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Question 1
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A 50-year-old male with schizophrenia is being evaluated by his psychiatrist. During the consultation, the psychiatrist observes that the patient appears disinterested and unresponsive when discussing recent and upcoming events in his life, such as his upcoming trip to Hawaii and his recent separation from his spouse.
What is the most appropriate term to describe the abnormality exhibited by the patient?Your Answer: Blunting of affect
Explanation:Emotional and Cognitive Symptoms in Mental Health
Blunting of affect is a condition where an individual experiences a loss of normal emotional expression towards events. This can be observed in people with schizophrenia, depression, and post-traumatic stress disorder. Anhedonia, on the other hand, is the inability to derive pleasure from activities that were once enjoyable. Depersonalisation is a feeling of detachment from oneself, where an individual may feel like they are not real. Labile affect is characterized by sudden and inappropriate changes in emotional expression. Lastly, thought blocking is a sudden interruption in the flow of thought.
These symptoms are commonly observed in individuals with mental health conditions and can significantly impact their daily lives. It is important to recognize and address these symptoms to provide appropriate treatment and support. By these symptoms, mental health professionals can better assess and diagnose their patients, leading to more effective treatment plans. Additionally, individuals experiencing these symptoms can seek help and support to manage their condition and improve their quality of life.
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This question is part of the following fields:
- Psychiatry
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Question 2
Correct
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A 35-year-old unemployed man visits his GP seeking assistance with his heroin addiction. He has been using heroin for more than a year after a friend suggested trying the drug after a night out. As a result, he has frequently used heroin. He has lost his job, ended his long-term relationship, and is currently sleeping on his friend's couch.
A few months ago, he attempted to quit because he wanted to turn his life around, but he found the withdrawal symptoms too difficult to handle and ended up using heroin again. He is eager to try and quit drugs, but he feels he cannot do it without some form of assistance.
Which of the following can be used for substitution therapy in opioid-dependent patients?Your Answer: Methadone
Explanation:Medications for Opioid Dependence and Withdrawal
Opioid dependence can be treated with medications under medical supervision. Methadone and buprenorphine are two options that can be used to substitute for illicit opioids. Buprenorphine should be given when the patient is experiencing withdrawal symptoms. Benzodiazepines like lorazepam and diazepam are used to treat withdrawal symptoms but not as a substitute for opioids. Lofexidine is also used to treat withdrawal symptoms. Naltrexone, an opioid antagonist, can be used to sustain abstinence in consenting patients.
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This question is part of the following fields:
- Psychiatry
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Question 3
Correct
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A 19-year-old male presents to the Emergency Department after consuming eight paracetamol tablets, four cans of strong cider and two mouthfuls of bleach in an attempt to end his life. He reports feeling extremely anxious and low in mood for the past week following a recent argument with his girlfriend. He believes he has no worth in society and thinks he is 'better off dead', hoping his girlfriend will understand how low he has been recently now that he has almost succeeded in ending his own life. He takes no regular medication and has a history of depression for which he sees his GP. He has no relevant family history. He has been to the emergency department with suicide attempts eight times in the last six months. He has no history of deliberate self-harm otherwise.
What is the necessary feature required for a diagnosis of a personality disorder?Your Answer: Over 18 years of age
Explanation:Undesirable personality traits that are pervasive are characteristic of personality disorders. These disorders cause long-term difficulties in interpersonal relationships and functioning in society. Diagnosis is only possible once a person’s personality has fully developed and their adaptive behaviours have become fixed, typically after the age of 18. However, borderline personality disorder may be diagnosed earlier if there is sufficient evidence that the patient has undergone puberty.
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 4
Correct
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A 32-year-old female presents to her primary care physician with her sister. The sister is worried that the patient may have a personality disorder due to her lack of interest in socializing and her preference for being alone. Upon further discussion, the patient admits to having no desire for romantic relationships, being unemployed, and lacking motivation to work. She denies any self-harm or suicidal thoughts and has no history of legal issues. During the consultation, she displays a flat and emotionless facial expression. What personality disorder is most likely present in this patient?
Your Answer: Schizoid
Explanation:The man’s presentation suggests that he may have schizoid personality disorder, which is characterized by negative symptoms similar to those seen in schizophrenia. These symptoms include a lack of interest in others, solitary behavior, and emotional detachment. It is important to rule out positive symptoms of schizophrenia such as hallucinations and delusions. Antisocial personality disorder, which involves disregard for others and criminal behavior, is not a likely diagnosis for this man as he has no history of such behavior. Avoidant personality disorder, which involves a desire for social contact but fear of rejection, is also not a likely diagnosis as the man has no desire for interpersonal contact. Emotionally unstable personality disorder, also known as borderline personality disorder, is not a likely diagnosis as the man does not exhibit the unstable relationships, self-image, or emotional reactions associated with this 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 5
Correct
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A 67-year-old man is prescribed duloxetine for a major depressive episode after having no response to citalopram or fluoxetine.
