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Question 1
Incorrect
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A senior citizen is referred to the memory clinic by their GP due to mild cognitive impairment. You rule out reversible causes and confirm that they are not prescribed any medications which might contribute to cognitive impairment.
The senior citizen is concerned about progression to Alzheimer's disease.
What would you advise has the best evidence to improve their cognitive performance at this stage?Your Answer: Rivastigmine
Correct Answer: Exercise
Explanation:Mild cognitive impairment (MCI) is a condition where individuals experience cognitive impairment but are still able to perform daily activities with minimal difficulty. However, those with MCI are at a higher risk of developing dementia compared to those without the condition. While there are currently no pharmacological options available, regular exercise has been shown to be the most effective intervention for MCI. It is important to note that some individuals with MCI may remain stable of even return to normal neurological function. These findings were reported in a practice guideline update summary by Peterson in the journal Neurology.
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.
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This question is part of the following fields:
- Old Age Psychiatry
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Question 2
Incorrect
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How can the ICD-11 diagnosis of personality disorder with borderline pattern be identified?
Your Answer: Preoccupation with being criticised of rejected in social situations
Correct Answer: Transient, psychotic-like features
Explanation:It is important to note that the question is asking for the option that is the most suggestive of a diagnosis of personality disorder with borderline pattern in the ICD-11. The correct answer is ‘transient, psychotic-like features’ as this is a qualifying element of the diagnosis. While the other options may also be present in individuals with this condition, they are not defining features.
Personality Disorder (Borderline)
History and Terminology
The term borderline personality disorder originated from early 20th-century theories that the disorder was on the border between neurosis and psychosis. The term borderline was coined by Adolph Stern in 1938. Subsequent attempts to define the condition include Otto Kernberg’s borderline personality organization, which identified key elements such as ego weakness, primitive defense mechanisms, identity diffusion, and unstable reality testing.
Features
The DSM-5 and ICD-11 both define borderline personality disorder as a pervasive pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity. Symptoms include efforts to avoid abandonment, unstable relationships, impulsivity, suicidal behavior, affective instability, chronic feelings of emptiness, difficulty controlling temper, and transient dissociative symptoms.
Abuse
Childhood abuse and neglect are extremely common among borderline patients, with up to 87% having suffered some form of trauma. The effect of abuse seems to depend on the stage of psychological development at which it takes place.
comorbidity
Borderline PD patients are more likely to receive a diagnosis of major depressive disorder, bipolar disorder, panic disorder, PTSD, OCD, eating disorders, and somatoform disorders.
Psychological Therapy
Dialectical Behavioral Therapy (DBT), Mentalization-Based Treatment (MBT), Schema-Focused Therapy (SFT), and Transference-Focused Psychotherapy (TFP) are the main psychological treatments for BPD. DBT is the most well-known and widely available, while MBT focuses on improving mentalization, SFT generates structural changes to a patient’s personality, and TFP examines dysfunctional interpersonal dynamics that emerge in interactions with the therapist in the transference.
NICE Guidelines
The NICE guidelines on BPD offer very little recommendations. They do not recommend medication for treatment of the core symptoms. Regarding psychological therapies, they make reference to DBT and MBT being effective but add that the evidence base is too small to draw firm conclusions. They do specifically say Do not use brief psychotherapeutic interventions (of less than 3 months’ duration) specifically for borderline personality disorder of for the individual symptoms of the disorder.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 3
Correct
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What is the approximate percentage of people in the UK who have dementia?
Your Answer: 1.30%
Explanation: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.
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This question is part of the following fields:
- Old Age Psychiatry
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Question 4
Incorrect
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A study comparing the benefit of two surgical procedures for patients over 65 concludes that the two procedures are equally effective. A researcher is then asked to conduct a cost analysis of the two procedures, considering only the financial expenses.
What is the best way to describe this approach?Your Answer: Cost-utility analysis
Correct Answer: Cost-minimisation analysis
Explanation:Methods of Economic Evaluation
There are four main methods of economic evaluation: cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), cost-utility analysis (CUA), and cost-minimisation analysis (CMA). While all four methods capture costs, they differ in how they assess health effects.
Cost-effectiveness analysis (CEA) compares interventions by relating costs to a single clinical measure of effectiveness, such as symptom reduction of improvement in activities of daily living. The cost-effectiveness ratio is calculated as total cost divided by units of effectiveness. CEA is typically used when CBA cannot be performed due to the inability to monetise benefits.
Cost-benefit analysis (CBA) measures all costs and benefits of an intervention in monetary terms to establish which alternative has the greatest net benefit. CBA requires that all consequences of an intervention, such as life-years saved, treatment side-effects, symptom relief, disability, pain, and discomfort, are allocated a monetary value. CBA is rarely used in mental health service evaluation due to the difficulty in converting benefits from mental health programmes into monetary values.
Cost-utility analysis (CUA) is a special form of CEA in which health benefits/outcomes are measured in broader, more generic ways, enabling comparisons between treatments for different diseases and conditions. Multidimensional health outcomes are measured by a single preference- of utility-based index such as the Quality-Adjusted-Life-Years (QALY). QALYs are a composite measure of gains in life expectancy and health-related quality of life. CUA allows for comparisons across treatments for different conditions.
Cost-minimisation analysis (CMA) is an economic evaluation in which the consequences of competing interventions are the same, and only inputs, i.e. costs, are taken into consideration. The aim is to decide the least costly way of achieving the same outcome.
Costs in Economic Evaluation Studies
There are three main types of costs in economic evaluation studies: direct, indirect, and intangible. Direct costs are associated directly with the healthcare intervention, such as staff time, medical supplies, cost of travel for the patient, childcare costs for the patient, and costs falling on other social sectors such as domestic help from social services. Indirect costs are incurred by the reduced productivity of the patient, such as time off work, reduced work productivity, and time spent caring for the patient by relatives. Intangible costs are difficult to measure, such as pain of suffering on the part of the patient.
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This question is part of the following fields:
- Research Methods, Statistics, Critical Review And Evidence-Based Practice
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Question 5
Correct
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What surgical procedure would be the most suitable for managing OCD that is unresponsive to other treatments?
Your Answer: Anterior capsulotomy
Explanation:Capsulotomy is a procedure that creates lesions on both sides of the anterior limb of the internal capsule and is commonly used to treat OCD and depression. Cingulotomy is another procedure used to treat refractory anxiety, pain, depression, and OCD. SST is primarily used for depression but can also be used for anxiety and OCD. Limbic leucopathy is a combination of SST and cingulotomy and is used to treat depression, anxiety, and OCD. Although amygdalotomy was originally developed to treat aggression, it is now rarely used.
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This question is part of the following fields:
- Organisation And Delivery Of Psychiatric Services
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Question 6
Correct
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What is the recommended antidepressant for an individual with epilepsy who experiences symptoms of depression?
Your Answer: Citalopram
Explanation:SSRIs, such as citalopram, are generally considered safe for individuals with epilepsy. However, when prescribing SSRIs to those with epilepsy, it is preferable to choose options that have a low likelihood of interacting with antiepileptic medications. Typically, citalopram or escitalopram are the preferred options, followed by sertraline.
Psychotropics and Seizure Threshold in People with Epilepsy
People with epilepsy are at an increased risk for various mental health conditions, including depression, anxiety, psychosis, and suicide. It is important to note that the link between epilepsy and mental illness is bidirectional, as patients with mental health conditions also have an increased risk of developing new-onset epilepsy. Psychotropic drugs are often necessary for people with epilepsy, but they can reduce the seizure threshold and increase the risk of seizures. The following tables provide guidance on the seizure risk associated with different classes of antidepressants, antipsychotics, and ADHD medications. It is important to use caution and carefully consider the risks and benefits of these medications when treating people with epilepsy.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 7
Correct
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You are asked to write a court report for a man convicted of a sexual assault, which of the following is most likely to increase his risk of subsequent sexual offending?:
Your Answer: Phallometric evidence of sexual interest in children
Explanation:Hanson & Bussiere (1998) conducted a thorough analysis on this topic and found that the most significant indicators of sexual offense recidivism are factors associated with sexual deviance, including deviant sexual preferences, previous sexual offenses, early onset of sexual offending, and the variety of sexual crimes committed. The most powerful predictor was determined to be sexual attraction to children, as measured by phallometric assessment.
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.
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This question is part of the following fields:
- Forensic Psychiatry
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Question 8
Correct
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What is the recommended initial treatment for a child with mild learning difficulties who has obsessive-compulsive disorder?
Your Answer: Cognitive behavioural therapy
Explanation:The treatment recommendations for OCD are similar for both adults and young people, regardless of whether they have a learning difficulty of not. The first line of treatment is psychological therapy, such as self-help of CBT with ERP. If this is not effective, an SSRI can be used. It is important to note that having a learning difficulty should not prevent someone from accessing psychological therapy. While severe disabilities may limit access, tailored forms of CBT can still be effective for those with less severe forms of learning difficulties.
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.
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This question is part of the following fields:
- Child And Adolescent Psychiatry
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Question 9
Incorrect
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What is the term used to describe the percentage of a population's disease that would be eradicated if their disease rate was lowered to that of the unexposed group?
