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  • Question 1 - A 32-year-old office worker presents to the Emergency Department after taking a handful...

    Correct

    • A 32-year-old office worker presents to the Emergency Department after taking a handful of various tablets following an argument with her current partner. She has a history of tumultuous relationships and struggles to maintain friendships or romantic relationships due to this. She also admits to experiencing intense emotions, frequently oscillating between extreme happiness and anger or anxiety. In the past, she has engaged in self-harm and frequently drinks to excess. A psychiatry review is requested to evaluate the possibility of a personality disorder. What personality disorder is the most probable diagnosis for this patient?

      Your Answer: Borderline personality disorder

      Explanation:

      Understanding Personality Disorders: Borderline Personality Disorder and Other Types

      Personality disorders are complex and severe disturbances in an individual’s character and behavior, causing significant personal and social disruption. These disorders are challenging to treat, but psychological and pharmacological interventions can help manage symptoms. One of the most common types of personality disorder is borderline personality disorder, characterized by intense emotions, unstable relationships, impulsive behavior, self-harm, and abandonment anxieties. Other types of personality disorders include schizoid personality disorder, avoidant personality disorder, dependent personality disorder, and narcissistic personality disorder. Understanding these disorders can help individuals seek appropriate treatment and support.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 2 - A 27-year-old woman comes to the GP for a mental health check-up. She...

    Incorrect

    • A 27-year-old woman comes to the GP for a mental health check-up. She had previously sought help 9 months ago for a major depressive episode that was successfully treated with fluoxetine, which she has now discontinued. Presently, she reports feeling fantastic. She has only slept for 4 hours each night over the past 5 days and has been busy renovating her entire house while still managing to attend work, where her boss has commended her on her newfound confidence and productivity. You observe that she speaks rapidly and that her thoughts are occasionally difficult to follow. There are no indications of self-neglect. What is the probable diagnosis?

      Your Answer: Type 1 bipolar affective disorder

      Correct Answer: Type 2 bipolar affective disorder

      Explanation:

      The distinction between type I and type II bipolar disorder lies in the presence of mania versus hypomania, respectively. Today, the patient exhibits symptoms of elated mood, decreased need for sleep, increased productivity, rapid speech, and flight of ideas, which are characteristic of mania. However, the absence of psychotic symptoms and the lack of impairment in functioning suggest a diagnosis of hypomania instead. Given the patient’s history of depression, her current presentation is consistent with bipolar affective disorder.

      Understanding Bipolar Disorder

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

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

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

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

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      • Psychiatry
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  • Question 3 - A 21-year-old woman comes to your clinic for an appointment scheduled by her...

    Correct

    • A 21-year-old woman comes to your clinic for an appointment scheduled by her father, who is worried about her lack of sleep. During the consultation, the patient reveals that she no longer feels the need to sleep for more than 2-3 hours. She appears talkative and mentions that she has been working on an online business that will bring her a lot of money. She is annoyed that people are questioning her, especially since she usually feels down, but now feels much better. There are no reports of delusions or hallucinations. What is the most probable diagnosis?

      Your Answer: Hypomanic phase of bipolar disorder

      Explanation:

      The patient is experiencing a significant decrease in sleep, but does not feel tired. This, along with other symptoms such as being excessively talkative and irritable, having an overconfident attitude towards their business, and a history of depression, suggests that they may be in a hypomanic phase of bipolar disorder. Insomnia, which typically results in feelings of tiredness and a desire to sleep, is less likely to be the cause of the patient’s symptoms. The absence of delusions or hallucinations rules out psychosis as a possible explanation. A manic phase of bipolar disorder is also unlikely, as the patient does not exhibit any delusions or hallucinations. The combination of symptoms suggests that there is more to the patient’s condition than just a resolution of depression.

      Understanding Bipolar Disorder

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

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

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

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

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      • Psychiatry
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  • Question 4 - A 33-year-old woman, accompanied by her husband, visits her GP with unusual behaviour....

    Correct

    • A 33-year-old woman, accompanied by her husband, visits her GP with unusual behaviour. Her husband reports that the changes have occurred mostly in the past week and he has never seen this behaviour before. He describes finding her walking around the house and talking to people who are not there. During the consultation, the patient appears distracted and occasionally smiles and waves at the wall behind the GP. There is no personal or family history of psychiatric illness. The patient does not seem distressed and politely asks if she can leave as she believes the appointment is a waste of time.

      The patient takes loratadine 10 mg once daily for hay-fever, salbutamol and beclomethasone inhalers for asthma, and has recently started a combined oral contraceptive pill for contraception. She is also taking a course of prednisolone tablets following a recent exacerbation of her asthma. Which medication is most likely to be causing her symptoms?

      Your Answer: Prednisolone

      Explanation:

      When a person experiences sudden onset psychosis after taking corticosteroids, it is important to consider the possibility of steroid-induced psychosis. Although both the beclomethasone inhaler and prednisolone are corticosteroids, the higher dose of prednisolone makes it the more likely culprit for the patient’s symptoms.

