ECT) is recommended by NICE for which clinical conditions?
Your Answer: In a patient with bipolar affective disorder, currently in a hypomanic episode
Correct Answer: In a catatonic patient
Explanation:Electroconvulsive therapy (ECT) should only be considered as a treatment option for individuals with severe major depressive disorder that is potentially life-threatening, and where other treatments have been ineffective. It is also recommended for those experiencing catatonia or a prolonged/severe manic episode.
Electroconvulsive therapy (ECT) is a viable treatment option for patients who suffer from severe depression that does not respond to medication, such as catatonia, or those who experience psychotic symptoms. The only absolute contraindication for ECT is when a patient has raised intracranial pressure.
Short-term side effects of ECT include headaches, nausea, short-term memory impairment, memory loss of events prior to the therapy, and cardiac arrhythmia. However, these side effects are typically temporary and resolve quickly.
Long-term side effects of ECT are less common, but some patients have reported impaired memory. It is important to note that the benefits of ECT often outweigh the potential risks, and it can be a life-changing treatment for those who have not found relief from other forms of therapy.
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This question is part of the following fields:
- Psychiatry
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Question 16
Incorrect
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A 36-year-old man is brought to the Emergency Mental Health Ward. He is speaking rapidly, claiming to be the ‘new Messiah’ and insisting that he has the ability to cure acquired immune deficiency syndrome (AIDS) with the assistance of his friends who are providing him with undisclosed 'classified' knowledge.
What medication would be appropriate to administer to this individual?Your Answer: Citalopram
Correct Answer: Olanzapine
Explanation:Choosing the Right Medication for Psychosis: A Comparison of Olanzapine, Diazepam, Citalopram, Clozapine, and Zopiclone
When a patient presents with psychosis, it is crucial to assess them urgently and rule out any organic medical causes. The primary treatment for psychosis is antipsychotics, such as olanzapine. While benzodiazepines like diazepam can be used to treat agitation associated with acute psychosis, they are not the first-line treatment. Citalopram, a selective serotonin reuptake inhibitor used for depression, would not be appropriate for treating psychosis. Clozapine, another antipsychotic, is only used on specialist advice due to the risk of agranulocytosis. Zopiclone, a hypnotic used for sleep, is not appropriate for treating psychosis. It is important to choose the right medication for psychosis to ensure the best possible outcome for the patient.
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This question is part of the following fields:
- Psychiatry
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Question 17
Incorrect
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A 36-year-old man with a known history of severe depression has been in hospital for the past year. He was diagnosed with depression at the age of 23 and has been on antidepressants since. He has had multiple self-harm and suicide attempts in the past. For the past year, he has been receiving treatment in hospital and has been making some progress with regard to his mental health. He is not happy to be in hospital, but the doctors thought that it was in his best interests to keep him in hospital for treatment. He has been under a Section which allowed him to be kept in hospital for six months. At the end of the first six months, the doctors applied for a second time for him to be kept for another six months, as they feel he is not yet fit for discharge.
For how long can the relevant Section be renewed for this patient for the third time?Your Answer: Three months
Correct Answer: One year
Explanation:Understanding the Time Limits of Mental Health Detention in the UK
In the UK, mental health detention is governed by specific time limits depending on the type of detention and the purpose of the detention. Here are some of the key time limits to be aware of:
– Section 2: This is the Section used for assessment, and a patient can be kept in hospital for a maximum of 28 days under this Section. It cannot be extended.
– Section 3: This is the Section used for treatment, and a patient can be detained for up to six months initially. The Section can be renewed for another six months, and then for one year at a time. Treatment without consent can be given for the first three months, and then only with the approval of an ‘approved second-opinion doctor’ for the next three months.
– Two years: While a patient can be kept in hospital for up to two years for treatment, Section 3 cannot be renewed for two years at a time. The patient can also be discharged earlier if the doctor thinks the patient is well enough.
– Six months: This is the time for which an initial Section 3 can be applied for and the time for which it can be renewed for a second time. For a third time and onwards, Section 3 can be renewed for one year each time, but the patient can be discharged earlier if doctors think it is not necessary for the patient to be under Section anymore.Understanding these time limits is important for both patients and healthcare professionals involved in mental health detention in the UK.
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This question is part of the following fields:
- Psychiatry
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Question 18
Incorrect
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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: Zopiclone
Correct 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 19
Correct
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You are advising a 35-year-old woman with major depressive disorder who is contemplating electroconvulsive therapy (ECT).
What is a temporary side effect of this treatment?Your Answer: Cardiac arrhythmias
Explanation:Knowing the side effects of ECT is crucial as it is a treatment that is often viewed with apprehension by the public. ECT is typically used to treat depression that is resistant to other treatments, as well as severe mania and catatonic schizophrenia. While it was once a feared treatment due to its use of high strengths and lack of anesthesia, it is now considered to be a relatively safe intervention. Short-term side effects of ECT include headaches, nausea, memory problems, and cardiac arrhythmias. There are few long-term effects, although some patients may experience long-term memory issues. ECT is used to treat mania and is being studied as a potential treatment for Parkinson’s disease. It induces a generalized seizure but is not associated with epilepsy or glaucoma.
Electroconvulsive therapy (ECT) is a viable treatment option for patients who suffer from severe depression that does not respond to medication, such as catatonia, or those who experience psychotic symptoms. The only absolute contraindication for ECT is when a patient has raised intracranial pressure.
