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  • Question 1 - Which of the following is not a characteristic of dementia? ...

    Incorrect

    • Which of the following is not a characteristic of dementia?

      Your Answer: Memory impairment

      Correct Answer: Clouding of consciousness

      Explanation:

      The presence of clouding of consciousness indicates delirium and is not a characteristic feature of pure dementia.

      Dementia: An Overview

      Dementia is a syndrome that results in a decline in memory and at least one other cognitive domain, such as language, visuospatial of executive functioning. This decline is significant enough to interfere with social and occupational function in an alert person. The diagnosis of dementia is based on evidence of neurocognitive impairment, which is demonstrated by standardized neuropsychological of cognitive testing. Behavioural changes may also be present, and the symptoms result in significant impairment in personal, family, social, educational, occupational, of other important areas of functioning.

      Epidemiology

      The total population prevalence of dementia among over 65s is 7.1%, which equals 1.3% of the entire UK population. Alzheimer’s disease is the most common cause of dementia in the UK, followed by vascular and Lewy body dementia. These conditions may coexist. The proportions of dementia severity among people with late-onset dementia are as follows: 55.4% have mild dementia, 32.1% have moderate dementia, and 12.5% have severe dementia.

    • This question is part of the following fields:

      • Old Age Psychiatry
      55.3
      Seconds
  • Question 2 - Which of the following is characterised by fluent, empty speech? ...

    Correct

    • Which of the following is characterised by fluent, empty speech?

      Your Answer: Semantic dementia

      Explanation:

      Frontotemporal Lobar Degeneration

      Frontotemporal lobar degeneration (FTLD) is a group of neurodegenerative disorders that involve the atrophy of the frontal and temporal lobes. The disease is characterized by progressive dysfunction in executive functioning, behavior, and language, and can mimic psychiatric disorders due to its prominent behavioral features. FTLD is the third most common form of dementia across all age groups and a leading type of early-onset dementia.

      The disease has common features such as onset before 65, insidious onset, relatively preserved memory and visuospatial skills, personality change, and social conduct problems. There are three recognized subtypes of FTLD: behavioral-variant (bvFTD), language variant – primary progressive aphasia (PPA), and the language variant is further subdivided into semantic variant PPA (aka semantic dementia) and non-fluent agrammatic variant PPA (nfvPPA).

      As the disease progresses, the symptoms of the three clinical variants can converge, as an initially focal degeneration becomes more diffuse and spreads to affect large regions in the frontal and temporal lobes. The key differences between the subtypes are summarized in the table provided. The bvFTD subtype is characterized by poor personal and social decorum, disinhibition, poor judgment and problem-solving, apathy, compulsive/perseverative behavior, hyperorality of dietary changes, and loss of empathy. The nfvPPA subtype is characterized by slow/slurred speech, decreased word output and phrase length, word-finding difficulties, apraxia of speech, and spared single-word comprehension. The svPPA subtype is characterized by intact speech fluency, word-finding difficulties (anomia), impaired single-word comprehension, repetitive speech, and reduced word comprehension.

      In conclusion, FTLD is a progressive, heterogeneous, neurodegenerative disorder that affects the frontal and temporal lobes. The disease is characterized by dysfunction in executive functioning, behavior, and language, and can mimic psychiatric disorders due to its prominent behavioral features. There are three recognized subtypes of FTLD, and as the disease progresses, the symptoms of the three clinical variants can converge.

    • This question is part of the following fields:

      • Old Age Psychiatry
      41.5
      Seconds
  • Question 3 - NICE has made a recommendation for the treatment of antisocial personality disorder, but...

    Incorrect

    • NICE has made a recommendation for the treatment of antisocial personality disorder, but the specific recommendation is not provided in the given information.

      Your Answer: Dialectic behavioural therapy

      Correct Answer: Group based cognitive interventions

      Explanation:

      NICE suggests that individuals with antisocial personality disorder, including those who struggle with substance misuse, who are receiving care in community and mental health services, should be offered group-based cognitive and behavioural interventions. These interventions aim to tackle issues such as impulsivity, interpersonal challenges, and antisocial behaviour.

      Personality Disorder (Antisocial / Dissocial)

      Antisocial personality disorder is characterized by impulsive, irresponsible, and often criminal behavior. The criteria for this disorder differ somewhat between the ICD-11 and DSM-5. The ICD-11 abolished all categories of personality disorder except for a general description of personality disorder. This diagnosis can be further specified as “mild,” “moderate,” of “severe.” Patient behavior can be described using one of more of five personality trait domains; negative affectivity, dissociality, anankastic, detachment, and disinhibition. Clinicians may also specify a borderline pattern qualifier.

      The core feature of dissociality is a disregard for the rights and feelings of others, encompassing both self-centeredness and lack of empathy. Common manifestations of Dissociality include self-centeredness and lack of empathy. The DSM-5 defines antisocial personality disorder as a pervasive pattern of disregard for and violation of the rights of others, occurring since age 15, as indicated by three (of more) of the following: failure to conform to social norms with respect to lawful behaviors, deceitfulness, impulsivity of failure to plan ahead, irritability and aggressiveness, reckless disregard for safety of self of others, consistent irresponsibility, and lack of remorse.

      Prevalence estimates are between 1%-6% in men and between 0.2-0.8% in women. Antisocial behaviors typically have their onset before age 8 years. Nearly 80% of people with ASPD developed their first symptom by age 11 years. Boys develop symptoms earlier than girls, who may not develop symptoms until puberty. An estimated 25% of girls and 40% of boys with Conduct Disorder will later meet criteria for ASPD.

      The 2009 NICE Guidelines essentially make two recommendations on treatment: consider offering group-based cognitive and behavioral interventions and pharmacological interventions should not be routinely used for the treatment of antisocial personality disorder of associated behaviors of aggression, anger, and impulsivity. A Cochrane review found that there is not enough good quality evidence to recommend of reject any psychological treatment for people with a diagnosis of AsPD.

      The term psychopathy has varied meanings. Some use the term synonymously with APD and consider it to represent the severe end of the spectrum of APD. Others maintain a clear distinction between psychopathy and APD. Psychopathy has been said to be a richer (broader) concept than APD. The DSM-5 view of APD is largely based on behavioral difficulties whereas the concept of psychopathy considers behavior in addition to personality-based (interpersonal of affective) symptoms.

    • This question is part of the following fields:

      • Forensic Psychiatry
      57.1
      Seconds
  • Question 4 - An aging patient with dementia who has shown improvement with donepezil treatment has...

    Incorrect

    • An aging patient with dementia who has shown improvement with donepezil treatment has had their dosage raised. They come back to the clinic reporting issues with urinary incontinence. What course of action would you recommend?

      Your Answer: Slowly withdraw the drug by a gradual reduction regime

      Correct Answer: Reduce the dose and suggest continuing

      Explanation:

      Since donepezil has shown a positive response, it would be inappropriate to discontinue it. However, urinary incontinence associated with the medication should not be disregarded as it can limit patients’ activities and quality of life. While it may often be transient and not serious, a lower dose of donepezil of the use of a peripherally acting cholinergic antagonist may be helpful in managing this adverse effect. It is important to recognize urinary incontinence as a potential manifestation of dementia. These recommendations were made by M Hashimoto in a 2000 article in The Lancet.

      Treatment of Dementia: AChE Inhibitors and Memantine

      Dementia is a debilitating condition that affects millions of people worldwide. Acetylcholinesterase inhibitors (AChE inhibitors) and memantine are two drugs used in the management of dementia. AChE inhibitors prevent cholinesterase from breaking down acetylcholine, which is deficient in Alzheimer’s due to loss of cholinergic neurons. Donepezil, galantamine, and rivastigmine are AChE inhibitors used in the management of Alzheimer’s. Memantine is an NMDA receptor antagonist that blocks the effects of pathologically elevated levels of glutamate that may lead to neuronal dysfunction.

      NICE guidelines recommend the use of AChE inhibitors for managing mild to moderate Alzheimer’s and memantine for managing moderate to severe Alzheimer’s. For those already taking an AChE inhibitor, memantine can be added if the disease is moderate of severe. AChE inhibitors are also recommended for managing mild, moderate, and severe dementia with Lewy bodies, while memantine is considered if AChE inhibitors are not tolerated of contraindicated. AChE inhibitors and memantine are not recommended for vascular dementia, frontotemporal dementia, of cognitive impairment due to multiple sclerosis.

      The British Association for Psychopharmacology recommends AChE inhibitors as the first choice for Alzheimer’s and mixed dementia, while memantine is the second choice. AChE inhibitors and memantine are also recommended for dementia with Parkinson’s and dementia with Lewy bodies.

      In summary, AChE inhibitors and memantine are important drugs used in the management of dementia. The choice of drug depends on the type and severity of dementia, as well as individual patient factors.

    • This question is part of the following fields:

      • Old Age Psychiatry
      7.2
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  • Question 5 - A medical colleague contacts you for advice regarding the management of a teenage...

    Correct

    • A medical colleague contacts you for advice regarding the management of a teenage patient with HIV. You have previously looked after this patient due to her having borderline personality disorder and mania. The patient has a long history of self-harm and remains at high risk of suicide. Which of the following antiretrovirals would you suggest your colleague specifically avoid in this case?:

      Your Answer: Efavirenz

      Explanation:

      For exams, it is important to be aware that Efavirenz, an antiretroviral, has been associated with both mania and fatal suicide.

      HIV and Mental Health: Understanding the Relationship and Treatment Options

      Human immunodeficiency virus (HIV) is a blood-borne virus that causes cellular immune deficiency, resulting in a decrease in the number of CD4+ T-cells. People with severe mental illness are at increased risk of contracting and transmitting HIV, and the prevalence of HIV infection among them is higher than in the general population. Antiretroviral drugs are used to manage HIV, but they are not curative.

      Depression is the most common mental disorder in the HIV population, and it can result from HIV of the psycho-social consequences of having the condition. HIV-associated neurocognitive disorder (HAND) is the umbrella term for the spectrum of neurocognitive impairment induced by HIV, ranging from mild impairment through to dementia. Poor episodic memory is the most frequently reported cognitive difficulty in HIV-positive individuals.

      Treatment options for mental health issues in people with HIV include atypical antipsychotics for psychosis, SSRIs for depression and anxiety, valproate for bipolar disorder, and antiretroviral therapy for HAND. It is important to avoid benzodiazepines for delirium and MAOIs for depression. Understanding the relationship between HIV and mental health and providing appropriate treatment options can improve the quality of life for people living with HIV.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 6 - A 45-year-old man is referred to you by his primary care physician. He...

    Incorrect

    • A 45-year-old man is referred to you by his primary care physician. He has a history of anxiety and is currently experiencing symptoms of low mood and difficulty sleeping. The physician is concerned about the possibility of depression.
      During your assessment, you note evidence of low mood, initial insomnia, and some feelings of hopelessness. The patient denies any suicidal thoughts.
      What treatment approach would you avoid as part of his management plan?

      Your Answer: Imipramine

      Correct Answer: Paroxetine

      Explanation:

      The patient’s symptoms suggest a moderate depressive episode, which can be treated with cognitive behavioural therapy (CBT) if it is easily accessible. During pregnancy, amitriptyline, imipramine, and fluoxetine are commonly used antidepressants. However, paroxetine should be avoided due to its short half-life, which can lead to neonatal irritability and withdrawal.

    • This question is part of the following fields:

      • General Adult Psychiatry
      85.6
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  • Question 7 - Which concept is commonly linked to the term 'mindfulness'? ...

    Correct

    • Which concept is commonly linked to the term 'mindfulness'?

      Your Answer: DBT

      Explanation:

      Dialectical Behavioural Therapy (DBT) is a form of psychotherapy that is tailored for patients with borderline personality disorder. It combines behavioural therapy with aspects of Zen Buddhism and dialectical thinking to help patients develop important interpersonal and emotional regulation skills. DBT has five functions, including enhancing behavioural capabilities, improving motivation to change, assuring new capabilities generalise to the natural environment, structuring the environment so that appropriate behaviours are reinforced, and enhancing motivation of the therapist.

      DBT uses a hierarchy of treatment targets to help the therapist determine the order in which problems should be addressed. The treatment targets in order of priority are life-threatening behaviours, therapy-interfering behaviours, quality of life behaviours, and skills acquisition. DBT skills include mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation. Overall, DBT is an effective form of therapy for patients with multiple problems, and it helps them develop the skills they need to achieve their goals and improve their quality of life.

    • This question is part of the following fields:

      • Psychotherapy
      7.4
      Seconds
  • Question 8 - What is a typical adverse effect of the stimulant drugs prescribed for managing...

    Incorrect

    • What is a typical adverse effect of the stimulant drugs prescribed for managing attention deficit hyperactivity disorder?

      Your Answer: Weight loss

      Correct Answer: Appetite suppression

      Explanation:

      Stimulant medications are commonly used to treat attention-deficit hyperactivity disorder (ADHD) in young people. However, they can cause some side effects. The most common side effects include appetite suppression, sleep disturbance, and abdominal pain. Uncommon side effects may include weight loss, restricted growth, headache, worsening of tics, behavioural rebound, and significantly raised blood pressure. It is important to monitor these side effects and discuss any concerns with a healthcare provider.

      ADHD (Diagnosis and Management in Children)

      ADHD is a behavioural syndrome characterised by symptoms of inattention, hyperactivity, and impulsivity. The DSM-5 and ICD-11 provide diagnostic criteria for the condition, with both recognising three subtypes: predominantly inattentive, predominantly hyperactive-impulsive, and combined.

      Treatment for children under 5 involves offering an ADHD-focused group parent-training programme as a first-line option. Medication should only be considered after obtaining advice from a specialist ADHD service. For children and young people aged 5-18, advice and support should be given, along with an ADHD-focused group parent-training programme. Medication should only be offered if ADHD symptoms persist after environmental modifications have been implemented and reviewed. Cognitive behavioural therapy may also be considered for those who have benefited from medication but still experience significant impairment.

      NICE advises against elimination diets, dietary fatty acid supplementation, and the use of the ‘few foods diet’. Methylphenidate of lisdexamfetamine is the first-line medication option, with dexamphetamine considered for those who respond to lisdexamfetamine but cannot tolerate the longer effect profile. Atomoxetine of guanfacine may be offered for those who cannot tolerate methylphenidate of lisdexamfetamine. Clonidine and atypical antipsychotics should only be used with advice from a tertiary ADHD service.

      Drug holidays may be considered for children and young people who have not met the expected height for their age due to medication. However, NICE advises that withdrawal from treatment is associated with a risk of symptom exacerbation.

    • This question is part of the following fields:

      • Child And Adolescent Psychiatry
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  • Question 9 - What is the ratio of suicide rates between individuals with Huntington's disease and...

    Correct

    • What is the ratio of suicide rates between individuals with Huntington's disease and the general population?

      Your Answer: 6

      Explanation:

      Patients with Huntington’s disease have a suicide rate that is four to six times higher than the general population.

      Psychiatric and Behavioural Symptoms of Huntington’s Disease

      Huntington’s disease is a condition that affects individuals with a triad of symptoms, including motor, cognitive, and psychiatric symptoms. While the symptoms typically begin in the third and fourth decades of life, individuals with a high number of CAG repeats may experience symptoms before the age of 20, known as juvenile Huntington’s disease.

      The psychiatric symptoms of Huntington’s disease can include depression, apathy, dementia, psychosis, anxiety, mania, sexual dysfunction, and even suicide. These symptoms can significantly impact an individual’s quality of life and require appropriate treatment. Advances in psychiatric treatment have been made to address these symptoms and improve the overall well-being of individuals with Huntington’s disease.

    • This question is part of the following fields:

      • Old Age Psychiatry
      5.5
      Seconds
  • Question 10 - A school conducts a new program in an attempt to prevent students with...

    Correct

    • A school conducts a new program in an attempt to prevent students with early signs of academic struggles from falling behind in their studies.

      They begin by identifying students who are showing signs of academic difficulties. Once identified, these students are offered a tutoring and mentoring intervention.

      What term best describes this intervention?

      Your Answer: Indicated prevention

      Explanation:

      The individuals being focused on already exhibit early signs, making this a suitable approach for indicated prevention.

      Prevention measures can be classified into different levels, depending on the stage at which they are implemented. The first model, developed in the 1960s, includes primary, secondary, and tertiary prevention. Primary prevention aims to intervene before a disease of problem begins, and can be universal (targeted to the general public), selective (targeted to a high-risk population), of indicated (targeted to individuals with minimal but detectable signs of a disorder). Secondary prevention aims to detect and treat disease that has not yet become symptomatic, while tertiary prevention involves the care of established disease.

      A newer model, developed in 1992, focuses on prevention interventions used before the initial onset of a disorder. This model also includes three levels: universal prevention (targeted to the general population), selective prevention (targeted to a high-risk population), and indicated prevention (targeted to individuals with minimal but detectable signs of a disorder). Examples of prevention measures include cognitive interventions for adolescents with cognitive deficits to prevent the later phases of schizophrenia, screening procedures for early detection and treatment of disease, and the use of low-dose atypical antipsychotics and CBT for patients with prodromal symptoms of schizophrenia to delay of prevent disease onset.

    • This question is part of the following fields:

      • Organisation And Delivery Of Psychiatric Services
      19
      Seconds
  • Question 11 - Who is credited with introducing the idea of the 'transitional object'? ...

    Correct

    • Who is credited with introducing the idea of the 'transitional object'?

      Your Answer: Winnicott

      Explanation:

      Winnicott: An Overview

      Donald Winnicott, a British paediatrician and psychotherapist, is known for his contributions to the field of child development and psychoanalysis. He introduced several concepts that are still relevant today.

      Good Enough Mother: Winnicott emphasised the importance of being a good enough mother rather than a perfect one. He believed that children needed someone who would attend to them but not immediately so that they could learn to tolerate frustration.

      Holding Environment: This refers to the psychic and physical space between the mother and infant that ensures the mother is there for the child when needed but allows them to explore independently when ready.

      Transitional Object: Winnicott talked about the two separate realities for a child, the ‘me’ and the ‘not me’. The transitional object is one that represents another (e.g. Mother) and is regarded as the first ‘not me’ possession.

      False Self: Winnicott described the situation of ‘not good-enough mothering’ as one in which the mother (consciously of unconsciously) is unable to respond adequately to her infant’s spontaneous behaviour (true self), but tends to impose her own wishes and desires (e.g. for an ‘ideal’ child). This may lead the infant to an adaptation on the basis of ’compliance’ (false self) and later, in adulthood, to the loss of a sense of personal autonomy and integrity.

    • This question is part of the following fields:

      • Psychotherapy
      3.1
      Seconds
  • Question 12 - What evidence suggests that interpersonal therapy has a distinct purpose of function? ...

    Correct

    • What evidence suggests that interpersonal therapy has a distinct purpose of function?

      Your Answer: Evidence of a significant role transition

      Explanation:

      Interpersonal Therapy: A Structured Approach to Addressing Social Functioning Problems

      Interpersonal therapy (IPT) is a structured form of psychotherapy that is often used to treat depression. It is based on the belief that social functioning problems have a significant impact on psychological problems. IPT is a time-limited therapy that typically runs for 10-16 one hour sessions. The therapy is organized into three phases, with the first phase involving data collection and formulation. The remaining sessions explore the formulation in more detail.

      IPT focuses on four areas of social functioning problems: grief, role transitions, interpersonal deficits, and interpersonal disputes. The therapy aims to intervene at the level of social functioning, rather than focusing on personality. The therapy has been found to be effective in treating depression, particularly in patients with severe depression. However, it may be less effective in treating people with depression and comorbid personality disorders.

      The evidence base for IPT is most developed for eating disorders, and the intervention is recommended in NICE guidelines for eating disorders. Overall, IPT is a structured approach to addressing social functioning problems that can be effective in treating depression and other psychological problems.

    • This question is part of the following fields:

      • Psychotherapy
      16.2
      Seconds
  • Question 13 - A study which aims to see if women over 40 years old have...

    Incorrect

    • A study which aims to see if women over 40 years old have a different length of pregnancy, compare the mean in a group of women of this age against the population mean. Which of the following tests would you use to compare the means?

      Your Answer: Paired t-test

      Correct Answer: One sample t-test

      Explanation:

      The appropriate statistical test for the study is a one-sample t-test as it involves the calculation of a single mean.