      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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      • Psychiatry
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  • Question 5 - A 28-year-old woman comes to her General Practitioner (GP) with her partner, concerned...

    Incorrect

    • A 28-year-old woman comes to her General Practitioner (GP) with her partner, concerned about her recent behavior. She has been having trouble sleeping for the past week and has been very active at night, working tirelessly on her new art project, which she believes will be a groundbreaking masterpiece. When questioned further, she admits to feeling very energetic and has been spending a lot of money on new materials for her project. Her partner is worried that this may be a recurrence of her known psychiatric condition. She is currently taking olanzapine and was recently started on fluoxetine for low mood six weeks ago. She has no significant family history. The couple has been actively trying to conceive for the past six months.

      What is the most appropriate next step in managing this patient?

      Your Answer: Switch olanzapine to quetiapine

      Correct Answer: Stop the fluoxetine

      Explanation:

      Managing Mania in Bipolar Disorder: Treatment Options

      When a patient with bipolar disorder develops mania while on an antidepressant and antipsychotic, it is important to adjust their medication regimen. According to NICE guideline CG185, the first step is to stop the antidepressant. In this case, the patient was on olanzapine and fluoxetine, so the fluoxetine should be discontinued.

      While lithium is a first-line mood stabilizer for bipolar disorder, it is contraindicated in this patient as she is trying to conceive. Instead, the patient could be switched from olanzapine to quetiapine, another antipsychotic that is similar in effectiveness.

      It is important not to stop both the antipsychotic and antidepressant, as this could worsen the patient’s condition. By adjusting the medication regimen, the patient can be effectively managed during a manic episode.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 6 - A 40-year-old man with schizophrenia has been taking clozapine for five years and...

    Correct

    • A 40-year-old man with schizophrenia has been taking clozapine for five years and has been stable during that time. During his latest check-up, it was discovered that his clozapine levels were higher than recommended, resulting in a reduction in his dosage.
      What is the most probable cause of an increase in clozapine blood levels?

      Your Answer: Smoking cessation

      Explanation:

      Stopping smoking can increase clozapine levels, while starting or increasing smoking can decrease them. Alcohol binges can also increase levels, while omitting doses can decrease them. Stress and weight gain have minimal effects on clozapine levels. It is important to discuss smoking cessation with a psychiatrist before making any changes.

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

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

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      • Psychiatry
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  • Question 7 - A 30-year-old woman visits her GP complaining of feeling down. She finds it...

    Incorrect

    • A 30-year-old woman visits her GP complaining of feeling down. She finds it difficult to work with her colleagues and believes they are not performing up to par. Consequently, she declines to delegate tasks and has become exhausted.
      Upon further inquiry, she adheres to a strict daily routine and tries to avoid deviating from it as much as possible. If she fails to follow this plan, she becomes anxious and spends her free time catching up on tasks.
      What is the most suitable course of action in managing her probable diagnosis?

      Your Answer: Exposure and response prevention

      Correct Answer: Dialectical behaviour therapy

      Explanation:

      The female librarian seeking advice exhibits inflexible behavior in her work and becomes easily annoyed when her routines are disrupted. She prefers to work alone, relying on lists and rules to structure her day, which are indicative of obsessive-compulsive personality disorder (OCPD). Dialectical behavior therapy (DBT) is the recommended approach for managing personality disorders, including OCPD. Exposure and response prevention (ERP) and eye movement desensitization and reprocessing (EMDR) are not appropriate for her condition, as they are used to manage obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD), respectively. Prescribing fluoxetine may be considered for any associated depression, but addressing the underlying cause with DBT is the initial priority.

      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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      • Psychiatry
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  • Question 8 - A 50-year-old woman presents with complaints of lower back pain, constipation, headaches, low...

    Incorrect

    • A 50-year-old woman presents with complaints of lower back pain, constipation, headaches, low mood, and difficulty concentrating. Which medication is most likely responsible for her symptoms?

      Your Answer: Imipramine

      Correct Answer: Lithium

      Explanation:

      Hypercalcaemia, which is indicated by the presented signs and symptoms, can be a result of long-term use of lithium. The mnemonic ‘stones, bones, abdominal moans, and psychic groans’ can be used to identify the symptoms. The development of hyperparathyroidism and subsequent hypercalcaemia is believed to be caused by lithium’s effect on calcium homeostasis, leading to parathyroid hyperplasia. To diagnose this condition, a U&Es and PTH test can be conducted. Unlike lithium, other psychotropic medications are not associated with the development of hyperparathyroidism and hypercalcaemia.

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

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

    • This question is part of the following fields:

      • Psychiatry
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  • Question 9 - A 26-year-old individual visits their GP with symptoms of flashbacks, nightmares, and difficulty...

    Incorrect

    • A 26-year-old individual visits their GP with symptoms of flashbacks, nightmares, and difficulty relaxing after being involved in a pub brawl 3 weeks ago. The patient has no significant medical history and has attempted breathing exercises to alleviate their symptoms without success. What is the most suitable course of action for managing this patient?