What is the mechanism of action of the newly added drug?Your Answer: Serotonin and noradrenaline reuptake inhibitor
Explanation:The mechanism of action of duloxetine involves inhibiting the reuptake of both serotonin and noradrenaline, making it a member of the antidepressant class known as serotonin and noradrenaline reuptake inhibitors. When selecting an antidepressant, patient preference, previous sensitization, overdose risk, and cost are all factors to consider. SSRIs are typically the first-line treatment due to their favorable risk-to-benefit ratio and comparable efficacy to other antidepressants.
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 6
Correct
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You are a Foundation Year 2 doctor in Psychiatry. During the ward round, you are asked to perform a mental state examination of a patient who has been on the ward for a month.
In which part of the mental state examination would you report neologisms, pressure, or poverty?Your Answer: Speech
Explanation:Assessing Mental State: Key Components to Consider
When assessing a patient’s mental state, there are several key components to consider. These include speech rate, rhythm, and volume, as well as the presence of neologisms, which may indicate a thought disorder. Poverty of speech may suggest reduced speech content, often seen in depression, while pressure of speech may indicate an increased rate, often seen in mania.
Insight is another important factor to consider, as it reflects the patient’s understanding of their condition and their willingness to accept treatment. Under the heading of Appearance and behaviour, it is important to note the patient’s level of self-care, rapport, and any non-verbal cues. Abnormal movements and level of motor activity should also be observed.
Mood and affect are subjective and objective measures of the patient’s emotional state. Mood refers to the patient’s internal experience, while affect refers to the external manifestation of that emotion. Thought content should also be assessed, including any preoccupations, obsessions, overvalued ideas, ideas of reference, delusions, or suicidal thoughts. By considering these key components, clinicians can gain a comprehensive understanding of a patient’s mental state.
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This question is part of the following fields:
- Psychiatry
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Question 7
Incorrect
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A 56-year-old man is brought to the emergency department by ambulance, after being found confused by members of the public for the fifth time in the past month. Upon review, he tells you that he came here by bicycle after spending the afternoon with his friends doing shopping, and then later tells you he spent today in the pub with his new dog. He smells strongly of alcohol and you notice a near-empty bottle of unlabelled spirit with him.
On examination, he has an ataxic gait, dysdiadochokinesia and horizontal nystagmus.
When you go back later to see him, he has forgotten your previous interaction.
Which of the following explains his signs and symptoms?Your Answer: Wernicke's encephalopathy
Correct Answer: Korsakoff's syndrome
Explanation:The individual who arrived at the emergency department is exhibiting symptoms of Korsakoff’s syndrome, which is a result of Wernicke’s encephalopathy. These symptoms include cerebellar signs, eye signs, anterograde and retrograde amnesia, and confabulation. Additionally, the individual is carrying a bottle of alcohol and is inconsistent in their recollection of recent events.
Understanding Korsakoff’s Syndrome
Korsakoff’s syndrome is a memory disorder that is commonly observed in individuals who have a history of alcoholism. The condition is caused by a deficiency of thiamine, which leads to damage and bleeding in the mammillary bodies of the hypothalamus and the medial thalamus. Korsakoff’s syndrome often develops after untreated Wernicke’s encephalopathy.
The symptoms of Korsakoff’s syndrome include anterograde amnesia, which is the inability to form new memories, and retrograde amnesia. Individuals with this condition may also experience confabulation, which is the production of fabricated or distorted memories to fill gaps in their recollection.
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This question is part of the following fields:
- Psychiatry
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Question 8
Correct
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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: 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 9
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 10
Correct
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A 35-year-old woman is experiencing a low mood after being laid off from her job. She struggles to fall asleep at night and has difficulty getting out of bed in the morning. She has little desire to socialize with her friends or spend time with her family. She is consumed with anxiety about her future and has lost weight due to a decreased appetite.
What are the primary symptoms of a depressive episode that she is experiencing?Your Answer: Depressed mood, anergia and anhedonia
Explanation:Understanding the Symptoms of Depression
Depression is a mental health condition that affects millions of people worldwide. It is characterized by a persistent feeling of sadness, hopelessness, and despair. The three core symptoms of depression are depressed mood, anhedonia, and anergia. To receive a diagnosis of depression, a person must have at least two of these core symptoms, as well as other non-core symptoms such as reduced concentration, disturbed sleep, and diminished appetite.
While disturbed sleep and diminished appetite are common symptoms of depression, they are not considered core symptoms. On the other hand, overactivity and grandiose ideation are not typical symptoms of depression, as patients with depression usually have reduced activity and negative thoughts.