Your Answer: Population attributable risk
Correct Answer: Attributable proportion
Explanation:Disease Rates and Their Interpretation
Disease rates are a measure of the occurrence of a disease in a population. They are used to establish causation, monitor interventions, and measure the impact of exposure on disease rates. The attributable risk is the difference in the rate of disease between the exposed and unexposed groups. It tells us what proportion of deaths in the exposed group were due to the exposure. The relative risk is the risk of an event relative to exposure. It is calculated by dividing the rate of disease in the exposed group by the rate of disease in the unexposed group. A relative risk of 1 means there is no difference between the two groups. A relative risk of <1 means that the event is less likely to occur in the exposed group, while a relative risk of >1 means that the event is more likely to occur in the exposed group. The population attributable risk is the reduction in incidence that would be observed if the population were entirely unexposed. It can be calculated by multiplying the attributable risk by the prevalence of exposure in the population. The attributable proportion is the proportion of the disease that would be eliminated in a population if its disease rate were reduced to that of the unexposed group.
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This question is part of the following fields:
- Research Methods, Statistics, Critical Review And Evidence-Based Practice
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Question 10
Incorrect
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Which of the following characteristics is not associated with antisocial personality disorder?
Your Answer:
Correct Answer: Rapidly shifting and shallow set of emotions
Explanation:Histrionic personality disorder is characterized by quick changes in emotions.
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.
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This question is part of the following fields:
- Forensic Psychiatry
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Question 11
Incorrect
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What is the likelihood of spina bifida occurring in a fetus if a pregnant woman is prescribed Epilim?
Your Answer:
Correct Answer: 1 in 100
Explanation:Valproate Use During Pregnancy Can Cause Birth Defects and Developmental Problems in Children
Valproate is a medication that is commonly used to treat epilepsy and bipolar disorder. However, when taken by pregnant women, it can cause serious birth defects in their babies. Studies have shown that around 1 in 10 babies born to women who took valproate during pregnancy will have a birth defect. These defects can include malformations of the spine, face, skull, limbs, heart, kidney, urinary tract, and sexual organs.
In addition to birth defects, children exposed to valproate in the womb may also experience developmental problems. About 3-4 children in every 10 may have issues with learning to walk and talk, lower intelligence than their peers, poor speech and language skills, and memory problems. There is also evidence to suggest that these children may be at a higher risk of developing autism or autistic spectrum disorders, as well as symptoms of attention deficit hyperactivity disorder (ADHD).
It is important for women who are pregnant of planning to become pregnant to discuss the risks and benefits of taking valproate with their healthcare provider. Alternative medications of treatment options may be available that are safer for both the mother and the developing baby.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 12
Incorrect
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A child is scheduled to undergo ECT. The nurse presents you with their medication list. Which medication should be stopped before ECT?
Your Answer:
Correct Answer: Diazepam
Explanation:ECT and Seizure Duration: Effect of Psychotropics
On the whole, most drugs do not interfere with ECT. However, it is important to note the effect of psychotropics on seizure duration. The table below summarizes the effect of important psychotropics and their advice:
Psychotropic class: Benzodiazepine
Effect on seizure duration: Reduced
Advice: Avoid where possiblePsychotropic class: SSRIs
Effect on seizure duration: Minimal effectPsychotropic class: Venlafaxine
Effect on seizure duration: Minimal effectPsychotropic class: TCAs
Effect on seizure duration: Possibly increased
Advice: TCAs are associated with arrhythmia following ECT in the elderly and those with cardiac disease, so they should be avoided in ECT in these groups.Psychotropic class: MAOIs
Effect on seizure duration: Minimal effectPsychotropic class: Lithium
Effect on seizure duration: Possibly increased
Advice: Generally used in ECT without significant problems.Psychotropic class: Antipsychotics
Effect on seizure duration: Some potential increase in clozapine and phenothiazines, other antipsychotics considered ok
Advice: Limited data.Psychotropic class: Anticonvulsants
Effect on seizure duration: Reduced
Advice: If used as a mood stabilizer, continue but be prepared to use higher energy stimulus.(Source: Maudsley Guidelines 10th Edition, p.187)
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This question is part of the following fields:
- Organisation And Delivery Of Psychiatric Services
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Question 13
Incorrect
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In the management of acute mania in adult patients, NICE recommends which of the following?
Your Answer:
Correct Answer: Risperidone
Explanation:Bipolar Disorder: Diagnosis and Management
Bipolar disorder is a lifelong condition characterized by episodes of mania or hypomania and episodes of depressed mood. The peak age of onset is 15-19 years, and the lifetime prevalence of bipolar I disorders is estimated to be around 2.1%. The diagnosis of bipolar disorder is based on the presence of manic or hypomanic episodes, which are characterized by elevated of expansive mood, rapid speech, and increased activity of energy. Psychotic symptoms, such as delusions and hallucinations, may also be present.
Bipolar depression differs from unipolar depression in several ways, including more rapid onset, more frequent episodes, and shorter duration. Rapid cycling is a qualifier that can be applied to bipolar I of bipolar II disorder and 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.
The management of bipolar disorder involves acute and long-term interventions. Acute management of mania or hypomania may involve stopping antidepressants and offering antipsychotics of mood stabilizers. Long-term management may involve psychological interventions and pharmacological treatments such as lithium, valproate, of olanzapine.
It is important to note that valproate should not be offered to women of girls of childbearing potential for long-term bipolar disorder unless other options are ineffective of not tolerated and a pregnancy prevention program is in place. Aripiprazole is recommended as an option for treating moderate to severe manic episodes in adolescents with bipolar I disorder.
Overall, the diagnosis and management of bipolar disorder require a comprehensive approach that takes into account the individual’s symptoms, history, and preferences.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 14
Incorrect
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Which of the following is not considered a known factor that increases the risk of suicide in older adults?
Your Answer:
Correct Answer: Alzheimer's disorder
Explanation:Epidemiology of Mental Disorders Among the Elderly
Depression:
Contrary to popular belief, studies have shown that rates of depression among the elderly in the general population are lower than in younger adults. However, elderly individuals who seek medical attention have a higher prevalence of depressive symptoms, with one study in London reporting a point prevalence of around 30%. Suicide risk factors in the elderly include a history of attempts, depressive disorder, access to lethal means, physical illness of disability, chronic pain, recent losses, and social isolation. Physician education in recognizing and treating depression and restricting access to lethal means have been found to reduce suicide rates.Personality Disorder:
There is limited information on the prevalence of personality disorders in the general population, but rates tend to decrease with age.Psychosis:
Very late-onset schizophrenia, with onset after the age of 60, has a 1-year prevalence of 0.1 to 0.5%. It is more common in women and has been associated with sensory impairment. Genetic factors appear to be less important than in earlier onset schizophrenia.Alcohol Misuse:
Studies have shown that men have higher rates of alcohol misuse than women in the elderly population. However, precise figures and prevalence rates are unreliable, and standard assessment tools may not be valid in this group.Dementia:
Dementia incidence is similar across all continents and regions of the world, with Alzheimer’s accounting for 60-70% and vascular dementia accounting for 15-20% of all dementia cases. Age is the strongest risk factor for dementia, with approximately 48% of people aged 95 and over having dementia. -
This question is part of the following fields:
- Old Age Psychiatry
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Question 15
Incorrect
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A 61 year old male recently started on a new treatment has suddenly started texting his wife rude text messages and binge eating. Which of the following treatment would you suspect he has been started on?:
Your Answer:
Correct Answer: Ropinirole
Explanation:Dopamine Agonists
Dopamine receptor agonists are medications that directly affect dopamine receptors and are commonly used to treat Parkinson’s disease. Examples of these drugs include apomorphine and ropinirole. However, these medications are known to have psychiatric side effects, particularly impulse control disorders such as pathological gambling, binge eating, and hypersexuality. This information is according to the British National Formulary (BNF) from March 2012.
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This question is part of the following fields:
- Old Age Psychiatry
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Question 16
Incorrect
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What is the best course of treatment for a 3-year-old child who has no physical issues but continues to experience bedwetting at night despite normal development?
Your Answer:
Correct Answer: Reassurance
Explanation:Reassurance is the most appropriate treatment option for this child as they are not yet old enough to be diagnosed with non-organic enuresis.
Elimination Disorders
Elimination disorders refer to conditions that affect a child’s ability to control their bladder of bowel movements. Enuresis, of lack of control over the bladder, typically occurs between the ages of 1-3, while control over the bowel usually occurs before that of the bladder for most toddlers. Toilet training can be influenced by various factors, including intellectual capacity, cultural determinants, and psychological interactions between the child and their parents.
Enuresis is characterized by involuntary voiding of urine, by day and/of by night, which is abnormal in relation to the individual’s age and is not a result of any physical abnormality. It is not normally diagnosed before age 5 and may be primary (the child never having achieved continence) of secondary. Treatment options include reassurance, enuresis alarms, and medication.
Encopresis refers to repeated stool evacuation in inappropriate places in children over the age of four. The behavior can be either involuntary of intentional and may be due to unsuccessful toilet training (primary encopresis) of occur after a period of normal bowel control (secondary encopresis). Treatment generally involves bowel clearance, prevention of impaction, and behavioral therapy.
Before a diagnosis of encopresis is made, organic causes must be excluded. Hirschsprung’s disease is a condition that results from an absence of parasympathetic ganglion cells in the rectum, colon, and sometimes the small intestine. It leads to a colonic obstruction and is diagnosed in at least half of all cases in the first year of life. It is twice as common in boys than in girls.