      Choosing the right statistical test can be challenging, but understanding the basic principles can help. Different tests have different assumptions, and using the wrong one can lead to inaccurate results. To identify the appropriate test, a flow chart can be used based on three main factors: the type of dependent variable, the type of data, and whether the groups/samples are independent of dependent. It is important to know which tests are parametric and non-parametric, as well as their alternatives. For example, the chi-squared test is used to assess differences in categorical variables and is non-parametric, while Pearson’s correlation coefficient measures linear correlation between two variables and is parametric. T-tests are used to compare means between two groups, and ANOVA is used to compare means between more than two groups. Non-parametric equivalents to ANOVA include the Kruskal-Wallis analysis of ranks, the Median test, Friedman’s two-way analysis of variance, and Cochran Q test. Understanding these tests and their assumptions can help researchers choose the appropriate statistical test for their data.

    • This question is part of the following fields:

      • Research Methods, Statistics, Critical Review And Evidence-Based Practice
      153.4
      Seconds
  • Question 14 - Which drug is most likely to cause withdrawal symptoms between doses? ...

    Incorrect

    • Which drug is most likely to cause withdrawal symptoms between doses?

      Your Answer: Nitrazepam

      Correct Answer: Oxazepam

      Explanation:

      Interdose withdrawal can occur with short-acting drugs, causing withdrawal symptoms to manifest as the effects of the previous dose start to diminish.

      Benzodiazepines are a class of drugs commonly used to treat anxiety and sleep disorders. It is important to have a working knowledge of the more common benzodiazepines and their half-life. Half-life refers to the amount of time it takes for half of the drug to be eliminated from the body.

      Some of the more common benzodiazepines and their half-life include diazepam with a half-life of 20-100 hours, clonazepam with a half-life of 18-50 hours, chlordiazepoxide with a half-life of 5-30 hours, nitrazepam with a half-life of 15-38 hours, temazepam with a half-life of 8-22 hours, lorazepam with a half-life of 10-20 hours, alprazolam with a half-life of 10-15 hours, oxazepam with a half-life of 6-10 hours, zopiclone with a half-life of 5-6 hours, zolpidem with a half-life of 2 hours, and zaleplon with a half-life of 2 hours. Understanding the half-life of these drugs is important for determining dosages and timing of administration.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 15 - Which of the following scenarios demonstrates information bias? ...

    Incorrect

    • Which of the following scenarios demonstrates information bias?

      Your Answer: Publication bias

      Correct Answer: Lead Time bias

      Explanation:

      Types of Bias in Statistics

      Bias is a systematic error that can lead to incorrect conclusions. Confounding factors are variables that are associated with both the outcome and the exposure but have no causative role. Confounding can be addressed in the design and analysis stage of a study. The main method of controlling confounding in the analysis phase is stratification analysis. The main methods used in the design stage are matching, randomization, and restriction of participants.

      There are two main types of bias: selection bias and information bias. Selection bias occurs when the selected sample is not a representative sample of the reference population. Disease spectrum bias, self-selection bias, participation bias, incidence-prevalence bias, exclusion bias, publication of dissemination bias, citation bias, and Berkson’s bias are all subtypes of selection bias. Information bias occurs when gathered information about exposure, outcome, of both is not correct and there was an error in measurement. Detection bias, recall bias, lead time bias, interviewer/observer bias, verification and work-up bias, Hawthorne effect, and ecological fallacy are all subtypes of information bias.

    • This question is part of the following fields:

      • Research Methods, Statistics, Critical Review And Evidence-Based Practice
      47.2
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  • Question 16 - A teenager is referred by the transplant team with moderate depression following a...

    Correct

    • A teenager is referred by the transplant team with moderate depression following a recent operation. They are prescribed cyclosporin. Which of the following would be the least appropriate antidepressant in this case?

      Your Answer: Nefazodone

      Explanation:

      The primary metabolic pathway for cyclosporin involves the CYP3A3/4 isoenzymes. When this system is inhibited, toxic levels of cyclosporin can accumulate. Reports have shown that interactions with nefazodone and fluvoxamine can lead to cyclosporine toxicity. Vella (1998) published a study on the interactions between cyclosporine and newer antidepressant medications in the American Journal of Kidney Diseases, which supports these findings.

      Interactions of Antidepressants with Cytochrome P450 System

      Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), can have significant effects on the cytochrome P450 system. This can result in drug interactions that can affect the efficacy and safety of the medications.

      One example of such interaction is between fluvoxamine and theophylline. Fluvoxamine is a potent inhibitor of CYP1A2, which can lead to increased levels of theophylline in the body. This can cause adverse effects such as nausea, vomiting, and tremors.

      Another example is between fluoxetine and clozapine. Fluoxetine is a potent inhibitor of CYP2D6, which can increase the risk of seizures with clozapine. Clozapine is metabolized by CYP1A2, CYP3A4, and CYP2D6, and any inhibition of these enzymes can affect its metabolism and increase the risk of adverse effects.

      It is important to be aware of these interactions and monitor patients closely when prescribing antidepressants, especially in those who are taking other medications that are metabolized by the cytochrome P450 system.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 17 - What is a true statement about delirium? ...

    Correct

    • What is a true statement about delirium?

      Your Answer: Hypoactive delirium is often missed as it is difficult to recognise

      Explanation:

      Delirium (also known as acute confusional state) is a condition characterized by a sudden decline in consciousness and cognition, with a particular impairment in attention. It often involves perceptual disturbances, abnormal psychomotor activity, and sleep-wake cycle impairment. Delirium typically develops over a few days and has a fluctuating course. The causes of delirium are varied, ranging from metabolic disturbances to medications. It is important to differentiate delirium from dementia, as delirium has a brief onset, early disorientation, clouding of consciousness, fluctuating course, and early psychomotor changes. Delirium can be classified into three subtypes: hypoactive, hyperactive, and mixed. Patients with hyperactive delirium demonstrate restlessness, agitation, and hyper vigilance, while those with hypoactive delirium present with lethargy and sedation. Mixed delirium demonstrates both hyperactive and hypoactive features. The hypoactive form is most common in elderly patients and is often misdiagnosed as depression of dementia.

    • This question is part of the following fields:

      • Old Age Psychiatry
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  • Question 18 - A decreased plasma clozapine to norclozapine ratio in an elderly patient with a...

    Correct

    • A decreased plasma clozapine to norclozapine ratio in an elderly patient with a stable clozapine dose indicates what?

      Your Answer: Enzyme induction

      Explanation:

      If a patient’s plasma clozapine to norclozapine ratio decreases while on a consistent clozapine dose, it may indicate enzyme induction. Conversely, an increase in the ratio may suggest enzyme inhibition of saturation, recent non-trough sample, of poor compliance. The clozapine to norclozapine ratio is typically stable among patients with stable clozapine doses.

    • This question is part of the following fields:

      • Organisation And Delivery Of Psychiatric Services
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  • Question 19 - A 38-year-old woman who has frequently attended in the past with multiple somatic...

    Correct

    • A 38-year-old woman who has frequently attended in the past with multiple somatic complaints is diagnosed with generalised anxiety disorder. She is initially treated with a low intensity psychological interventions which unfortunately fails to improve her symptoms. What is the most appropriate medication to offer her next line?

      Your Answer: Sertraline

      Explanation:

      Anxiety (NICE guidelines)

      The NICE Guidelines on Generalised anxiety disorder and panic disorder were issued in 2011. For the management of generalised anxiety disorder, NICE suggests a stepped approach. For mild GAD, education and active monitoring are recommended. If there is no response to step 1, low-intensity psychological interventions such as CBT-based self-help of psychoeducational groups are suggested. For those with marked functional impairment of those who have not responded to step 2, individual high-intensity psychological intervention of drug treatment is recommended. Specialist treatment is suggested for those with very marked functional impairment, no response to step 3, self-neglect, risks of self-harm or suicide, of significant comorbidity. Benzodiazepines should not be used beyond 2-4 weeks, and SSRIs are first line. For panic disorder, psychological therapy (CBT), medication, and self-help have all been shown to be effective. Benzodiazepines, sedating antihistamines, of antipsychotics should not be used. SSRIs are first line, and if they fail, imipramine of clomipramine can be used. Self-help (CBT based) should be encouraged. If the patient improves with an antidepressant, it should be continued for at least 6 months after the optimal dose is reached, after which the dose can be tapered. If there is no improvement after a 12-week course, an alternative medication of another form of therapy should be offered.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 20 - You are asked to see a new adolescent patient admitted to the ward...

    Incorrect

    • You are asked to see a new adolescent patient admitted to the ward by one of your colleagues. The patient has been diagnosed with acute mania and requires some medication. The patient is keen to discuss the options. The patient asks you which medication is best tolerated. Which of the following medications has been shown to be most acceptable to adolescent patients with acute mania?

      Your Answer: Lithium

      Correct Answer: Olanzapine

      Explanation:

      Antimanic Drugs: Efficacy and Acceptability

      The Lancet published a meta-analysis conducted by Cipriani in 2011, which compared the efficacy and acceptability of various anti-manic drugs. The study found that antipsychotics were more effective than mood stabilizers in treating mania. The drugs that were best tolerated were towards the right of the figure, while the most effective drugs were towards the top. The drugs that were both well-tolerated and effective were considered the best overall, including olanzapine, risperidone, haloperidol, and quetiapine. Other drugs included in the analysis were aripiprazole, asenapine, carbamazepine, valproate, gabapentin, lamotrigine, lithium, placebo, topiramate, and ziprasidone. This study provides valuable information for clinicians in selecting the most appropriate antimanic drug for their patients.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 21 - The national health organization has a team of analysts to compare the effectiveness...

    Incorrect

    • The national health organization has a team of analysts to compare the effectiveness of two different cancer treatments in terms of cost and patient outcomes. They have gathered data on the number of years of life gained by each treatment and are seeking your recommendation on what type of analysis to conduct next. What analysis would you suggest they undertake?

      Your Answer: Cost effectiveness analysis

      Correct Answer: Cost utility analysis

      Explanation:

      Cost utility analysis is a method used in health economics to determine the cost-effectiveness of a health intervention by comparing the cost of the intervention to the benefit it provides in terms of the number of years lived in full health. The cost is measured in monetary units, while the benefit is quantified using a measure that assigns values to different health states, including those that are less desirable than full health. In health technology assessments, this measure is typically expressed as quality-adjusted life years (QALYs).

    • This question is part of the following fields:

      • Research Methods, Statistics, Critical Review And Evidence-Based Practice
      2.8
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  • Question 22 - If a couple has a child with autism, what advice would you give...

    Incorrect

    • If a couple has a child with autism, what advice would you give them regarding the likelihood of having another child with the same condition?

      Your Answer: There is a 5 fold increase in risk to a future sibling

      Correct Answer: There is a 8 fold increase in risk to a future sibling

      Explanation:

      According to a study conducted in 2019 across various countries, the likelihood of developing ASD is significantly higher if a sibling has already been diagnosed with the disorder, with an 8-fold increase in risk.

      Autism Spectrum Disorder (ASD) is a lifelong disorder characterized by deficits in communication and social understanding, as well as restrictive and repetitive behaviors. The distinction between autism and Asperger’s has been abandoned, and they are now grouped together under the ASD category. Intellectual ability is difficult to assess in people with ASD, with an estimated 33% having an intellectual disability. ASD was first described in Europe and the United States using different terms, with Leo Kanner and Hans Asperger being the pioneers. Diagnosis is based on persistent deficits in social communication and social interaction, as well as restricted, repetitive patterns of behavior. The worldwide population prevalence is about 1%, with comorbidity being common. Heritability is estimated at around 90%, and both genetic and environmental factors seem to cause ASD. Currently, there are no validated pharmacological treatments that alleviate core ASD symptoms, but second-generation antipsychotics are the first-line pharmacological treatment for children and adolescents with ASD and associated irritability.

    • This question is part of the following fields:

      • Child And Adolescent Psychiatry
      3.5
      Seconds
  • Question 23 - How can the ethnic differences observed in psychiatry in the UK be accurately...

    Correct

    • How can the ethnic differences observed in psychiatry in the UK be accurately described?

      Your Answer: People from Black minorities have the highest rate of mental illness in UK

      Explanation:

      Institutional Racism in Psychiatry

      There has been growing concern that institutional racism may be contributing to the overrepresentation of Black patients in mental health settings. Despite ethnic minorities making up only 9% of the UK population, the 2010 ‘Count me in Census’ found that 23% of inpatients and those on CTOs were from Black and minority ethnic groups. Black minority groups also had higher rates of admission, detention, and seclusion.

      While patient factors, such as higher rates of mental illness in Black minority groups, may contribute to these findings, there is also a suggestion of inherent racism within psychiatry. This may manifest in perceptions of Black and minority ethnic patients being at greater risk, as well as systemic factors that disadvantage these groups.

      It is important to address these issues and work towards a more equitable and just mental health system for all patients, regardless of their ethnicity.

    • This question is part of the following fields:

      • Organisation And Delivery Of Psychiatric Services
      10.3
      Seconds
  • Question 24 - A woman is referred by her GP due to her persistent belief that...

    Correct

    • A woman is referred by her GP due to her persistent belief that she has stomach cancer. She remains convinced of this despite multiple normal investigations and reassurance from medical specialists. What is the most probable diagnosis for her condition?

      Your Answer: Hypochondriasis

      Explanation:

      There is often confusion between hypochondriasis and bodily distress disorder. Hypochondriasis involves a fixation on having a particular illness, while bodily distress disorder is characterized by a preoccupation with symptoms rather than a specific diagnosis.

      Somatoform and dissociative disorders are two groups of psychiatric disorders that are characterized by physical symptoms and disruptions in the normal integration of identity, sensations, perceptions, affects, thoughts, memories, control over bodily movements, of behavior. Somatoform disorders are characterized by physical symptoms that are presumed to have a psychiatric origin, while dissociative disorders are characterized by the loss of integration between memories, identity, immediate sensations, and control of bodily movements. The ICD-11 lists two main types of somatoform disorders: bodily distress disorder and body integrity dysphoria. Dissociative disorders include dissociative neurological symptom disorder, dissociative amnesia, trance disorder, possession trance disorder, dissociative identity disorder, partial dissociative identity disorder, depersonalization-derealization disorder, and other specified dissociative disorders. The symptoms of these disorders result in significant impairment in personal, family, social, educational, occupational, of other important areas of functioning. Diagnosis of these disorders involves a thorough evaluation of the individual’s symptoms and medical history, as well as ruling out other possible causes of the symptoms.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 25 - What is accurate about project MATCH, also known as Matching alcoholism treatments to...

    Incorrect

    • What is accurate about project MATCH, also known as Matching alcoholism treatments to client heterogeneity?

      Your Answer: Showed benzodiazepines to be superior to placebo

      Correct Answer: It found that the three psychological therapies tested were equal in effectiveness

      Explanation:

      Project MATCH: Investigating the Best Treatment for Alcoholics

      Project MATCH was an extensive research study that spanned over 8 years and aimed to determine which types of alcoholics respond best to which forms of treatment. The study investigated three types of treatment: Cognitive Behavioural Coping Skills Therapy, Motivational Enhancement Therapy, and Twelve-Step Facilitation Therapy.

      Cognitive Behavioural Coping Skills Therapy focused on correcting poor self-esteem and distorted, negative, and self-defeating thinking. Motivational Enhancement Therapy helped clients become aware of and build on personal strengths that could improve their readiness to quit. Twelve-Step Facilitation Therapy was designed to familiarize patients with the AA philosophy and encourage participation.

      After the study, it was concluded that patient-treatment matching is not necessary in alcoholism treatment because the three techniques are equally effective. This study provides valuable insights into the treatment of alcoholism and can help healthcare professionals make informed decisions about the best treatment options for their patients.

    • This question is part of the following fields:

      • Substance Misuse/Addictions
      139.9
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  • Question 26 - What is the relationship between Takotsubo cardiomyopathy and anorexia nervosa? ...

    Incorrect

    • What is the relationship between Takotsubo cardiomyopathy and anorexia nervosa?

      Your Answer: It is usually fatal and requires immediate treatment with inotropes

      Correct Answer: It results from coronary vasospasm

      Explanation:

      Takotsubo cardiomyopathy is a form of cardiomyopathy that is not caused by a lack of blood flow to the heart. It is believed to be caused by spasms in the coronary arteries and can resemble a heart attack. Typically, levels of cardiac enzymes are elevated. In individuals with anorexia, Takotsubo cardiomyopathy is a rare event that usually occurs after stress of low blood sugar. Although it is usually self-limiting and only requires supportive care, in rare cases, it can progress to cardiogenic shock.

      Anorexia is a serious mental health condition that can have severe physical complications. These complications can affect various systems in the body, including the cardiac, skeletal, hematologic, reproductive, metabolic, gastrointestinal, CNS, and dermatological systems. Some of the recognized physical complications of anorexia nervosa include bradycardia, hypotension, osteoporosis, anemia, amenorrhea, hypothyroidism, delayed gastric emptying, cerebral atrophy, and lanugo.

      The Royal College of Psychiatrists has issued advice on managing sick patients with anorexia nervosa, recommending hospital admission for those with high-risk items. These items include a BMI of less than 13, a pulse rate of less than 40 bpm, a SUSS test score of less than 2, a sodium level of less than 130 mmol/L, a potassium level of less than 3 mmol/L, a serum glucose level of less than 3 mmol/L, and a QTc interval of more than 450 ms. The SUSS test involves assessing the patient’s ability to sit up and squat without using their hands. A rating of 0 indicates complete inability to rise, while a rating of 3 indicates the ability to rise without difficulty. Proper management and treatment of anorexia nervosa are crucial to prevent of manage these physical complications.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 27 - What is the most precise estimation of the occurrence of mental health disorders...

    Incorrect

    • What is the most precise estimation of the occurrence of mental health disorders among adults who have learning disabilities?

      Your Answer: 20%

      Correct Answer: 40%

      Explanation:

      Learning Disability and comorbid Psychiatric Illness

      It is estimated that 30-50% of adults with learning disabilities also experience mental health problems, including problem behavior. Specific prevalence rates for various mental health disorders in this population have been identified through research. For example, psychotic disorders are present in 4% of adults with learning disabilities, while affective disorders are present in 6%. Autism is the most prevalent disorder, affecting 7.5% of this population.

      It is important to note that major depressive disorder can occur at all IQ levels in people with learning disabilities, but may be missed of misinterpreted as challenging behavior. Additionally, individuals with learning disabilities are more susceptible to the negative effects of life events and may develop adjustment disorder. Post-traumatic stress disorder is also common in this population.

      Stimulant drugs may be less effective in children with learning disabilities and should be used with caution in individuals with Tourette’s of autism, as they may trigger tics. Overall, it is crucial to recognize and address comorbid psychiatric illness in individuals with learning disabilities to ensure appropriate treatment and support.

    • This question is part of the following fields:

      • Learning Disability
      4.5
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  • Question 28 - Out of the options provided, which one is the least probable cause of...

    Incorrect

    • Out of the options provided, which one is the least probable cause of postural hypotension?

      Your Answer: Clozapine

      Correct Answer: Aripiprazole

      Explanation:

      Antipsychotics: Common Side Effects and Relative Adverse Effects

      Antipsychotics are medications used to treat various mental health conditions, including schizophrenia and bipolar disorder. However, they can also cause side effects that can be bothersome of even serious. The most common side effects of antipsychotics are listed in the table below, which includes the adverse effects associated with their receptor activity.

      Antidopaminergic effects: These effects are related to the medication’s ability to block dopamine receptors in the brain. They can cause galactorrhoea, gynecomastia, menstrual disturbance, lowered sperm count, reduced libido, Parkinsonism, dystonia, akathisia, and tardive dyskinesia.

      Anticholinergic effects: These effects are related to the medication’s ability to block acetylcholine receptors in the brain. They can cause dry mouth, blurred vision, urinary retention, and constipation.

      Antiadrenergic effects: These effects are related to the medication’s ability to block adrenaline receptors in the body. They can cause postural hypotension and ejaculatory failure.

      Histaminergic effects: These effects are related to the medication’s ability to block histamine receptors in the brain. They can cause drowsiness.

      The Maudsley Guidelines provide a rough guide to the relative adverse effects of different antipsychotics. The table below summarizes their findings, with +++ indicating a high incidence of adverse effects, ++ indicating a moderate incidence, + indicating a low incidence, and – indicating a very low incidence.