Short-term side effects of ECT include headaches, nausea, short-term memory impairment, memory loss of events prior to the therapy, and cardiac arrhythmia. However, these side effects are typically temporary and resolve quickly.
Long-term side effects of ECT are less common, but some patients have reported impaired memory. It is important to note that the benefits of ECT often outweigh the potential risks, and it can be a life-changing treatment for those who have not found relief from other forms of therapy.
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This question is part of the following fields:
- Psychiatry
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Question 20
Correct
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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: 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 21
Correct
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A 52-year-old man presents to his GP with a 6-month history of erectile dysfunction. He reports a weaker morning erection and difficulty maintaining an erection during sexual activity. He feels depressed about his symptoms. Upon further questioning, he mentions that his morning erection is still present but weaker than usual. He also admits to consuming approximately 50 units of alcohol per week and gaining weight recently. Despite his symptoms, he remains hopeful for improvement. What signs would indicate a psychological origin for his condition?
Your Answer: Stress leading to performance anxiety
Explanation:Stress can lead to performance anxiety, which can cause erectile dysfunction. If the cause of erectile dysfunction is organic, there would be a loss of morning erections and difficulty during sexual activity. However, if the cause is psychological, men still get erections in the mornings but not during sexual activity. Previous transurethral resection of the prostate (TURP) for prostate cancer can also cause erectile dysfunction. Excessive alcohol consumption, such as drinking 50-60 units per week, can also lead to erectile dysfunction. Symptoms such as feeling tired all the time, low mood, gaining weight, and hopelessness may suggest hypothyroidism, which can also cause erectile dysfunction. Tenderness and enlargement of breast tissue may indicate hyperprolactinaemia, which can be caused by a pituitary adenoma or iatrogenic factors. Checking prolactin levels is necessary to diagnose hyperprolactinaemia.
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This question is part of the following fields:
- Psychiatry
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Question 22
Incorrect
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A 24-year-old medical student presents to the emergency department accompanied by his partner, reporting a 10-hour history of aggression, irritability, and hallucinations. The partner suspects a mental breakdown due to sleep deprivation from studying for exams. Laboratory tests for drugs and infection are negative. The patient is admitted for observation and returns to baseline the following day.
What is the probable diagnosis?Your Answer: Adjustment disorder
Correct Answer: Brief psychotic disorder
Explanation:The correct answer is Brief psychotic disorder, which is a short-term disturbance characterized by the sudden onset of at least one positive psychotic symptom. These symptoms include delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. The disorder often resolves with a return to baseline functioning. Adjustment disorder, bipolar disorder, and schizoaffective disorder are not the correct answers as they are different mental health conditions with distinct symptoms and characteristics.
Understanding Psychosis
Psychosis is a term used to describe a person’s experience of perceiving things differently from those around them. This can manifest in various ways, including hallucinations, delusions, thought disorganization, alogia, tangentiality, clanging, and word salad. Associated features may include agitation/aggression, neurocognitive impairment, depression, and thoughts of self-harm. Psychotic symptoms can occur in a range of conditions, such as schizophrenia, depression, bipolar disorder, puerperal psychosis, brief psychotic disorder, neurological conditions, and drug use. The peak age of first-episode psychosis is around 15-30 years.
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This question is part of the following fields:
- Psychiatry
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Question 23
Correct
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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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This question is part of the following fields:
- Psychiatry
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Question 24
Correct
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While working in psychiatry, you are taking a history from a patient with a new diagnosis of generalised anxiety disorder (GAD). You take a thorough past medical history. Which of the following is a risk factor for GAD development?
Your Answer: Being divorced or separated
Explanation:Generalised anxiety disorder is more likely to occur in individuals who are divorced or separated.
There are several risk factors associated with the development of GAD, including being between the ages of 35 and 54, living alone, and being a lone parent. On the other hand, being between the ages of 16 and 24 and being married or cohabiting are protective factors against GAD.
It is important to note that having a hyperthyroid disease or atrial fibrillation may cause symptoms similar to GAD, but they are not considered risk factors for developing the disorder.
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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This question is part of the following fields:
- Psychiatry
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Question 25
Correct
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A 38-year-old woman who has often presented with various physical complaints is diagnosed with generalised anxiety disorder. Despite receiving low intensity psychological interventions, her symptoms remain unchanged. What medication would be the most suitable next step in her treatment?
Your Answer: Sertraline
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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This question is part of the following fields:
- Psychiatry
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Question 26
Incorrect
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A mental state examination is conducted on a 32-year-old individual. When asked about their breakfast, they start by describing their morning routine, then talk about their favourite recipes, followed by a story about a cooking competition they participated in, and finally mention having cereal for breakfast. Their speech is at a regular pace and flow.
What type of thought process is demonstrated in this scenario?Your Answer: Derailment of thoughts
Correct Answer: Circumstantiality
Explanation:Circumstantiality refers to the tendency to provide excessive and unnecessary detail when answering a question, ultimately reaching the intended goal but taking a circuitous route. This is different from tangentiality, where the patient wanders away from the topic without returning, derailment of thoughts, where there are illogical jumps between topics, and flight of ideas, where the patient quickly moves from one related topic to another.