      Your Answer: Refer for eye movement desensitisation and reprocessing

      Correct Answer: Refer for cognitive-behavioural therapy

      Explanation:

      For individuals experiencing acute stress disorder within the first 4 weeks of a traumatic event, trauma-focused cognitive-behavioural therapy (CBT) should be the primary treatment option. The use of benzodiazepines, such as diazepam, should only be considered for acute symptoms like sleep disturbance and with caution. Selective serotonin reuptake inhibitors and other drug treatments should not be the first-line treatment for adults. Debriefings, which are single-session interventions after a traumatic event, are not recommended. Eye movement desensitisation and reprocessing may be used for more severe cases of post-traumatic stress disorder that occur after 4 weeks of exposure to a traumatic experience.

      Acute stress disorder is a condition that occurs within the first four weeks after a person has experienced a traumatic event, such as a life-threatening situation or sexual assault. It is characterized by symptoms such as intrusive thoughts, dissociation, negative mood, avoidance, and arousal. These symptoms can include flashbacks, nightmares, feeling disconnected from reality, and being hypervigilant.

      To manage acute stress disorder, trauma-focused cognitive-behavioral therapy (CBT) is typically the first-line treatment. This type of therapy helps individuals process their traumatic experiences and develop coping strategies. In some cases, benzodiazepines may be used to alleviate acute symptoms such as agitation and sleep disturbance. However, caution must be taken when using these medications due to their addictive potential and potential negative impact on adaptation. Overall, early intervention and appropriate treatment can help individuals recover from acute stress disorder and prevent the development of more chronic conditions such as PTSD.

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      • Psychiatry
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  • Question 10 - A 16-year-old boy with Tourette's syndrome is brought to the GP by his...

    Correct

    • 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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      • Psychiatry
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  • Question 11 - A 45-year-old woman presents to the Outpatient clinic with complaints of involuntary muscle...

    Correct

    • A 45-year-old woman presents to the Outpatient clinic with complaints of involuntary muscle movements of her tongue, fingers and trunk for the past 2 months. She was diagnosed with schizophrenia 10 years ago and has been on flupenthixol and then haloperidol, with good compliance. On examination, her temperature is 37.7 °C, blood pressure 115/80 mmHg and pulse 92 bpm. Her respiratory rate is 14 cycles/min. There is pronounced choreoathetoid movement of the hand and fingers.
      What is the next line of management of this patient?

      Your Answer: Stop the haloperidol and start olanzapine

      Explanation:

      Treatment options for extrapyramidal side-effects of anti-psychotic medication

      Extrapyramidal side-effects are common with anti-psychotic medication, particularly with typical anti-psychotics such as haloperidol and chlorpromazine. Tardive dyskinesia is one such side-effect, which can be treated by switching to an atypical anti-psychotic medication like olanzapine. Acute dystonia, on the other hand, can be managed with anticholinergics. Decreasing the dose of haloperidol can help alleviate akathisia, or motor restlessness. Supportive therapy is not effective in treating extrapyramidal side-effects. It is important to monitor patients for these side-effects and adjust medication accordingly to ensure optimal treatment outcomes.

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      • Psychiatry
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  • Question 12 - A 35-year-old man who is an accountant presents with complaints of fainting spells,...

    Correct

    • A 35-year-old man who is an accountant presents with complaints of fainting spells, dizziness, palpitations and pressure in his chest. He experiences these symptoms for 5-10 minutes during which he becomes anxious about fainting and dying. He takes a longer route to work to avoid crossing busy streets as he fears getting hit by a car if he faints. He avoids public speaking and works late into the night from home, which exacerbates his symptoms. What is the probable diagnosis?

      Your Answer: Panic disorder with agoraphobia

      Explanation:

      Differentiating Panic Disorder from Other Conditions

      Panic disorder is a mental health condition characterized by intense anxiety episodes with somatic symptoms and an exaggerated sense of danger. However, it can be challenging to distinguish panic disorder from other conditions that share similar symptoms. Here are some examples:

      Panic Disorder vs. Somatisation Disorder

      Patients with somatisation disorder also experience physical symptoms, but they fall into four different clusters: pain, gastrointestinal, urogenital, and neurological dysfunction. In contrast, panic disorder symptoms are more generalized and not limited to specific bodily functions.

      Panic Disorder vs. Hypoglycemia

      Hypoglycemia rarely induces severe panic or anticipatory anxiety, except in cases of insulin reactions. Patients with hypoglycemia typically experience symptoms such as sweating and hunger, which are not necessarily associated with panic disorder.

      Panic Disorder vs. Paroxysmal Atrial Tachycardia

      Paroxysmal atrial tachycardia is a heart condition that causes a doubling of the pulse rate and requires electrocardiographic evidence for diagnosis. While it may cause some anxiety, it is not typically accompanied by the intense subjective anxiety seen in panic disorder.

      Panic Disorder vs. Specific Phobia

      Specific phobias involve reactions to limited cues or situations, such as spiders, blood, or needles. While they may trigger panic attacks and avoidance, they are not as generalized as panic disorder and are limited to specific feared situations.

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      • Psychiatry
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  • Question 13 - A 25-year-old female complains of headache, weakness, and pains in her arms and...