      Drug Sedation Weight gain Diabetes EPSE Anticholinergic Postural Hypotension Prolactin elevation
      Amisulpride – + + + – – +++
      Aripiprazole – +/- – +/- – – –
      Asenapine + + +/- +/- – – +/-
      Clozapine +++ +++ +++ – +++ +++ –
      Flupentixol + ++ + ++ ++ + +++
      Fluphenazine + + + +++ ++ + +++
      Haloperidol + + +/- +++ + + +++
      Olanzapine ++ +++ +++ +/- + + +
      Paliperidone + ++ + + + ++ +++
      Pimozide + + – + + + +++
      Quetiapine ++ ++ ++ – + ++ –
      Risperidone + ++ + + + ++ +++
      Zuclopenthixol ++ ++ + ++ ++ + +++

      Overall, it is important to discuss the potential side effects of antipsychotics with a healthcare provider and to monitor for any adverse effects while taking these medications.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 29 - What is the most frequent symptom observed in individuals with Huntington's disease? ...

    Incorrect

    • What is the most frequent symptom observed in individuals with Huntington's disease?

      Your Answer: Depressed mood

      Correct Answer: Lack of initiative

      Explanation:

      Huntington’s disease is more likely to cause a lack of initiative than a depressed mood.

      Psychiatric and Behavioural Symptoms of Huntington’s Disease

      Huntington’s disease is a condition that affects individuals with a triad of symptoms, including motor, cognitive, and psychiatric symptoms. While the symptoms typically begin in the third and fourth decades of life, individuals with a high number of CAG repeats may experience symptoms before the age of 20, known as juvenile Huntington’s disease.

      The psychiatric symptoms of Huntington’s disease can include depression, apathy, dementia, psychosis, anxiety, mania, sexual dysfunction, and even suicide. These symptoms can significantly impact an individual’s quality of life and require appropriate treatment. Advances in psychiatric treatment have been made to address these symptoms and improve the overall well-being of individuals with Huntington’s disease.

    • This question is part of the following fields:

      • Old Age Psychiatry
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  • Question 30 - A 67 year old man attends clinic with his son. The son reports...

    Incorrect

    • A 67 year old man attends clinic with his son. The son reports significant memory impairment and explains that his father keeps forgetting important appointments and repeating himself frequently. The patient complains about his own memory and says that he has trouble remembering recent events (such as his wedding anniversary) and has gotten lost while driving in familiar areas.
      The patient admits to feeling down and says that he has lost interest in his hobbies. He also reports difficulty sleeping and occasional thoughts of self-harm. On examination he appears disheveled and scores 24/30 on the MMSE. A CT scan reveals mild atrophy.
      Which of the following would be most helpful in differentiating between dementia and pseudodementia?

      Your Answer: Features of low mood

      Correct Answer: Patients own concern about her memory loss

      Explanation:

      Depression in the Elderly

      Depression in the elderly is similar to depression in younger people, but there is a type of depression called vascular depression that has more cognitive impairment and apathy than depressive ideation. It can be difficult to distinguish between depression and dementia, but there are some key differences. Dementia has a rapid onset, while depression has symptoms of short duration. Mood and behavior fluctuate in dementia, while depression has consistently depressed mood. Patients with dementia often give don’t know answers, while those with depression give near miss answers. Patients with dementia try to conceal their forgetfulness, while those with depression highlight it. Cognitive impairment is relatively stable in dementia, while it fluctuates greatly in depression. Higher cortical dysfunction is evident in dementia, while it is absent in depression.

    • This question is part of the following fields:

      • Old Age Psychiatry
      7
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  • Question 31 - What is the required frequency and duration of bedwetting behavior to meet the...

    Correct

    • What is the required frequency and duration of bedwetting behavior to meet the diagnostic threshold for enuresis?

      Your Answer: Systemic

      Explanation:

      Family Therapy Models

      Family therapy emerged in the 1950s, shifting the focus from individual problems to the context of the environment. There are five main models of family therapy: structural, strategic, systemic, transgenerational, and solution-focused.

      Structural therapy, developed by Salvador Minuchin, assumes that the family’s structure is wrong and aims to establish clear boundaries and no coalitions. Dysfunctional families are marked by impaired boundaries, inappropriate alignments, and power imbalances.

      Strategic therapy, associated with Jay Haley and Cloe Madanes, claims that difficulties in families arise due to distorted hierarchies. Dysfunctional families communicate in problematic repetitive patterns that kept them dysfunctional. Key terms include task setting and goal setting.

      Systemic therapy, associated with Mara Selvini-Palazzoli, sees the family as a self-regulating system that controls itself according to rules formed over time. The focus is on exploring differences between family members’ behaviors, emotional responses, and beliefs at different points in time. Key terms include hypothesizing, neutrality, positive connotation, paradox and counterparadox, circular and interventive questioning, and the use of reflecting teams.

      Transgenerational family therapy aims to understand how families, across generations, develop patterns of behaving and responding to stress in ways that prevent health development and lead to problems. Seven interlocking concepts make up the theory.

      Solution-focused therapy emphasizes solutions over problems and collaborates with the family through in-depth questioning to focus on the solutions already being used by the clients. The therapist is non-interventionist, and the focus is on the present and the future. Blame, shame, and conflict are seen as issues that impede people from realizing these solutions.

    • This question is part of the following fields:

      • Psychotherapy
      12.4
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  • Question 32 - What is the likelihood of weight gain when a patient is prescribed risperidone,...

    Incorrect

    • What is the likelihood of weight gain when a patient is prescribed risperidone, given that 6 out of 10 patients experience weight gain as a side effect?

      Your Answer: 0.6

      Correct Answer: 1.5

      Explanation:

      1. The odds of an event happening are calculated by dividing the number of times it occurs by the number of times it does not occur.
      2. The odds of an event happening in a given situation are 6 to 4.
      3. This translates to a ratio of 1.5, meaning the event is more likely to happen than not.
      4. The risk of the event happening is calculated by dividing the number of times it occurs by the total number of possible outcomes.
      5. In this case, the risk of the event happening is 6 out of 10.

      Measures of Effect in Clinical Studies

      When conducting clinical studies, we often want to know the effect of treatments of exposures on health outcomes. Measures of effect are used in randomized controlled trials (RCTs) and include the odds ratio (of), risk ratio (RR), risk difference (RD), and number needed to treat (NNT). Dichotomous (binary) outcome data are common in clinical trials, where the outcome for each participant is one of two possibilities, such as dead of alive, of clinical improvement of no improvement.

      To understand the difference between of and RR, it’s important to know the difference between risks and odds. Risk is a proportion that describes the probability of a health outcome occurring, while odds is a ratio that compares the probability of an event occurring to the probability of it not occurring. Absolute risk is the basic risk, while risk difference is the difference between the absolute risk of an event in the intervention group and the absolute risk in the control group. Relative risk is the ratio of risk in the intervention group to the risk in the control group.

      The number needed to treat (NNT) is the number of patients who need to be treated for one to benefit. Odds are calculated by dividing the number of times an event happens by the number of times it does not happen. The odds ratio is the odds of an outcome given a particular exposure versus the odds of an outcome in the absence of the exposure. It is commonly used in case-control studies and can also be used in cross-sectional and cohort study designs. An odds ratio of 1 indicates no difference in risk between the two groups, while an odds ratio >1 indicates an increased risk and an odds ratio <1 indicates a reduced risk.

    • This question is part of the following fields:

      • Research Methods, Statistics, Critical Review And Evidence-Based Practice
      7.2
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  • Question 33 - What is the estimated percentage of individuals in Great Britain who have a...

    Incorrect

    • What is the estimated percentage of individuals in Great Britain who have a personality disorder?

      Your Answer: 1.90%

      Correct Answer: 4.40%

      Explanation:

      Personality Disorder: Understanding the Clinical Diagnosis

      A personality disorder is a long-standing pattern of behavior and inner experience that deviates significantly from cultural expectations, is inflexible and pervasive, and causes distress of impairment. The DSM-5 and ICD-11 have different approaches to classifying personality disorders. DSM-5 divides them into 10 categories, while ICD-11 has a general category with six trait domains that can be added. To diagnose a personality disorder, clinicians must first establish that the general diagnostic threshold is met before identifying the subtype(s) present. The course of personality disorders varies, with some becoming less evident of remitting with age, while others persist.

      DSM-5 and ICD-11 have different classification systems for personality disorders. DSM-5 divides them into three clusters (A, B, and C), while ICD-11 has a general category with six trait domains that can be added. The prevalence of personality disorders in Great Britain is 4.4%, with Cluster C being the most common. Clinicians are advised to avoid diagnosing personality disorders in children, although a diagnosis can be made in someone under 18 if the features have been present for at least a year (except for antisocial personality disorder).

      Overall, understanding the clinical diagnosis of personality disorders is important for effective treatment and management of these conditions.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 34 - What is the subtype of Niemann-Pick disease that manifests in the first few...

    Incorrect

    • What is the subtype of Niemann-Pick disease that manifests in the first few weeks of life and is identified by symptoms such as abdominal swelling, a cherry red spot, feeding challenges, and a gradual decline in early motor abilities?

      Your Answer: Type C

      Correct Answer: Type A

      Explanation:

      Niemann-Pick disease is a group of inherited diseases where lipids accumulate in the cells of the liver, spleen, and brain. Niemann-Pick Type C (NPC) is the most relevant type for psychiatric presentations, with about one-third of cases presenting in adolescence of adulthood. Symptoms include progressive ataxia/dystonia, cognitive decline, and atypical psychotic symptoms. There are four other types of Niemann-Pick disease, each with their own causes and symptoms. Type A and B have a lack of sphingomyelinase and present in early childhood of mid-childhood/adolescence, respectively. Type C has reduced sphingomyelinase activity and can present at any age, with symptoms including enlarged liver and spleen, learning difficulties, seizures, and slurred speech. Type D is a variant of Type C and has similar symptoms. Type E has reduced sphingomyelinase activity and presents in adulthood with similar symptoms to the other types.

    • This question is part of the following fields:

      • Child And Adolescent Psychiatry
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  • Question 35 - What are the accurate statements about the endocrine complications observed in individuals with...

    Correct

    • What are the accurate statements about the endocrine complications observed in individuals with anorexia nervosa?

      Your Answer: Severe hypoglycemia can indicate infection

      Explanation:

      – Severe hypoglycemia can indicate infection and can be fatal
      – Triiodothyronine levels are usually low
      – Hypercortisolaemia does not result in Cushingoid features
      – Primary and secondary amenorrhoea are common
      – Insulin-like growth factor-1 is reduced

      Anorexia is a serious mental health condition that can have severe physical complications. These complications can affect various systems in the body, including the cardiac, skeletal, hematologic, reproductive, metabolic, gastrointestinal, CNS, and dermatological systems. Some of the recognized physical complications of anorexia nervosa include bradycardia, hypotension, osteoporosis, anemia, amenorrhea, hypothyroidism, delayed gastric emptying, cerebral atrophy, and lanugo.

      The Royal College of Psychiatrists has issued advice on managing sick patients with anorexia nervosa, recommending hospital admission for those with high-risk items. These items include a BMI of less than 13, a pulse rate of less than 40 bpm, a SUSS test score of less than 2, a sodium level of less than 130 mmol/L, a potassium level of less than 3 mmol/L, a serum glucose level of less than 3 mmol/L, and a QTc interval of more than 450 ms. The SUSS test involves assessing the patient’s ability to sit up and squat without using their hands. A rating of 0 indicates complete inability to rise, while a rating of 3 indicates the ability to rise without difficulty. Proper management and treatment of anorexia nervosa are crucial to prevent of manage these physical complications.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 36 - What factor increases the risk of developing puerperal psychosis? ...

    Correct

    • What factor increases the risk of developing puerperal psychosis?

      Your Answer: Pre-existing affective psychosis

      Explanation:

      Puerperal Psychosis: Incidence, Risk Factors, and Treatment

      Postpartum psychosis is a subtype of bipolar disorder with an incidence of 1-2 in 1000 pregnancies. It typically occurs rapidly between day 2 and day 14 following delivery, with almost all cases occurring within 8 weeks of delivery. Risk factors for puerperal psychosis include a past history of puerperal psychosis, pre-existing psychotic illness (especially affective psychosis) requiring hospital admission, and a family history of affective psychosis in first of second degree relatives. However, factors such as twin pregnancy, breastfeeding, single parenthood, and stillbirth have not been shown to be associated with an increased risk. Treatment for puerperal psychosis is similar to that for psychosis in general, but special consideration must be given to potential issues if the mother is breastfeeding.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 37 - After how much time since the last drink do the symptoms of alcohol...

    Incorrect

    • After how much time since the last drink do the symptoms of alcohol withdrawal typically start?

      Your Answer: 24-48 hours

      Correct Answer: 3-12 hrs

      Explanation:

      Alcohol withdrawal is characterized by overactivity of the autonomic nervous system, resulting in symptoms such as agitation, tremors, sweating, nausea, vomiting, fever, and tachycardia. These symptoms typically begin 3-12 hours after drinking stops, peak between 24-48 hours, and can last up to 14 days. Withdrawal seizures may occur before blood alcohol levels reach zero, and a small percentage of people may experience delirium tremens (DT), which can be fatal if left untreated. Risk factors for DT include abnormal liver function, old age, severity of withdrawal symptoms, concurrent medical illness, heavy alcohol use, self-detox, previous history of DT, low potassium, low magnesium, and thiamine deficiency.

      Pharmacologically assisted detox is often necessary for those who regularly consume more than 15 units of alcohol per day, and inpatient detox may be needed for those who regularly consume more than 30 units per day. The Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar) can be used to assess the severity of withdrawal symptoms and guide treatment decisions. Benzodiazepines are the mainstay of treatment, as chronic alcohol exposure results in decreased overall brain excitability and compensatory decrease of GABA-A neuroreceptor response to GABA. Chlordiazepoxide is a good first-line agent, while oxazepam, temazepam, and lorazepam are useful in patients with liver disease. Clomethiazole is effective but carries a high risk of respiratory depression and is not recommended. Thiamine should be offered to prevent Wernicke’s encephalopathy, and long-acting benzodiazepines can be used as prophylaxis for withdrawal seizures. Haloperidol is the treatment of choice if an antipsychotic is required.

    • This question is part of the following fields:

      • Substance Misuse/Addictions
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  • Question 38 - Among the listed medications, which one has the strongest evidence for reducing persistent...

    Correct

    • Among the listed medications, which one has the strongest evidence for reducing persistent aggression and violence in individuals with schizophrenia?

      Your Answer: Clozapine

      Explanation:

      Recent research suggests that clozapine may be effective in reducing persistent aggression in individuals with schizophrenia, even independent of its antipsychotic properties. However, this evidence is largely based on uncontrolled trials. Additionally, there is some indication that mood stabilizers, specifically carbamazepine, may be helpful as an adjunct treatment for assaultive behavior in schizophrenia. On the other hand, there is currently no strong evidence to support the use of benzodiazepines of high-dose antipsychotics for chronic aggression in this population. These findings were discussed in a 2005 article by Davison on the management of violence in general psychiatry.

      Clozapine is an effective antipsychotic drug used in the management of treatment-resistant schizophrenia (TRS). It was reintroduced in the 1990s with mandatory blood monitoring due to the risk of agranulocyte

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 39 - What is the highest approved dosage of risperidone that can be administered for...

    Incorrect

    • What is the highest approved dosage of risperidone that can be administered for treating aggression and agitation related to Alzheimer's disease?

      Your Answer: 500 µg BD

      Correct Answer: 1 mg BD

      Explanation:

      According to the Maudsley 14th, Risperidone is approved for a maximum dosage of 1 mg twice daily, but the recommended of optimal dose is 500 µg.

      Management of Non-Cognitive Symptoms in Dementia

      Non-cognitive symptoms of dementia can include agitation, aggression, distress, psychosis, depression, anxiety, sleep problems, wandering, hoarding, sexual disinhibition, apathy, and shouting. Non-pharmacological measures, such as music therapy, should be considered before prescribing medication. Pain may cause agitation, so a trial of analgesics is recommended. Antipsychotics, such as risperidone, olanzapine, and aripiprazole, may be used for severe distress of serious risk to others, but their use is controversial due to issues of tolerability and an association with increased mortality. Cognitive enhancers, such as AChE-Is and memantine, may have a modest benefit on BPSD, but their effects may take 3-6 months to take effect. Benzodiazepines should be avoided except in emergencies, and antidepressants, such as citalopram and trazodone, may have mixed evidence for BPSD. Mood stabilizers, such as valproate and carbamazepine, have limited evidence to support their use. Sedating antihistamines, such as promethazine, may cause cognitive impairment and should only be used short-term. Melatonin has limited evidence to support its use but is safe to use and may be justified in some cases where benefits are seen. For Lewy Body dementia, clozapine is favored over risperidone, and quetiapine may be a reasonable choice if clozapine is not appropriate. Overall, medication should only be used when non-pharmacological measures are ineffective, and the need is balanced with the increased risk of adverse effects.

    • This question is part of the following fields:

      • Old Age Psychiatry
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  • Question 40 - A teenage patient with schizophrenia has been prescribed olanzapine and amisulpride, two different...

    Correct

    • A teenage patient with schizophrenia has been prescribed olanzapine and amisulpride, two different oral atypical antipsychotics. The patient's healthcare team suspects non-compliance as the patient continues to display positive and negative symptoms. What would be the most suitable course of action for the patient's management?

      Your Answer: Switch to an intramuscular antipsychotic

      Explanation:

      Consider administering clozapine via the intramuscular route in cases where patients are noncompliant with oral medications, provided that two different antipsychotics (at least one of which is an atypical) have been tried at effective doses and with adequate compliance.

      Clozapine is an effective antipsychotic drug used in the management of treatment-resistant schizophrenia (TRS). It was reintroduced in the 1990s with mandatory blood monitoring due to the risk of agranulocyte

    • This question is part of the following fields:

      • General Adult Psychiatry
      37.8
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  • Question 41 - What is the recommended antidepressant for starting treatment in a pregnant woman with...

    Correct

    • What is the recommended antidepressant for starting treatment in a pregnant woman with no prior history of depression, as per the Maudsley guidelines?

      Your Answer: Sertraline

      Explanation:

      Paroxetine Use During Pregnancy: Is it Safe?

      Prescribing medication during pregnancy and breastfeeding is challenging due to the potential risks to the fetus of baby. No psychotropic medication has a UK marketing authorization specifically for pregnant of breastfeeding women. Women are encouraged to breastfeed unless they are taking carbamazepine, clozapine, of lithium. The risk of spontaneous major malformation is 2-3%, with drugs accounting for approximately 5% of all abnormalities. Valproate and carbamazepine are associated with an increased risk of neural tube defects, and lithium is associated with cardiac malformations. Benzodiazepines are associated with oral clefts and floppy baby syndrome. Antidepressants have been linked to preterm delivery and congenital malformation, but most findings have been inconsistent. TCAs have been used widely without apparent detriment to the fetus, but their use in the third trimester is known to produce neonatal withdrawal effects. Sertraline appears to result in the least placental exposure among SSRIs. MAOIs should be avoided in pregnancy due to a suspected increased risk of congenital malformations and hypertensive crisis. If a pregnant woman is stable on an antipsychotic and likely to relapse without medication, she should continue the antipsychotic. Depot antipsychotics should not be offered to pregnant of breastfeeding women unless they have a history of non-adherence with oral medication. The Maudsley Guidelines suggest specific drugs for use during pregnancy and breastfeeding. NICE CG192 recommends high-intensity psychological interventions for moderate to severe depression and anxiety disorders. Antipsychotics are recommended for pregnant women with mania of psychosis who are not taking psychotropic medication. Promethazine is recommended for insomnia.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 42 - What case prompted the creation of the Fraser Guidelines? ...

    Correct

    • What case prompted the creation of the Fraser Guidelines?

      Your Answer: Gillick

      Explanation:

      Gillick Competency and Fraser Guidelines

      Gillick competency and Fraser guidelines refer to a legal case which looked specifically at whether doctors should be able to give contraceptive advice of treatment to under 16-year-olds without parental consent. But since then, they have been more widely used to help assess whether a child has the maturity to make their own decisions and to understand the implications of those decisions.

      In 1982, Mrs Victoria Gillick took her local health authority (West Norfolk and Wisbech Area Health Authority) and the Department of Health and Social Security to court in an attempt to stop doctors from giving contraceptive advice of treatment to under 16-year-olds without parental consent.