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 27
Incorrect
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A 50-year-old male with schizophrenia is evaluated by his psychiatrist, who has been his doctor for more than a decade. During the consultation, the psychiatrist observes that the patient provides brief responses to all inquiries and appears to lack the spontaneous speech that would typically accompany such a response. For instance, when asked How have your grandchildren been since I last saw you?, the patient replies, Fine. Later on, the psychiatrist inquires, Which of your grandchildren are doing well? The patient responds, Samantha. It takes several more questions to determine that Samantha has been excelling in school and has recently won an award.
Which symptom of schizophrenia is the patient exhibiting?Your Answer: Apathy
Correct Answer: Alogia
Explanation:Symptoms of Schizophrenia
Alogia, affective flattening, anhedonia, apathy, and formal thought disorder are all symptoms of schizophrenia. Alogia is characterized by a lack of spontaneous speech, where the individual fails to elaborate on their answers in a way that is expected. Affective flattening refers to the loss of a normal range of emotional expression, where the individual may not react appropriately to events. Anhedonia is the inability to experience pleasure from activities that were once enjoyable. Apathy is a sense of indifference and lack of interest in things that would normally be of interest. Formal thought disorder can manifest in various ways, such as circumstantiality, tangentiality, or derailments. These symptoms can significantly impact an individual’s ability to function in daily life and can be distressing for both the individual and their loved ones.
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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 25-year-old woman who is a law student has severe anxiety about public speaking and in informal social settings. She avoids situations where she might have to enter into conversations with strangers. She reports that she thinks others are frustrated by her inability in casual social interactions and that she ‘feels stupid and awkward’. Her social problems are also affecting her academic performance. She is considering leaving university for a less stressful environment.
Which is the most appropriate form of psychotherapy for this woman?Your Answer: Psychoanalytic psychotherapy
Correct Answer: Cognitive behavioural therapy
Explanation:Choosing the Right Treatment for Social Phobia: Cognitive Behavioural Therapy
Social phobia is a type of anxiety disorder that can cause panic and avoidance of social situations. For patients with this condition, cognitive behavioural therapy (CBT) is often the best treatment option. CBT can help patients identify and change negative thought patterns that contribute to their anxiety, and it often includes exposure therapy as a component.
Other treatment options, such as vocational counselling or psychoanalytic psychotherapy, may not be as effective for social phobia. Suggesting these options could reinforce the patient’s belief that their symptoms cannot be treated therapeutically. Network therapy is designed for substance abusers, and self-help groups may be helpful for some patients, but only if they can manage their anxiety enough to participate effectively.
In summary, for patients with social phobia, cognitive behavioural therapy is the most effective treatment option. It can help patients overcome their anxiety and improve their quality of life.
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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 38-year-old man presents to the Emergency Department complaining of epigastric pain. The patient reports that he developed acute abdominal pain 2 hours prior to presentation after eating a cheeseburger. The patient otherwise has no significant past medical history. He does not take any medications and denies smoking, alcohol consumption and drug use. He has been recently been released from prison and has not got stable living and has had to sleep outside since his release.
On examination, the patient has normal vital signs. His abdominal examination demonstrates normoactive bowel sounds, no tenderness to palpation in the epigastrium and no guarding or rebound tenderness. Rectal exam for stool occult blood is negative and a chest X-ray does not reveal free air under the diaphragm. A right upper quadrant ultrasound does not demonstrate stones. The doctor recommends antacids. When the doctor tells the patient that he is safe for discharge, the patient insists that he must be admitted to hospital for further tests.
Which of the following is the most likely diagnosis?Your Answer: Hypochondriasis
Correct Answer: Malingering
Explanation:Differentiating between Malingering, Factitious Disorder, Conversion Disorder, and Hypochondriasis
When a patient presents with physical symptoms but there are no physical or imaging signs of significant illness, the likely diagnosis is malingering. In such cases, it is important to investigate the patient’s history to see if there could be other factors impacting their symptoms. Malingering is often suspected when a patient insists on staying in the hospital despite negative test results.
Factitious disorder refers to a patient who assumes the sick role without any physical or organic disease. These patients find satisfaction in being taken care of and often seek frequent outpatient visits and psychotherapy.
Factitious or induced illness is similar to factitious disorder, but it involves a patient seeking the sick role vicariously through a second patient. For example, a mother suffering from factitious disorder may abuse her child so that she can bring the child to the doctor for treatment. The patient assumes the sick role by proxy through the child.
Conversion disorder refers to the manifestation of psychological illness as neurologic pathology. Patients with conversion disorder suffer from symptoms such as weakness, numbness, blindness, or paralysis as a result of underlying psychiatric illness. They are often not bothered by their symptoms, a condition known as la belle indifférence.
Hypochondriasis refers to the fear of having a medical illness despite negative tests and reassurance. It is not associated with secondary gain.
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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 39-year-old male has been taking olanzapine for the last 3 years. After experiencing an episode of tardive dyskinesia, he researched the potential side-effects of the medication. What is the most probable biochemical side-effect that this patient may experience?
Your Answer: Hypoprolactineamia
Correct Answer: Hypercholesterolaemia
Explanation:Antipsychotics have been found to cause metabolic side effects such as dysglycaemia, dyslipidaemia, and diabetes mellitus. Olanzapine, along with other antipsychotics, is known to primarily cause hyperlipidemia, hypercholesterolemia, hyperglycemia, and weight gain. These drugs act as dopamine antagonists, leading to hyperprolactinemia as dopamine is a prolactin antagonist. However, they do not have any impact on parathyroid hormones or electrolytes.