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This question is part of the following fields:
- Child And Adolescent Psychiatry
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Question 17
Incorrect
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A 60-year-old woman is brought to the Emergency department after being found collapsed at home. She is a retired teacher. She has been on oral anticoagulants for some weeks after suffering a pulmonary embolism.
On assessment, you find her to be febrile, tachycardic and in need of supplemental oxygen. Her pupils are highly constricted.
What is the most appropriate next step in managing this patient?Your Answer:
Correct Answer: Refer for an urgent CT scan of brain and management in intensive care
Explanation:If a patient presents with pinpoint pupils, it may indicate an opioid overdose. However, if hyperthermia and tachycardia are also present, a pontine hemorrhage is a more probable cause. In such cases, intensive care management with input from neurology/neurosurgery is necessary. It is important to note that the use of injectable low molecular weight heparin (commonly used for treating deep vein thrombosis) and a high-stress job could increase the risk of an intracranial bleed.
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This question is part of the following fields:
- Substance Misuse/Addictions
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Question 18
Incorrect
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What is the highest approved dosage of olanzapine?
Your Answer:
Correct Answer: 20 mg/day
Explanation:Antipsychotics (Maximum Doses)
It is important to be aware of the maximum doses for commonly used antipsychotics. The following are the maximum doses for various antipsychotics:
– Clozapine (oral): 900 mg/day
– Haloperidol (oral): 20 mg/day
– Olanzapine (oral): 20 mg/day
– Quetiapine (oral): 750mg/day (for schizophrenia) and 800 mg/day (for bipolar disorder)
– Risperidone (oral): 16 mg/day
– Amisulpride (oral): 1200 mg/day
– Aripiprazole (oral): 30 mg/day
– Flupentixol (depot): 400 mg/week
– Zuclopenthixol (depot): 600 mg/week
– Haloperidol (depot): 300 mg every 4 weeksIt is important to keep these maximum doses in mind when prescribing antipsychotics to patients.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 19
Incorrect
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What is another name for a DaTscan?
Your Answer:
Correct Answer: FP-CIT SPECT
Explanation:The purpose of a DaTscan is to aid in the identification of dementia with Lewy bodies in individuals who are suspected to have it.
Dementia is a condition that can be diagnosed and supported with the use of neuroimaging techniques. In Alzheimer’s disease, MRI and CT scans are used to assess volume changes in specific areas of the brain, such as the mesial temporal lobe and temporoparietal cortex. SPECT and PET scans can also show functional changes, such as hypoperfusion and glucose hypometabolism. Vascular dementia can be detected with CT and MRI scans that show atrophy, infarcts, and white matter lesions, while SPECT scans reveal a patchy multifocal pattern of hypoperfusion. Lewy body dementia tends to show nonspecific and subtle changes on structural imaging, but SPECT and PET scans can reveal posterior deficits and reduced D2 receptor density. Frontotemporal dementia is characterized by frontal lobe atrophy, which can be seen on CT and MRI scans, while SPECT scans show anterior perfusion deficits. NICE recommends the use of MRI for early diagnosis and detection of subcortical vascular changes, SPECT for differentiating between Alzheimer’s disease, vascular dementia, and frontotemporal dementia, and DaTscan for establishing a diagnosis of dementia with Lewy bodies.
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This question is part of the following fields:
- Old Age Psychiatry
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Question 20
Incorrect
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A woman initially seen by the nurse practitioner presented with low mood, and insomnia, and was commenced on reboxetine 4 mg BD without any benefit. You assess and confirmed she actually suffers from obsessive compulsive disorder, what will be the appropriate treatment?
Your Answer:
Correct Answer: Citalopram
Explanation:The recommended first-line medication for treating OCD in adults is an SSRI.
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 21
Incorrect
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A 30-year old woman is brought to the outpatient clinic by her sister who is concerned about her. She reports concern that she has no friends and that even her contact with her family is minimal and superficial. She reports that she has been this way all her life. She is concerned that this is now affecting her ability to work and leave home.
The woman engages to a limited extent with the interview. She explains that she does not enjoy social contact and avoids socialising where possible, this also includes avoiding the workplace in view of the social demands. She is avoidant of eye contact but is able to maintain reasonable reciprocal conversation. There is no evidence of restrictive of repetitive behaviours.
You note on interview that she appears aloof and lacking in any emotional expression.
Which ICD-11 condition is most likely to be present according to this history and assessment?Your Answer:
Correct Answer: Personality disorder with detachment
Explanation:It should be noted that there is no indication of impaired reciprocal interaction of restrictive/repetitive behaviors, which would not support a diagnosis of autism spectrum disorder. Additionally, Asperger’s and infantile autism are no longer recognized as diagnoses in the ICD-11. Based on the presented case, it appears that the individual may have a personality disorder with detachment, which requires evidence of long standing interpersonal dysfunction and social/emotional distance. It is important to note that while this may share similarities with avoidant personality disorder in the DSM-5, it is not the same diagnosis.
Personality Disorder: Avoidant
Avoidant Personality Disorder (AVPD) is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. According to the DSM-5, individuals with AVPD exhibit at least four of the following symptoms: avoidance of occupational activities that involve interpersonal contact, unwillingness to be involved unless certain of being liked, restraint in intimate relationships due to fear of ridicule, preoccupation with being criticized of rejected in social situations, inhibition in new interpersonal situations due to feelings of inadequacy, viewing oneself as inept and inferior to others, and reluctance to take personal risks of engage in new activities due to potential embarrassment.
In contrast, the ICD-11 does not have a specific category for AVPD but instead uses the qualifier of detachment trait. The Detachment trait domain is characterized by a tendency to maintain interpersonal and emotional distance. Common manifestations of Detachment include social detachment (avoidance of social interactions, lack of friendships, and avoidance of intimacy) and emotional detachment (reserve, aloofness, and limited emotional expression and experience). It is important to note that not all individuals with Detachment will exhibit all of these symptoms at all times.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 22
Incorrect
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Typically, how much time elapses before delirium tremens (DTs) occur after a person stops drinking completely?
Your Answer:
Correct Answer: 3-5 days
Explanation:The onset of DTs typically happens between three to five days after stopping drinking. However, tremulousness of withdrawal convulsions (also known as rum fits) can occur during a drinking binge of shortly after stopping drinking. Alcoholic hallucinosis, on the other hand, can develop over a period of days of weeks and is characterized by auditory hallucinations. Unlike DTs, it is typically accompanied by less severe agitation and mental confusion.
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This question is part of the following fields:
- Substance Misuse/Addictions
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Question 23
Incorrect
-
What is a true statement about dementia caused by Parkinson's disease?
Your Answer:
Correct Answer: Cognitive deficits such as alexia, dyspraxia, and anomia are less pronounced in dementia due to Parkinson's
Explanation:Dementia with Parkinson’s Disease: Understanding Cognitive Symptoms
Dementia with Parkinson’s disease is a syndrome that involves a decline in memory and other cognitive domains, leading to social and occupational dysfunction. Along with motor problems, non-motor symptoms such as cognitive, behavioral, and psychological issues can also arise. There is debate over whether Lewy body dementia and dementia due to Parkinson’s are different conditions. Drugs used to treat Parkinson’s can interfere with cognitive function, and people with this type of dementia tend to have marked problems with executive function. Cholinesterase inhibitors can improve cognitive performance, but they are not well tolerated and can cause side effects. Understanding the cognitive symptoms of dementia with Parkinson’s disease is crucial for effective clinical management.
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This question is part of the following fields:
- Old Age Psychiatry
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Question 24
Incorrect
-
Which statement accurately describes the clinical symptoms of Wernicke's?
Your Answer:
Correct Answer: Ophthalmoplegia is an expected feature
Explanation:Wernicke’s Encephalopathy: Symptoms, Causes, and Treatment
Wernicke’s encephalopathy is a serious condition that is characterized by confusion, ophthalmoplegia, and ataxia. However, the complete triad is only present in 10% of cases, which often leads to underdiagnosis. The condition results from prolonged thiamine deficiency, which is commonly seen in people with alcohol dependency, but can also occur in other conditions such as anorexia nervosa, malignancy, and AIDS.
The onset of Wernicke’s encephalopathy is usually abrupt, but it may develop over several days to weeks. The lesions occur in a symmetrical distribution in structures surrounding the third ventricle, aqueduct, and fourth ventricle. The mammillary bodies are involved in up to 80% of cases, and atrophy of these structures is specific for Wernicke’s encephalopathy.
Treatment involves intravenous thiamine, as oral forms of B1 are poorly absorbed. IV glucose should be avoided when thiamine deficiency is suspected as it can precipitate of exacerbate Wernicke’s. With treatment, ophthalmoplegia and confusion usually resolve within days, but the ataxia, neuropathy, and nystagmus may be prolonged of permanent.
Untreated cases of Wernicke’s encephalopathy can lead to Korsakoff’s syndrome, which is characterized by memory impairment associated with confabulation. The mortality rate associated with Wernicke’s encephalopathy is 10-20%, making early diagnosis and treatment crucial.
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This question is part of the following fields:
- Substance Misuse/Addictions
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Question 25
Incorrect
-
What is the correct approach to treating insomnia?
Your Answer:
Correct Answer: Dependence is more likely to develop when the patient has a history of anxiety problems
Explanation: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.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 26
Incorrect
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What is the most effective way to distinguish between dementia and delirium?