      The case went to the High Court where Mr Justice Woolf dismissed Mrs Gillick’s claims. The Court of Appeal reversed this decision, but in 1985 it went to the House of Lords and the Law Lords (Lord Scarman, Lord Fraser and Lord Bridge) ruled in favour of the original judgement delivered by Mr Justice Woolf.

      The Fraser Guidelines were laid down by Lord Fraser in the House of Lords’ case and state that it is lawful for doctors to provide contraceptive advice and treatment without parental consent providing that they are satisfied that:

      – The young person will understand the professional’s advice
      – The young person cannot be persuaded to inform their parents
      – The young person is likely to begin, of to continue having, sexual intercourse with of without contraceptive treatment
      – Unless the young person receives contraceptive treatment, their physical of mental health, of both, are likely to suffer
      – The young person’s best interests require them to receive contraceptive advice of treatment with of without parental consent.

    • This question is part of the following fields:

      • Organisation And Delivery Of Psychiatric Services
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  • Question 43 - Which p-value would provide the strongest evidence in favor of the alternative hypothesis?...

    Incorrect

    • Which p-value would provide the strongest evidence in favor of the alternative hypothesis?

      Your Answer: p < 0.05

      Correct Answer:

      Explanation:

      Understanding Hypothesis Testing in Statistics

      In statistics, it is not feasible to investigate hypotheses on entire populations. Therefore, researchers take samples and use them to make estimates about the population they are drawn from. However, this leads to uncertainty as there is no guarantee that the sample taken will be truly representative of the population, resulting in potential errors. Statistical hypothesis testing is the process used to determine if claims from samples to populations can be made and with what certainty.

      The null hypothesis (Ho) is the claim that there is no real difference between two groups, while the alternative hypothesis (H1 of Ha) suggests that any difference is due to some non-random chance. The alternative hypothesis can be one-tailed of two-tailed, depending on whether it seeks to establish a difference of a change in one direction.

      Two types of errors may occur when testing the null hypothesis: Type I and Type II errors. Type I error occurs when the null hypothesis is rejected when it is true, while Type II error occurs when the null hypothesis is accepted when it is false. The power of a study is the probability of correctly rejecting the null hypothesis when it is false, and it can be increased by increasing the sample size.

      P-values provide information on statistical significance and help researchers decide if study results have occurred due to chance. The p-value is the probability of obtaining a result that is as large of larger when in reality there is no difference between two groups. The cutoff for the p-value is called the significance level (alpha level), typically set at 0.05. If the p-value is less than the cutoff, the null hypothesis is rejected, and if it is greater or equal to the cut off, the null hypothesis is not rejected. However, the p-value does not indicate clinical significance, which may be too small to be meaningful.

    • This question is part of the following fields:

      • Research Methods, Statistics, Critical Review And Evidence-Based Practice
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  • Question 44 - What does a smaller p-value indicate in terms of the strength of evidence?...

    Correct

    • What does a smaller p-value indicate in terms of the strength of evidence?

      Your Answer: The alternative hypothesis

      Explanation:

      A p-value represents the likelihood of rejecting a null hypothesis that is actually true. A smaller p-value indicates a lower chance of mistakenly rejecting the null hypothesis, providing evidence in favor of the alternative hypothesis.

      Understanding Hypothesis Testing in Statistics

      In statistics, it is not feasible to investigate hypotheses on entire populations. Therefore, researchers take samples and use them to make estimates about the population they are drawn from. However, this leads to uncertainty as there is no guarantee that the sample taken will be truly representative of the population, resulting in potential errors. Statistical hypothesis testing is the process used to determine if claims from samples to populations can be made and with what certainty.

      The null hypothesis (Ho) is the claim that there is no real difference between two groups, while the alternative hypothesis (H1 of Ha) suggests that any difference is due to some non-random chance. The alternative hypothesis can be one-tailed of two-tailed, depending on whether it seeks to establish a difference of a change in one direction.

      Two types of errors may occur when testing the null hypothesis: Type I and Type II errors. Type I error occurs when the null hypothesis is rejected when it is true, while Type II error occurs when the null hypothesis is accepted when it is false. The power of a study is the probability of correctly rejecting the null hypothesis when it is false, and it can be increased by increasing the sample size.

      P-values provide information on statistical significance and help researchers decide if study results have occurred due to chance. The p-value is the probability of obtaining a result that is as large of larger when in reality there is no difference between two groups. The cutoff for the p-value is called the significance level (alpha level), typically set at 0.05. If the p-value is less than the cutoff, the null hypothesis is rejected, and if it is greater or equal to the cut off, the null hypothesis is not rejected. However, the p-value does not indicate clinical significance, which may be too small to be meaningful.

    • This question is part of the following fields:

      • Research Methods, Statistics, Critical Review And Evidence-Based Practice
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  • Question 45 - A 35-year-old woman has a 10 year history of treatment resistant bipolar disorder,...

    Correct

    • A 35-year-old woman has a 10 year history of treatment resistant bipolar disorder, currently stabilized on lithium. She lives independently but has noticed a gradual weight gain of 10 pounds over the past year and is worried about it.
      What is the next step in addressing her weight gain concerns?

      Your Answer: Advise dietary counselling and exercise

      Explanation:

      To optimize the effectiveness of weight control measures, it is recommended to provide dietary counseling and encourage exercise to patients on clozapine before weight gain occurs. Nonetheless, if the patient is stable on clozapine, these interventions should still be implemented as a first step.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 46 - Which of the following is not a recognized factor that increases the likelihood...

    Correct

    • Which of the following is not a recognized factor that increases the likelihood of child abuse?

      Your Answer: Having a parent with a low IQ

      Explanation:

      There is no evidence to suggest that a parent’s IQ level increases the likelihood of child abuse.

      Child Abuse: Risk Factors and Protective Factors

      Child abuse is a serious problem that can have long-lasting effects on a child’s physical and emotional well-being. There are several risk factors that increase the likelihood of child abuse occurring. These include a history of abuse in the caregiver, substance misuse in the caregiver, inaccurate knowledge about child development, teenage parents, children of single parents, domestic violence in the home, high levels of stress within the family, younger children, children with disabilities, poverty, social isolation, and living in a dangerous neighborhood.

      However, there are also protective factors that can help prevent child abuse from occurring. These include parental resilience, social connections, knowledge of parenting and child development, concrete support in times of need, and social and emotional competence of children. By promoting these protective factors, we can help reduce the risk of child abuse and create a safer and healthier environment for children to grow and thrive.

    • This question is part of the following fields:

      • Child And Adolescent Psychiatry
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  • Question 47 - What conclusion did the POTS study draw about treating OCD in children? ...

    Correct

    • What conclusion did the POTS study draw about treating OCD in children?

      Your Answer: Children with OCD should begin treatment with the combination of CBT plus an SSRI of CBT alone

      Explanation:

      The recommended treatment for children and adolescents with OCD is either a combination of CBT and a selective serotonin reuptake inhibitor of CBT alone, according to the study’s findings.

      POTS Study: Combination of CBT and Sertraline Best for Treating Pediatric OCD

      The Pediatric OCD Treatment Study (POTS I) was the first randomized trial in pediatric OCD to compare the efficacy of sertraline, OCD-specific cognitive behavioral treatment (CBT), their combination, and a placebo control condition in treating children and adolescents with clinically significant OCD. The study took place in the United States and involved 112 participants who were randomly assigned to receive CBT alone, sertraline alone, combined CBT and sertraline, of a placebo for 12 weeks.

      The study found that all three active treatments (CBT alone, sertraline alone, and combined treatment) were significantly more effective than the placebo. The combined treatment was found to be the most effective, with a remission rate of 53.6%, followed by CBT alone (39.3%) and sertraline alone (21.4%). The study also found that combined treatment was less susceptible to setting-specific variations than CBT and sertraline alone.

      The study concluded that children and adolescents with OCD should begin treatment with the combination of CBT plus a selective serotonin reuptake inhibitor of CBT alone. The three active treatments were found to be acceptable and well-tolerated, with no evidence of treatment-emergent harm to self of others.

    • This question is part of the following fields:

      • Child And Adolescent Psychiatry
      61.1
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  • Question 48 - A study is designed to assess a new proton pump inhibitor (PPI) in...

    Correct

    • A study is designed to assess a new proton pump inhibitor (PPI) in middle-aged patients who are taking aspirin. The new PPI is given to 120 patients whilst a control group of 240 is given the standard PPI. Over a five year period 24 of the group receiving the new PPI had an upper GI bleed compared to 60 who received the standard PPI. What is the absolute risk reduction?

      Your Answer: 5%

      Explanation:

      Measures of Effect in Clinical Studies

      When conducting clinical studies, we often want to know the effect of treatments of exposures on health outcomes. Measures of effect are used in randomized controlled trials (RCTs) and include the odds ratio (of), risk ratio (RR), risk difference (RD), and number needed to treat (NNT). Dichotomous (binary) outcome data are common in clinical trials, where the outcome for each participant is one of two possibilities, such as dead of alive, of clinical improvement of no improvement.

      To understand the difference between of and RR, it’s important to know the difference between risks and odds. Risk is a proportion that describes the probability of a health outcome occurring, while odds is a ratio that compares the probability of an event occurring to the probability of it not occurring. Absolute risk is the basic risk, while risk difference is the difference between the absolute risk of an event in the intervention group and the absolute risk in the control group. Relative risk is the ratio of risk in the intervention group to the risk in the control group.

      The number needed to treat (NNT) is the number of patients who need to be treated for one to benefit. Odds are calculated by dividing the number of times an event happens by the number of times it does not happen. The odds ratio is the odds of an outcome given a particular exposure versus the odds of an outcome in the absence of the exposure. It is commonly used in case-control studies and can also be used in cross-sectional and cohort study designs. An odds ratio of 1 indicates no difference in risk between the two groups, while an odds ratio >1 indicates an increased risk and an odds ratio <1 indicates a reduced risk.

    • This question is part of the following fields:

      • Research Methods, Statistics, Critical Review And Evidence-Based Practice
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  • Question 49 - Which neuroanatomical structure has been the primary focus of studies examining the effectiveness...

    Incorrect

    • Which neuroanatomical structure has been the primary focus of studies examining the effectiveness of deep brain stimulation (DBS) for treating depression that does not respond to other treatments?

      Your Answer: Ventral capsule/ventral striatum

      Correct Answer: Subgenual cingulate gyrus

      Explanation:

      Studies investigating the effectiveness of DBS in treating depression have most commonly focused on the subgenual cingulate gyrus. A review conducted in 2012 found that out of the six studies (with a total of 65 patients) that were analyzed, all of them targeted this area. Other areas that were targeted in smaller studies included the ventral capsule/ventral striatum (two studies with 32 patients) and the nucleus accumbens (three studies with 24 patients). There were also individual case reports that looked at the inferior thalamic peduncle and lateral habenula.

    • This question is part of the following fields:

      • Organisation And Delivery Of Psychiatric Services
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  • Question 50 - How can containment be defined in the context of psychotherapy? ...

    Incorrect

    • How can containment be defined in the context of psychotherapy?

      Your Answer:

      Correct Answer: An ability of the therapist to modify and return the patient's difficult material in a way that they can tolerate

      Explanation:

      The Significance of Containment in Therapeutic Relationships

      Containment is a term coined by Bion to describe the process of emotional containment, which is best exemplified by the relationship between a mother and her infant. Infants often project their unbearable feelings onto their mothers, who receive and accommodate them for a while, making them tolerable and acceptable again to the child.

      In therapeutic relationships, containment plays a crucial role. It occurs when one person receives and comprehends the emotional communication of another without being overwhelmed by it. The receiver then processes the information and communicates understanding and recognition back to the other person. This process can help restore the other person’s capacity to think.

      Overall, containment is an essential aspect of therapeutic relationships, as it allows individuals to express their emotions without fear of being judged of rejected. It creates a safe space for individuals to explore their feelings and thoughts, leading to greater self-awareness and personal growth.

    • This question is part of the following fields:

      • Psychotherapy
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  • Question 51 - What is the most suitable course of action for managing a patient with...

    Incorrect

    • What is the most suitable course of action for managing a patient with Alzheimer's disease who exhibits signs of psychosis and poses a threat to others?

      Your Answer:

      Correct Answer: Risperidone

      Explanation:

      Risperidone has been approved as a viable treatment for behavioral issues associated with Alzheimer’s disease.

      Management of Non-Cognitive Symptoms in Dementia

      Non-cognitive symptoms of dementia can include agitation, aggression, distress, psychosis, depression, anxiety, sleep problems, wandering, hoarding, sexual disinhibition, apathy, and shouting. Non-pharmacological measures, such as music therapy, should be considered before prescribing medication. Pain may cause agitation, so a trial of analgesics is recommended. Antipsychotics, such as risperidone, olanzapine, and aripiprazole, may be used for severe distress of serious risk to others, but their use is controversial due to issues of tolerability and an association with increased mortality. Cognitive enhancers, such as AChE-Is and memantine, may have a modest benefit on BPSD, but their effects may take 3-6 months to take effect. Benzodiazepines should be avoided except in emergencies, and antidepressants, such as citalopram and trazodone, may have mixed evidence for BPSD. Mood stabilizers, such as valproate and carbamazepine, have limited evidence to support their use. Sedating antihistamines, such as promethazine, may cause cognitive impairment and should only be used short-term. Melatonin has limited evidence to support its use but is safe to use and may be justified in some cases where benefits are seen. For Lewy Body dementia, clozapine is favored over risperidone, and quetiapine may be a reasonable choice if clozapine is not appropriate. Overall, medication should only be used when non-pharmacological measures are ineffective, and the need is balanced with the increased risk of adverse effects.

    • This question is part of the following fields:

      • Old Age Psychiatry
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  • Question 52 - What is the recommended first-line treatment for severe OCD in children? ...

    Incorrect

    • What is the recommended first-line treatment for severe OCD in children?

      Your Answer:

      Correct Answer: CBT (including ERP)

      Explanation:

      OCD and BDD are two mental health disorders that can affect children. OCD is characterized by obsessions and compulsions, while BDD is characterized by a preoccupation with an imagined defect in one’s appearance. Both disorders can cause significant distress and impairment in daily functioning.

      For mild cases of OCD, guided self-help may be considered along with support and information for the family of caregivers. For moderate to severe cases of OCD, cognitive-behavioral therapy (CBT) that involves the family of caregivers and is adapted to suit the child’s developmental age is recommended. For all children and young people with BDD, CBT (including exposure and response prevention) is recommended.

      If a child declines psychological treatment, a selective serotonin reuptake inhibitor (SSRI) may be prescribed. However, a licensed medication (sertraline of fluvoxamine) should be used for children and young people with OCD, while fluoxetine should be used for those with BDD. If an SSRI is ineffective of not tolerated, another SSRI of clomipramine may be tried. Tricyclic antidepressants other than clomipramine should not be used to treat OCD of BDD in children and young people. Other antidepressants (MAOIs, SNRIs) and antipsychotics should not be used alone in the routine treatment of OCD of BDD in children of young people, but may be considered as an augmentation strategy.

    • This question is part of the following fields:

      • Child And Adolescent Psychiatry
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  • Question 53 - What is the maintenance treatment used for individuals with opioid dependence syndrome? ...

    Incorrect

    • What is the maintenance treatment used for individuals with opioid dependence syndrome?

      Your Answer:

      Correct Answer: Methadone

      Explanation:

      Synthetic opioids like methadone and buprenorphine are utilized as a replacement for heroin. Alpha2 adrenergic agonists such as clonidine and lofexidine are employed in detox settings to alleviate a range of opioid withdrawal symptoms.

      Opioid Maintenance Therapy and Detoxification

      Withdrawal symptoms can occur after as little as 5 days of regular opioid use. Short-acting opioids like heroin have acute withdrawal symptoms that peak in 32-72 hours and last for 3-5 days. Longer-acting opioids like methadone have acute symptoms that peak at day 4-6 and last for 10 days. Buprenorphine withdrawal lasts up to 10 days and includes symptoms like myalgia, anxiety, and increased drug craving.

      Opioids affect the brain through opioid receptors, with the µ receptor being the main target for opioids. Dopaminergic cells in the ventral tegmental area produce dopamine, which is released into the nucleus accumbens upon stimulation of µ receptors, producing euphoria and reward. With repeat opioid exposure, µ receptors become less responsive, causing dysphoria and drug craving.

      Methadone and buprenorphine are maintenance-oriented treatments for opioid dependence. Methadone is a full agonist targeting µ receptors, while buprenorphine is a partial agonist targeting µ receptors and a partial k agonist of functional antagonist. Naloxone and naltrexone are antagonists targeting all opioid receptors.

      Methadone is preferred over buprenorphine for detoxification, and ultra-rapid detoxification should not be offered. Lofexidine may be considered for mild of uncertain dependence. Clonidine and dihydrocodeine should not be used routinely in opioid detoxification. The duration of detoxification should be up to 4 weeks in an inpatient setting and up to 12 weeks in a community setting.

      Pregnant women dependent on opioids should use opioid maintenance treatment rather than attempt detoxification. Methadone is preferred over buprenorphine, and transfer to buprenorphine during pregnancy is not advised. Detoxification should only be considered if appropriate for the women’s wishes, circumstances, and ability to cope. Methadone or buprenorphine treatment is not a contraindication to breastfeeding.

    • This question is part of the following fields:

      • Substance Misuse/Addictions
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  • Question 54 - What condition of situation would make rTMS inappropriate of unsafe to use? ...

    Incorrect

    • What condition of situation would make rTMS inappropriate of unsafe to use?

      Your Answer:

      Correct Answer: Cochlear implant

      Explanation:

      Neurostimulation is a treatment that uses electromagnetic energy targeted at the brain. There are several forms of neurostimulation, including TMS, deep brain stimulation, and ECT. TMS is a non-invasive, non-convulsive technique used to stimulate neural tissue. It involves the placement of an electromagnetic coil on the patient’s scalp to deliver a short, powerful magnetic field pulse through the scalp and induce electric current in the brain. TMS is used to treat depression when standard treatments have failed. Deep brain stimulation is a neurosurgical technique that involves placing an electrode within the brain to deliver a high-frequency current in a specific subcortical of deep cortical structure. It has been used to treat Parkinson’s, dysthymia, OCD, and Tourette syndrome. There is RCT evidence to demonstrate its effectiveness in OCD, but conflicting results in depression and Tourette’s. DBS is also being trailed in other conditions such as anorexia, bipolar, and additions.

    • This question is part of the following fields:

      • Organisation And Delivery Of Psychiatric Services
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  • Question 55 - A 75 year old man presents to the emergency department in a state...

    Incorrect

    • A 75 year old man presents to the emergency department in a state of agitation and obvious distress. According to his son, he has been deteriorating over the past few days, displaying confusion and disorientation, and appears to be suffering from a chest infection. Despite being typically healthy, the man's condition has rapidly declined. An ECG reveals no abnormalities. What medication would you recommend to alleviate the man's distress?

      Your Answer:

      Correct Answer: Haloperidol

      Explanation:

      Based on the patient’s history, it appears that they are experiencing delirium. Therefore, the appropriate medication to use would be haloperidol. Lorazepam would only be considered if haloperidol is not a viable option due to contraindications.

      Delirium Management

      Pharmacological management of delirium includes the use of haloperidol as a prophylactic measure. NICE guidelines recommend short-term use of haloperidol in cases where delirium is associated with distress of risk to self/others. Quetiapine is also considered a first-choice option in many units. Lorazepam can be used as an alternative if haloperidol is contraindicated, but it is more likely to cause respiratory depression, over-sedation, and paradoxical excitement.

      Non-pharmacological management of delirium includes appropriate lighting and clear signage, talking to the person to reorient them, cognitively stimulating activities, regular visits from family and friends, and promoting good sleep patterns. Additional options such as donepezil, rivastigmine, melatonin, trazodone, and sodium valproate are not recommended. It is important to carefully consider the individual’s needs and medical history when choosing a management plan for delirium.

    • This question is part of the following fields:

      • Old Age Psychiatry
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  • Question 56 - The parents of an 8-year-old girl attend clinic for a review of her...