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 31
Correct
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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: 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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This question is part of the following fields:
- Psychiatry
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Question 32
Correct
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A 78-year-old man is admitted with new-onset confusion. He is usually independent and enjoys gardening in his spare time. When he didn't show up for his weekly gardening club meeting, a friend went to his house. The friend noticed that the patient appeared disoriented and was speaking nonsensically, prompting them to call for medical assistance.
What distinguishes delirium from dementia?Your Answer: Fluctuating level of consciousness
Explanation:Dementia vs Delirium: Understanding the Differences
Dementia and delirium are two conditions that can affect cognitive abilities and behavior. While they share some similarities, there are also important differences between them.
Dementia is a group of neurodegenerative disorders that cause a progressive decline in cognition and/or behavior from previous levels of functioning. It is characterized by a slow, insidious progression and is rarely reversible. Memory loss, executive functioning problems, speech and language difficulties, social interaction loss, personality changes, and visuospatial problems are some of the areas of loss associated with dementia. Mobility and gait disturbances are also common.
Delirium, on the other hand, is an acute confusional state characterized by a relatively rapid onset and variable, fluctuating progression. It may cause a global reduction in cognitive abilities but is usually reversible if the underlying cause is promptly identified. Common causes include sepsis, medications, metabolic derangement, and causes of raised intracranial pressure.
While there are some similarities between dementia and delirium, there are also some differences. For example, dementia is never associated with a persistent fluctuating level of consciousness, which is a feature of delirium. Visual hallucinations are present in both delirium and dementia, particularly Lewy body dementia. Impaired memory and dysarthria are also present in both conditions, as is urinary incontinence.
In summary, understanding the differences between dementia and delirium is important for proper diagnosis and treatment. While both conditions can affect cognitive abilities and behavior, they have distinct features that can help differentiate them.
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This question is part of the following fields:
- Psychiatry
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Question 33
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 34
Incorrect
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A 50-year-old man visits his GP in a state of distress. He recently returned from a vacation and forgot to renew his prescriptions, resulting in him not taking his medications for the past week. The patient is currently experiencing general discomfort, nausea, and excessive diarrhea. Upon conducting a thorough examination and reviewing his medical history, the GP suspects that his symptoms are due to the discontinuation of one of his medications. The patient has a medical history of depression, gout, hypothyroidism, and type two diabetes mellitus. He also occasionally uses zopiclone to treat his insomnia. Which medication withdrawal is likely causing the patient's symptoms?
Your Answer: Zopiclone
Correct Answer: Paroxetine
Explanation:SSRI discontinuation syndrome can cause gastrointestinal side-effects such as diarrhoea, with paroxetine having a particularly high risk of such symptoms. Withdrawal of SSRIs should be done gradually over several weeks to reduce the incidence of discontinuation symptoms. Colchicine, a gout medication, is associated with gastrointestinal side effects but does not cause significant symptoms upon withdrawal. Levothyroxine withdrawal does not cause any particular symptoms, but stopping long-term use can lead to hypothyroidism symptoms such as constipation. Metformin withdrawal does not cause acute symptoms, but stopping long-term use can worsen diabetic control, and diarrhoea is a side effect of metformin treatment.
Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.
The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.
When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.
When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.
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This question is part of the following fields:
- Psychiatry
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Question 35
Correct
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A 35-year-old male has been diagnosed with a personality disorder by his therapist. He has difficulty maintaining relationships as he often feels that his partners are not trustworthy or committed enough. He becomes jealous and possessive, constantly checking their phone and social media accounts. He also struggles with anger management and has been involved in physical altercations in the past.
What personality disorder is he likely to have been diagnosed with?Your Answer: Obsessive-compulsive
Explanation:The most likely diagnosis for the patient in the stem is obsessive-compulsive personality disorder. This is different from obsessive-compulsive disorder, which involves repetitive compulsions. Patients with obsessive-compulsive personality disorder are often rigid in their morals, ethics, and values, and have difficulty delegating tasks to others. They also exhibit perfectionism, which can interfere with completing tasks and social activities. The patient in the stem has struggled with perfectionism and reluctance to delegate, which has affected her job and free time.
Avoidant personality disorder involves avoiding social contact due to fear of criticism or rejection, which does not fit the patient in the stem. Dependent personality disorder involves difficulty making decisions and requiring reassurance, which is not seen in the stem. Narcissistic personality disorder involves a sense of self-importance and entitlement, which is not evident in the patient in the stem. Schizoid personality disorder involves a lack of close friendships and indifference to praise, but does not involve the moral rigidity and perfectionism seen in the patient in the stem.
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 36
Correct
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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.
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This question is part of the following fields:
- Psychiatry
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Question 37
Incorrect
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A 30-year-old man without known psychiatric history is admitted to the psychiatry ward, after presenting to the emergency department with delusions and homicidal ideations.
Following a negative drugs screen, antipsychotic treatment is initiated with haloperidol.
The patient is reviewed 3-hours after the initiation of treatment and is noted to have a sustained upward deviation of both eyes. When asked, he reports that his eyes are extremely painful.
What is the most appropriate initial management option based on the likely diagnosis?Your Answer: Levodopa
Correct Answer: Procyclidine
Explanation:Acute dystonic reactions, such as oculogyric crisis, can occur within the first 4 days of starting or increasing the dose of antipsychotic medication. These reactions can be treated with anticholinergic procyclidine, which can take effect within 5 minutes. To prevent future attacks, the dose of antipsychotic medication may need to be reduced.