Your Answer:
Correct Answer: Fluctuating consciousness
Explanation:The primary distinction between delirium and dementia is the variability of consciousness levels.
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.
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This question is part of the following fields:
- Old Age Psychiatry
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Question 27
Incorrect
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A teenage boy begins smoking cannabis regularly at the age of 16. How much does this increase his likelihood of developing schizophrenia by his early twenties compared to an individual who has never used cannabis?
Your Answer:
Correct Answer: 4 fold
Explanation:Individuals who smoked cannabis regularly at the age of 15 have a 4.5 times higher risk of developing schizophrenia at the age of 26, whereas those who did not report regular use until the age of 18 have a 1.65 times higher risk.
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.
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This question is part of the following fields:
- Substance Misuse/Addictions
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Question 28
Incorrect
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What factors affect the statistical power of a study?
Your Answer:
Correct Answer: Sample size
Explanation:A study that has a greater sample size is considered to have higher power, meaning it is capable of detecting a significant difference of effect that is clinically relevant.
The Importance of Power in Statistical Analysis
Power is a crucial concept in statistical analysis as it helps researchers determine the number of participants needed in a study to detect a clinically significant difference of effect. It represents the probability of correctly rejecting the null hypothesis when it is false, which means avoiding a Type II error. Power values range from 0 to 1, with 0 indicating 0% and 1 indicating 100%. A power of 0.80 is generally considered the minimum acceptable level.
Several factors influence the power of a study, including sample size, effect size, and significance level. Larger sample sizes lead to more precise parameter estimations and increase the study’s ability to detect a significant effect. Effect size, which is determined at the beginning of a study, refers to the size of the difference between two means that leads to rejecting the null hypothesis. Finally, the significance level, also known as the alpha level, represents the probability of a Type I error. By considering these factors, researchers can optimize the power of their studies and increase the likelihood of detecting meaningful effects.
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This question is part of the following fields:
- Research Methods, Statistics, Critical Review And Evidence-Based Practice
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Question 29
Incorrect
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What is a true statement about fitness to plead?
Your Answer:
Correct Answer: If a person is found unfit to plead, there is usually a trial of the facts.
Explanation:When a person is deemed unfit to plead, typically a trial of the facts follows. Unfitness to plead is determined at the time of trial, rather than at the time of the offense, and can be caused by physical illness.
Fitness to Plead: Criteria and Process
Fitness to plead is determined by specific criteria established by the Pritchard case law in 1836. The criteria include the ability to instruct solicitor and counsel, understand the charges, decide whether to plead guilty of not, follow court proceedings, challenge a juror, and give evidence in one’s defense. Schizophrenia and other enduring mental illnesses are the most common conditions associated with unfitness to plead, particularly when positive psychotic symptomatology is present. Intellectual impairment is not a significant factor in most cases. If the issue is raised by the defense, it must be established on a balance of probability, while if raised by the prosecution of judge, it must be proved beyond reasonable doubt. Amnesia does not render someone unfit to plead. The decision on fitness to plead is made by a judge, not a jury. If someone is found unfit to plead, they are subject to the Criminal Procedures Act 1991, which involves a trial of facts, complete acquittal if the facts are not found, and flexible disposal by the judge if the facts are found, except for murder, which requires mandatory committal to hospital.
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This question is part of the following fields:
- Forensic Psychiatry
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Question 30
Incorrect
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What type of regression is appropriate for analyzing data with dichotomous variables?
Your Answer:
Correct Answer: Logistic
Explanation:Logistic regression is employed when dealing with dichotomous variables, which are variables that have only two possible values, such as live/dead of head/tail.
Stats: Correlation and Regression
Correlation and regression are related but not interchangeable terms. Correlation is used to test for association between variables, while regression is used to predict values of dependent variables from independent variables. Correlation can be linear, non-linear, of non-existent, and can be strong, moderate, of weak. The strength of a linear relationship is measured by the correlation coefficient, which can be positive of negative and ranges from very weak to very strong. However, the interpretation of a correlation coefficient depends on the context and purposes. Correlation can suggest association but cannot prove of disprove causation. Linear regression, on the other hand, can be used to predict how much one variable changes when a second variable is changed. Scatter graphs are used in correlation and regression analyses to visually determine if variables are associated and to detect outliers. When constructing a scatter graph, the dependent variable is typically placed on the vertical axis and the independent variable on the horizontal axis.
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This question is part of the following fields:
- Research Methods, Statistics, Critical Review And Evidence-Based Practice
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Question 31
Incorrect
-
A 25-year-old female with a diagnosis of bipolar disorder is admitted to your unit. She is convinced that her roommates are plotting against her and becomes verbally aggressive towards them. The nursing staff is concerned that this may escalate to physical aggression and calls for your advice on how to manage the situation.
Which of the following statements is true regarding the management of this situation?Your Answer:
Correct Answer: Physical restraint of an individual in the prone position carries risks
Explanation:When dealing with situations involving aggression, it is important to prioritize non-coercive management techniques such as de-escalation of time out, which require the patient’s agreement. Physical restraint may be necessary in cases of immediate danger, but should be used for the shortest possible time to avoid potential harm. Seclusion should only be considered as a last resort due to the significant loss of freedom it entails. Rapid tranquillisation is intended to address acute situations rather than the underlying illness, which may require a longer-term approach.
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This question is part of the following fields:
- Forensic Psychiatry
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Question 32
Incorrect
-
What is the likelihood of a significant birth defect occurring in a confirmed pregnancy without any known cause of external factors?
Your Answer:
Correct Answer: 2-4%
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.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 33
Incorrect
-
Which of the following pairs of instincts proposed by Freud are correct?
Your Answer:
Correct Answer: Thanatos and eros
Explanation:Aggression – Freud
According to Freud, aggression is a result of the primary instinct called thanatos, also known as the death instinct. He believed that every individual possesses this drive, which aims to cause complete destruction and death. Additionally, Freud proposed the existence of an opposing instinct called eros, which is the life instinct. He also introduced the concept of catharsis, which is a process of releasing libidinal energy and inducing a sense of calmness. This process occurs when we witness an aggressive act of engage in a mildly aggressive act.
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This question is part of the following fields:
- Psychotherapy
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Question 34
Incorrect
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Among the listed drugs, which one poses the highest risk of causing myocarditis?
Your Answer:
Correct Answer: Clozapine
Explanation: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
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This question is part of the following fields:
- General Adult Psychiatry
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Question 35
Incorrect
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A teenager presents to A&E in a state of distress and you are told by his friend that he is withdrawing from 'speed'. Which of the following is least likely to be present?
Your Answer:
Correct Answer: Reduced appetite
Explanation:Withdrawal from amphetamine, commonly referred to as speed, usually leads to an increase in appetite rather than a decrease.
Illicit drugs, also known as illegal drugs, are substances that are prohibited by law and can have harmful effects on the body and mind. Some of the most commonly used illicit drugs in the UK include opioids, amphetamines, cocaine, MDMA (ecstasy), cannabis, and hallucinogens.
Opioids, such as heroin, are highly addictive and can cause euphoria, drowsiness, constipation, and respiratory depression. Withdrawal symptoms may include piloerection, insomnia, restlessness, dilated pupils, yawning, sweating, and abdominal cramps.
Amphetamines and cocaine are stimulants that can increase energy, cause insomnia, hyperactivity, euphoria, and paranoia. Withdrawal symptoms may include hypersomnia, hyperphagia, depression, irritability, agitation, vivid dreams, and increased appetite.
MDMA, also known as ecstasy, can cause increased energy, sweating, jaw clenching, euphoria, enhanced sociability, and increased response to touch. Withdrawal symptoms may include depression, insomnia, depersonalisation, and derealisation.
Cannabis, also known as marijuana of weed, can cause relaxation, intensified sensory experience, paranoia, anxiety, and injected conjunctiva. Withdrawal symptoms may include insomnia, reduced appetite, and irritability.
Hallucinogens, such as LSD, can cause perceptual changes, pupillary dilation, tachycardia, sweating, palpitations, tremors, and incoordination. There is no recognised withdrawal syndrome for hallucinogens.
Ketamine, also known as Vitamin K, Super K, Special K, of donkey dust, can cause euphoria, dissociation, ataxia, and hallucinations. There is no recognised withdrawal syndrome for ketamine.
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This question is part of the following fields:
- Substance Misuse/Addictions
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Question 36
Incorrect
-
What traits of conditions can be passed down through autosomal dominant inheritance?
Your Answer:
Correct Answer: Velocardiofacial syndrome
Explanation:Inheritance Patterns and Examples
Autosomal Dominant:
Neurofibromatosis type 1 and 2, tuberous sclerosis, achondroplasia, Huntington disease, and Noonan’s syndrome are all examples of conditions that follow an autosomal dominant inheritance pattern. This means that only one copy of the mutated gene is needed to cause the condition.Autosomal Recessive:
Phenylketonuria, homocystinuria, Hurler’s syndrome, galactosaemia, Tay-Sach’s disease, Friedreich’s ataxia, Wilson’s disease, and cystic fibrosis are all examples of conditions that follow an autosomal recessive inheritance pattern. This means that two copies of the mutated gene are needed to cause the condition.X-Linked Dominant:
Vitamin D resistant rickets and Rett syndrome are examples of conditions that follow an X-linked dominant inheritance pattern. This means that the mutated gene is located on the X chromosome and only one copy of the gene is needed to cause the condition.X-Linked Recessive:
Cerebellar ataxia, Hunter’s syndrome, and Lesch-Nyhan are examples of conditions that follow an X-linked recessive inheritance pattern. This means that the mutated gene is located on the X chromosome and two copies of the gene are needed to cause the condition.Mitochondrial:
Leber’s hereditary optic neuropathy and Kearns-Sayre syndrome are examples of conditions that follow a mitochondrial inheritance pattern. This means that the mutated gene is located in the mitochondria and is passed down from the mother to her offspring. -
This question is part of the following fields:
- Child And Adolescent Psychiatry
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Question 37
Incorrect
-
What is the recommended duration of SSRI treatment for preventing relapse in adults with body dysmorphic disorder, according to the NICE guidelines?