    Incorrect

    • The parents of an 8-year-old girl attend clinic for a review of her attention deficit hyperactivity disorder. She was diagnosed and started on treatment with methylphenidate 12 months ago with good effect. Her teachers report considerable improvement at school. Although the girl's behaviour is improved, the parents are concerned about her growth which they believe has been slowed down since she started the medication. The growth measurements show that she has grown approximately 4 cm in the year since treatment was commenced which is slightly less than would be expected. Which of the following would be the most appropriate course of action?

      Your Answer:

      Correct Answer: Suggest that the medication could be stopped during the summer holidays to allow for his growth to catch up

      Explanation:

      The only option endorsed by NICE would be taking a break from medication during the summer vacation.

      ADHD (Diagnosis and Management in Children)

      ADHD is a behavioural syndrome characterised by symptoms of inattention, hyperactivity, and impulsivity. The DSM-5 and ICD-11 provide diagnostic criteria for the condition, with both recognising three subtypes: predominantly inattentive, predominantly hyperactive-impulsive, and combined.

      Treatment for children under 5 involves offering an ADHD-focused group parent-training programme as a first-line option. Medication should only be considered after obtaining advice from a specialist ADHD service. For children and young people aged 5-18, advice and support should be given, along with an ADHD-focused group parent-training programme. Medication should only be offered if ADHD symptoms persist after environmental modifications have been implemented and reviewed. Cognitive behavioural therapy may also be considered for those who have benefited from medication but still experience significant impairment.

      NICE advises against elimination diets, dietary fatty acid supplementation, and the use of the ‘few foods diet’. Methylphenidate of lisdexamfetamine is the first-line medication option, with dexamphetamine considered for those who respond to lisdexamfetamine but cannot tolerate the longer effect profile. Atomoxetine of guanfacine may be offered for those who cannot tolerate methylphenidate of lisdexamfetamine. Clonidine and atypical antipsychotics should only be used with advice from a tertiary ADHD service.

      Drug holidays may be considered for children and young people who have not met the expected height for their age due to medication. However, NICE advises that withdrawal from treatment is associated with a risk of symptom exacerbation.

    • This question is part of the following fields:

      • Child And Adolescent Psychiatry
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  • Question 57 - What symptom is commonly observed in individuals with bipolar disorder and psychosis? ...

    Incorrect

    • What symptom is commonly observed in individuals with bipolar disorder and psychosis?

      Your Answer:

      Correct Answer: Prominent affective symptoms and mood congruent delusions

      Explanation:

      Bipolar Disorder Diagnosis

      Bipolar and related disorders are mood disorders characterized by manic, mixed, of hypomanic episodes alternating with depressive episodes. The lifetime risk of suicide in individuals with bipolar disorder is estimated to be at least 15 times that of the general population. Under the ICD-11, there are three subtypes of bipolar disorder: Bipolar I, Bipolar II, and Cyclothymic disorder.

      Bipolar I disorder is diagnosed when an individual has a history of at least one manic of mixed episode. The typical course of the disorder is characterized by recurrent depressive and manic of mixed episodes. Onset of the first mood episode most often occurs during the late teen years, but onset of bipolar type I can occur at any time through the life cycle. The lifetime prevalence of bipolar I disorder is estimated to be around 2.1%.

      Bipolar II disorder is diagnosed when an individual has a history of at least one hypomanic episode and at least one depressive episode. The typical course of the disorder is characterized by recurrent depressive and hypomanic episodes. Onset of bipolar type II most often occurs during the mid-twenties. The number of lifetime episodes tends to be higher for bipolar II disorder than for major depressive disorder of bipolar I disorder.

      Cyclothymic disorder is diagnosed when an individual experiences mood instability over an extended period of time characterized by numerous hypomanic and depressive periods. The symptoms are present for more days than not, and there is no history of manic or mixed episodes. The course of cyclothymic disorder is often gradual and persistent, and onset commonly occurs during adolescence of early adulthood.

      Rapid cycling is not a subtype of bipolar disorder but instead is a qualifier. It is defined as the presence of at least four mood episodes in the previous 12 months that meet the criteria for a manic, hypomanic, of major depressive episode. Rapid cycling is associated with an increased risk of suicide and tends to be precipitated by stressors such as life events, alcohol abuse, use of antidepressants, and medical disorders.

      Overall, the diagnosis of bipolar disorder requires careful evaluation of an individual’s symptoms and history. Treatment typically involves a combination of medication and psychotherapy.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 58 - Which of the following search methods would be best suited for a user...

    Incorrect

    • Which of the following search methods would be best suited for a user seeking all references that discuss psychosis resulting from cannabis use and sexual abuse in adolescents?

      Your Answer:

      Correct Answer: Psychosis AND (cannabis of sexual abuse)

      Explanation:

      The search ‘Psychosis AND (cannabis AND sexual abuse)’ would also return citations with all three terms, but it allows for the possibility of citations that include both cannabis and sexual abuse, but not necessarily psychosis.

      Evidence-based medicine involves four basic steps: developing a focused clinical question, searching for the best evidence, critically appraising the evidence, and applying the evidence and evaluating the outcome. When developing a question, it is important to understand the difference between background and foreground questions. Background questions are general questions about conditions, illnesses, syndromes, and pathophysiology, while foreground questions are more often about issues of care. The PICO system is often used to define the components of a foreground question: patient group of interest, intervention of interest, comparison, and primary outcome.

      When searching for evidence, it is important to have a basic understanding of the types of evidence and sources of information. Scientific literature is divided into two basic categories: primary (empirical research) and secondary (interpretation and analysis of primary sources). Unfiltered sources are large databases of articles that have not been pre-screened for quality, while filtered resources summarize and appraise evidence from several studies.

      There are several databases and search engines that can be used to search for evidence, including Medline and PubMed, Embase, the Cochrane Library, PsycINFO, CINAHL, and OpenGrey. Boolean logic can be used to combine search terms in PubMed, and phrase searching and truncation can also be used. Medical Subject Headings (MeSH) are used by indexers to describe articles for MEDLINE records, and the MeSH Database is like a thesaurus that enables exploration of this vocabulary.

    • This question is part of the following fields:

      • Research Methods, Statistics, Critical Review And Evidence-Based Practice
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  • Question 59 - A 25-year-old woman who gave birth 3 days ago comes in for a...

    Incorrect

    • A 25-year-old woman who gave birth 3 days ago comes in for a consultation as she is worried about her mood. She is experiencing trouble sleeping and feels generally anxious and weepy. Since giving birth, she has also noticed herself being short-tempered with her partner. This is her first pregnancy, she is not nursing, and there is no history of mental health issues in her medical history. What is the best course of action for managing her symptoms?

      Your Answer:

      Correct Answer: Explanation and reassurance

      Explanation:

      It is common for women to experience the baby-blues, which affects approximately two-thirds of them. Although lack of sleep can be a symptom of depression, it is a normal occurrence for new mothers.

      Perinatal Depression, Baby Blues, and Postpartum Depression

      Perinatal depression, also known as postpartum depression, is a common mood disorder experienced by new mothers after childbirth. The term baby blues is used to describe the emotional lability that some mothers experience during the first week after childbirth, which usually resolves by day 10 without treatment. The prevalence of baby blues is around 40%. Postpartum depression, on the other hand, refers to depression that occurs after childbirth. While neither DSM-5 nor ICD-11 specifically mention postpartum depression, both diagnostic systems offer categories that encompass depression during pregnancy of in the weeks following delivery. The prevalence of postpartum depression is approximately 10-15%.

      Various factors have been shown to increase the risk of postnatal depression, including youth, marital and family conflict, lack of social support, anxiety and depression during pregnancy, substance misuse, previous pregnancy loss, ambivalence about the current pregnancy, and frequent antenatal admissions to a maternity hospital. However, obstetric factors such as length of labor, assisted delivery, of separation of the mother from the baby in the Special Care Baby Unit do not seem to influence the development of postnatal depression. Additionally, social class does not appear to be associated with postnatal depression.

      Puerperal psychosis, along with severe depression, is thought to be mainly caused by biological factors, while psychosocial factors are most important in the milder postnatal depressive illnesses.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 60 - A 30-year-old female who has experienced Herpes encephalitis presents with significant weight gain...

    Incorrect

    • A 30-year-old female who has experienced Herpes encephalitis presents with significant weight gain and intense cravings for carbohydrates. What is the most probable diagnosis?

      Your Answer:

      Correct Answer: Klüver-Bucy syndrome

      Explanation:

      Kluver-Bucy Syndrome: Causes and Symptoms

      Kluver-Bucy syndrome is a neurological disorder that results from bilateral medial temporal lobe dysfunction, particularly in the amygdala. This condition is characterized by a range of symptoms, including hyperorality (a tendency to explore objects with the mouth), hypersexuality, docility, visual agnosia, and dietary changes.

      The most common causes of Kluver-Bucy syndrome include herpes, late-stage Alzheimer’s disease, frontotemporal dementia, trauma, and bilateral temporal lobe infarction. In some cases, the condition may be reversible with treatment, but in others, it may be permanent and require ongoing management. If you of someone you know is experiencing symptoms of Kluver-Bucy syndrome, it is important to seek medical attention promptly to determine the underlying cause and develop an appropriate treatment plan.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 61 - What signs of symptoms would indicate a diagnosis of conduct disorder instead of...

    Incorrect

    • What signs of symptoms would indicate a diagnosis of conduct disorder instead of oppositional defiant disorder?

      Your Answer:

      Correct Answer: Often lies to obtain goods of favours of to avoid obligations

      Explanation:

      Disruptive Behaviour of Dissocial Disorders

      Conduct disorders are the most common reason for referral of young children to mental health services. These disorders are characterized by a repetitive and persistent pattern of antisocial, aggressive, of defiant conduct that goes beyond ordinary childish mischief of adolescent rebelliousness. Oppositional defiant disorder (ODD) shares some negative attributes but in a more limited fashion.

      ICD-11 terms the disorder as ‘Conduct-dissocial disorder’, while DSM-5 recognizes three separate conditions related to emotional/behavioral problems seen in younger people: conduct disorder, oppositional defiant disorder, and intermittent explosive disorder. Conduct disorder is about poorly controlled behavior, intermittent explosive disorder is about poorly controlled emotions, and ODD is in between. Conduct disorders are further divided into childhood onset (before 10 years) and adolescent onset (10 years of older).

      The behavior pattern of conduct disorders must be persistent and recurrent, including multiple incidents of aggression towards people of animals, destruction of property, deceitfulness of theft, and serious violations of rules. The pattern of behavior must result in significant impairment in personal, family, social, educational, occupational, of other important areas of functioning.

      Oppositional defiant disorder represents a less severe form of conduct disorder, where there is an absence of more severe dissocial of aggressive acts. The behavior pattern of ODD includes persistent difficulty getting along with others, provocative, spiteful, of vindictive behavior, and extreme irritability of anger.

      The prevalence of conduct disorders increases throughout childhood and is more common in boys than girls. The most frequent comorbid problem seen with conduct disorder is hyperactivity. The conversion rate from childhood conduct disorder to adult antisocial personality disorder varies from 40 to 70% depending on the study.

      NICE recommends group parent-based training programs of parent and child training programs for children with complex needs for ages 3-11, child-focused programs for ages 9-14, and multimodal interventions with a family focus for ages 11-17. Medication is not recommended in routine practice, but risperidone can be used where other approaches fail and they are seriously aggressive.

    • This question is part of the following fields:

      • Child And Adolescent Psychiatry
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  • Question 62 - At what age do male offenders in the UK typically reach their highest...

    Incorrect

    • At what age do male offenders in the UK typically reach their highest rate of criminal activity?

      Your Answer:

      Correct Answer: 17-18

      Explanation:

      Offending in the UK: Gender and Age Differences

      The peak age for offending in the UK is different for girls and boys, with girls peaking at 14 years and boys at 17-18 years. Half of the more serious indictable crimes are committed by individuals under the age of 21. As individuals mature, crime rates generally decrease, except for a small peak in women aged 40-50 around menopause.

      In the UK, males convicted of crimes outnumber females by a ratio of 5 to 1. Females are less frequently reported for crimes, especially by male police officers, yet they are up to three times more likely to be imprisoned for their first offense than males.

      Female offenders tend to come from more damaged backgrounds and exhibit more psychological and behavioral disturbances than males who have committed the same offense. This is reflected in the fact that females in prison tend to be more behaviorally and psychiatrically disturbed than their male counterparts.

    • This question is part of the following fields:

      • Forensic Psychiatry
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  • Question 63 - What intervention has been supported by placebo-controlled randomized controlled trials as effective in...

    Incorrect

    • What intervention has been supported by placebo-controlled randomized controlled trials as effective in managing aggression among individuals with dementia?

      Your Answer:

      Correct Answer: Risperidone

      Explanation:

      Management of Non-Cognitive Symptoms in Dementia

      Non-cognitive symptoms of dementia can include agitation, aggression, distress, psychosis, depression, anxiety, sleep problems, wandering, hoarding, sexual disinhibition, apathy, and shouting. Non-pharmacological measures, such as music therapy, should be considered before prescribing medication. Pain may cause agitation, so a trial of analgesics is recommended. Antipsychotics, such as risperidone, olanzapine, and aripiprazole, may be used for severe distress of serious risk to others, but their use is controversial due to issues of tolerability and an association with increased mortality. Cognitive enhancers, such as AChE-Is and memantine, may have a modest benefit on BPSD, but their effects may take 3-6 months to take effect. Benzodiazepines should be avoided except in emergencies, and antidepressants, such as citalopram and trazodone, may have mixed evidence for BPSD. Mood stabilizers, such as valproate and carbamazepine, have limited evidence to support their use. Sedating antihistamines, such as promethazine, may cause cognitive impairment and should only be used short-term. Melatonin has limited evidence to support its use but is safe to use and may be justified in some cases where benefits are seen. For Lewy Body dementia, clozapine is favored over risperidone, and quetiapine may be a reasonable choice if clozapine is not appropriate. Overall, medication should only be used when non-pharmacological measures are ineffective, and the need is balanced with the increased risk of adverse effects.

    • This question is part of the following fields:

      • Old Age Psychiatry
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  • Question 64 - What is the percentage of mothers who go through postpartum depression? ...

    Incorrect

    • What is the percentage of mothers who go through postpartum depression?

      Your Answer:

      Correct Answer: 10%

      Explanation:

      Perinatal Depression, Baby Blues, and Postpartum Depression

      Perinatal depression, also known as postpartum depression, is a common mood disorder experienced by new mothers after childbirth. The term baby blues is used to describe the emotional lability that some mothers experience during the first week after childbirth, which usually resolves by day 10 without treatment. The prevalence of baby blues is around 40%. Postpartum depression, on the other hand, refers to depression that occurs after childbirth. While neither DSM-5 nor ICD-11 specifically mention postpartum depression, both diagnostic systems offer categories that encompass depression during pregnancy of in the weeks following delivery. The prevalence of postpartum depression is approximately 10-15%.

      Various factors have been shown to increase the risk of postnatal depression, including youth, marital and family conflict, lack of social support, anxiety and depression during pregnancy, substance misuse, previous pregnancy loss, ambivalence about the current pregnancy, and frequent antenatal admissions to a maternity hospital. However, obstetric factors such as length of labor, assisted delivery, of separation of the mother from the baby in the Special Care Baby Unit do not seem to influence the development of postnatal depression. Additionally, social class does not appear to be associated with postnatal depression.

      Puerperal psychosis, along with severe depression, is thought to be mainly caused by biological factors, while psychosocial factors are most important in the milder postnatal depressive illnesses.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 65 - What is the accurate definition of the standardised mortality ratio? ...

    Incorrect

    • What is the accurate definition of the standardised mortality ratio?

      Your Answer:

      Correct Answer: The ratio between the observed number of deaths in a study population and the number of deaths that would be expected

      Explanation:

      Calculation of Standardised Mortality Ratio (SMR)

      To calculate the SMR, age and sex-specific death rates in the standard population are obtained. An estimate for the number of people in each category for both the standard and study populations is needed. The number of expected deaths in each age-sex group of the study population is calculated by multiplying the age-sex-specific rates in the standard population by the number of people in each category of the study population. The sum of all age- and sex-specific expected deaths gives the expected number of deaths for the whole study population. The observed number of deaths is then divided by the expected number of deaths to obtain the SMR.

      The SMR can be standardised using the direct of indirect method. The direct method is used when the age-sex-specific rates for the study population and the age-sex-structure of the standard population are known. The indirect method is used when the age-specific rates for the study population are unknown of not available. This method uses the observed number of deaths in the study population and compares it to the number of deaths that would be expected if the age distribution was the same as that of the standard population.

      The SMR can be interpreted as follows: an SMR less than 1.0 indicates fewer than expected deaths in the study population, an SMR of 1.0 indicates the number of observed deaths equals the number of expected deaths in the study population, and an SMR greater than 1.0 indicates more than expected deaths in the study population (excess deaths). It is sometimes expressed after multiplying by 100.

    • This question is part of the following fields:

      • Research Methods, Statistics, Critical Review And Evidence-Based Practice
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  • Question 66 - What is the recommendation of NICE guidelines regarding the use of a certain...

    Incorrect

    • What is the recommendation of NICE guidelines regarding the use of a certain treatment for depression?

      Your Answer:

      Correct Answer: Dosulepin

      Explanation:

      NICE recommends against the use of dosulepin due to the higher risk of cardiac complications and overdose toxicity, which outweigh any potential benefits in terms of tolerability compared to other antidepressants.

      Depression Treatment Guidelines by NICE

      The National Institute for Health and Care Excellence (NICE) provides guidelines for the treatment of depression. The following are some general recommendations:

      – Selective serotonin reuptake inhibitors (SSRIs) are preferred when prescribing antidepressants.
      – Antidepressants are not the first-line treatment for mild depression.
      – After remission, continue antidepressant treatment for at least six months.
      – Continue treatment for at least two years if at high risk of relapse of have a history of severe or prolonged episodes of inadequate response.
      – Use a stepped care approach to depression treatment, starting at the appropriate level based on the severity of depression.

      The stepped care approach involves the following steps:

      – Step 1: Assessment, support, psychoeducation, active monitoring, and referral for further assessment and interventions.
      – Step 2: Low-intensity psychosocial interventions, psychological interventions, medication, and referral for further assessment and interventions.
      – Step 3: Medication, high-intensity psychological interventions, combined treatments, collaborative care, and referral for further assessment and interventions.
      – Step 4: Medication, high-intensity psychological interventions, electroconvulsive therapy, crisis service, combined treatments, multiprofessional and inpatient care.

      Individual guided self-help programs based on cognitive-behavioral therapy (CBT) principles should be supported by a trained practitioner and last 9 to 12 weeks. Physical activity programs should consist of three sessions per week of moderate duration over 10 to 14 weeks.

      NICE advises against using antidepressants routinely to treat persistent subthreshold depressive symptoms of mild depression. However, they may be considered for people with a past history of moderate or severe depression, initial presentation of subthreshold depressive symptoms that have been present for a long period, of subthreshold depressive symptoms of mild depression that persist after other interventions.

      NICE recommends a combination of antidepressant medication and a high-intensity psychological intervention (CBT of interpersonal therapy) for people with moderate of severe depression. Augmentation of antidepressants with lithium, antipsychotics, of other antidepressants may be appropriate, but benzodiazepines, buspirone, carbamazepine, lamotrigine, of valproate should not be routinely used.

      When considering different antidepressants, venlafaxine is associated with a greater risk of death from overdose compared to other equally effective antidepressants. Tricyclic antidepressants (TCAs) except for lofepramine are associated with the greatest risk in overdose. Higher doses of venlafaxine may exacerbate cardiac arrhythmias, and venlafaxine and duloxetine may exacerbate hypertension. TCAs may cause postural hypotension and arrhythmias, and mianserin requires hematological monitoring in elderly people.

      The review frequency depends on the age and suicide risk of the patient. If the patient is over 30 and has no suicide risk, see them after two weeks and then at intervals of 2-4 weeks for the first three months. If the patient is under 30 and has a suicide risk, see them after one week.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 67 - Which of the options below is not an approved method for treating insomnia?...

    Incorrect

    • Which of the options below is not an approved method for treating insomnia?

      Your Answer:

      Correct Answer: Promethazine

      Explanation:

      Promethazine is approved for temporary use in managing sedation, allergies, hives, and symptoms of nausea and vomiting. However, it is not approved for treating insomnia.