Benzodiazepines, such as diazepam, are not effective in treating acute dystonic reactions. However, they can be used to treat serotonin syndrome, which can occur after taking serotonin agonists like SSRIs and MAOIs. Serotonin syndrome presents with rigidity, hyperreflexia, and autonomic dysfunction.
Levodopa, a dopamine precursor used to treat Parkinson’s disease, is not effective in managing extrapyramidal side effects (EPSEs) caused by antipsychotic medication. EPSEs are caused by dopamine blockage at the mesolimbic pathway, not a dopamine deficiency.
IV fluids are not helpful in treating oculogyric crisis. However, they can be useful in treating neuroleptic malignant syndrome, another side effect that can occur with antipsychotic treatment. Neuroleptic malignant syndrome presents with lead-pipe muscle rigidity, fever, and autonomic dysfunction.
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 38
Incorrect
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A 28-year-old man presents to his GP with ongoing sleep issues due to tension in his relationship with his girlfriend. He feels she is distant and suspects she is spending time with her ex-boyfriend who works in the same office. Upon further questioning, he reveals a history of feeling uninterested in past relationships and struggles with mood swings. He expresses feeling alone in the world and that even his friends are against him. Although he self-harms, he denies any suicidal thoughts. A referral to psychiatry leads to a diagnosis of borderline personality disorder. What is the most appropriate treatment for this patient?
Your Answer: Cognitive behavioural therapy (CBT)
Correct Answer: Dialectical behaviour therapy (DBT)
Explanation:Dialectical behaviour therapy (DBT) is an effective treatment for borderline personality disorder, as it is specifically designed to help individuals who experience intense emotions. Cognitive behavioural therapy (CBT) is not a targeted therapy for personality disorder patients and is more beneficial for those with depression or anxiety-related conditions. Exposure and response prevention therapy (ERP) is a treatment option for patients with obsessive-compulsive disorder, while eye movement desensitisation and reprocessing therapy (EMDR) is a treatment option for patients with post-traumatic stress 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 39
Correct
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A 78-year-old man comes to see you, struggling to cope after his wife passed away suddenly 5 months ago. He appears sad and spends most of the appointment looking down, but answers your questions. He expresses concern that he may be losing his mind because he has started seeing his wife sitting in her old chair and sometimes talks to her when he is alone. He confirms that he can hear her voice responding to him. He says he mostly talks to her while cooking in the kitchen or when he is alone at night. Despite these experiences, he knows that what he sees and hears is not real. He reports occasional memory loss and some abdominal pain due to his irritable bowel syndrome, but is otherwise healthy. He has no history of psychiatric conditions in himself or his family. What is the most likely diagnosis?
Your Answer: Normal grief reaction
Explanation:Pseudohallucinations may be a normal part of the grieving process, and differ from true hallucinations in that the individual is aware that what they are experiencing is not real. While pseudohallucinations can be distressing, they are not considered pathological unless accompanied by urinary symptoms, which would require further investigation. The patient in question displays low mood and avoids eye contact, but responds well to questioning and is able to prepare food independently. While depression with psychotic features can involve true hallucinations, there are no other symptoms to suggest this diagnosis. Lewy-body dementia, which can cause visual hallucinations, Parkinsonian features, and cognitive impairment, is not a likely explanation for this patient’s symptoms. Abnormal grief reactions are typically defined as persisting for at least six months after the loss.
Understanding Pseudohallucinations
Pseudohallucinations are false sensory perceptions that occur in the absence of external stimuli, but with the awareness that they are not real. While not officially recognized in the ICD 10 or DSM-5, there is a general consensus among specialists about their definition. Some argue that it is more helpful to view hallucinations on a spectrum, from mild sensory disturbances to full-blown hallucinations, to avoid misdiagnosis or mistreatment.
One example of a pseudohallucination is a hypnagogic hallucination, which occurs during the transition from wakefulness to sleep. These vivid auditory or visual experiences are fleeting and can happen to anyone. It is important to reassure patients that these experiences are normal and do not necessarily indicate the development of a mental illness.
Pseudohallucinations are particularly common in people who are grieving. Understanding the nature of these experiences can help healthcare professionals provide appropriate support and reassurance to those who may be struggling with them. By acknowledging the reality of pseudohallucinations and their potential impact on mental health, we can better equip ourselves to provide compassionate care to those who need it.
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This question is part of the following fields:
- Psychiatry
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Question 40
Correct
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A 25-year-old basketball player undergoes an anterior cruciate ligament repair following an injury. He is advised by his medical team that he will need an extended period of rest and physiotherapy before he resumes competitive basketball. Following the surgery, he says he feels better and discharges himself. He later goes out with his friends and tells them that he will be back on the court next week.
What type of coping is this?Your Answer: Avoidance
Explanation:Coping Mechanisms: Understanding Different Approaches to Dealing with Stress
When faced with stress, individuals often employ coping mechanisms to manage their emotions and reactions. Here are some common coping mechanisms and their definitions:
Avoidance: This coping mechanism involves denying the existence of a stressor and continuing with one’s usual behavior without making any changes. It is often used when the stressor is too overwhelming to deal with immediately.
Appraisal: Appraisal involves assessing past events and experiences to make decisions for future arrangements. This coping mechanism can help individuals feel more in control of their situation.
Projection: Projection is when an individual attributes unwanted thoughts and feelings onto someone else. This can be a way to avoid dealing with one’s own emotions.