Reduced self-esteem and self-confidence are also common in depression, but they are not considered core symptoms. In severe cases of depression, patients may experience catatonia and paranoid ideation, as well as other psychotic symptoms such as hallucinations and delusions.
It is important to recognize the symptoms of depression and seek help if you or someone you know is struggling with this condition. With proper treatment, including therapy and medication, many people with depression can recover and lead fulfilling lives.
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This question is part of the following fields:
- Psychiatry
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Question 11
Incorrect
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You are working in a GP surgery and your next patient is John, a 35-year-old man with a diagnosis of generalised anxiety disorder (GAD). He is currently prescribed sertraline 200mg daily.
During the review of his symptoms today, John reports that he does not feel like the sertraline is helping, and he remains anxious almost all of the time. He experiences frequent episodes where he feels his heart pounding in his chest and his head is spinning. Additionally, he notes that he often struggles to get to sleep and can lie awake for hours at night.
As you observe John, he appears visibly distressed. He seems unable to sit still in his chair and is trembling slightly.
What would be the next step in John's management?Your Answer: Change the prescription to pregabalin
Correct Answer: Change the prescription to duloxetine
Explanation:If sertraline is not effective or not well-tolerated in the treatment of generalised anxiety disorder (GAD), an alternative SSRI or SNRI should be prescribed. In this case, duloxetine is the recommended option as it is an SNRI. Mirtazapine, although it has been shown to have an effect on anxiety symptoms, is not part of the NICE guidance for GAD treatment. Pregabalin may be considered if the patient cannot tolerate SSRI or SNRI treatment, but this is not yet necessary for Susan. Increasing the dose of sertraline is not an option as she is already on the maximum dose. Benzodiazepines should not be offered for the treatment of GAD except as a short-term measure during a crisis, according to NICE guidelines.
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 12
Correct
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A person in their mid-30s has been taking an anti-psychotic medication for a few years. They have also recently begun taking fluoxetine. During a visit to their general practitioner, they reported experiencing troubling symptoms such as lip smacking, difficulty swallowing, and excessive blinking. What is the probable diagnosis?
Your Answer: Tardive dyskinesia
Explanation:Tardive dyskinesia is a side effect that occurs after taking antipsychotics for an extended period of time. The patient’s recent use of fluoxetine is not relevant to this condition. Neuroleptic malignant syndrome and acute dystonia typically manifest within the first few days or weeks of starting an antipsychotic medication, making them unlikely in this case. Malignant hyperthermia, on the other hand, is a potential side effect of anaesthetic drugs.
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 13
Incorrect
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A woman in her early thirties is considering pregnancy while taking paroxetine. She is concerned about any potential negative effects on her pregnancy. What guidance should you provide?
Your Answer: It is advised that while no studies have been carried out, paroxetine is generally regarded as safe to use during pregnancy, but folic acid should be taken at 5mg/day
Correct Answer: It is advised that paroxetine be avoided during pregnancy unless the benefits outweigh the risk, as paroxetine can lead to an increased risk of congenital malformations
Explanation:When considering the use of Paroxetine during pregnancy, it is important to note that it can increase the risk of congenital malformations, especially during the first trimester. The use of SSRIs during pregnancy should be carefully evaluated, weighing the potential benefits against the risks. While there is a small increased risk of congenital heart defects when using SSRIs during the first trimester, using them during the third trimester can result in persistent pulmonary hypertension of the newborn. Therefore, it is crucial to consider all potential risks before deciding to use Paroxetine or any other SSRIs during pregnancy.
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 14
Correct
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A 21-year-old woman is brought to her General Practitioner for follow-up 1 week after being attacked and raped by an acquaintance on her university campus. Immediately after the episode, she was seen in the Emergency Department for her injuries and evidence gathering, interviewed by the police and discharged home. Today she reports difficulty sleeping and flashbacks about the event. She has had difficulty concentrating at university and feels anxious that ‘something bad’ might happen to her again.
Which one of the following is the most likely diagnosis?Your Answer: Acute stress disorder
Explanation:Differentiating between Acute Stress Disorder, Adjustment Disorder, Generalized Anxiety Disorder, Post-Traumatic Stress Disorder, and Panic Disorder
Acute Stress Disorder: This disorder is characterized by persistently heightened awareness, difficulty sleeping, flashbacks, and interference of thoughts with daily activities. It occurs within 1 month of a life-threatening or extremely traumatic event.
Adjustment Disorder: To diagnose this disorder, there must be an identifiable stressor, a maladaptive response to the stressor that interferes with activities, symptom onset within 3 months of the stressor, and symptoms that do not meet criteria for any other psychiatric disorder. Symptoms typically last no longer than 6 months after removal of the stressor.