      Insomnia is a sleep disorder characterized by difficulty falling asleep, staying asleep, waking up too early, of feeling unrefreshed after sleep. The management of insomnia depends on whether it is short-term (lasting less than 3 months) of long-term (lasting more than 3 months). For short-term insomnia, sleep hygiene and a sleep diary are recommended first. If severe daytime impairment is present, a short course of a non-benzodiazepine hypnotic medication may be considered for up to 2 weeks. For long-term insomnia, cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment.

      Pharmacological therapy should be avoided, but a short-term hypnotic medication may be appropriate for some individuals with severe symptoms of an acute exacerbation. Referral to a sleep clinic of neurology may be necessary if another sleep disorder is suspected of if long-term insomnia has not responded to primary care management. Good sleep hygiene practices include establishing fixed sleep and wake times, relaxing before bedtime, maintaining a comfortable sleeping environment, avoiding napping during the day, avoiding caffeine, nicotine, and alcohol before bedtime, avoiding exercise before bedtime, avoiding heavy meals late at night, and using the bedroom only for sleep and sexual activity.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 68 - Which of the following options is NOT a suitable initial treatment for an...

    Incorrect

    • Which of the following options is NOT a suitable initial treatment for an adult diagnosed with obsessive-compulsive disorder?

      Your Answer:

      Correct Answer: Mirtazapine

      Explanation:

      SSRIs are recommended for the treatment of OCD in adults.

      Maudsley Guidelines

      First choice: SSRI of clomipramine (SSRI preferred due to tolerability issues with clomipramine)

      Second line:

      – SSRI + antipsychotic
      – Citalopram + clomipramine
      – Acetylcysteine + (SSRI of clomipramine)
      – Lamotrigine + SSRI
      – Topiramate + SSRI

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 69 - What is a true statement about the SCOFF questionnaire? ...

    Incorrect

    • What is a true statement about the SCOFF questionnaire?

      Your Answer:

      Correct Answer: The negative predictive value of the SCOFF is 99.3%

      Explanation:

      The SCOFF Questionnaire for Screening Eating Disorders

      The SCOFF questionnaire is a tool used to screen for eating disorders. It consists of five questions that aim to identify symptoms of anorexia nervosa or bulimia. The questions include whether the individual makes themselves sick because they feel uncomfortably full, worries about losing control over how much they eat, has recently lost more than one stone in a three-month period, believes themselves to be fat when others say they are too thin, and whether food dominates their life.

      A score of two or more positive responses indicates a likely case of anorexia nervosa or bulimia. The questionnaire has a sensitivity of 84.6% and specificity of 98.6% when two or more questions are answered positively. This means that if a patient responds positively to two of more questions, there is a high likelihood that they have an eating disorder. The negative predictive value of the questionnaire is 99.3%, which means that if a patient responds negatively to the questions, there is a high probability that they do not have an eating disorder.

      Overall, the SCOFF questionnaire is a useful tool for healthcare professionals to quickly screen for eating disorders and identify individuals who may require further assessment and treatment.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 70 - What are the endocrine changes observed in individuals with Anorexia nervosa? ...

    Incorrect

    • What are the endocrine changes observed in individuals with Anorexia nervosa?

      Your Answer:

      Correct Answer: Increased cortisol levels

      Explanation:

      Eating Disorders: Lab Findings and Medical Complications

      Eating disorders can lead to a range of medical complications, including renal failure, peripheral edema, sinus bradycardia, QT-prolongation, pericardial effusion, and slowed GI motility. Other complications include constipation, cathartic colon, esophageal esophagitis, hair loss, and dental erosion. Blood abnormalities are also common in patients with eating disorders, including hyponatremia, hypokalemia, hypophosphatemia, and hypoglycemia. Additionally, patients may experience leucopenia, anemia, low albumin, elevated liver enzymes, and vitamin deficiencies. These complications can cause significant morbidity and mortality in patients with eating disorders. It is important for healthcare providers to monitor patients for these complications and provide appropriate treatment.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 71 - In what circumstances does Lyonization always take place? ...

    Incorrect

    • In what circumstances does Lyonization always take place?

      Your Answer:

      Correct Answer: Klinefelter's syndrome

      Explanation:

      Klinefelter’s syndrome is a condition that occurs when a male has one of more extra copies of the X chromosome in their cells. This extra genetic material interferes with male sexual development, causing the testes to function abnormally and reducing testosterone levels. This can lead to delayed of incomplete puberty, genital abnormalities, gynecomastia, reduced facial and body hair, and infertility. Additionally, individuals with Klinefelter’s syndrome may experience learning disabilities, delayed speech and language development, and a shy personality. The syndrome is typically caused by one extra X chromosome in each cell, but can also be caused by two of three extra X chromosomes. The severity of symptoms increases with the number of extra sex chromosomes. Some individuals with Klinefelter’s syndrome have the extra X chromosome in only some of their cells, which can result in milder symptoms. Lyonization, which occurs when there are multiple X chromosomes in a cell, is present to some degree in all individuals with Klinefelter’s syndrome.

      Lyonization: The Process of X-Inactivation

      The X chromosome is crucial for proper development and cell viability, containing over 1,000 essential genes. However, females carry two copies of the X chromosome, which can result in a potentially toxic double dose of X-linked genes. To address this imbalance, females undergo a process called Lyonization, of X-inactivation, where one of their two X chromosomes is transcriptionally silenced. The silenced X chromosome then condenses into a compact structure known as a Barr body, which remains in a silent state.

      X-inactivation occurs randomly, with no preference for the paternal or maternal X chromosome. It takes place early in embryogenesis, soon after fertilization when the dividing conceptus is about 16-32 cells big. This process occurs in all somatic cells of women, but not in germ cells involved in forming gametes. X-inactivation affects most, but not all, genes on the X chromosome. If a cell has more than two X chromosomes, the extra Xs are also inactivated.

    • This question is part of the following fields:

      • Child And Adolescent Psychiatry
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  • Question 72 - Which statement accurately describes the court process in the UK? ...

    Incorrect

    • Which statement accurately describes the court process in the UK?

      Your Answer:

      Correct Answer: All criminal cases will first go to the Magistrates Court

      Explanation:

      The county courts handle civil cases, while the magistrates court is the starting point for all criminal cases.

      Court Structure in England and Wales

      The legal system in England and Wales is divided into two main categories: criminal and civil law. Criminal law governs the rules set by the state for citizens, while civil law regulates the relationships and transactions between citizens.

      All criminal cases begin in the Magistrates’ Court. Criminal offenses are classified into three main categories: summary offenses, triable either way offenses, and indictable offenses. Summary offenses are the least serious and are tried in the Magistrates’ Court, with a maximum penalty of six months imprisonment and/of a fine of up to £5,000. Triable either way offenses are the middle range of crimes and can be tried in either the Magistrates’ Court of Crown Court. Indictable offenses are the most serious crimes, including murder, manslaughter, and rape, and must be tried in the Crown Court, with the first hearing at the Magistrates’ Court.

      Magistrates’ courts handle 95% of cases, including many civil cases such as family matters, liquor licensing, and betting and gaming. Magistrates cannot typically order sentences of imprisonment exceeding six months (of 12 months for consecutive sentences) of fines exceeding £5,000. In cases triable either way, the offender may be committed by the magistrates to the Crown Court for sentencing if a more severe sentence is deemed necessary.

      The Crown Court deals with serious criminal cases, some of which are on appeal of referred from Magistrates’ courts. Trials are heard by a Judge and a 12-person jury. The Crown Court is located at 77 centers across England and Wales and handles cases transferred from the Magistrates’ Courts. It also hears appeals against decisions of Magistrate’s Courts and deals with cases sent for sentence from Magistrates’ Courts.

    • This question is part of the following fields:

      • Forensic Psychiatry
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  • Question 73 - A team of scientists aims to conduct a systematic review on the effectiveness...

    Incorrect

    • A team of scientists aims to conduct a systematic review on the effectiveness of a new medication for elderly patients with dementia. They decide to search for studies published in languages other than English, as they know that positive results are more likely to be published in English-language journals, while negative results are more likely to be published in non-English language journals. What type of bias are they trying to prevent?

      Your Answer:

      Correct Answer: Tower of Babel bias

      Explanation:

      When conducting a systematic review, restricting the selection of studies to those published only in English may introduce a bias known as the Tower of Babel effect. This occurs because studies conducted in non-English speaking countries that report positive results are more likely to be published in English language journals, while those with negative results are more likely to be published in non-English language journals.

    • This question is part of the following fields:

      • Research Methods, Statistics, Critical Review And Evidence-Based Practice
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  • Question 74 - What are the typical features of post-traumatic stress disorder? ...

    Incorrect

    • What are the typical features of post-traumatic stress disorder?

      Your Answer:

      Correct Answer: Exaggerated startle response

      Explanation:

      Stress disorders, such as Post Traumatic Stress Disorder (PTSD), are emotional reactions to traumatic events. The diagnosis of PTSD requires exposure to an extremely threatening of horrific event, followed by the development of a characteristic syndrome lasting for at least several weeks, consisting of re-experiencing the traumatic event, deliberate avoidance of reminders likely to produce re-experiencing, and persistent perceptions of heightened current threat. Additional clinical features may include general dysphoria, dissociative symptoms, somatic complaints, suicidal ideation and behaviour, social withdrawal, excessive alcohol of drug use, anxiety symptoms, and obsessions of compulsions. The emotional experience of individuals with PTSD commonly includes anger, shame, sadness, humiliation, of guilt. The onset of PTSD symptoms can occur at any time during the lifespan following exposure to a traumatic event, and the symptoms and course of PTSD can vary significantly over time and individuals. Key differentials include acute stress reaction, adjustment disorder, and complex PTSD. Management of PTSD includes trauma-focused cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and supported trauma-focused computerized CBT interventions. Drug treatments, including benzodiazepines, are not recommended for the prevention of treatment of PTSD in adults, but venlafaxine of a selective serotonin reuptake inhibitor (SSRI) may be considered for adults with a diagnosis of PTSD if the person has a preference for drug treatment. Antipsychotics such as risperidone may be considered in addition if disabling symptoms and behaviors are present and have not responded to other treatments. Psychological debriefing is not recommended for the prevention of treatment of PTSD. For children and young people, individual trauma-focused CBT interventions of EMDR may be considered, but drug treatments are not recommended.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 75 - Which statement accurately describes borderline learning disability? ...

    Incorrect

    • Which statement accurately describes borderline learning disability?

      Your Answer:

      Correct Answer: It is not generally associated with deficits in adaptive functioning

      Explanation:

      To diagnose a learning disability, there must be evidence of both impaired intelligence and difficulties in adaptive functioning, such as the ability to live independently, manage finances, and attend to personal safety. Borderline learning disability, on the other hand, is typically not accompanied by deficits in adaptive functioning.

      Borderline Learning Disability

      Borderline learning disability is a term used to describe individuals with an IQ between 70-85. This category is not officially recognized as a diagnosis by the ICD-11. It is estimated that approximately 15% of the population falls within this range (Chaplin, 2005). Unlike mild learning disability, borderline learning disability is not typically associated with deficits in adaptive functioning, such as grooming, dressing, safety, of money management.

    • This question is part of the following fields:

      • Learning Disability
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  • Question 76 - What tool is the most effective in predicting violent behavior? ...

    Incorrect

    • What tool is the most effective in predicting violent behavior?

      Your Answer:

      Correct Answer: VRAG

      Explanation:

      Methods of Risk Assessment

      Methods of risk assessment are important in determining the potential harm that an individual may pose to others. There are three main methods for assessing risk to others: unstructured clinical approach, actuarial risk assessment, and structured professional judgment. The unstructured clinical approach is based solely on professional experience and does not involve any specific framework. Actuarial risk assessment uses tools that are based on statistical models of weighted factors supported by research as being predictive for future risk. Structured professional judgment combines professional judgment with a consideration of static and dynamic risk factors. Following this, the risk is formulated, and a plan is devised. There are various tools available for each method, such as the Historical-Clinical-Risk Management-20 (HCR-20) for violence, the Risk of Sexual Violence Protocol (RSVP) for sexual risk, and the Hare Psychopathy Checklist (PCL-R) for violence. It is important to use a multidisciplinary approach and consider all relevant risk factors in the formulation.

    • This question is part of the following fields:

      • Forensic Psychiatry
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  • Question 77 - Which option has the strongest evidence to support its effectiveness as a method...

    Incorrect

    • Which option has the strongest evidence to support its effectiveness as a method for quickly calming someone down?

      Your Answer:

      Correct Answer: Inhaled loxapine

      Explanation:

      Violence and aggression can be managed through rapid tranquillisation, although the evidence base for this approach is not strong. Different guidelines provide varying recommendations for rapid tranquillisation, including NICE, Maudsley Guidelines, and the British Association for Psychopharmacology (BAP). NICE recommends using IM lorazepam of IM haloperidol + IM promethazine for rapid tranquillisation in adults, taking into account factors such as previous response and patient preference. BAP provides a range of options for oral, inhaled, IM, and IV medications, including inhaled loxapine, buccal midazolam, and oral antipsychotics. Maudsley Guidelines suggest using oral lorazepam, oral promethazine, of buccal midazolam if prescribed a regular antipsychotic, of oral olanzapine, oral risperidone, of oral haloperidol if not already taking an antipsychotic. IM options include lorazepam, promethazine, olanzapine, aripiprazole, and haloperidol, although drugs should not be mixed in the same syringe. Haloperidol should ideally be used with promethazine to reduce the risk of dystonia.

    • This question is part of the following fields:

      • Forensic Psychiatry
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  • Question 78 - What statement accurately describes paraphilias? ...

    Incorrect

    • What statement accurately describes paraphilias?

      Your Answer:

      Correct Answer: They tend to be ego-syntonic

      Explanation:

      Paraphilias are intense and persistent sexual interests other than sexual interest in genital stimulation of preparatory fondling with phenotypically normal, physically mature, consenting human partners. They are divided into those relating to erotic activity and those relating to erotic target. In order to become a disorder, paraphilias must be associated with distress of impairment to the individual of with harm to others. The DSM-5 lists 8 recognised paraphilic disorder but acknowledges that there are many more. Treatment modalities for the paraphilias have limited scientific evidence to support their use. Psychological therapy (especially CBT) is often used (with extremely variable results). Pharmacological options include SSRI, Naltrexone, Antipsychotics, GnRH agonists, and Anti-androgens and progestational drugs (e.g. cyproterone acetate).

    • This question is part of the following fields:

      • Forensic Psychiatry
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  • Question 79 - You have been asked to assess a 60-year-old female at the cardiac unit...

    Incorrect

    • You have been asked to assess a 60-year-old female at the cardiac unit of the local general hospital. She suffered a myocardial (MI) infarction three weeks ago and has been recovering well physically.
      The medical team are concerned that she is experiencing frequent crying spells. You observe evidence of low mood, anhedonia and sleep disturbance.
      The woman feels hopeless about the future and has fleeting thoughts of suicide. She has a history of depression which responded well to antidepressant treatment.
      Which antidepressant would you recommend based on its demonstrated safety post-myocardial infarction?

      Your Answer:

      Correct Answer: Sertraline

      Explanation:

      According to a study published in JAMA, sertraline is a safe and effective treatment for depression in patients who have recently experienced a myocardial infarction (MI) of unstable angina. The study found that sertraline not only has antidepressant effects but also inhibits platelet aggregation. This suggests that sertraline may have additional benefits for patients with cardiovascular disease. For more information, refer to Glassman et al.’s study in JAMA.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 80 - What drug works by increasing the release of dopamine? ...

    Incorrect

    • What drug works by increasing the release of dopamine?

      Your Answer:

      Correct Answer: Amphetamine

      Explanation:

      Amphetamine induces the direct release of dopamine by stimulating it, while also causing the internalization of dopamine transporters from the cell surface. In contrast, cocaine only blocks dopamine transporters and does not induce dopamine release.

      Mechanisms of action for illicit drugs can be classified based on their effects on ionotropic receptors of ion channels, G coupled receptors, of monoamine transporters. Cocaine and amphetamine both increase dopamine levels in the synaptic cleft, but through different mechanisms. Cocaine directly blocks the dopamine transporter, while amphetamine binds to the transporter and increases dopamine efflux through various mechanisms, including inhibition of vesicular monoamine transporter 2 and monoamine oxidase, and stimulation of the intracellular receptor TAAR1. These mechanisms result in increased dopamine levels in the synaptic cleft and reuptake inhibition.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 81 - Which term is used to refer to the alternative hypothesis in hypothesis testing?...

    Incorrect

    • Which term is used to refer to the alternative hypothesis in hypothesis testing?

      a) Research hypothesis
      b) Statistical hypothesis
      c) Simple hypothesis
      d) Null hypothesis
      e) Composite hypothesis

      Your Answer:

      Correct Answer: Research hypothesis

      Explanation:

      Understanding Hypothesis Testing in Statistics

      In statistics, it is not feasible to investigate hypotheses on entire populations. Therefore, researchers take samples and use them to make estimates about the population they are drawn from. However, this leads to uncertainty as there is no guarantee that the sample taken will be truly representative of the population, resulting in potential errors. Statistical hypothesis testing is the process used to determine if claims from samples to populations can be made and with what certainty.

      The null hypothesis (Ho) is the claim that there is no real difference between two groups, while the alternative hypothesis (H1 of Ha) suggests that any difference is due to some non-random chance. The alternative hypothesis can be one-tailed of two-tailed, depending on whether it seeks to establish a difference of a change in one direction.

      Two types of errors may occur when testing the null hypothesis: Type I and Type II errors. Type I error occurs when the null hypothesis is rejected when it is true, while Type II error occurs when the null hypothesis is accepted when it is false. The power of a study is the probability of correctly rejecting the null hypothesis when it is false, and it can be increased by increasing the sample size.

      P-values provide information on statistical significance and help researchers decide if study results have occurred due to chance. The p-value is the probability of obtaining a result that is as large of larger when in reality there is no difference between two groups. The cutoff for the p-value is called the significance level (alpha level), typically set at 0.05. If the p-value is less than the cutoff, the null hypothesis is rejected, and if it is greater or equal to the cut off, the null hypothesis is not rejected. However, the p-value does not indicate clinical significance, which may be too small to be meaningful.

    • This question is part of the following fields:

      • Research Methods, Statistics, Critical Review And Evidence-Based Practice
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  • Question 82 - Which treatment is considered most effective for atypical depression? ...

    Incorrect

    • Which treatment is considered most effective for atypical depression?

      Your Answer:

      Correct Answer: MAOIs

      Explanation:

      Atypical Depression: Symptoms and Treatment

      Atypical depression is a subtype of major depressive disorder that is characterized by low mood with mood reactivity and a reversal of the typical features seen in depression. This includes hypersomnia, hyperphagia, weight gain, and libidinal increases. People with atypical depression tend to respond best to MAOIs, while their response to tricyclics is poor, and SSRIs perform somewhere in the middle.

      The DSM-5 defines atypical depression as a subtype of major depressive disorder ‘with atypical features’, which includes mood reactivity, significant weight gain of increase in appetite, hypersomnia, leaden paralysis, and a long-standing pattern of interpersonal rejection sensitivity that results in significant social of occupational impairment. However, this subtype is not specifically recognized in ICD-11.

      If you of someone you know is experiencing symptoms of atypical depression, it is important to seek professional help. Treatment options may include therapy, medication, of a combination of both. MAOIs may be the most effective medication for atypical depression, but it is important to work with a healthcare provider to determine the best course of treatment.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 83 - What is a risk management factor included in the HCR-20? ...

    Incorrect

    • What is a risk management factor included in the HCR-20?

      Your Answer:

      Correct Answer: Exposure to destabilizers

      Explanation:

      The HCR-20 is a comprehensive tool used to assess the risk of violence in adults. It takes into account various factors from the past, present, and future to provide a holistic view of the individual’s risk. The tool consists of 20 items, which are divided into three domains: historical, clinical, and risk management.

      The historical domain includes factors such as previous violence, young age at first violent incident, relationship instability, employment problems, substance use problems, major mental illness, psychopathy, early maladjustment, personality disorder, and prior supervision failure. These factors are important to consider as they provide insight into the individual’s past behavior and potential risk for future violence.

      The clinical domain includes factors such as lack of insight, negative attitudes, active symptoms of major mental illness, impulsivity, and unresponsiveness to treatment. These factors are important to consider as they provide insight into the individual’s current mental state and potential risk for future violence.