Problem-focused: This coping mechanism involves identifying the causes of a stressor and taking action to reduce or eliminate it. It is a proactive approach to dealing with stress.
Emotion-focused: Emotion-focused coping involves managing the emotions that a stressor creates. This can involve using drugs or other methods to regulate one’s emotional response.
Understanding these coping mechanisms can help individuals choose the most effective approach for dealing with stress in their lives.
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This question is part of the following fields:
- Psychiatry
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Question 41
Incorrect
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A 50-year-old male with a past of alcohol addiction comes in with ataxia, confusion, and nystagmus. During the examination, a weakness in the sixth cranial nerve is observed.
What is the probable diagnosis?Your Answer: Korsakoff's psychosis
Correct Answer: Wernicke encephalopathy
Explanation:Neurological Disorders Associated with Alcoholism
Wernicke encephalopathy is a neurological disorder that occurs due to a deficiency in vitamin B-1, which is essential for carbohydrate metabolism. Alcohol consumption interferes with the absorption of thiamine, leading to a deficiency. Chronic liver disease also reduces the activation of thiamine pyrophosphate and the liver’s capacity to store thiamine. The symptoms of Wernicke encephalopathy include ataxia, confusion, and ocular abnormalities.
de Clerambault’s syndrome is a delusional disorder where the sufferer believes that someone of higher social or professional standing is in love with them. Delirium tremens is a condition that occurs due to alcohol withdrawal and is characterized by confusion, hallucinations, and autonomic disturbance. The symptoms of delirium tremens usually peak 48-72 hours after stopping alcohol.
Korsakoff’s psychosis is a type of dementia that occurs as a result of untreated Wernicke’s encephalopathy. The main symptom of Korsakoff’s psychosis is confabulation, where the sufferer creates false memories to fill gaps in their memory. These neurological disorders are commonly associated with alcoholism and can have severe consequences if left untreated.
Neurological Disorders Associated with Alcoholism
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This question is part of the following fields:
- Psychiatry
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Question 42
Correct
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A 60-year-old patient with a history of bipolar disorder visits your GP clinic for routine blood tests. Despite feeling completely fine, he wants to check his health status. Upon clinical examination, there are no signs of splenomegaly or lymphadenopathy.
The following are the results:
- Hb 140 g/L Male: (135-180) Female: (115 - 160)
- Platelets 160 * 109/L (150 - 400)
- WBC 14 * 109/L (4.0 - 11.0)
- Na+ 144 mmol/L (135 - 145)
- K+ 4.7 mmol/L (3.5 - 5.0)
- Urea 5.4 mmol/L (2.0 - 7.0)
- Creatinine 114 µmol/L (55 - 120)
- Thyroid stimulating hormone (TSH) 5.2 mU/L (0.5-5.5)
- Free thyroxine (T4) 9.5 pmol/L (9.0 - 18)
- Lithium level 0.75 mmol/L (0.6 - 1.2)
What advice would you give to this patient?Your Answer: Safety net to return if symptoms develop, arrange repeat blood tests as per usual, under the normal monitoring schedule
Explanation:Lithium, a mood-stabilizing drug commonly used in bipolar disorder, can lead to various health complications such as thyroid, cardiac, renal, and neurological issues. One of the common side effects of lithium is benign leucocytosis, which is also associated with other drugs like corticosteroids and beta-blockers. In this case, it is appropriate to continue with the normal monitoring schedule and safety netting for any signs of infection or malignancy, as there are no indications of either. Antibiotics would not be necessary. Malignant leucocytosis is unlikely as there are no accompanying symptoms such as night sweats, weight loss, bleeding, lymphadenopathy, or bone pain. Withholding lithium would not be advisable as it is effectively managing the patient’s condition. The psychiatric team should be consulted before making any decisions regarding the medication.
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 43
Correct
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A 16-year-old boy with Tourette's syndrome is brought to the GP by his father as he is concerned about some unusual behaviors he has observed. During the appointment, you discover that he has been extremely anxious about his upcoming driving test. He feels compelled to check the locks on all the doors in the house repeatedly before leaving, as otherwise, he becomes more anxious about the test.
What signs or symptoms would suggest a diagnosis of psychosis rather than obsessive-compulsive disorder?Your Answer: She truly believes that if she does not perform these acts that she will definitely fail her exams
Explanation:The level of insight into their actions can differentiate obsessive-compulsive disorder from psychosis. OCD is characterized by obsessions and compulsions, where patients have intrusive thoughts and perform acts to reduce them. Patients with OCD typically have a good understanding of their condition and know that not performing the acts will not make their obsessive thoughts come true. However, they still feel the urge to perform them. If a patient lacks insight into their condition and believes that not performing the acts will lead to a negative outcome, it may indicate a delusional element and suggest a diagnosis other than OCD, such as psychosis. Gender is not linked to OCD, and Tourette’s is associated with OCD, not psychosis. Patients with untreated OCD may need to perform more acts over time, but this does not indicate psychosis. While there is a genetic link to OCD, the absence of a family history does not suggest another underlying diagnosis.
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 44
Correct
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A 28-year-old woman is brought to the Emergency Department after taking an overdose of paracetamol due to a recent breakup with her partner. She expresses remorse for her actions, denies any suicidal thoughts, and requests to be discharged. Her parents and a friend arrive at the hospital soon after. Paracetamol levels at 4 hours are below the treatment limit.