Generalized Anxiety Disorder: This disorder is characterized by pervasive, excessive worry about many different aspects of a person’s life such as finances, work, and family. It often manifests first with somatic symptoms such as fatigue, difficulty sleeping, irritability, and muscle tension.
Post-Traumatic Stress Disorder (PTSD): If symptoms persist longer than 1 month, patients meet criteria for PTSD. The diagnostic differentiation between acute stress and PTSD is the duration of symptoms only.
Panic Disorder: This disorder is characterized by shortness of breath, chest pain, palpitations, diaphoresis, nausea, choking, abdominal distress, and feelings of impending doom. Symptoms mimic those of extreme autonomic arousal, are abrupt in onset, and resolve quickly.
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This question is part of the following fields:
- Psychiatry
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Question 15
Correct
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A 42-year-old woman visits her GP with her husband, reporting that she has been experiencing a racing heart for the past year. She also feels sweaty and sometimes has difficulty breathing. Despite seeing a cardiologist, no abnormalities were found in her heart. The patient admits to worrying about various things, which has affected her relationships with her loved ones. She also suffers from insomnia 3-4 nights a week. The patient has no significant medical history, but her cousin has a history of depression. On examination, the patient's heart rate is 89 bpm, and her palms are sweaty. Blood tests show no abnormalities, including normal thyroid function and calcium levels. Which neuroendocrine axis is involved in the patient's condition?
Your Answer: Hypothalamic–pituitary–adrenal (HPA)
Explanation:The Role of Hypothalamic-Pituitary Axes in Health and Disease
The hypothalamic-pituitary axes play a crucial role in maintaining homeostasis in the body. Among these axes, the hypothalamic-pituitary-adrenal (HPA) axis is particularly important in the pathophysiology of anxiety disorders. Overactivation of the HPA axis leads to the release of catecholamines, resulting in the fight or flight response. Environmental factors and genetics may contribute to the development of anxiety disorders, but the final common pathway is the dysregulation of the HPA axis.
The hypothalamic-pituitary-thyroid (HPT) axis is involved in thyroid disorders, such as hyperthyroidism and hypothyroidism. However, normal thyroid function rules out this axis as a cause of the patient’s symptoms.
The hypothalamic-pituitary-gonadal (HPG) axis is responsible for the release of sex hormones, such as oestrogen and testosterone. Disorders affecting the HPG axis can impact puberty and sexual development.
The hypothalamic-pituitary-prolactin (HPP) axis regulates the release of prolactin, which acts on the mammary glands. Medications can cause dysregulation of the HPP axis, resulting in hyperprolactinaemia or hypoprolactinaemia.
Finally, the hypothalamic-pituitary-somatotropic (HPS) axis is involved in the release of growth hormone and insulin-like growth factor 1. Dysregulation of the HPS axis can lead to growth hormone deficiency and Laron syndrome.
Understanding the role of these hypothalamic-pituitary axes is crucial in diagnosing and treating various health conditions.
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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 25-year-old man with type I diabetes mellitus visits his General Practitioner (GP) with concerns about his deteriorating glycaemic control. The GP suspects poor compliance with diet and medication. What is the most effective approach to enhance his compliance during a brief consultation?
Your Answer: Cognitive behavioural therapy (CBT)
Correct Answer: Motivational interview
Explanation:Effective Psychological Interventions in Primary Care
Primary care settings are often the first point of contact for patients seeking help for mental health or physical conditions. To provide effective care, healthcare professionals can employ various psychological interventions. Here are some of the most effective ones:
Motivational Interviewing: This patient-centred approach involves resisting a didactic course of action, understanding the reasons for the change in behaviour, listening to the patient’s ideas, concerns or expectations, and empowering the patient to understand they are able to change their behaviour. It has been proven to increase compliance with medication.
Cognitive Behavioural Therapy (CBT): This talking therapy explores the patient’s understanding, concepts and reactions towards a certain problem, gradually building behavioural changes to challenge the concepts and manage the problem. It is used predominantly in the treatment of anxiety and depression, but can also be employed in many other mental health or physical conditions.
Self-Help Materials: Self-help materials in the form of leaflets and aids are a useful tool in the primary care setting, but the patient needs to be motivated for change in order for these to work.
Psychotherapy: This form of counselling employs various techniques to induce behavioural changes and habits that will stay with the patient in the long term. This requires a set amount of sessions over a period of time and therefore, cannot be performed in a short consultation.
Supportive Counselling: This psychological intervention has been shown to be best suited for treating mild to moderate depression and can be used in combination with other methods such as CBT.
By employing these psychological interventions, healthcare professionals can provide effective care for patients seeking help for mental health or physical conditions in primary care settings.