      The risk management domain includes factors such as plans lack feasibility, exposure to destabilizers, lack of personal support, noncompliance with remediation attempts, and stress. These factors are important to consider as they provide insight into the individual’s ability to manage their risk and potential for future violence.

      Overall, the HCR-20 is a valuable tool for assessing the risk of violence in adults. It provides a comprehensive view of the individual’s risk and can be used to inform treatment and risk management strategies.

    • This question is part of the following fields:

      • Forensic Psychiatry
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  • Question 84 - What is the recommended approach by NICE for managing distress in patients with...

    Incorrect

    • What is the recommended approach by NICE for managing distress in patients with delirium?

      Your Answer:

      Correct Answer: Haloperidol

      Explanation:

      Delirium Management

      Pharmacological management of delirium includes the use of haloperidol as a prophylactic measure. NICE guidelines recommend short-term use of haloperidol in cases where delirium is associated with distress of risk to self/others. Quetiapine is also considered a first-choice option in many units. Lorazepam can be used as an alternative if haloperidol is contraindicated, but it is more likely to cause respiratory depression, over-sedation, and paradoxical excitement.

      Non-pharmacological management of delirium includes appropriate lighting and clear signage, talking to the person to reorient them, cognitively stimulating activities, regular visits from family and friends, and promoting good sleep patterns. Additional options such as donepezil, rivastigmine, melatonin, trazodone, and sodium valproate are not recommended. It is important to carefully consider the individual’s needs and medical history when choosing a management plan for delirium.

    • This question is part of the following fields:

      • Old Age Psychiatry
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  • Question 85 - What is the percentage of the study's findings that support the internal validity...

    Incorrect

    • What is the percentage of the study's findings that support the internal validity of the two question depression screening test compared to the Beck Depression Inventory?

      Your Answer:

      Correct Answer: Convergent validity

      Explanation:

      Validity in statistics refers to how accurately something measures what it claims to measure. There are two main types of validity: internal and external. Internal validity refers to the confidence we have in the cause and effect relationship in a study, while external validity refers to the degree to which the conclusions of a study can be applied to other people, places, and times. There are various threats to both internal and external validity, such as sampling, measurement instrument obtrusiveness, and reactive effects of setting. Additionally, there are several subtypes of validity, including face validity, content validity, criterion validity, and construct validity. Each subtype has its own specific focus and methods for testing validity.

    • This question is part of the following fields:

      • Research Methods, Statistics, Critical Review And Evidence-Based Practice
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  • Question 86 - Which principle was not mentioned by Yalom as a therapeutic aspect of group...

    Incorrect

    • Which principle was not mentioned by Yalom as a therapeutic aspect of group therapy?

      Your Answer:

      Correct Answer: Autonomy

      Explanation:

      Group Psychotherapy: Yalom’s Therapeutic Principles

      Group psychotherapy involves a trained therapist and a group of individuals. Yalom, a prominent figure in group therapy, outlined the therapeutic principles of group psychotherapy. These principles include universality, altruism, instillation of hope, imparting information, corrective recapitulation of the primary family experience, development of socializing techniques, imitative behavior, cohesiveness, existential factors, catharsis, interpersonal learning, and self-understanding. Psychodrama, a specific form of group therapy, involves examining relationships and problems through drama.

      Bion and Basic Assumption Groups

      Bion, a psychoanalyst interested in group dynamics, believed that groups had a collective unconscious that operated similarly to an individual’s. He distinguished between two types of groups: working groups and basic assumption groups. Basic assumption groups act out primitive fantasies and prevent things from getting done. Bion described different types of basic assumption groups, including dependency, fight-flight, and pairing. Dependency involves the group turning to a leader to protect them from anxiety. Fight-flight involves the group acting as if there is an enemy who must be attacked of avoided. Pairing involves the group acting as if the answer lies in the pairing of two members.

    • This question is part of the following fields:

      • Psychotherapy
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  • Question 87 - What is the recommended initial treatment for psychotic depression? ...

    Incorrect

    • What is the recommended initial treatment for psychotic depression?

      Your Answer:

      Correct Answer: Tricyclic antidepressant plus antipsychotic

      Explanation:

      The Maudsley Guidelines and NICE guidance both recommend the use of a tricyclic antidepressant in combination with an antipsychotic for the treatment of psychotic depression. This approach is also supported by a systematic review which found that augmentation was superior to using an antidepressant or antipsychotic alone. The review was conducted by Kruizinga in 2021 and published in the Cochrane Database of Systematic Reviews.

      Psychotic Depression

      Psychotic depression is a type of depression that is characterized by the presence of delusions and/of hallucinations in addition to depressive symptoms. This condition is often accompanied by severe anhedonia, loss of interest, and psychomotor retardation. People with psychotic depression are tormented by hallucinations and delusions with typical themes of worthlessness, guilt, disease, of impending disaster. This condition affects approximately 14.7-18.5% of depressed patients and is estimated to affect around 0.4% of community adult samples, with a higher prevalence in the elderly community at around 1.4-3.0%. People with psychotic depression are at a higher risk of attempting and completing suicide than those with non-psychotic depression.

      Diagnosis

      Psychotic depression is currently classified as a subtype of depression in both the ICD-11 and the DSM-5. The main difference between the two is that in the ICD-11, the depressive episode must be moderate of severe to qualify for a diagnosis of depressive episode with psychotic symptoms, whereas in the DSM-5, the diagnosis can be applied to any severity of depressive illness.

      Treatment

      The recommended treatment for psychotic depression is tricyclics as first-line treatment, with antipsychotic augmentation. Second-line treatment includes SSRI/SNRI. Augmentation of antidepressant with olanzapine or quetiapine is recommended. The optimum dose and duration of antipsychotic augmentation are unknown. If one treatment is to be stopped during the maintenance phase, then this should be the antipsychotic. ECT should be considered where a rapid response is required of where other treatments have failed. According to NICE (ng222), combination treatment with antidepressant medication and antipsychotic medication (such as olanzapine or quetiapine) should be considered for people with depression with psychotic symptoms. If a person with depression with psychotic symptoms does not wish to take antipsychotic medication in addition to an antidepressant, then treat with an antidepressant alone.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 88 - In the UK, what is the schedule classification for non-benzodiazepine hypnotics such as...

    Incorrect

    • In the UK, what is the schedule classification for non-benzodiazepine hypnotics such as zopiclone?

      Your Answer:

      Correct Answer: 4

      Explanation:

      Drug Misuse (Law and Scheduling)

      The Misuse of Drugs Act (1971) regulates the possession and supply of drugs, classifying them into three categories: A, B, and C. The maximum penalty for possession varies depending on the class of drug, with Class A drugs carrying a maximum sentence of 7 years.

      The Misuse of Drugs Regulations 2001 further categorizes controlled drugs into five schedules. Schedule 1 drugs are considered to have no therapeutic value and cannot be lawfully possessed of prescribed, while Schedule 2 drugs are available for medical use but require a controlled drug prescription. Schedule 3, 4, and 5 drugs have varying levels of restrictions and requirements.

      It is important to note that a single drug can have multiple scheduling statuses, depending on factors such as strength and route of administration. For example, morphine and codeine can be either Schedule 2 of Schedule 5.

      Overall, the Misuse of Drugs Act and Regulations aim to regulate and control the use of drugs in the UK, with the goal of reducing drug misuse and related harm.

    • This question is part of the following fields:

      • Substance Misuse/Addictions
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  • Question 89 - What is the most accurate approximation of the lifetime occurrence rate of major...

    Incorrect

    • What is the most accurate approximation of the lifetime occurrence rate of major depression?

      Your Answer:

      Correct Answer: 15%

      Explanation:

      Epidemiological surveys and prevalence estimates have been conducted to determine the prevalence of various mental health conditions. The Epidemiological Catchment Area (ECA) study was conducted in the mid-1980s using the Diagnostic Interview Schedule (DIS) based on DSM-III criteria. The National Comorbidity Survey (NCS) used the Composite International Diagnostic Interview (CIDI) and was conducted in the 1990s and repeated in 2001. The Adult Psychiatric Morbidity Survey (APMS) used the Clinical Interview Schedule (CIS-R) and was conducted in England every 7 years since 1993. The WHO World Mental Health (WMH) Survey Initiative used the World Mental Health Composite International Diagnostic Interview (WMH-CIDI) and was conducted in close to 30 countries from 2001 onwards.

      The main findings of these studies show that major depression has a prevalence of 4-10% worldwide, with 6.7% in the past 12 months and 16.6% lifetime prevalence. Generalised anxiety disorder (GAD) has a 3.1% 12-month prevalence and 5.7% lifetime prevalence. Panic disorder has a 2.7% 12-month prevalence and 4.7% lifetime prevalence. Specific phobia has an 8.7% 12-month prevalence and 12.5% lifetime prevalence. Social anxiety disorder has a 6.8% 12-month prevalence and 12.1% lifetime prevalence. Agoraphobia without panic disorder has a 0.8% 12-month prevalence and 1.4% lifetime prevalence. Obsessive-compulsive disorder (OCD) has a 1.0% 12-month prevalence and 1.6% lifetime prevalence. Post-traumatic stress disorder (PTSD) has a 1.3-3.6% 12-month prevalence and 6.8% lifetime prevalence. Schizophrenia has a 0.33% 12-month prevalence and 0.48% lifetime prevalence. Bipolar I disorder has a 1.5% 12-month prevalence and 2.1% lifetime prevalence. Bulimia nervosa has a 0.63% lifetime prevalence, anorexia nervosa has a 0.16% lifetime prevalence, and binge eating disorder has a 1.53% lifetime prevalence.

      These prevalence estimates provide important information for policymakers, healthcare providers, and researchers to better understand the burden of mental health conditions and to develop effective prevention and treatment strategies.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 90 - Who among these psychosurgeons received the Nobel Prize in medicine? ...

    Incorrect

    • Who among these psychosurgeons received the Nobel Prize in medicine?

      Your Answer:

      Correct Answer: Moniz

      Explanation:

      The History of Psychosurgery

      Psychosurgery, the surgical treatment of mental illness, has a long and controversial history. The modern era of psychosurgery began in the late 19th century with the pioneering work of Swiss neurosurgeon Burckhardt, who removed areas of cortex from the frontal and parietal regions of six patients.

      In 1910, Russian neurosurgeon Puseep ablated the frontoparietal tracts of three bipolar patients. However, it was Egas Moniz who refined psychosurgical techniques and was awarded the Nobel Prize for Medicine in 1949 for his work in the treatment of psychiatric disorders.

      American neurosurgeon Freeman also developed similar procedures and advocated for psychosurgery as a first-line treatment for mental illness. Luver and Bucy described the effect of temporal lobectomy on aggression, further advancing the field of psychosurgery. Despite its controversial history, psychosurgery continues to be used today in select cases as a treatment option for severe mental illness.

    • This question is part of the following fields:

      • Organisation And Delivery Of Psychiatric Services
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  • Question 91 - The ICD-11 defines a condition characterized by distressing emotional, behavioral, and physical symptoms...

    Incorrect

    • The ICD-11 defines a condition characterized by distressing emotional, behavioral, and physical symptoms that occur in the premenstrual phase of the menstrual cycle as:

      Your Answer:

      Correct Answer: Premenstrual dysphoric disorder

      Explanation:

      There is currently no evidence to support the use of vitamin supplements for the treatment of premenstrual dysphoric disorder. However, lifestyle changes such as regular exercise, a healthy diet, and stress reduction techniques may be helpful in managing symptoms. It is important to consult with a healthcare provider to determine the best course of treatment for individual cases of PMDD.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 92 - What structure has been linked to the development of post traumatic stress disorder?...

    Incorrect

    • What structure has been linked to the development of post traumatic stress disorder?

      Your Answer:

      Correct Answer: Amygdala

      Explanation:

      Aetiology of Post Traumatic Stress Disorder

      Post traumatic stress disorder (PTSD) is a mental health condition that can develop after experiencing of witnessing a traumatic event. The aetiology of PTSD is complex and involves various factors, including changes in cortisol levels and alterations in brain structures.

      Studies have shown that individuals with PTSD have lower ambient cortisol levels than normal, which has been attributed to chronic adrenal exhaustion resulting from the inhibition of the hypothalamic-pituitary-adrenal (HPA) axis by persistent severe anxiety. This suggests that the stress response system in individuals with PTSD may be dysregulated, leading to abnormal cortisol levels.

      Two brain structures, the amygdala and the hippocampus, have also been implicated in the aetiology of PTSD. The amygdala is responsible for processing emotions, particularly fear, and is hyperactive in individuals with PTSD. This hyperactivity may contribute to the intense fear and anxiety experienced by individuals with PTSD. The hippocampus, which is involved in memory processing, is also affected in individuals with PTSD. Studies have shown that the hippocampus is smaller in individuals with PTSD, which may contribute to the difficulty in recalling traumatic events and the intrusive memories associated with PTSD.

      Overall, the aetiology of PTSD is multifactorial and involves changes in cortisol levels and alterations in brain structures, particularly the amygdala and hippocampus. Understanding these underlying mechanisms is crucial for developing effective treatments for individuals with PTSD.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 93 - What symptom of characteristic would strongly indicate the presence of Niemann-Pick disease as...

    Incorrect

    • What symptom of characteristic would strongly indicate the presence of Niemann-Pick disease as an underlying diagnosis?

      Your Answer:

      Correct Answer: Treatment resistant psychosis with executive dysfunction

      Explanation:

      If a patient presents with both treatment resistant psychosis and executive dysfunction, it may be worth considering Niemann-Pick disease. Additionally, if a patient experiences treatment resistant anxiety symptoms accompanied by tachycardia, a pheochromocytoma should be considered. In cases where a patient exhibits personality changes and attentional issues in adulthood, along with irritability, aggression, and jaundice, it may suggest a mixed presentation of Wilson’s disease.

      Niemann-Pick disease is a group of inherited diseases where lipids accumulate in the cells of the liver, spleen, and brain. Niemann-Pick Type C (NPC) is the most relevant type for psychiatric presentations, with about one-third of cases presenting in adolescence of adulthood. Symptoms include progressive ataxia/dystonia, cognitive decline, and atypical psychotic symptoms. There are four other types of Niemann-Pick disease, each with their own causes and symptoms. Type A and B have a lack of sphingomyelinase and present in early childhood of mid-childhood/adolescence, respectively. Type C has reduced sphingomyelinase activity and can present at any age, with symptoms including enlarged liver and spleen, learning difficulties, seizures, and slurred speech. Type D is a variant of Type C and has similar symptoms. Type E has reduced sphingomyelinase activity and presents in adulthood with similar symptoms to the other types.

    • This question is part of the following fields:

      • Child And Adolescent Psychiatry
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  • Question 94 - Which statement about Rett syndrome is accurate? ...

    Incorrect

    • Which statement about Rett syndrome is accurate?

      Your Answer:

      Correct Answer: It almost exclusively occurs in females

      Explanation:

      Females make up the vast majority of Rett syndrome cases.

      Rett Syndrome: A Rare Neurodevelopmental Disorder

      Rett syndrome is a neurodevelopmental disorder that is rare, affecting approximately 1 in 10,000 female births. Although it mostly affects females, there have been cases of males with the disorder. While the exact cause of the disorder is not known, it is believed to have a genetic basis, with mutations in the MECP2 gene (Xq28) being associated with the disorder. Monozygotic twins have been found to have complete concordance in cases of Rett syndrome.

      The disorder has a unique presentation, with affected children experiencing a normal period of development until 6-18 months. After this period, they begin to develop problems with language, losing previously acquired speech. Purposeful hand movements are replaced with stereotypic movements, such as hand wringing, and ataxia and psychomotor retardation may occur. Other stereotypical movements, such as finger licking of biting and tapping of slapping, may also be seen. Head circumference is normal at birth, but growth begins to decelerate between 6-12 months, resulting in microcephaly. All language skills are lost, both receptive and expressive, and social skills plateau at developmental levels between 6-12 months.

      Seizures are associated with Rett syndrome in 75% of those affected, and almost all affected children have abnormal EEG findings. Breathing problems, such as hyperventilation, apnea, and breath holding, are also seen. Children with Rett syndrome may live for well over a decade after the onset of the disorder, but after 10 years, many patients are wheelchair-bound with virtually no language ability. Additional features of the disorder include seizures, breath holding and hyperventilation, sleep difficulties, and issues with locomotion.

    • This question is part of the following fields:

      • Child And Adolescent Psychiatry
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  • Question 95 - Which antidepressants are recommended by the Maudsley guidelines for breastfeeding women? ...

    Incorrect

    • Which antidepressants are recommended by the Maudsley guidelines for breastfeeding women?

      Your Answer:

      Correct Answer: Sertraline of mirtazapine

      Explanation:

      Paroxetine Use During Pregnancy: Is it Safe?

      Prescribing medication during pregnancy and breastfeeding is challenging due to the potential risks to the fetus of baby. No psychotropic medication has a UK marketing authorization specifically for pregnant of breastfeeding women. Women are encouraged to breastfeed unless they are taking carbamazepine, clozapine, of lithium. The risk of spontaneous major malformation is 2-3%, with drugs accounting for approximately 5% of all abnormalities. Valproate and carbamazepine are associated with an increased risk of neural tube defects, and lithium is associated with cardiac malformations. Benzodiazepines are associated with oral clefts and floppy baby syndrome. Antidepressants have been linked to preterm delivery and congenital malformation, but most findings have been inconsistent. TCAs have been used widely without apparent detriment to the fetus, but their use in the third trimester is known to produce neonatal withdrawal effects. Sertraline appears to result in the least placental exposure among SSRIs. MAOIs should be avoided in pregnancy due to a suspected increased risk of congenital malformations and hypertensive crisis. If a pregnant woman is stable on an antipsychotic and likely to relapse without medication, she should continue the antipsychotic. Depot antipsychotics should not be offered to pregnant of breastfeeding women unless they have a history of non-adherence with oral medication. The Maudsley Guidelines suggest specific drugs for use during pregnancy and breastfeeding. NICE CG192 recommends high-intensity psychological interventions for moderate to severe depression and anxiety disorders. Antipsychotics are recommended for pregnant women with mania of psychosis who are not taking psychotropic medication. Promethazine is recommended for insomnia.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 96 - What are some recognized risk factors for suicide among incarcerated individuals? ...

    Incorrect

    • What are some recognized risk factors for suicide among incarcerated individuals?

      Your Answer:

      Correct Answer: Remand prisoners

      Explanation:

      Prisoners who are male, recently admitted to prison within the past week, on remand, charged with a violent of sexual offense, and with a previous history of mental illness are recognized as established risk factors for suicide in prisons.

    • This question is part of the following fields:

      • Forensic Psychiatry
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  • Question 97 - What is a true statement regarding schizophrenia in women? ...

    Incorrect

    • What is a true statement regarding schizophrenia in women?

      Your Answer:

      Correct Answer: Schizophrenia in women is associated with fewer structural brain abnormalities than in men

      Explanation:

      Schizophrenia presents differently in men and women. Women tend to have a later onset and respond better to treatment, requiring lower doses of antipsychotics. Men, on the other hand, have an earlier onset, poorer premorbid functioning, and more negative symptoms and cognitive deficits. They also have greater structural brain and neurophysiological abnormalities. Females display more affective symptoms, auditory hallucinations, and persecutory delusions, but have a more favorable short- and middle-term course of illness with less smoking and substance abuse. Families of males are more critical, and expressed emotion has a greater negative impact on them. Certain neurological soft signs may be more prevalent in males. There are no clear sex differences in family history, obstetric complications, and minor physical anomalies.

      Schizophrenia Epidemiology

      Prevalence:
      – In England, the estimated annual prevalence for psychotic disorders (mostly schizophrenia) is around 0.4%.
      – Internationally, the estimated annual prevalence for psychotic disorders is around 0.33%.
      – The estimated lifetime prevalence for psychotic disorders in England is approximately 0.63% at age 43, consistent with the typically reported 1% prevalence over the life course.
      – Internationally, the estimated lifetime prevalence for psychotic disorders is around 0.48%.

      Incidence:
      – In England, the pooled incidence rate for non-affective psychosis (mostly schizophrenia) is estimated to be 15.2 per 100,000 years.
      – Internationally, the incidence of schizophrenia is about 0.20/1000/year.

      Gender:
      – The male to female ratio is 1:1.