What should be the next course of action in managing her case?Your Answer: Arrange review by mental health liaison team prior to discharge
Explanation:Importance of Mental Health Liaison Team Review Prior to Discharge for Paracetamol Overdose Patients
Paracetamol overdose is a common presentation of self-harm in emergency departments. While medical management is crucial, patients may also require mental health support. A hospital-based mental health liaison team can provide advice on discharge and arrange follow-up if necessary. Discharging a patient without follow-up increases the risk of further self-harm. However, temporary compulsory detention under the Mental Health Act is not appropriate for low-risk patients. Prescribing N-acetyl-L-cysteine is unnecessary if the paracetamol levels are below treatment threshold. Emergency admission to an inpatient psychiatric unit is only necessary for high-risk patients. Therefore, mental health liaison team review prior to discharge is crucial for appropriate management of paracetamol overdose patients.
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This question is part of the following fields:
- Psychiatry
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Question 45
Incorrect
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A 35-year-old woman complains that she is unable to leave the house and as a result, her children are missing out and she is a bad mother. She reports feeling anxious most of the time, but when she is in public, she experiences a rapid heartbeat, fast breathing, and believes that everyone is staring at her. These symptoms began approximately three weeks after she lost her job when the company she worked for shut down. Since then, she has been unable to find enjoyment in anything and feels constantly fatigued. What is her diagnosis?
Your Answer: Generalised anxiety disorder
Correct Answer: Depression with secondary anxiety
Explanation:Understanding the Relationship Between Depression and Anxiety: A Clinical Perspective
Depression and anxiety are two common mental health conditions that often co-occur. However, it is important to distinguish between the two and determine which is the primary diagnosis, as this will guide treatment. In cases where depression is the underlying main diagnosis, patients may develop secondary symptoms such as anxiety and panic attacks. On the other hand, in cases where anxiety is the primary diagnosis, patients may also experience secondary depressive symptoms.
One key factor in determining the primary diagnosis is the temporal development of symptoms. In cases where depressive symptoms clearly started first, a correct diagnosis of depression is important, as treating the underlying disorder can also improve secondary anxiety symptoms. Symptoms of depression include low mood, anhedonia, and anergia.
Generalized anxiety disorder is characterized by uncontrollable and irrational worry or anxiety about a wide range of issues and situations, while agoraphobia is an excessive fear of being in a situation where a person cannot freely escape or where help may not be available. Panic disorder is diagnosed when a person has recurrent, severe panic attacks without an obvious precipitant.
In cases where anxiety is secondary to depression, it is important to address the underlying depressive symptoms in order to improve the abnormal anxiety. Symptoms of abnormal anxiety and depression frequently present co-morbidly, and careful history-taking is necessary to determine which is the primary diagnosis. By understanding the relationship between depression and anxiety, clinicians can provide more effective treatment for their patients.
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This question is part of the following fields:
- Psychiatry
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Question 46
Correct
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A 16-year-old is brought to her General Practitioner by her parents after they noticed her eating habits had become irregular. The parents report that the patient eats large volumes of foods and is sometimes found vomiting shortly after eating dinner. This behaviour has been occurring for the past 6 months. On examination, the patient’s vital signs are normal and she has a body mass index (BMI) of 23. She has excoriations on the knuckles of her right hand. She also has erosions on her teeth and swelling bilaterally on the lateral aspects of the face along the mandibular rami.
What is the most likely diagnosis?Your Answer: Bulimia nervosa
Explanation:Common Mental Health Disorders: Symptoms and Characteristics
Bulimia Nervosa
Bulimia nervosa is an eating disorder characterized by binge eating followed by purging, usually in the form of vomiting. Patients with bulimia nervosa often have normal BMI, despite purging behavior. Symptoms associated with vomiting include teeth erosion, swelling along the mandibular rami (parotitis), and excoriations of the knuckles (Russell’s sign).Avoidant Personality Disorder
Avoidant personality disorder is characterized by a person who desires social connections but is too shy to form relationships due to fear of rejection. This is different from the schizoid personality, which prefers to be alone.Anorexia Nervosa
Anorexia nervosa is associated with decreased dietary intake, with or without purging behavior. Patients with anorexia nervosa tend to have extremely low BMI due to low calorie intake. They also suffer from early osteoporosis and electrolyte abnormalities due to malnutrition.Binge Eating Disorder
Binge eating disorder is characterized by purely binge eating, without purging behavior. Patients with binge eating disorder often experience distress and weight gain.Gender Dysphoria
Gender dysphoria is characterized by a strong identification with a gender other than that assigned at birth. This can be managed through social transition (living as their preferred gender) or medical transition (hormone or surgical treatments that are gender-affirming).Understanding Common Mental Health Disorders
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This question is part of the following fields:
- Psychiatry
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Question 47
Incorrect
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What is the mechanism of action of venlafaxine for elderly patients?
Your Answer: Neuroleptic
Correct Answer: Serotonin and noradrenaline reuptake inhibitor
Explanation:The mechanism of action of venlafaxine involves inhibiting the reuptake of both serotonin and noradrenaline, making it a type of antidepressant known as a serotonin and noradrenaline reuptake inhibitor. When choosing an antidepressant, factors such as patient preference, previous sensitization, overdose risk, and cost should be considered, although SSRIs are typically the first-line treatment due to their favorable risk-to-benefit ratio.