Your Answer:
Correct Answer: 12 months
Explanation: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 38
Incorrect
-
Who is recognized for creating an improved version of CBT specifically designed for treating eating disorders?
Your Answer:
Correct Answer: Fairburn
Explanation:Although CBT is effective in treating bulimia nervosa, it is not always successful in achieving full and lasting recovery for all patients. To address this, an enhanced form of CBT was developed by Fairburn. This treatment uses a range of strategies and procedures to improve treatment adherence and outcomes, and to identify and address obstacles to change. It has also been adapted to be suitable for all forms of eating disorders, not just bulimia, based on the transdiagnostic theory of the maintenance of eating disorders.
The enhanced CBT treatment comes in two forms: a focused form that concentrates solely on eating disorder psychopathology, and a broad form that also addresses external barriers to change, such as clinical perfectionism, core low self-esteem, and interpersonal difficulties. Eating disorders are often complex, with patients experiencing other problems such as mood disorders, substance misuse, personality disorders, and physical complications. Enhanced CBT is designed to manage these issues while providing treatment.
Eating Disorders: NICE Guidelines
Anorexia:
For adults with anorexia nervosa, consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), of specialist supportive clinical management (SSCM). If these are not acceptable, contraindicated, of ineffective, consider eating-disorder-focused focal psychodynamic therapy (FPT). For children and young people, consider anorexia-nervosa-focused family therapy (FT-AN) of individual CBT-ED. Do not offer medication as the sole treatment.Bulimia:
For adults, the first step is an evidence-based self-help programme. If this is not effective, consider individual CBT-ED. For children and young people, offer bulimia-nervosa-focused family therapy (FT-BN) of individual CBT-ED. Do not offer medication as the sole treatment.Binge Eating Disorder:
The first step is a guided self-help programme. If this is not effective, offer group of individual CBT-ED. For children and young people, offer the same treatments recommended for adults. Do not offer medication as the sole treatment.Advice for those with eating disorders:
Encourage people with an eating disorder who are vomiting to avoid brushing teeth immediately after vomiting, rinse with non-acid mouthwash, and avoid highly acidic foods and drinks. Advise against misusing laxatives of diuretics and excessive exercise.Additional points:
Do not offer physical therapy as part of treatment. Consider bone mineral density scans after 1 year of underweight in children and young people, of 2 years in adults. Do not routinely offer oral of transdermal oestrogen therapy to treat low bone mineral density in children of young people with anorexia nervosa. Consider transdermal 17-β-estradiol of bisphosphonates for women with anorexia nervosa.Note: These guidelines are taken from NICE guidelines 2017.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 39
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.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 40
Incorrect
-
What is the condition that typically develops during childhood and is marked by sudden, involuntary, repetitive movements of vocalizations that have no clear purpose?
Your Answer:
Correct Answer: Tourette's syndrome
Explanation:Ekbom syndrome refers to two distinct syndromes. The first is known as delusional parasitosis, which is characterized by the false belief that the skin is infested with parasites. The second, also known as Willis-Ekbom syndrome, is restless legs syndrome, which causes uncomfortable sensations in the limbs that disrupt sleep. While European physicians tend to use the term to refer to delusional parasitosis, Americans typically use it to describe restless legs syndrome.
Lesch-Nyhan syndrome is a genetic disorder that results in congenital mental retardation. It is caused by mutations in the HPRT gene on the X chromosome, which leads to defective purine metabolism and severe self-injury. The HPRT gene codes for an enzyme called hypoxanthine phosphoribosyltransferase 1, which is responsible for recycling purines. When this enzyme is absent, purines are broken down but not recycled, resulting in abnormally high levels of uric acid.
Rett syndrome is a developmental disorder that primarily affects girls and is caused by an X-linked dominant mutation. It is characterized by acquired microcephaly, a reversal of cognitive and social development, ataxia, and stereotypic hand movements and manual dyspraxia known as hand-wringing.
Tourette’s Syndrome: Understanding the Disorder and Management Options
Tourette’s syndrome is a type of tic disorder characterized by multiple motor tics and one of more vocal tics. Tics are sudden, involuntary movements of vocalizations that serve no apparent purpose and can be suppressed for varying periods of time. Unlike stereotyped repetitive movements seen in other disorders, tics lack rhythmicity. Manneristic motor activities tend to be more complex and variable than tics, while obsessive-compulsive acts have a defined purpose.
Tourette’s syndrome typically manifests in childhood, with a mean age of onset of six to seven years. Tics tend to peak in severity between nine and 11 years of age and may be exacerbated by external factors such as stress, inactivity, and fatigue. The estimated prevalence of Tourette’s syndrome is 1% of children, and it is more common in boys than girls. A family history of tics is also common.
Management of Tourette’s syndrome may involve pharmacological options of behavioral programs. Clonidine is recommended as first-line medication, with antipsychotics as a second-line option due to their side effect profile. Selective serotonin reuptake inhibitors (SSRIs) have not been found to be effective in suppressing tics. However, most people with tics never require medication, and behavioral programs appear to work equally as well.
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This question is part of the following fields:
- Child And Adolescent Psychiatry
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Question 41
Incorrect
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What is the required frequency and duration of bedwetting behavior to meet the diagnostic threshold for enuresis?
Your Answer:
Correct 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.
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This question is part of the following fields:
- Psychotherapy
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Question 42
Incorrect
-
Which substance is most similar to Mephedrone among the given options?
Your Answer:
Correct Answer: Ecstasy
Explanation:New Psychoactive Substances, previously known as ‘legal highs’, are synthetic compounds designed to mimic the effects of traditional illicit drugs. They became popular due to their ability to avoid legislative control, but the introduction of the Psychoactive Substances Act 2016 changed this. There is no standard for clinical classification, but some common legal highs include Mephedrone, Piperazines, GBL, Synthetic cannabinoids, and Benzofuran compounds. These substances have effects similar to ecstasy, amphetamines, and cannabis, and are classified as either Class B of Class C drugs in the UK.
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This question is part of the following fields:
- Substance Misuse/Addictions
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Question 43
Incorrect
-
What is the classification system that exclusively identifies the causes of paternal filicide?
Your Answer:
Correct Answer: Scott
Explanation:Hopwood (1927) and Meyer and Oberman (2001) focused on maternal filicide, while Resnick (1969) examined filicide committed by both genders and identified five motives. Guileyardo (1999) expanded on Resnick’s work to include a wider range of motives. Scott (1973) created the initial classification of filicide based on a sample of fathers exclusively.
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This question is part of the following fields:
- Forensic Psychiatry
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Question 44
Incorrect
-
A man who has recently turned 60 and is still taking medication for hypertension develops mania. He fails to respond to olanzapine. Considering the fact that he is taking medication for hypertension, which of the following is the most appropriate next step?
Your Answer:
Correct Answer: Quetiapine
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.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 45
Incorrect
-
A woman who has had bipolar affective disorder for the past 3 years presents with an episode of mania. She is admitted to hospital to the ward on which you are the resident doctor. She has been taking aripiprazole 20 mg for the past three years and has been compliant. What would be your recommendation in this case?
Your Answer:
Correct Answer: Increase the dose of aripiprazole
Explanation:Before implementing any management plan, it is crucial to verify adherence and confirm that the dosage is suitable. In cases of mania, the maximum dosage of aripiprazole can be raised to 30mg per day.
Bipolar Disorder: Diagnosis and Management
Bipolar disorder is a lifelong condition characterized by episodes of mania or hypomania and episodes of depressed mood. The peak age of onset is 15-19 years, and the lifetime prevalence of bipolar I disorders is estimated to be around 2.1%. The diagnosis of bipolar disorder is based on the presence of manic or hypomanic episodes, which are characterized by elevated of expansive mood, rapid speech, and increased activity of energy. Psychotic symptoms, such as delusions and hallucinations, may also be present.
Bipolar depression differs from unipolar depression in several ways, including more rapid onset, more frequent episodes, and shorter duration. Rapid cycling is a qualifier that can be applied to bipolar I of bipolar II disorder and 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.
The management of bipolar disorder involves acute and long-term interventions. Acute management of mania or hypomania may involve stopping antidepressants and offering antipsychotics of mood stabilizers. Long-term management may involve psychological interventions and pharmacological treatments such as lithium, valproate, of olanzapine.
It is important to note that valproate should not be offered to women of girls of childbearing potential for long-term bipolar disorder unless other options are ineffective of not tolerated and a pregnancy prevention program is in place. Aripiprazole is recommended as an option for treating moderate to severe manic episodes in adolescents with bipolar I disorder.