    Correct

    • A 25-year-old female complains of headache, weakness, and pains in her arms and legs. She reports feeling like her symptoms are worsening. She has no significant medical history except for a miscarriage two years ago.

      Upon examination, her neurological and musculoskeletal functions appear normal, and there are no alarming signs in her headache history. Her GP conducts a comprehensive blood test, which yields normal results.

      What is the most probable diagnosis for this patient?

      Your Answer: Somatoform disorder

      Explanation:

      The young woman has physical symptoms without any disease process, which may be a form of somatisation/somatoform disorder. This disorder is often caused by underlying psychological distress and may result in depression or anxiety. Hypochondriasis is a belief that one is suffering from a severe disorder, while Münchausen syndrome is a disorder where a patient mimics a particular disorder to gain attention. To diagnose malingering, there needs to be evidence that the patient is purposefully generating symptoms for some kind of gain. In a somatisation disorder, the patient may have no clinical evidence of illness or physical injury but believes they have one.

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      • Psychiatry
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  • Question 14 - A 72-year-old patient comes to see the General Practitioner with his daughter. She...

    Correct

    • A 72-year-old patient comes to see the General Practitioner with his daughter. She expresses concern that her father has been acting differently lately. Once the daughter leaves the room, he confides in the doctor that the woman who came with him is not his daughter, but an imposter. He firmly believes this and cannot be convinced otherwise.
      What is the most probable diagnosis?

      Your Answer: Capgras syndrome

      Explanation:

      Different Types of Delusional Disorders

      Delusional disorders are a group of mental illnesses characterized by false beliefs that persist despite evidence to the contrary. Here are some of the different types of delusional disorders:

      1. Capgras syndrome: Patients believe that a loved one has been replaced by an exact double.

      2. Cotard syndrome: Patients have nihilistic delusions, such as believing that they or parts of their body are dead or decaying.

      3. Othello syndrome: Patients believe that their partner is cheating on them, despite no proof.

      4. De Clerambault syndrome: Patients believe that someone famous is deeply in love with them.

      It is important to note that these disorders are rare and require professional diagnosis and treatment.

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      • Psychiatry
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  • Question 15 - You are requested to assess a patient with generalized anxiety disorder (GAD) who...

    Correct

    • You are requested to assess a patient with generalized anxiety disorder (GAD) who has been on sertraline for the past 6 months. They have previously attempted citalopram with minimal improvement. The patient complains of persistent anxiety, chest tightness, and palpitations and wishes to explore a different medication. What would be the most suitable medication to recommend for this patient?

      Your Answer: Duloxetine

      Explanation:

      If sertraline is ineffective or not tolerated as a first-line SSRI for GAD, consider trying another SSRI or an SNRI. The recommended medication in this case would be duloxetine. Since the patient has already tried citalopram with little benefit, it would not be appropriate to prescribe it again. Clomipramine, a tricyclic antidepressant, is not typically recommended for GAD management. Diazepam, a benzodiazepine, is also not recommended for GAD treatment due to the risk of tolerance and addiction.

      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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      • Psychiatry
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  • Question 16 - A 28-year-old man who works as a software engineer has recently been terminated...

    Correct

    • A 28-year-old man who works as a software engineer has recently been terminated by his supervisor, citing missed deadlines and a decline in the quality of his work. He disputes this and claims that his supervisor has always had a personal vendetta against him. He has confided in his family and close friends, but despite their reassurances, he believes that some of his colleagues were colluding with his supervisor to oust him. During his mental health evaluation, he appears to be generally stable, except for his fixation on his supervisor and coworkers conspiring against him. His family reports that he is easily offended and has a tendency to believe in conspiracies. What is the most probable diagnosis?

      Your Answer: Paranoid personality disorder

      Explanation:

      The diagnosis of paranoid personality disorder may be appropriate for individuals who exhibit hypersensitivity, hold grudges when insulted, doubt the loyalty of those around them, and are hesitant to confide in others.

      In the given case, the correct diagnosis is paranoid personality disorder as the individual is reacting strongly to being fired by her manager and believes it to be a conspiracy involving her manager and colleagues. This aligns with the classic symptoms of paranoid personality disorder, and the individual’s family has also observed her tendency to be easily offended and paranoid.

      Borderline personality disorder is an incorrect diagnosis as it is characterized by emotional instability, difficulty controlling anger, unstable relationships, and recurrent suicidal thoughts, rather than paranoia.

      Schizoid personality disorder is also an incorrect diagnosis as it is characterized by a preference for solitary activities, lack of interest in socializing, and a lack of close relationships, rather than paranoia.

      Schizophrenia is an incorrect diagnosis as the individual’s mental state examination is broadly normal, whereas schizophrenia typically presents with delusions, hallucinations, and disordered thinking.

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

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

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

    • This question is part of the following fields:

      • Psychiatry
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  • Question 17 - A 25-year-old man is receiving electroconvulsive therapy (ECT) for his treatment-resistant depression. What...