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This question is part of the following fields:
- Psychiatry
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Question 17
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 3 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 18
Correct
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A 36-year-old woman comes to her General Practitioner (GP) complaining of mood changes eight days after giving birth. She expresses that she does not want the baby and believes that it is dying. She feels like crying constantly. She experiences auditory and visual hallucinations that tell her to harm herself. Apart from this, she has no significant medical history.
What is the diagnosis for this patient?Your Answer: Postpartum psychosis
Explanation:Differentiating Postpartum Psychosis from Other Psychiatric Disorders
Postpartum psychosis is a severe form of postpartum depression that presents with psychotic features, including auditory hallucinations instructing the patient to harm herself and rejection of the child. Antipsychotic medication is required for intervention in severe cases, while cognitive behavioural therapy and selective serotonin reuptake inhibitors may be used for milder cases. On the other hand, postnatal blues is a mild, transient disturbance in mood occurring between the third and sixth day after delivery, while adjustment disorder is diagnosed in the absence of another psychiatric diagnosis and does not involve auditory or visual hallucinations. Anxiety disorder, specifically generalised anxiety disorder, is characterised by excessive worry disproportionate to the situation, restlessness, fatigue, impaired concentration, muscle tenderness, and poor sleep, but does not occur specifically post-delivery. Schizoid personality disorder, which involves a lack of interest in social relationships, solitary lifestyle, secretiveness, emotional coldness, and apathy, is not an acute presentation like postpartum psychosis.
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This question is part of the following fields:
- Psychiatry
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Question 19
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 20
Correct
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You are asked to see a 50-year-old woman who reports feeling down for several months. Upon further questioning, you discover that she has lost interest in activities she previously enjoyed, such as hiking and going to the theater. She has also been experiencing fatigue, causing her to miss work, and has had occasional thoughts of not wanting to be alive, although she denies any intention of harming herself. In the past month, her symptoms have worsened, with episodes of anxiety occurring at least once a week. These episodes last around five minutes and are characterized by hyperventilation, nausea, and a fear of having a heart attack. No physical abnormalities have been found. What is the most likely diagnosis?
Your Answer: Depression with secondary panic attacks
Explanation:Understanding Different Types of Anxiety and Related Disorders
Anxiety and related disorders can manifest in various ways, making it important to understand the different types and their symptoms. Depression with secondary panic attacks is a common occurrence, where panic attacks and other anxiety symptoms are a secondary feature of depression. Agoraphobia is an excessive fear of being in situations where escape or help may not be available, leading to avoidance of such situations. Generalised anxiety disorder is characterised by uncontrollable and irrational worry or anxiety about a wide range of issues and situations. Panic disorder is diagnosed when a person has recurrent, severe panic attacks without an obvious precipitant. Chronic fatigue syndrome is characterised by persistent, unexplained fatigue over several months. Understanding these disorders and their symptoms can help in proper diagnosis and treatment.
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This question is part of the following fields:
- Psychiatry
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Question 21
Incorrect
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A 60-year-old man is admitted from the angiography suite after the cardiologist discovered severe triple vessel disease. He awaits transfer to a tertiary hospital for a coronary artery bypass graft. After 48 hours of admission, you receive a call to see him as he has become confused, sweaty, tremulous, and agitated.
Upon reviewing his record, you note a history of asthma, variceal bleed, and cirrhosis secondary to alcohol excess. His observations show a pyrexia at 37.9ºC, heart rate of 105 bpm, and blood pressure 175/98 mmHg. What would be the most appropriate immediate intervention given the likely diagnosis?Your Answer: IV antibiotics
Correct Answer: Chlordiazepoxide
Explanation:Chlordiazepoxide or diazepam are effective treatments for delirium tremens and alcohol withdrawal. Symptoms of alcohol withdrawal can include confusion, agitation, tremors, hallucinations, and autonomic dysfunction such as high blood pressure, sweating, and fever.
Chlordiazepoxide is the most appropriate answer for this scenario. While confusion, sweating, and agitation can be signs of infection, the patient’s alcohol history suggests that delirium tremens is the more likely diagnosis. IV antibiotics would not address the primary issue of alcohol withdrawal. The patient’s high blood pressure also suggests that infection is not the cause of their symptoms.
Intravenous hydration may be necessary if the patient is experiencing excessive fluid loss due to sweating, but it would not be the best treatment for alcohol withdrawal in this case.
Alcohol withdrawal occurs when an individual who has been consuming alcohol chronically suddenly stops or reduces their intake. Chronic alcohol consumption enhances the inhibitory effects of GABA in the central nervous system, similar to benzodiazepines, and inhibits NMDA-type glutamate receptors. However, alcohol withdrawal leads to the opposite effect, resulting in decreased inhibitory GABA and increased NMDA glutamate transmission. Symptoms of alcohol withdrawal typically start at 6-12 hours and include tremors, sweating, tachycardia, and anxiety. Seizures are most likely to occur at 36 hours, while delirium tremens, which includes coarse tremors, confusion, delusions, auditory and visual hallucinations, fever, and tachycardia, peak at 48-72 hours.