Overall, the diagnosis and management of bipolar disorder require a comprehensive approach that takes into account the individual’s symptoms, history, and preferences.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 46
Incorrect
-
Which of the following is not considered a known factor that increases the risk of developing Charles Bonnet Syndrome?
Your Answer:
Correct Answer: Polypharmacy
Explanation:Charles Bonnet Syndrome: A Condition of Complex Visual Hallucinations
Charles Bonnet Syndrome (CBS) is a condition characterized by persistent of recurrent complex visual hallucinations that occur in clear consciousness. This condition is observed in individuals who have suffered damage to the visual pathway, which can be caused by damage to any part of the pathway from the eye to the cortex. The hallucinations are thought to result from a release phenomenon secondary to the deafferentation of the cerebral cortex. CBS is equally distributed between sexes and does not show any familial predisposition. The most common ophthalmological conditions associated with this syndrome are age-related macular degeneration, followed by glaucoma and cataract.
Risk factors for CBS include advanced age, peripheral visual impairment, social isolation, sensory deprivation, and early cognitive impairment. Well-formed complex visual hallucinations are thought to occur in 10-30 percent of individuals with severe visual impairment. Only around a third of individuals find the hallucinations themselves an unpleasant or disturbing experience. The most effective treatment is reversal of the visual impairment. Antipsychotic drugs are commonly prescribed but are largely ineffective. CBS is a long-lasting condition, with 88% of individuals experiencing it for two years of more, and only 25% resolving at nine years.
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This question is part of the following fields:
- Old Age Psychiatry
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Question 47
Incorrect
-
Which of the following statements accurately describes the features of a distribution that is negatively skewed?
Your Answer:
Correct Answer: Mean < median < mode
Explanation:Skewed Data: Understanding the Relationship between Mean, Median, and Mode
When analyzing a data set, it is important to consider the shape of the distribution. In a normally distributed data set, the curve is symmetrical and bell-shaped, with the median, mode, and mean all equal. However, in skewed data sets, the distribution is asymmetrical, with the bulk of the data concentrated on one side of the figure.
In a negatively skewed distribution, the left tail is longer, and the bulk of the data is concentrated to the right of the figure. In contrast, a positively skewed distribution has a longer right tail, with the bulk of the data concentrated to the left of the figure. In both cases, the median is positioned between the mode and the mean, as it represents the halfway point of the distribution.
However, the mean is affected by extreme values of outliers, causing it to move away from the median in the direction of the tail. In positively skewed data, the mean is greater than the median, which is greater than the mode. In negatively skewed data, the mode is greater than the median, which is greater than the mean.
Understanding the relationship between mean, median, and mode in skewed data sets is crucial for accurate data analysis and interpretation. By recognizing the shape of the distribution, researchers can make informed decisions about which measures of central tendency to use and how to interpret their results.
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This question is part of the following fields:
- Research Methods, Statistics, Critical Review And Evidence-Based Practice
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Question 48
Incorrect
-
Which tricyclic antidepressant should breastfeeding women avoid using?
Your Answer:
Correct Answer: Doxepin
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.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 49
Incorrect
-
Which of the following is not a requirement for a defendant to be considered fit to plead?
Your Answer:
Correct Answer: Recall the events of the crime
Explanation:Fitness to Plead: Criteria and Process
Fitness to plead is determined by specific criteria established by the Pritchard case law in 1836. The criteria include the ability to instruct solicitor and counsel, understand the charges, decide whether to plead guilty of not, follow court proceedings, challenge a juror, and give evidence in one’s defense. Schizophrenia and other enduring mental illnesses are the most common conditions associated with unfitness to plead, particularly when positive psychotic symptomatology is present. Intellectual impairment is not a significant factor in most cases. If the issue is raised by the defense, it must be established on a balance of probability, while if raised by the prosecution of judge, it must be proved beyond reasonable doubt. Amnesia does not render someone unfit to plead. The decision on fitness to plead is made by a judge, not a jury. If someone is found unfit to plead, they are subject to the Criminal Procedures Act 1991, which involves a trial of facts, complete acquittal if the facts are not found, and flexible disposal by the judge if the facts are found, except for murder, which requires mandatory committal to hospital.
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This question is part of the following fields:
- Forensic Psychiatry
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Question 50
Incorrect
-
Which of the options below is not utilized as a means of opioid detoxification?
Your Answer:
Correct Answer: Ephedrine
Explanation:Medications utilized for opioid detoxification comprise of Methadone, Buprenorphine, and Lofexidine.
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.
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This question is part of the following fields:
- Substance Misuse/Addictions
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Question 51
Incorrect
-
In a cohort study investigating the association between smoking and Alzheimer's dementia, what is the typical variable used to measure the outcome?
Your Answer:
Correct Answer: Relative risk
Explanation:The odds ratio is used in case-control studies to measure the association between exposure and outcome, while the relative risk is used in cohort studies to measure the risk of developing an outcome in the exposed group compared to the unexposed group. To convert the odds ratio to a relative risk, one can use the formula: relative risk = odds ratio / (1 – incidence in the unexposed group x odds ratio).
Types of Primary Research Studies and Their Advantages and Disadvantages
Primary research studies can be categorized into six types based on the research question they aim to address. The best type of study for each question type is listed in the table below. There are two main types of study design: experimental and observational. Experimental studies involve an intervention, while observational studies do not. The advantages and disadvantages of each study type are summarized in the table below.
Type of Question Best Type of Study
Therapy Randomized controlled trial (RCT), cohort, case control, case series
Diagnosis Cohort studies with comparison to gold standard test
Prognosis Cohort studies, case control, case series
Etiology/Harm RCT, cohort studies, case control, case series
Prevention RCT, cohort studies, case control, case series
Cost Economic analysisStudy Type Advantages Disadvantages
Randomized Controlled Trial – Unbiased distribution of confounders – Blinding more likely – Randomization facilitates statistical analysis – Expensive – Time-consuming – Volunteer bias – Ethically problematic at times
Cohort Study – Ethically safe – Subjects can be matched – Can establish timing and directionality of events – Eligibility criteria and outcome assessments can be standardized – Administratively easier and cheaper than RCT – Controls may be difficult to identify – Exposure may be linked to a hidden confounder – Blinding is difficult – Randomization not present – For rare disease, large sample sizes of long follow-up necessary
Case-Control Study – Quick and cheap – Only feasible method for very rare disorders of those with long lag between exposure and outcome – Fewer subjects needed than cross-sectional studies – Reliance on recall of records to determine exposure status – Confounders – Selection of control groups is difficult – Potential bias: recall, selection
Cross-Sectional Survey – Cheap and simple – Ethically safe – Establishes association at most, not causality – Recall bias susceptibility – Confounders may be unequally distributed – Neyman bias – Group sizes may be unequal
Ecological Study – Cheap and simple – Ethically safe – Ecological fallacy (when relationships which exist for groups are assumed to also be true for individuals)In conclusion, the choice of study type depends on the research question being addressed. Each study type has its own advantages and disadvantages, and researchers should carefully consider these when designing their studies.
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This question is part of the following fields:
- Research Methods, Statistics, Critical Review And Evidence-Based Practice
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Question 52
Incorrect
-
What are the accurate statements about the renal and biochemical complications associated with anorexia nervosa?
Your Answer:
Correct Answer: Patients usually have normal albumin levels
Explanation:Infection may be indicated by low serum albumin levels, as the body shifts its production from albumin to acute phase proteins. It is important to note that normal albumin levels should not be relied upon as a marker of nutritional status, as patients with anorexia may still have normal levels despite electrolyte imbalances. Additionally, eGFR may overestimate renal function in these patients due to low muscle mass. Binge-purge anorexia carries a higher risk of electrolyte disturbance, particularly hypokalaemia and hypomagnesaemia, due to induced vomiting and subsequent loss of hydrogen ions and potassium in the urine.
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.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 53
Incorrect
-
How can we describe the consistency of a test in producing similar results when measured multiple times?
Your Answer:
Correct Answer: Precision
Explanation:Accuracy and reproducibility together make up precision.
Clinical tests are used to determine the presence of absence of a disease of condition. To interpret test results, it is important to have a working knowledge of statistics used to describe them. Two by two tables are commonly used to calculate test statistics such as sensitivity and specificity. Sensitivity refers to the proportion of people with a condition that the test correctly identifies, while specificity refers to the proportion of people without a condition that the test correctly identifies. Accuracy tells us how closely a test measures to its true value, while predictive values help us understand the likelihood of having a disease based on a positive of negative test result. Likelihood ratios combine sensitivity and specificity into a single figure that can refine our estimation of the probability of a disease being present. Pre and post-test odds and probabilities can also be calculated to better understand the likelihood of having a disease before and after a test is carried out. Fagan’s nomogram is a useful tool for calculating post-test probabilities.
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This question is part of the following fields:
- Research Methods, Statistics, Critical Review And Evidence-Based Practice
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Question 54
Incorrect
-
Which of the options below does not demonstrate selection bias?
Your Answer:
Correct Answer: Recall 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.