    Correct

    • A 25-year-old man is receiving electroconvulsive therapy (ECT) for his treatment-resistant depression. What is the most probable side effect he may encounter?

      Your Answer: Retrograde amnesia

      Explanation:

      ECT has the potential to cause memory impairment, which is its most significant side effect. The NICE guidelines recommend that memory should be evaluated before and after each treatment course. Retrograde amnesia, which is the inability to recall events before the treatment, is more common than anterograde amnesia, which is the inability to form new memories after the treatment.

      Immediate side effects of ECT include drowsiness, confusion, headache, nausea, aching muscles, and loss of appetite. On the other hand, long-term side effects may include apathy, anhedonia, difficulty concentrating, loss of emotional responses, and difficulty learning new information.

      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.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 18 - A 9-year-old girl is brought to see the General Practitioner (GP) by her...

    Correct

    • A 9-year-old girl is brought to see the General Practitioner (GP) by her father, who is concerned about her behaviour at home and school. Over the past 18 months, her father has noted problems with inattention, hyperactivity and impulsivity. Teachers have also been raising similar issues about her behaviour in school. Her symptoms are affecting her performance in school and her relationship at home with her parents and siblings.
      Which one of the following conditions is she most likely to be diagnosed with?

      Your Answer: Attention deficit/hyperactivity disorder (ADHD)

      Explanation:

      The patient is exhibiting signs of ADHD, which is characterized by persistent patterns of inattention, hyperactivity, and impulsivity that interfere with functioning or development. These symptoms must have been present before the age of 12 and evident in multiple settings for at least six months. However, there are no indications of autism spectrum disorder, learning difficulty, or learning disability. Additionally, the patient does not display any symptoms of oppositional defiance disorder, which is characterized by angry or irritable mood, argumentative behavior, or vindictiveness lasting at least six months and causing distress or impairment in social, educational, or occupational functioning.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 19 - A 42-year-old accountant comes to see you for a follow-up review 2 weeks...

    Incorrect

    • A 42-year-old accountant comes to see you for a follow-up review 2 weeks after presenting with symptoms suggesting low mood. He had felt ‘down’ for several weeks, no longer enjoyed work or seeing friends and was sleeping more than usual. Despite this, he had a normal appetite, a strong sense of self-worth, denied any thoughts of self-harm or suicide and came across as reasonably active and lively. He says that he feels very anxious on Sunday evenings before going to work on a Monday and is getting increasingly ‘short and snappy’ with his colleagues. However, he says that work is otherwise going well and he is managing to get through the day. He does not feel any better at today’s consultation and is requesting advice about treatment options. He says he is ‘not a tablet person’.
      What should you advise?

      Your Answer: A combination of referral for group CBT and treatment with an SSRI antidepressant for 6 months

      Correct Answer: A trial of computer-based cognitive behavioural therapy (CBT) or peer support

      Explanation:

      For a patient with mild depression symptoms, the recommended first-line treatment is low-intensity psychosocial interventions such as computer-based CBT, group-based CBT, or peer support groups performing physical activity programs. If the patient prefers non-pharmacological treatment, antidepressants should not be used as first-line. Benzodiazepines should be avoided due to their addictive potential and side-effect profile. In the presence of both depression and anxiety, depression should be treated first according to NICE guidelines.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 20 - A 72-year-old man is admitted to the hospital by his wife who reports...

    Incorrect

    • A 72-year-old man is admitted to the hospital by his wife who reports that he has been experiencing distressing visual hallucinations of animals in their home. You suspect that he may be suffering from Charles-Bonnet syndrome. What are some potential risk factors that could make him more susceptible to this condition?

      Your Answer: Occupational history of working in sewers

      Correct Answer: Peripheral visual impairment

      Explanation:

      Peripheral visual impairment is a risk factor for Charles-Bonnet syndrome, which is a condition characterized by visual hallucinations in individuals with eye disease. The most frequent hallucinations include faces, children, and wild animals. This syndrome is more common in older individuals, without significant difference in occurrence between males and females, and no known increased risk associated with family history.

      Understanding Charles-Bonnet Syndrome

      Charles-Bonnet syndrome (CBS) is a condition characterized by complex hallucinations, usually visual or auditory, that occur in clear consciousness. These hallucinations persist or recur and are often experienced by individuals with visual impairment, although this is not a mandatory requirement for diagnosis. People with CBS maintain their insight and do not exhibit any other significant neuropsychiatric disturbance. The risk factors for CBS include advanced age, peripheral visual impairment, social isolation, sensory deprivation, and early cognitive impairment. The syndrome is equally distributed between sexes and does not show any familial predisposition. The most common ophthalmological conditions associated with CBS are age-related macular degeneration, glaucoma, and cataract.

      Well-formed complex visual hallucinations are experienced by 10-30% of individuals with severe visual impairment. The prevalence of CBS in visually impaired people is estimated to be between 11 and 15%. However, around a third of people with CBS find the hallucinations unpleasant or disturbing. A large study published in the British Journal of Ophthalmology found that 88% of people had CBS for two years or more, and only 25% experienced resolution at nine years. Therefore, CBS is not generally a transient experience.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 21 - You are about to prescribe fluoxetine, a selective serotonin reuptake inhibitor (SSRI) to...