Patients with a history of complex withdrawals from alcohol, such as delirium tremens, seizures, or blackouts, should be admitted to the hospital for monitoring until their withdrawals stabilize. The first-line treatment for alcohol withdrawal is long-acting benzodiazepines, such as chlordiazepoxide or diazepam, which are typically given as part of a reducing dose protocol. Lorazepam may be preferable in patients with hepatic failure. Carbamazepine is also effective in treating alcohol withdrawal, while phenytoin is said to be less effective in treating alcohol withdrawal seizures.
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This question is part of the following fields:
- Psychiatry
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Question 22
Incorrect
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A 20-year-old individual presents with obsessive thoughts about causing harm to others since moving away from home to attend college. They are particularly anxious about using the shared kitchen in their dormitory and tend to prepare and eat meals during the night to avoid contact with their roommates. After completing a Yale-Brown Obsessive Compulsive Scale (Y-BOCS), they are diagnosed with mild OCD. What treatment option would be most suitable for this individual?
Your Answer: Clomipramine
Correct Answer: Cognitive behavioural therapy
Explanation:For patients with mild symptoms of obsessive-compulsive disorder (OCD) and mild impairment, the recommended first-line treatment is cognitive behavioural therapy (CBT) with exposure and response prevention (ERP). While clomipramine, a tricyclic antidepressant, may be used in some cases, it is not typically the first choice. Dialectical behaviour therapy is not commonly used in the treatment of OCD, as CBT and ERP are more effective. Fluoxetine, an SSRI antidepressant, may also be used in the treatment of OCD, but is not typically the first-line treatment for mild cases.
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 23
Incorrect
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A 45-year-old woman is brought in by her daughter because ‘she is acting wild again’. She drinks moderately about once a week. She is not sleeping much, talks incessantly about plans to travel the world and has made many impulsive and irrational purchases. She reports hearing voices but refuses to discuss this issue when questioned by the admitting psychiatrist. She begins a task but does not complete it, all the while making lists of things to be done. She has been starting tasks and not finishing them. She had a similar episode 3 years ago. She also has depressive episodes several times over the last few years and recovered in between them.
What is the most likely underlying diagnosis?Your Answer: Schizoaffective disorder
Correct Answer: Bipolar, manic, with mood-congruent psychotic features
Explanation:Understanding Psychotic Disorders: Differential Diagnosis
Psychotic disorders are a group of mental illnesses characterized by the presence of psychotic symptoms such as hallucinations, delusions, and disorganized thinking. However, differentiating between these disorders can be challenging. Here are some possible diagnoses for a patient presenting with manic and psychotic symptoms:
Bipolar, manic, with mood-congruent psychotic features: This diagnosis is appropriate for a patient with both manic symptoms and mood-congruent psychotic features. The patient’s lack of insight is characteristic of either mania or psychosis. The need to get a history from a third party is typical. What distinguishes this from schizophrenia is that the patient appears to have a normal mood state.
Substance-induced psychosis: The use of substances in this scenario is far too little to account for the patient’s symptoms, ruling out psychosis secondary to substance abuse.
Schizophreniform disorder: This diagnosis is appropriate for a patient with symptoms of schizophrenia of <6 months' duration. Schizophrenia, paranoid type: This diagnosis is appropriate for a patient with symptoms for >6 months and multiple psychotic symptoms such as hallucinations, bizarre delusions, and social impairment.
Schizoaffective disorder: This diagnosis is appropriate for a patient with both mood disorder and schizophrenic symptoms. However, the patient in this scenario is not expressing enough schizophrenic symptoms to establish a diagnosis of schizoaffective disorder.
In conclusion, accurate diagnosis of psychotic disorders requires careful evaluation of the patient’s symptoms, history, and social functioning. A thorough understanding of the differential diagnosis is essential for effective treatment and management of these complex conditions.
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This question is part of the following fields:
- Psychiatry
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Question 24
Correct
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A middle-aged couple visits the clinic with concerns about the husband's behavior. The wife reports that her partner has been acting strangely, constantly checking on their son throughout the day and night, sometimes up to twenty times. When questioned, he reveals that he had a frightening experience with his son last month and cannot stop reliving it in his mind. He avoids going to places where he might lose sight of his son and has trouble sleeping. There is no significant medical or psychiatric history. What is the most probable diagnosis?