Understanding Serotonin and Noradrenaline Reuptake Inhibitors
Serotonin and noradrenaline reuptake inhibitors (SNRIs) are a type of antidepressant medication that work by increasing the levels of serotonin and noradrenaline in the brain. These neurotransmitters are responsible for regulating mood, emotions, and anxiety levels. By inhibiting the reuptake of these chemicals, SNRIs help to maintain higher levels of serotonin and noradrenaline in the synaptic cleft, which can lead to improved mood and reduced anxiety.
Examples of SNRIs include venlafaxine and duloxetine, which are commonly used to treat major depressive disorders, generalised anxiety disorder, social anxiety disorder, panic disorder, and menopausal symptoms. These medications are relatively new and have been found to be effective in treating a range of mental health conditions. SNRIs are often preferred over other types of antidepressants because they have fewer side effects and are less likely to cause weight gain or sexual dysfunction.
Overall, SNRIs are an important class of medication that can help to improve the lives of people struggling with mental health conditions. By increasing the levels of serotonin and noradrenaline in the brain, these medications can help to regulate mood and reduce anxiety, leading to a better quality of life for those who take them.
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This question is part of the following fields:
- Psychiatry
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Question 48
Incorrect
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During an out of hours shift, you are called to see an 80-year-old man who has developed acute urinary retention on a background of 3 years of urinary hesitancy and poor stream. He has a history of ischaemic heart disease, hypertension and he tells you that his usual GP has recently started him on a new medication for neuropathic pain. Which of the following drugs is most likely to have precipitated the urinary retention?
Your Answer: Diazepam
Correct Answer: Amitriptyline
Explanation:Urinary retention may be a side effect of tricyclic antidepressants, particularly with the use of Amitriptyline due to its anticholinergic properties. This can lead to symptoms such as tachycardia, dry mouth, and mydriasis. However, SSRIs like fluoxetine and SNRIs like venlafaxine are less likely to cause urinary retention and dry mouth. Benzodiazepines like diazepam do not have anticholinergic effects.
Tricyclic Antidepressants for Neuropathic Pain
Tricyclic antidepressants (TCAs) were once commonly used for depression, but their side-effects and toxicity in overdose have led to a decrease in their use. However, they are still widely used in the treatment of neuropathic pain, where smaller doses are typically required. TCAs such as low-dose amitriptyline are commonly used for the management of neuropathic pain and the prophylaxis of headache, while lofepramine has a lower incidence of toxicity in overdose. It is important to note that some TCAs, such as amitriptyline and dosulepin, are considered more dangerous in overdose than others.
Common side-effects of TCAs include drowsiness, dry mouth, blurred vision, constipation, urinary retention, and lengthening of the QT interval. When choosing a TCA for neuropathic pain, the level of sedation may also be a consideration. Amitriptyline, clomipramine, dosulepin, and trazodone are more sedative, while imipramine, lofepramine, and nortriptyline are less sedative. It is important to work with a healthcare provider to determine the appropriate TCA and dosage for the individual’s specific needs.
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This question is part of the following fields:
- Psychiatry
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Question 49
Correct
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A 29-year-old woman arrives at the Emergency Department in a state of distress. She admits to having lost a significant amount of money through gambling and then taking 4 packets of paracetamol. This is not the first time she has engaged in such behavior. She discloses that her partner of 3 years has been offered a job overseas and is considering accepting it. Despite her initial heartbreak, they had a major argument and she now claims to be indifferent about whether he stays or goes.
What is the most appropriate course of action based on the probable diagnosis?Your Answer: Dialectical behaviour therapy
Explanation:Borderline personality disorder (BPD) is characterized by recurrent self-harm and intense interpersonal relationships that alternate between idealization and devaluation as a way to cope with strong emotions during strained relationships. The defense mechanism of devaluation is evident in the patient’s quick emotional switches, without middle ground. Dialectical behavior therapy is an effective treatment for BPD, while cognitive behavior therapy is more suitable for depression or anxiety disorders. The clinical picture is more consistent with BPD than depression, and antidepressants may not be effective for BPD. Lithium, the mood stabilizer of choice for bipolar disorder, is not appropriate for this acute event, which occurred over the past few hours rather than days.
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 50
Incorrect
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A 29-year-old man presented to the hospital, accompanied by the police after having had a fight in a casino. The casino manager called the police when the man refused to leave after he had spent almost 24 hours gambling. The patient ran out of money and was harassing other clients, trying to borrow money from them and telling them that he will return it after he had won and invested the prize money. The patient has no known next of kin and refuses to engage with the attending doctor. He threatens to assault the medical staff and is eventually put under urgent mental health Section 4. A review of his medical notes reveals that the only medication on which he has been is lithium for a known psychiatric illness, but he has not been in touch with his general practitioner for the past two months.
What is the best course of action for managing this patient?Your Answer: Stop lithium and start olanzapine
Correct Answer: Check the lithium levels and consider adding olanzapine
Explanation:Management of Bipolar Depression with Mania or Hypomania
According to the latest NICE guideline CG85, patients with bipolar depression presenting with mania or hypomania should have their lithium levels checked and consider adding an antipsychotic such as haloperidol, olanzapine, quetiapine or risperidone. Therefore, checking the lithium levels and considering adding olanzapine is the correct answer in this case.
Stopping lithium without checking the levels first is not recommended as it is a mood stabiliser and may be required for the patient. Starting haloperidol or risperidone without checking the lithium levels is also not recommended as the doctor must consider the patient’s lithium levels before adding an antipsychotic.
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This question is part of the following fields:
- Psychiatry
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