    Correct

    • You are about to prescribe fluoxetine, a selective serotonin reuptake inhibitor (SSRI) to a 50-year-old man who has just started a new relationship. He asks about common side-effects.
      Which of the below is a common side-effect that it would be most important to council this patient about?

      Your Answer: Sexual dysfunction

      Explanation:

      Understanding the Side-Effects of SSRIs: Sexual Dysfunction, Constipation, Sedation, Urinary Retention, and Dry Mouth

      Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for major depressive and generalized anxiety disorders. These drugs work by increasing serotonin concentration in the synaptic cleft, which stimulates post-synaptic neurons and improves mood. However, SSRIs can also cause several side-effects that patients should be aware of.

      One of the most important side-effects to keep in mind is sexual dysfunction. Patients may feel uncomfortable discussing this issue, so it is important for healthcare providers to ask about it specifically. Sildenafil can be useful in treating this side-effect.

      SSRIs can also cause gastrointestinal upset, including dyspepsia, nausea, abdominal pain, diarrhea, and constipation. However, given the patient’s age, it would be most appropriate to counsel regarding sexual dysfunction.

      While SSRIs are associated with insomnia, restlessness, and general agitation, they are not typically associated with sedation. Urinary disorders can be associated with SSRIs, but they are more commonly seen with the use of tricyclic antidepressants. Dry mouth is a common side-effect of SSRIs, but it is less important to counsel patients about than sexual dysfunction.

      In summary, patients taking SSRIs should be aware of the potential side-effects, including sexual dysfunction, gastrointestinal upset, insomnia, urinary disorders, and dry mouth. Healthcare providers should ask about sexual dysfunction specifically and provide appropriate treatment options.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 22 - A 32-year-old woman with schizophrenia has been under the care of mental health...

    Correct

    • A 32-year-old woman with schizophrenia has been under the care of mental health services for a few years with a fluctuating pattern of illness. Her consultant, in collaboration with the patient’s Community Psychiatric Nurse (CPN), decides to initiate clozapine treatment. As a component of the prescription, she is registered into the Clozapine Monitoring Service scheme.
      What is the primary rationale for her registration?

      Your Answer: To monitor the white cell count

      Explanation:

      The Importance of Monitoring White Cell Count in Patients on Clozapine Therapy

      Schizophrenia is commonly treated with anti-psychotic medications, including typical and atypical agents. Clozapine, an atypical anti-psychotic, is often prescribed for patients who do not respond to other medications. While effective, clozapine carries a risk of agranulocytosis, a condition characterized by a lowered white blood cell count that increases the risk of infection. To mitigate this risk, patients on clozapine therapy must be enrolled in a monitoring program that includes regular blood tests to check their white cell count. This monitoring is crucial for patient safety and should be a top priority for healthcare providers.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 23 - A 32-year-old male construction worker presents to the clinic with concerns about his...

    Incorrect

    • A 32-year-old male construction worker presents to the clinic with concerns about his recent behavior at work. Over the past week, he has been very talkative and easily distracted while on the job. This is unusual for him as he typically prefers to stay focused and get his work done efficiently. He also reports feeling more energetic than usual and needing less sleep. He denies any impulsive behavior, drug use, or sexual promiscuity. There is no significant medical history, but his father has a history of bipolar disorder.

      What would be the most appropriate next step in managing this patient's symptoms?

      Your Answer: Prescribe quetiapine

      Correct Answer: Routine referral to the community mental health team

      Explanation:

      When a patient presents with symptoms of hypomania in primary care, it is important to refer them to the community mental health team for confirmation of the diagnosis before prescribing any medication. Quetiapine is often used as a first-line treatment for acute bipolar disorder, but it should not be prescribed until the diagnosis is confirmed. SSRIs are not recommended for depressive episodes in bipolar disorder, and olanzapine and fluoxetine should only be used in rare circumstances for acute depression. Lithium is a common medication for bipolar disorder, but it should not be prescribed until the diagnosis is confirmed. Routine referral to the community mental health team is advised for patients presenting with hypomania in primary care, and urgent referral may be necessary if the patient is at risk of self-harm or harm to others. Referral may also be necessary if the patient demonstrates poor judgment in areas such as employment, personal relationships, finances, driving, sexual activity, or drug use.

      Understanding Bipolar Disorder

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

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

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

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

    • This question is part of the following fields:

      • Psychiatry
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  • Question 24 - A 28-year-old artist visits his GP complaining of anxiety related to social interactions....

    Correct

    • A 28-year-old artist visits his GP complaining of anxiety related to social interactions. He prefers solitude and is hesitant to share his beliefs with others, which they find peculiar. During the consultation, the patient talks in a high-pitched voice about his fascination with horror movies and his 'spirit-guide' that protects him. However, he denies experiencing any visual or auditory hallucinations and does not display any delusional thinking. Additionally, there is no evidence of pressure of speech. What is the probable diagnosis?