      Course and Prognosis:
      – Long-term follow-up studies suggest that after 5 years of illness, one quarter of people with schizophrenia recover completely, and for most people, the condition gradually improves over their lifetime.
      – Schizophrenia has a worse prognosis with onset in childhood of adolescence than with onset in adult life.
      – Younger age of onset predicts a worse outcome.
      – Failure to comply with treatment is a strong predictor of relapse.
      – Over a 2-year period, one-third of patients with schizophrenia showed a benign course, and two-thirds either relapsed of failed to recover.
      – People with schizophrenia have a 2-3 fold increased risk of premature death.

      Winter Births:
      – Winter births are associated with an increased risk of schizophrenia.

      Urbanicity:
      – There is a higher incidence of schizophrenia associated with urbanicity.

      Migration:
      – There is a higher incidence of schizophrenia associated with migration.

      Class:
      – There is a higher prevalence of schizophrenia among lower socioeconomic classes.

      Learning Disability:
      – Prevalence rates for schizophrenia in people with learning disabilities are approximately three times greater than for the general population.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 98 - As a healthcare AI language model, I cannot provide medical advice of recommendations....

    Incorrect

    • As a healthcare AI language model, I cannot provide medical advice of recommendations. It is important to consult with a qualified healthcare professional who can assess the patient's individual needs and medical history to determine the best course of treatment.

      Your Answer:

      Correct Answer: Olanzapine

      Explanation:

      One of the notable side effects of olanzapine is its potential to induce diabetes.

      Antipsychotics: Common Side Effects and Relative Adverse Effects

      Antipsychotics are medications used to treat various mental health conditions, including schizophrenia and bipolar disorder. However, they can also cause side effects that can be bothersome of even serious. The most common side effects of antipsychotics are listed in the table below, which includes the adverse effects associated with their receptor activity.

      Antidopaminergic effects: These effects are related to the medication’s ability to block dopamine receptors in the brain. They can cause galactorrhoea, gynecomastia, menstrual disturbance, lowered sperm count, reduced libido, Parkinsonism, dystonia, akathisia, and tardive dyskinesia.

      Anticholinergic effects: These effects are related to the medication’s ability to block acetylcholine receptors in the brain. They can cause dry mouth, blurred vision, urinary retention, and constipation.

      Antiadrenergic effects: These effects are related to the medication’s ability to block adrenaline receptors in the body. They can cause postural hypotension and ejaculatory failure.

      Histaminergic effects: These effects are related to the medication’s ability to block histamine receptors in the brain. They can cause drowsiness.

      The Maudsley Guidelines provide a rough guide to the relative adverse effects of different antipsychotics. The table below summarizes their findings, with +++ indicating a high incidence of adverse effects, ++ indicating a moderate incidence, + indicating a low incidence, and – indicating a very low incidence.

      Drug Sedation Weight gain Diabetes EPSE Anticholinergic Postural Hypotension Prolactin elevation
      Amisulpride – + + + – – +++
      Aripiprazole – +/- – +/- – – –
      Asenapine + + +/- +/- – – +/-
      Clozapine +++ +++ +++ – +++ +++ –
      Flupentixol + ++ + ++ ++ + +++
      Fluphenazine + + + +++ ++ + +++
      Haloperidol + + +/- +++ + + +++
      Olanzapine ++ +++ +++ +/- + + +
      Paliperidone + ++ + + + ++ +++
      Pimozide + + – + + + +++
      Quetiapine ++ ++ ++ – + ++ –
      Risperidone + ++ + + + ++ +++
      Zuclopenthixol ++ ++ + ++ ++ + +++

      Overall, it is important to discuss the potential side effects of antipsychotics with a healthcare provider and to monitor for any adverse effects while taking these medications.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 99 - A teenager prescribed clozapine for schizophrenia develops depression and is given an SSRI....

    Incorrect

    • A teenager prescribed clozapine for schizophrenia develops depression and is given an SSRI. Three days after starting the new tablets they have a seizure and are admitted to hospital. What is the most probable cause of the seizure?

      Your Answer:

      Correct Answer: Fluoxetine

      Explanation:

      When taken with clozapine, many SSRIs can cause an increase in its levels. However, citalopram and escitalopram are considered safe as they do not affect the cytochrome system. Although paroxetine is believed to interact, it has been proven safe when used at normal clinical doses alongside clozapine. Sertraline has minimal impact on clozapine levels.

      Interactions of Antidepressants with Cytochrome P450 System

      Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), can have significant effects on the cytochrome P450 system. This can result in drug interactions that can affect the efficacy and safety of the medications.

      One example of such interaction is between fluvoxamine and theophylline. Fluvoxamine is a potent inhibitor of CYP1A2, which can lead to increased levels of theophylline in the body. This can cause adverse effects such as nausea, vomiting, and tremors.

      Another example is between fluoxetine and clozapine. Fluoxetine is a potent inhibitor of CYP2D6, which can increase the risk of seizures with clozapine. Clozapine is metabolized by CYP1A2, CYP3A4, and CYP2D6, and any inhibition of these enzymes can affect its metabolism and increase the risk of adverse effects.

      It is important to be aware of these interactions and monitor patients closely when prescribing antidepressants, especially in those who are taking other medications that are metabolized by the cytochrome P450 system.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 100 - Which epilepsy medication can alleviate concerns about weight gain and may even lead...

    Incorrect

    • Which epilepsy medication can alleviate concerns about weight gain and may even lead to weight loss for a patient with epilepsy?

      Your Answer:

      Correct Answer: Topiramate

      Explanation:

      Topiramate is a medication used for epilepsy and bipolar affective disorder. It works by inhibiting voltage gated sodium channels and increasing GABA levels. Unlike most psychotropic drugs, it is associated with weight loss.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 101 - What is the calculation that the nurse performed to determine the patient's average...

    Incorrect

    • What is the calculation that the nurse performed to determine the patient's average daily calorie intake over a seven day period?

      Your Answer:

      Correct Answer: Arithmetic mean

      Explanation:

      You don’t need to concern yourself with the specifics of the various means. Simply keep in mind that the arithmetic mean is the one utilized in fundamental biostatistics.

      Measures of Central Tendency

      Measures of central tendency are used in descriptive statistics to summarize the middle of typical value of a data set. There are three common measures of central tendency: the mean, median, and mode.

      The median is the middle value in a data set that has been arranged in numerical order. It is not affected by outliers and is used for ordinal data. The mode is the most frequent value in a data set and is used for categorical data. The mean is calculated by adding all the values in a data set and dividing by the number of values. It is sensitive to outliers and is used for interval and ratio data.

      The appropriate measure of central tendency depends on the measurement scale of the data. For nominal and categorical data, the mode is used. For ordinal data, the median of mode is used. For interval data with a normal distribution, the mean is preferable, but the median of mode can also be used. For interval data with skewed distribution, the median is used. For ratio data, the mean is preferable, but the median of mode can also be used for skewed data.

      In addition to measures of central tendency, the range is also used to describe the spread of a data set. It is calculated by subtracting the smallest value from the largest value.

    • This question is part of the following fields:

      • Research Methods, Statistics, Critical Review And Evidence-Based Practice
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  • Question 102 - A father is concerned that his 16-year-old daughter's marijuana consumption may lead to...

    Incorrect

    • A father is concerned that his 16-year-old daughter's marijuana consumption may lead to the development of schizophrenia. How would you explain to him the difference in the risk of schizophrenia between cannabis use and non-use?

      Your Answer:

      Correct Answer: There is a 2-4 fold increase in the risk of schizophrenia attributable to cannabis

      Explanation:

      Schizophrenia and Cannabis Use

      The relationship between cannabis use and the risk of developing schizophrenia is a topic of ongoing debate. However, research suggests that cannabis use may increase the risk of later schizophrenia of schizophreniform disorder by two-fold (Arseneault, 2004). The risk of developing schizophrenia appears to be higher in individuals who start using cannabis at a younger age. For instance, regular cannabis smokers at the age of 15 are 4.5 times more likely to develop schizophrenia at the age of 26, compared to those who did not report regular use until age 18 (Murray, 2004).

      A systematic review published in the Lancet in 2007 found that the lifetime risk of developing psychosis increased by 40% in individuals who had ever used cannabis (Moore, 2007). Another meta-analysis reported that the age at onset of psychosis was 2.70 years younger in cannabis users than in non-users (Large, 2011). These findings suggest that cannabis use may have a significant impact on the development of schizophrenia and related disorders.

    • This question is part of the following fields:

      • Substance Misuse/Addictions
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  • Question 103 - A woman in considerable distress visits the emergency department due to alcohol withdrawal....

    Incorrect

    • A woman in considerable distress visits the emergency department due to alcohol withdrawal. She inquires about the duration of her symptoms. When is the typical peak period for alcohol withdrawal symptoms?

      Your Answer:

      Correct Answer: 24-48 hours

      Explanation:

      Alcohol withdrawal is characterized by overactivity of the autonomic nervous system, resulting in symptoms such as agitation, tremors, sweating, nausea, vomiting, fever, and tachycardia. These symptoms typically begin 3-12 hours after drinking stops, peak between 24-48 hours, and can last up to 14 days. Withdrawal seizures may occur before blood alcohol levels reach zero, and a small percentage of people may experience delirium tremens (DT), which can be fatal if left untreated. Risk factors for DT include abnormal liver function, old age, severity of withdrawal symptoms, concurrent medical illness, heavy alcohol use, self-detox, previous history of DT, low potassium, low magnesium, and thiamine deficiency.

      Pharmacologically assisted detox is often necessary for those who regularly consume more than 15 units of alcohol per day, and inpatient detox may be needed for those who regularly consume more than 30 units per day. The Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-Ar) can be used to assess the severity of withdrawal symptoms and guide treatment decisions. Benzodiazepines are the mainstay of treatment, as chronic alcohol exposure results in decreased overall brain excitability and compensatory decrease of GABA-A neuroreceptor response to GABA. Chlordiazepoxide is a good first-line agent, while oxazepam, temazepam, and lorazepam are useful in patients with liver disease. Clomethiazole is effective but carries a high risk of respiratory depression and is not recommended. Thiamine should be offered to prevent Wernicke’s encephalopathy, and long-acting benzodiazepines can be used as prophylaxis for withdrawal seizures. Haloperidol is the treatment of choice if an antipsychotic is required.

    • This question is part of the following fields:

      • Substance Misuse/Addictions
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  • Question 104 - A 16-year-old male is caught spying on his neighbour whilst she is undressing....

    Incorrect

    • A 16-year-old male is caught spying on his neighbour whilst she is undressing. The police report that this is the fifth time he has been caught doing this in the past 6 months. He is assessed by a psychiatrist and discloses a six-month history of intense urges to watch females undressing in their homes. He denies feeling distressed by these urges.

      Which of the following conclusion would be most appropriate in this case according to the DSM-5?

      Your Answer:

      Correct Answer: A diagnosis of ‘Voyeuristic Disorder’ should not be made as the individual is under the age of 18

      Explanation:

      Voyeuristic disorder is typically observed in adult males who develop a sexual interest in secretly observing individuals without their knowledge. While this interest may first arise during adolescence, a diagnosis of voyeuristic disorder is only made after the age of 18 due to challenges in distinguishing it from normal sexual curiosity during puberty. The DSM-5 identifies voyeuristic behavior as a disorder when it causes harm, which can manifest as either personal distress of engaging in non-consensual acts.

      Paraphilias are intense and persistent sexual interests other than sexual interest in genital stimulation of preparatory fondling with phenotypically normal, physically mature, consenting human partners. They are divided into those relating to erotic activity and those relating to erotic target. In order to become a disorder, paraphilias must be associated with distress of impairment to the individual of with harm to others. The DSM-5 lists 8 recognised paraphilic disorder but acknowledges that there are many more. Treatment modalities for the paraphilias have limited scientific evidence to support their use. Psychological therapy (especially CBT) is often used (with extremely variable results). Pharmacological options include SSRI, Naltrexone, Antipsychotics, GnRH agonists, and Anti-androgens and progestational drugs (e.g. cyproterone acetate).

    • This question is part of the following fields:

      • Forensic Psychiatry
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  • Question 105 - A 50 year old lady with breast cancer taking Tamoxifen visits her GP...

    Incorrect

    • A 50 year old lady with breast cancer taking Tamoxifen visits her GP complaining of depression. The GP decides to prescribe an antidepressant. What medication should the GP steer clear of due to its interaction with Tamoxifen?

      Your Answer:

      Correct Answer: Fluoxetine

      Explanation:

      Tamoxifen and Antidepressant Interactions

      Tamoxifen is a medication used to treat breast cancer by reducing relapse rates and increasing overall survival. It works by antagonizing estrogen in the breast, with its anti-estrogen affinity depending on its primary metabolite, endoxifen. However, tamoxifen is metabolized to endoxifen through the liver enzyme CYP2D6, and any drug that inhibits this enzyme can reduce the conversion of tamoxifen to endoxifen.

      Women taking tamoxifen for breast cancer treatment of prevention may also take antidepressants for psychiatric disorders of hot flushes. Some antidepressants have been found to inhibit the metabolism of tamoxifen to its more active metabolites by the CYP2D6 enzyme, thereby decreasing its anticancer effect. Strong CYP2D6 inhibitors include paroxetine, fluoxetine, bupropion, and duloxetine, while moderate inhibitors include sertraline, escitalopram, and doxepin, and venlafaxine is a weak inhibitor.

      Therefore, it is important for healthcare providers to consider potential drug interactions when prescribing antidepressants to women taking tamoxifen for breast cancer treatment of prevention.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 106 - A male patient with anorexia nervosa would likely have elevated levels of which...

    Incorrect

    • A male patient with anorexia nervosa would likely have elevated levels of which of the following?

      Your Answer:

      Correct Answer: Liver enzymes

      Explanation:

      In individuals with anorexia, the majority of their blood test results are typically below normal levels, with the exception of growth hormone, cholesterol, and cortisol.

      Eating Disorders: Lab Findings and Medical Complications

      Eating disorders can lead to a range of medical complications, including renal failure, peripheral edema, sinus bradycardia, QT-prolongation, pericardial effusion, and slowed GI motility. Other complications include constipation, cathartic colon, esophageal esophagitis, hair loss, and dental erosion. Blood abnormalities are also common in patients with eating disorders, including hyponatremia, hypokalemia, hypophosphatemia, and hypoglycemia. Additionally, patients may experience leucopenia, anemia, low albumin, elevated liver enzymes, and vitamin deficiencies. These complications can cause significant morbidity and mortality in patients with eating disorders. It is important for healthcare providers to monitor patients for these complications and provide appropriate treatment.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 107 - What would be your recommendation for a pregnant woman with bipolar disorder who...

    Incorrect

    • What would be your recommendation for a pregnant woman with bipolar disorder who is currently taking antipsychotic medication and wishes to continue the pregnancy, but may be at risk of relapse without treatment?

      Your Answer:

      Correct Answer: Continue with the current dose of the antipsychotic and monitor regularly

      Explanation:

      According to the NICE Guidelines, if women discontinue treatment during pregnancy, the likelihood of relapse is increased, and therefore, it is recommended to continue with the antipsychotic medication.

      Bipolar Disorder in Women of Childbearing Potential

      Prophylaxis is recommended for women with bipolar disorder, as postpartum relapse rates are high. Women without prophylactic pharmacotherapy during pregnancy have a postpartum relapse rate of 66%, compared to 23% for women with prophylaxis. Antipsychotics are recommended for pregnant women with bipolar disorder, according to NICE Guidelines (CG192) and the Maudsley. Women taking valproate, lithium, carbamazepine, of lamotrigine should discontinue treatment and start an antipsychotic, especially if taking valproate. If a woman with bipolar disorder is taking lithium and becomes pregnant, she should gradually stop lithium over a 4 week period and start an antipsychotic. If this is not possible, lithium levels must be taken regularly, and the dose adjusted accordingly. For acute mania, an antipsychotic should be considered. For mild depressive symptoms, self-help approaches, brief psychological interventions, and antidepressant medication can be considered. For moderate to severe depressive symptoms, psychological treatment (CBT) for moderate depression and combined medication and structured psychological interventions for severe depression should be considered.

      Reference: Wesseloo, R., Kamperman, A. M., Munk-Olsen, T., Pop, V. J., Kushner, S. A., & Bergink, V. (2016). Risk of postpartum relapse in bipolar disorder and postpartum psychosis: a systematic review and meta-analysis. The American Journal of Psychiatry, 173(2), 117-127.

    • This question is part of the following fields:

      • General Adult Psychiatry
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  • Question 108 - What is a true statement about Cognitive Analytic Therapy? ...

    Incorrect

    • What is a true statement about Cognitive Analytic Therapy?

      Your Answer:

      Correct Answer: It was developed to be suitable for research

      Explanation:

      Understanding Cognitive Analytic Therapy

      Cognitive Analytic Therapy (CAT) is a form of therapy that combines psychodynamic and cognitive approaches. It is a brief therapy that typically lasts between 16-24 sessions. Developed by Anthony Ryle, CAT aims to identify the useful parts of psychotherapy and make it more efficient. It also aims to create a therapy that can be easily researched.

      CAT focuses on identifying key issues early on and conceptualizing them as repeated unsuccessful strategies. These strategies are categorized into traps, dilemmas, and snags. Traps are flawed thinking patterns that result in a vicious cycle of negative assumptions and actions. Dilemmas occur when a person believes their choices are restricted to opposite actions, neither of which is satisfactory. Snags are thinking patterns that restrict actions due to a perception of potential harm of failure.

      CAT follows a procedural sequence model, where the problem is appraised, options are discussed, a plan is created and put into place, and consequences are evaluated. The therapist often summarizes the problem and plan in a letter to the client.

      CAT also identifies reciprocal role procedures (RRPs), which are patterns observed in the way we related to others. These patterns are visually presented using a sequential diagrammatic reformulation. For example, a client who rebelled against a stern, dominating father may be dismissive of therapy because they see the therapist as a demanding authority figure.

      Overall, CAT is a useful therapy that combines psychodynamic and cognitive approaches to identify and address maladaptive patterns. Its procedural sequence model and use of RRPs make it an efficient and effective therapy.

    • This question is part of the following fields:

      • Psychotherapy
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  • Question 109 - What is the most frequently observed psychiatric disorder in children with PANDAS? ...

    Incorrect

    • What is the most frequently observed psychiatric disorder in children with PANDAS?

      Your Answer:

      Correct Answer: Obsessive compulsive disorder

      Explanation:

      PANDAS: Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections

      PANDAS is a condition characterized by sudden onset of worsening of obsessive compulsive disorder (OCD) and tic disorders in children between the ages of 3 and puberty. It is associated with group A beta-hemolytic streptococcal infection, which can be confirmed through a positive throat culture of history of scarlet fever. In addition to psychiatric symptoms, PANDAS is also associated with neurological abnormalities such as physical hyperactivity and jerky movements that are not under the child’s control. The presence of these diagnostic features can help identify PANDAS in affected children.

    • This question is part of the following fields:

      • Child And Adolescent Psychiatry
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  • Question 110 - Which vitamin is referred to as thiamine? ...

    Incorrect

    • Which vitamin is referred to as thiamine?

      Your Answer:

      Correct Answer: Vitamin B1

      Explanation:

      Korsakoff’s Syndrome

      Korsakoff’s Syndrome, also known as amnesic syndrome, is a chronic condition that affects recent and anterograde memory in an alert and responsive patient. It is caused by prolonged thiamine (vitamin B1) deficiency and often follows Wernicke’s encephalopathy. The syndrome is characterized by a lack of insight, apathy, and confabulation. Thiamine is essential for glucose metabolism in the brain, and its deficiency leads to a toxic buildup of glucose, causing neuronal loss. The Mammillary bodies are the main areas affected in Korsakoff’s syndrome.

      While intelligence on the WAIS is preserved, episodic memory is severely affected in Korsakoff’s syndrome. Semantic memory is variably affected, but implicit aspects of memory, such as response to priming and procedural memory, are preserved. Immediate memory tested with the digit span is normal, but information can only be retained for a few minutes at most. Patients with Korsakoff’s syndrome often display apathy, lack of initiative, and profound lack of insight.

      Source: Kopelman M (2009) The Korsakoff Syndrome: Clinical Aspects, Psychology and Treatment. Alcohol and Alcoholism 44 (2): 148-154.

    • This question is part of the following fields:

      • Substance Misuse/Addictions