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This question is part of the following fields:
- Research Methods, Statistics, Critical Review And Evidence-Based Practice
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Question 55
Incorrect
-
One of Bion's fundamental group assumptions is:
Your Answer:
Correct Answer: Pairing
Explanation:Bion, a psychoanalyst, was fascinated by group dynamics and believed that groups had a collective unconscious that functioned similarly to that of an individual. He argued that this unconsciousness protected the group from the pain of reality. Bion identified two types of groups: the ‘working group’ that functioned well and achieved its goals, and the ‘basic assumption group’ that acted out primitive fantasies and prevented progress. Bion then described different types of basic assumption groups, including ‘dependency,’ where the group turns to a leader to alleviate anxiety, ‘fight-flight,’ where the group perceives an enemy and either attacks of avoids them, and ‘pairing,’ where the group believes that the solution lies in the pairing of two members. These dynamics can be observed in various settings, such as when strangers come together for the first time of when doctors in different specialties criticize one another.
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This question is part of the following fields:
- Psychotherapy
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Question 56
Incorrect
-
How many months of consecutive voluntary or involuntary passage of normal feces in inappropriate places are required to meet the diagnostic criteria for encopresis in a child?
Your Answer:
Correct Answer: 3
Explanation:Elimination Disorders
Elimination disorders refer to conditions that affect a child’s ability to control their bladder of bowel movements. Enuresis, of lack of control over the bladder, typically occurs between the ages of 1-3, while control over the bowel usually occurs before that of the bladder for most toddlers. Toilet training can be influenced by various factors, including intellectual capacity, cultural determinants, and psychological interactions between the child and their parents.
Enuresis is characterized by involuntary voiding of urine, by day and/of by night, which is abnormal in relation to the individual’s age and is not a result of any physical abnormality. It is not normally diagnosed before age 5 and may be primary (the child never having achieved continence) of secondary. Treatment options include reassurance, enuresis alarms, and medication.
Encopresis refers to repeated stool evacuation in inappropriate places in children over the age of four. The behavior can be either involuntary of intentional and may be due to unsuccessful toilet training (primary encopresis) of occur after a period of normal bowel control (secondary encopresis). Treatment generally involves bowel clearance, prevention of impaction, and behavioral therapy.
Before a diagnosis of encopresis is made, organic causes must be excluded. Hirschsprung’s disease is a condition that results from an absence of parasympathetic ganglion cells in the rectum, colon, and sometimes the small intestine. It leads to a colonic obstruction and is diagnosed in at least half of all cases in the first year of life. It is twice as common in boys than in girls.
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This question is part of the following fields:
- Child And Adolescent Psychiatry
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Question 57
Incorrect
-
Which antidepressant medication, as per NICE Guidelines, necessitates hematological monitoring (FBC) for elderly individuals?
Your Answer:
Correct Answer: Mianserin
Explanation:Mianserin is a type of antidepressant that falls under the category of tetracyclic antidepressants. The British National Formulary (BNF) recommends that patients undergo a full blood count every four weeks during the first three months of treatment. Even after this initial period, patients should continue to be clinically monitored. If any signs of infection, such as fever, sore throat, of stomatitis, develop, treatment should be stopped and a full blood count should be obtained.
In 1979, there were reports of blood dyscrasias associated with mianserin, including neutropenia/leukopenia and agranulocytosis, which led to fatalities. The elderly population was particularly affected, with an excess of cases and deaths reported in this group. The estimated rate of agranulocytosis was between 1:2000 and 1:4000 exposures. These findings were controversial, and the manufacturer even went to court to prevent the drug withdrawal in the UK.
Due to the risk of blood dyscrasias, mianserin requires close haematological monitoring for at least the first three months of use, especially in the elderly population. This monitoring requirement limits the drug’s usefulness in this group, even though it lacks cardiotoxicity.
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.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 58
Incorrect
-
What is the GRADE approach used in evidence based medicine and what are its characteristics?
Your Answer:
Correct Answer: The system can be applied to observational studies
Explanation:Levels and Grades of Evidence in Evidence-Based Medicine
To evaluate the quality of evidence on a subject of question, levels of grades are used. The traditional hierarchy approach places systematic reviews of randomized control trials at the top and case-series/report at the bottom. However, this approach is overly simplistic as certain research questions cannot be answered using RCTs. To address this, the Oxford Centre for Evidence-Based Medicine introduced their 2011 Levels of Evidence system, which separates the type of study questions and gives a hierarchy for each.
The grading approach to be aware of is the GRADE system, which classifies the quality of evidence as high, moderate, low, of very low. The process begins by formulating a study question and identifying specific outcomes. Outcomes are then graded as critical of important. The evidence is then gathered and criteria are used to grade the evidence, with the type of evidence being a significant factor. Evidence can be promoted of downgraded based on certain criteria, such as limitations to study quality, inconsistency, uncertainty about directness, imprecise of sparse data, and reporting bias. The GRADE system allows for the promotion of observational studies to high-quality evidence under the right circumstances.
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This question is part of the following fields:
- Research Methods, Statistics, Critical Review And Evidence-Based Practice
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Question 59
Incorrect
-
What condition would make it inappropriate to use the Student's t-test for conducting a significance test?
Your Answer:
Correct Answer: Using it with data that is not normally distributed
Explanation:T-tests are appropriate for parametric data, which means that the data should conform to a normal distribution.
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.
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This question is part of the following fields:
- Research Methods, Statistics, Critical Review And Evidence-Based Practice
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Question 60
Incorrect
-
What is a true statement about transference?
Your Answer:
Correct Answer: It is often intense in patients with borderline personality disorder
Explanation:Transference and Countertransference
Transference is the unconscious transfer of feelings, attitudes, thoughts, desires, fantasies, of behaviors from past significant relationships to a current interpersonal relationship. It is often observed in therapy, and the therapist interprets its meaning and source to help the patient understand how their past experiences affect their current relationships. Factors that increase transference include anxiety, frequent contact with a key worker, and borderline personality disorder. Effective management of transference involves recognizing the importance of the relationship to the patient, maintaining professional boundaries, interpreting the transference, and being a reliable therapist.
Countertransference, on the other hand, refers to the therapist’s emotional, cognitive, of behavioral response to the patient, triggered by some characteristic of the patient but ultimately resulting from unresolved conflicts within the therapist. There are different conceptions of countertransference, including the classical definition, the totalistic conception, the complementary conception, and the relational perspective. However, a working definition suggests that countertransference is a response to the patient triggered by unresolved conflicts within the therapist. Effective management of countertransference involves understanding the patient’s interpersonal style of relating and framing therapeutic interventions accordingly.
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This question is part of the following fields:
- Psychotherapy
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Question 61
Incorrect
-
Which of the following is most likely to be reduced by implementing 'drug holidays' for patients with attention deficit hyperactivity disorder who are taking stimulant medication?
Your Answer:
Correct Answer: Growth restriction
Explanation: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.
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This question is part of the following fields:
- Child And Adolescent Psychiatry
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Question 62
Incorrect
-
What is a licensed treatment for bulimia nervosa?
Your Answer:
Correct Answer: Fluoxetine
Explanation:Antidepressants (Licensed Indications)
The following table outlines the specific licensed indications for antidepressants in adults, as per the Maudsley Guidelines and the British National Formulary. It is important to note that all antidepressants are indicated for depression.
– Nocturnal enuresis in children: Amitriptyline, Imipramine, Nortriptyline
– Phobic and obsessional states: Clomipramine
– Adjunctive treatment of cataplexy associated with narcolepsy: Clomipramine
– Panic disorder and agoraphobia: Citalopram, Escitalopram, Sertraline, Paroxetine, Venlafaxine
– Social anxiety/phobia: Escitalopram, Paroxetine, Sertraline, Moclobemide, Venlafaxine
– Generalised anxiety disorder: Escitalopram, Paroxetine, Duloxetine, Venlafaxine
– OCD: Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline, Clomipramine
– Bulimia nervosa: Fluoxetine
– PTSD: Paroxetine, Sertraline -
This question is part of the following fields:
- General Adult Psychiatry
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Question 63
Incorrect
-
What percentage of individuals aged 16 years and older in the UK are considered to be harmful drinkers?
Your Answer:
Correct Answer: 4%
Explanation:Out of the population aged 16 of over, 19% do not consume alcohol, while 60% have a low risk pattern of alcohol consumption. 17% have an increased risk pattern, and 4% have a higher risk pattern, according to the classification of alcohol consumption based on weekly units.
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This question is part of the following fields:
- Organisation And Delivery Of Psychiatric Services
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Question 64
Incorrect
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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.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 65
Incorrect
-
Which area experiences the most significant degeneration in Wilson's disease?
Your Answer:
Correct Answer: The lenticular nucleus
Explanation:Hepatolenticular degeneration is another name for Wilson’s disease.
Understanding Wilson’s Disease: A Disorder of Copper Storage
Wilson’s disease, also known as hepatolenticular degeneration, is a genetic disorder that affects copper storage in the body. This condition is caused by a defect in the ATP7B gene, which leads to the accumulation of copper in the liver and brain. The onset of symptoms usually occurs between the ages of 10 and 25 years, with liver disease being the most common presentation in children and neurological symptoms in young adults.
The excessive deposition of copper in the tissues can cause a range of symptoms, including hepatitis, cirrhosis, basal ganglia degeneration, speech and behavioral problems, asterixis, chorea, dementia, Kayser-Fleischer rings, renal tubular acidosis, haemolysis, and blue nails. Diagnosis is based on reduced serum ceruloplasmin, reduced serum copper, and increased 24-hour urinary copper excretion. However, the majority of patients exhibit low levels of both ceruloplasmin and total serum copper.