      Your Answer: Schizotypal personality disorder

      Explanation:

      The man seeking help has social anxiety and prefers to be alone. He has an interest in paranormal phenomena and talks in a high-pitched voice when discussing his spirit guide. These symptoms suggest that he may have schizotypal personality disorder, which is characterized by magical thinking and odd speech patterns. Emotionally unstable personality disorder, histrionic personality disorder, schizoaffective disorder, and schizoid personality disorder are all incorrect diagnoses.

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

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

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

    • This question is part of the following fields:

      • Psychiatry
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  • Question 25 - You are a junior doctor working at an inpatient psychiatry unit. You have...

    Incorrect

    • You are a junior doctor working at an inpatient psychiatry unit. You have been asked to assess a patient by the nursing staff as they are currently occupied by a distressed patient and relative. The patient you've been asked to review has known schizophrenia and wishes to leave the unit. However, following consultation with the patient, you are concerned they are exhibiting features of an acute psychotic episode.
      Which section of the Mental Health Act (2007) could be used to detain the patient?

      Your Answer: Section 2

      Correct Answer: Section 5(2)

      Explanation:

      Understanding the Different Sections of the Mental Health Act (2007)

      The Mental Health Act (2007) provides a legal framework for patients with confirmed or suspected mental disorders that pose a risk to themselves or the public. The Act outlines specific guidelines for detention, treatment, and the individuals authorized to use its powers. Here are some of the key sections of the Mental Health Act:

      Section 5(2): This section allows for the temporary detention of a patient already in the hospital for up to 72 hours, after which a full Mental Health Act assessment must be conducted. A doctor who is fully registered (FY2 or above) can use this section to detain a patient.

      Section 3: This section is used for admission for treatment for up to 6 months, with the exact mental disorder being treated stated on the application. It can be renewed for a further six months if required, and the patient has the right to appeal.

      Section 2: This section allows for compulsory admission for assessment of presumed mental disorder. The section lasts for 28 days and must be signed by two doctors, one of whom is approved under Section 12(2), usually a consultant psychiatrist, and another doctor who knows the patient in a professional capacity, usually their GP.

      Section 5(4): This section can be used by psychiatric nursing staff to detain a patient for up to 6 hours while arranging review by appropriate medical personnel for further assessment and either conversion to a Section 5(2). If this time elapses, there is no legal right for the nursing staff to detain the patient. In this scenario, the nursing staff are unavailable to assess the patient.

      Section 7: This section is an application for guardianship. It is used for patients in the community where an approved mental health practitioner (AMHP), usually a social worker, requests compulsory treatment requiring the patient to live in a specified location, attend specific locations for treatment, and allow access for authorized persons.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 26 - A 25-year-old male has been taking antipsychotics for a few months and is...

    Incorrect

    • A 25-year-old male has been taking antipsychotics for a few months and is experiencing a severe side-effect that causes repetitive involuntary movements such as grimacing and sticking out the tongue. This side-effect is known to occur only in individuals who have been on antipsychotics for an extended period. What medication is the most appropriate for treating this side-effect?

      Your Answer: Benztropine

      Correct Answer: Tetrabenazine

      Explanation:

      Tetrabenazine is an effective treatment for moderate to severe tardive dyskinesia, which is the condition that this patient is experiencing. Propranolol is typically used to alleviate symptoms of akathisia, while procyclidine and benztropine are commonly prescribed for acute dystonia.

      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.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 27 - A 40-year-old woman has been seen by her general practitioner (GP) with symptoms...

    Correct

    • A 40-year-old woman has been seen by her general practitioner (GP) with symptoms of moderate anxiety, including frequent panic attacks, feeling very tired all the time, poor appetite and a short temper. She is taking time off work, arguing with her family and friends and becoming increasingly isolated as a result of the symptoms. She has tried cognitive behavioural therapy but found no benefit. She would like to try medication, and the GP has agreed to start citalopram.
      What advice should she be given before starting the medication?

      Your Answer: There is a risk he will develop discontinuation symptoms if he abruptly stops taking the medication

      Explanation:

      Understanding Selective Serotonin Reuptake Inhibitors (SSRIs)

      When taking an SSRI, it is important to be aware of potential discontinuation symptoms if the medication is stopped abruptly. These symptoms can include rebound anxiety or depressive symptoms, flu-like symptoms, dizziness, nausea, or sleep disturbances. Patients should seek advice from a doctor before reducing or withdrawing the medication, and it is recommended that the discontinuation is done over four weeks.

      While patients may feel some benefit after one week of taking an SSRI, the full benefit can take up to 12 weeks. It is important to be patient and continue taking the medication as prescribed.

      During the first three months of starting medication, patients should be seen every two to four weeks to monitor for adverse effects such as increased anxiety symptoms, sleep disturbance, or gastrointestinal upset. After this initial period, patients should be seen every three months, with the frequency of reviews potentially increasing if symptoms worsen.

      Possible side-effects of taking an SSRI include dyspepsia, worsening of anxiety symptoms, agitation, and sleep problems. Patients should be aware of these potential side-effects.