Your Answer: Post traumatic stress disorder (PTSD)
Explanation:Understanding Post-Traumatic Stress Disorder (PTSD)
Post-traumatic stress disorder (PTSD) is a mental health condition that can develop in individuals of any age following a traumatic event. This can include experiences such as natural disasters, accidents, or even childhood abuse. PTSD is characterized by a range of symptoms, including re-experiencing the traumatic event through flashbacks or nightmares, avoidance of situations or people associated with the event, hyperarousal, emotional numbing, depression, and even substance abuse.
Effective management of PTSD involves a range of interventions, depending on the severity of the symptoms. Single-session interventions are not recommended, and watchful waiting may be used for mild symptoms lasting less than four weeks. Military personnel have access to treatment provided by the armed forces, while trauma-focused cognitive behavioral therapy (CBT) or eye movement desensitization and reprocessing (EMDR) therapy may be used in more severe cases.
It is important to note that drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used, venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline, should be tried. In severe cases, NICE recommends that risperidone may be used. Overall, understanding the symptoms and effective management of PTSD is crucial in supporting individuals who have experienced traumatic events.
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This question is part of the following fields:
- Psychiatry
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Question 25
Correct
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A 25-year-old man is worried about several recent incidents related to his sleep. He reports experiencing paralysis upon waking up and occasionally when falling asleep, accompanied by what he describes as 'hallucinations' such as seeing another person in the room. These episodes are causing him increasing anxiety. What is the probable diagnosis?
Your Answer: Sleep paralysis
Explanation:Understanding Sleep Paralysis
Sleep paralysis is a condition that affects many people and is characterized by a temporary inability to move the skeletal muscles when waking up or falling asleep. It is believed to be linked to the natural paralysis that occurs during REM sleep. This phenomenon is recognized in various cultures and is often accompanied by hallucinations or vivid images.
The paralysis occurs either before falling asleep or after waking up, and it can be a frightening experience for those who are not familiar with it. However, it is a relatively harmless condition that does not require medical attention in most cases. If the symptoms are particularly bothersome, medication such as clonazepam may be prescribed to alleviate the symptoms.
In summary, sleep paralysis is a common occurrence that affects many people. It is characterized by temporary paralysis of the skeletal muscles and is often accompanied by hallucinations. While it can be a frightening experience, it is generally harmless and does not require medical attention.
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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 63-year-old man presents to his general practitioner with stiffness in his muscles, difficulty initiating movements such as getting up from a chair, slow movements and hand shaking, which started 5 weeks ago. He has a medical history of schizophrenia and has had good compliance with his medication for the past 3 months. He is taking haloperidol. On examination, his temperature is 37.5 °C, blood pressure 120/81 mmHg and pulse 98 bpm. On examination, there is decreased facial expression, pill-rolling tremor, cogwheel rigidity and festinating gait.
Which of the following terms describes the symptoms of this patient?Your Answer: Neuroleptic malignant syndrome
Correct Answer: Bradykinesia
Explanation:Common Neurological Side Effects of Medications
Medications can sometimes cause neurological side effects that mimic symptoms of neurological disorders. One such side effect is called pseudo-parkinsonism, which is characterized by bradykinesia or slowness in movements. This can be caused by typical and atypical antipsychotic medication, anti-emetics like metoclopramide, and some calcium channel blockers like cinnarizine.
Another side effect is acute dystonia, which is the sudden and sustained contraction of muscles in any part of the body, usually following the administration of a neuroleptic agent. Akathisia is another symptom associated with antipsychotic use, which is characterized by restlessness and the inability to remain motionless.
Tardive dyskinesia is a neurological side effect that is characterized by involuntary muscle movements, usually affecting the tongue, lips, trunk, and extremities. This is seen in patients who are on long-term anti-dopaminergic medication such as antipsychotic medication (both typical and atypical), some antidepressants, metoclopramide, prochlorperazine, carbamazepine, phenytoin, and others.
Finally, neuroleptic malignant syndrome is a life-threatening condition associated with the use of antipsychotic medication. It is characterized by hyperthermia, muscle rigidity, changes in level of consciousness, and autonomic instability. Management is supportive, and symptoms generally resolve within 1-2 weeks.
Understanding the Neurological Side Effects of Medications
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This question is part of the following fields:
- Psychiatry
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Question 27
Correct
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A 20-year old man with suspected schizophrenia is reviewed in clinic. During the consultation the patient informs you that there is a plot to destroy the world and that he has been chosen as a saviour.