      While there is an increased risk of suicidal thinking and self-harm for patients under the age of 30 starting an SSRI, this risk is not present for everyone. Patients under 30 should be monitored more closely for signs of suicidal thoughts or self-harm and seen weekly for the first month after medication is started.

      In summary, understanding the potential risks and benefits of taking an SSRI is important for patients to make informed decisions about their mental health treatment.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 28 - Sarah is a 35-year-old married woman with two children. She comes to you...

    Correct

    • Sarah is a 35-year-old married woman with two children. She comes to you in distress and expresses suicidal thoughts, stating that she has considered taking an overdose. She has no history of self-harm or suicide attempts, and no psychiatric background. Despite having a loving family and enjoying her job, she is struggling. What is a risk factor for suicide in this case?

      Your Answer: Male gender

      Explanation:

      Suicide Risk Factors and Protective Factors

      Suicide risk assessment is a common practice in psychiatric care, with patients being stratified into high, medium, or low risk categories. However, there is a lack of evidence on the positive predictive value of individual risk factors. A review in the BMJ concluded that such assessments may not be useful in guiding decision-making, as 50% of suicides occur in patients deemed low risk. Nevertheless, certain factors have been associated with an increased risk of suicide, including male sex, history of deliberate self-harm, alcohol or drug misuse, mental illness, depression, schizophrenia, chronic disease, advancing age, unemployment or social isolation, and being unmarried, divorced, or widowed.

      If a patient has attempted suicide, there are additional risk factors to consider, such as efforts to avoid discovery, planning, leaving a written note, final acts such as sorting out finances, and using a violent method. On the other hand, there are protective factors that can reduce the risk of suicide, such as family support, having children at home, and religious belief. It is important to consider both risk and protective factors when assessing suicide risk and developing a treatment plan.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 29 - A 25-year-old woman goes to her GP to discuss symptoms she believes are...

    Incorrect

    • A 25-year-old woman goes to her GP to discuss symptoms she believes are related to a diagnosis of obsessive-compulsive disorder (OCD). She has been struggling with these symptoms for a few years, but they have worsened in recent months since she started working as a janitor. She experiences intrusive and persistent thoughts about germs, which lead her to repeatedly wash her hands, clothes, and clean her home. Her partner is worried about her, and they argue when he tries to encourage her to resist the urge to clean, as this exacerbates her anxiety symptoms. Which medication is approved for treating OCD?

      Your Answer: Diazepam

      Correct Answer: Sertraline

      Explanation:

      Medications for OCD: A Comparison of Sertraline, Venlafaxine, Citalopram, Diazepam, and Imipramine

      Obsessive-compulsive disorder (OCD) is a mental health condition characterized by intrusive thoughts and repetitive behaviors. The National Institute for Health and Care Excellence (NICE) recommends cognitive behavioral therapy with exposure response therapy and/or selective serotonin reuptake inhibitors (SSRIs) for managing OCD. Sertraline is an SSRI that is licensed for treating OCD. Venlafaxine, a serotonin and noradrenaline reuptake inhibitor (SNRI), is not licensed for OCD treatment. Citalopram, another SSRI, is licensed for depression or panic disorder but not for OCD. Diazepam, a benzodiazepine, is not licensed for OCD treatment due to the risk of dependence or tolerance. Imipramine, a tricyclic antidepressant, is also not licensed for OCD treatment. The choice of medication or therapy should be based on the severity of symptoms and patient preferences.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 30 - A 30-year-old man is brought to his psychiatrist by his sister. His sister...

    Incorrect

    • A 30-year-old man is brought to his psychiatrist by his sister. His sister is worried that her brother firmly believes that he is a superhero, despite having no evidence or abilities to support this belief. Upon assessment, the man appears physically healthy. There are no signs of delusions, disorientation, or unusual speech patterns. However, he maintains an unyielding conviction that Beyonce is in live with him. What is the appropriate diagnosis for this condition?

      Your Answer:

      Correct Answer: De Clerambault's syndrome

      Explanation:

      The correct term for the delusion that a famous person is in love with someone, without any other psychotic symptoms, is De Clerambault’s syndrome. Capgras syndrome, on the other hand, refers to the delusion that a close relative has been replaced by an impostor, while De Frégoli syndrome is the delusion of seeing a familiar person in different individuals.

      De Clerambault’s Syndrome: A Delusional Belief in Famous Love

      De Clerambault’s syndrome, also known as erotomania, is a type of paranoid delusion that has a romantic aspect. Typically, the patient is a single person who firmly believes that a well-known person is in love with them. This condition is characterized by a persistent and irrational belief that the famous person is sending secret messages or signals of love, even though there is no evidence to support this belief. The patient may engage in behaviors such as stalking, sending letters or gifts, or attempting to contact the object of their affection. Despite repeated rejections or lack of response, the patient remains convinced of the love affair. This syndrome can be distressing for both the patient and the object of their delusion, and it often requires psychiatric treatment.

    • This question is part of the following fields:

      • Psychiatry
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SESSION STATS - PERFORMANCE PER SPECIALTY

Psychiatry (17/29) 59%
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