Which of the following terms most appropriately describes this patient's belief?Your Answer: Delusion
Explanation:Understanding Psychotic Symptoms: Delusions, Illusions, Perseveration, and Hallucinations
Psychotic symptoms are not simply exaggerations of normal experiences like anxiety or depression. They include hallucinations, delusions, and thought disorder. Delusions are false beliefs that are not shared by others in a cultural group and can be characteristic of different psychiatric disorders. Persecutory delusions are the most common form in schizophrenia and delusional disorder. Schizophrenia is characterized by episodes of delusions, hallucinations, bizarre behavior, incoherent thought processes, and flat or inappropriate affect. Illusions, on the other hand, are misinterpretations of existing sensory stimuli and suggest delirium or intoxication. Perseveration is the persistent repetition of words, phrases, or simple motor behavior and can occur in delirium, dementia, or psychosis. Hallucinations are perceptions of stimuli that are not there and are less common than delusions in schizophrenia. Mood-congruent delusions are consistent with the reported or observed mood and may be markers of the severity of mood disturbance, while mood-incongruent delusions are less easily explained but are commonly associated with a worse prognosis.
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This question is part of the following fields:
- Psychiatry
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Question 28
Correct
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A 17-year-old boy visits his doctor complaining of low mood. He has been experiencing this for the past 5 weeks along with fatigue, anhedonia, and oversleeping. The doctor orders a set of blood tests and his PHQ-9 score indicates moderate depression. The patient has no medical history. He is not interested in cognitive behavioural therapy and wants to begin medication. What is the best medication for him to start with?
Your Answer: Fluoxetine
Explanation:Fluoxetine is the preferred SSRI for treating depression in children and adolescents.
Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.
The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.
When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.
When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.
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This question is part of the following fields:
- Psychiatry
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Question 29
Correct
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A 28-year-old man visits his GP with complaints of poor memory. He works in a consulting company and recently faced trouble at work after missing a flight to a client in Tokyo. He has difficulty falling asleep and wakes up feeling exhausted. Sometimes he wakes up in the middle of the night screaming. When awake, he cannot relax and appears to be constantly on edge.
The patient has a history of attention-deficit hyperactivity disorder during childhood and one major depressive episode during his university years. He has not had any mental health-related complaints since then. He drinks one bottle of wine on Saturdays with his wife and admits to occasional past cocaine use. However, he stopped using cocaine after being ambushed and stabbed while dealing with a dealer during his last vacation in Thailand two months ago. His wife has recently complained that he appears emotionally unavailable.
Upon physical examination, no abnormalities are found. However, during the mental state examination, the patient exhibits low mood and an increased startle response. What is the most likely diagnosis?Your Answer: Post-traumatic stress disorder
Explanation:The individual is displaying common symptoms of PTSD, including re-experiencing the traumatic event through nightmares, avoiding triggers associated with the event, and experiencing hyperarousal such as hypervigilance and difficulty sleeping. It has been over a month since the traumatic event occurred, ruling out acute stress disorder. There are no signs of psychosis, and the individual has been sober from cocaine for two months. While anxiety is a symptom of PTSD, there is no indication of a generalized anxiety disorder or major depressive episode.
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 30
Incorrect
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A 31-year-old woman presents to her general practitioner 7 days after giving birth to her first child. The patient has been complaining of feeling ‘down’ for the last 4 or 5 days. She also describes being tearful and tired. She denies loss of interest in her hobbies, difficulty concentrating, guilt, change in appetite, sluggishness and suicidal thoughts. She also denies hallucination.
Which of the following statements concerning this patient’s likely condition is most accurate?Your Answer: Her condition occurs in about 10% of women after giving birth
Correct Answer: Her condition will probably improve within 10–14 days following birth
Explanation:Understanding Postpartum Mood Disorders: Symptoms and Treatment Options
Postpartum mood disorders are a common occurrence among women after giving birth. There are three main types of postpartum mood disorders: postpartum blues, postpartum depression, and postpartum psychosis.
Postpartum blues is the mildest form and affects at least 50% of women. Symptoms include fatigue, tearfulness, and a depressed mood that develops 2-3 days after giving birth. This condition usually resolves without treatment within 10-14 days following birth.
Postpartum depression is a more serious condition that affects about 10% of women. Patients present with at least 2 weeks of depressed mood that begins within 4 weeks of delivery. They also suffer from five of the following symptoms: change in sleep, loss of interest, guilt, decreased energy, difficulty concentrating, sluggishness, and suicidal ideation. Treatment options include antidepressants and psychotherapy.
Postpartum psychosis is the rarest form, with an incidence rate of about 0.1%. It is characterized by hallucinations and delusions, and patients may feel suicidal or homicidal, especially towards the newborn. This condition can last 1 month or more and often requires hospitalization with anti-psychotic treatment.
It is important to note that there is no time limit on diagnosing these conditions. If you or someone you know is experiencing symptoms of a postpartum mood disorder, seek medical attention immediately. With proper treatment, these conditions can be managed effectively, and the patient can make a full recovery.
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This question is part of the following fields:
- Psychiatry
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