The traditional first-line treatment for Wilson’s disease is penicillamine, which chelates copper. Trientine hydrochloride is an alternative chelating agent that may become first-line treatment in the future. Tetrathiomolybdate is a newer agent that is currently under investigation. Early diagnosis and treatment are crucial to prevent irreversible damage to the liver and brain.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 66
Incorrect
-
Which statement accurately describes the measurement of serum potassium in 1,000 patients with anorexia nervosa, where the mean potassium is 4.6 mmol/l and the standard deviation is 0.3 mmol/l?
Your Answer:
Correct Answer: 68.3% of values lie between 4.3 and 4.9 mmol/l
Explanation:Standard Deviation and Standard Error of the Mean
Standard deviation (SD) and standard error of the mean (SEM) are two important statistical measures used to describe data. SD is a measure of how much the data varies, while SEM is a measure of how precisely we know the true mean of the population. The normal distribution, also known as the Gaussian distribution, is a symmetrical bell-shaped curve that describes the spread of many biological and clinical measurements.
68.3% of the data lies within 1 SD of the mean, 95.4% of the data lies within 2 SD of the mean, and 99.7% of the data lies within 3 SD of the mean. The SD is calculated by taking the square root of the variance and is expressed in the same units as the data set. A low SD indicates that data points tend to be very close to the mean.
On the other hand, SEM is an inferential statistic that quantifies the precision of the mean. It is expressed in the same units as the data and is calculated by dividing the SD of the sample mean by the square root of the sample size. The SEM gets smaller as the sample size increases, and it takes into account both the value of the SD and the sample size.
Both SD and SEM are important measures in statistical analysis, and they are used to calculate confidence intervals and test hypotheses. While SD quantifies scatter, SEM quantifies precision, and both are essential in understanding and interpreting data.
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This question is part of the following fields:
- Research Methods, Statistics, Critical Review And Evidence-Based Practice
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Question 67
Incorrect
-
At what age is encopresis typically diagnosed?
Your Answer:
Correct Answer: Age 4
Explanation:Elimination Disorders
Elimination disorders refer to conditions that affect a child’s ability to control their bladder of bowel movements. Enuresis, of lack of control over the bladder, typically occurs between the ages of 1-3, while control over the bowel usually occurs before that of the bladder for most toddlers. Toilet training can be influenced by various factors, including intellectual capacity, cultural determinants, and psychological interactions between the child and their parents.
Enuresis is characterized by involuntary voiding of urine, by day and/of by night, which is abnormal in relation to the individual’s age and is not a result of any physical abnormality. It is not normally diagnosed before age 5 and may be primary (the child never having achieved continence) of secondary. Treatment options include reassurance, enuresis alarms, and medication.
Encopresis refers to repeated stool evacuation in inappropriate places in children over the age of four. The behavior can be either involuntary of intentional and may be due to unsuccessful toilet training (primary encopresis) of occur after a period of normal bowel control (secondary encopresis). Treatment generally involves bowel clearance, prevention of impaction, and behavioral therapy.
Before a diagnosis of encopresis is made, organic causes must be excluded. Hirschsprung’s disease is a condition that results from an absence of parasympathetic ganglion cells in the rectum, colon, and sometimes the small intestine. It leads to a colonic obstruction and is diagnosed in at least half of all cases in the first year of life. It is twice as common in boys than in girls.
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This question is part of the following fields:
- Child And Adolescent Psychiatry
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Question 68
Incorrect
-
What potential adverse effect on the neonate may be linked to the use of SSRIs after 20 weeks of gestation?
Your Answer:
Correct Answer: Persistent pulmonary hypertension
Explanation:According to the 13th edition of Maudsley, taking SSRIs after 20 weeks of pregnancy may be linked to a higher chance of persistent pulmonary hypertension in newborns. However, the risk is relatively low and may only be present if the exposure occurs in late pregnancy. It’s important to note that this increased risk is based on comparisons with the general population, not women who have depression, for whom the risk is unknown.
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.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 69
Incorrect
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Which statement accurately describes conduct disorder?
Your Answer:
Correct Answer: Males develop the condition at a younger age than females
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.
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This question is part of the following fields:
- Child And Adolescent Psychiatry
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Question 70
Incorrect
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A 54 year old man is admitted to hospital following a hip fracture. In view of a shortage of theatre space his operation is delayed. Three days following admission the nurse becomes concerned by his change in presentation. She has noticed that the man has become increasingly agitated, and has a sustained tachycardia. He has also started complaining that he is hearing people talking about him despite him being in a side room. Which of the following do you most suspect?
Your Answer:
Correct Answer: Delirium tremens
Explanation:The man’s symptoms of agitation and hallucinations could be attributed to a psychotic illness, but the presence of a sustained tachycardia suggests another underlying condition. Based on the delayed presentation and the complete set of symptoms, delirium tremens is the most probable explanation. While meningitis is a possibility, it is less likely than delirium tremens, which is a common condition.
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.
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This question is part of the following fields:
- Substance Misuse/Addictions
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Question 71
Incorrect
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What is the most accurate estimate of the ratio of males to females with OCD?
Your Answer:
Correct Answer: 1:01
Explanation:Both males and females are equally likely to experience OCD, according to most studies. While some discrepancies have been reported, the majority support a 1:1 ratio.
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 72
Incorrect
-
A 56 year-old man attends the out-patient clinic. He was started on fluoxetine eight weeks ago for depression and is now requesting to stop his medication as he feels so well. Your assessment indicates that he is now in remission. What should be recommended regarding his treatment?
Your Answer:
Correct Answer: It should be continued for at least another 6 months
Explanation:To minimize the likelihood of relapse, it is recommended to maintain treatment for at least 6 months after achieving remission. It is important to note that antidepressants are not habit-forming, and patients should be reassured of this fact.
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.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 73
Incorrect
-
What is a true statement about eating disorders?
Your Answer:
Correct Answer: When treating anorexia nervosa, helping people to reach a healthy body weight of BMI for their age is a key goal
Explanation:A key objective in the treatment of anorexia nervosa is to assist individuals in achieving a healthy body weight of BMI appropriate for their age. It is not recommended to rely solely on screening tools like SCOFF to diagnose eating disorders. While eating disorders can occur at any age, it is important to note that the risk is greatest for adolescents between the ages of 13 and 17, particularly young men and women. It is not advisable to use a single metric such as BMI of duration of illness to determine whether treatment for an eating disorder is necessary.
Eating Disorders: NICE Guidelines
Anorexia:
For adults with anorexia nervosa, consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), of specialist supportive clinical management (SSCM). If these are not acceptable, contraindicated, of ineffective, consider eating-disorder-focused focal psychodynamic therapy (FPT). For children and young people, consider anorexia-nervosa-focused family therapy (FT-AN) of individual CBT-ED. Do not offer medication as the sole treatment.Bulimia:
For adults, the first step is an evidence-based self-help programme. If this is not effective, consider individual CBT-ED. For children and young people, offer bulimia-nervosa-focused family therapy (FT-BN) of individual CBT-ED. Do not offer medication as the sole treatment.Binge Eating Disorder:
The first step is a guided self-help programme. If this is not effective, offer group of individual CBT-ED. For children and young people, offer the same treatments recommended for adults. Do not offer medication as the sole treatment.Advice for those with eating disorders:
Encourage people with an eating disorder who are vomiting to avoid brushing teeth immediately after vomiting, rinse with non-acid mouthwash, and avoid highly acidic foods and drinks. Advise against misusing laxatives of diuretics and excessive exercise.Additional points:
Do not offer physical therapy as part of treatment. Consider bone mineral density scans after 1 year of underweight in children and young people, of 2 years in adults. Do not routinely offer oral of transdermal oestrogen therapy to treat low bone mineral density in children of young people with anorexia nervosa. Consider transdermal 17-β-estradiol of bisphosphonates for women with anorexia nervosa.Note: These guidelines are taken from NICE guidelines 2017.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 74
Incorrect
-
A 72-year-old man comes to you with complaints of feeling low and having trouble sleeping. Upon further discussion and using a validated symptom measure, you diagnose him with moderate depression. He has a history of cerebrovascular disease and is currently on aspirin, ramipril, and simvastatin. What would be the best course of action in this case?
Your Answer:
Correct Answer: Start citalopram + lansoprazole
Explanation:SSRI and Bleeding Risk: Management Strategies
SSRIs have been linked to an increased risk of bleeding, particularly in vulnerable populations such as the elderly, those with a history of bleeding, and those taking medications that predispose them to bleeding. The risk of bleeding is further elevated in patients with comorbidities such as liver of renal disease, smoking, and alcohol of drug misuse.
To manage this risk, the Maudsley recommends avoiding SSRIs in patients receiving NSAIDs, aspirin, of oral anticoagulants, of those with a history of cerebral of GI bleeds. If SSRI use cannot be avoided, close monitoring and prescription of gastroprotective proton pump inhibitors are recommended. The degree of serotonin reuptake inhibition varies among antidepressants, with some having weaker of no inhibition, which may be associated with a lower risk of bleeding.
NICE recommends caution when using SSRIs in patients taking aspirin and suggests considering alternative antidepressants such as trazodone, mianserin, of reboxetine. In patients taking warfarin of heparin, SSRIs are not recommended, but mirtazapine may be considered with caution.
Overall, healthcare providers should carefully weigh the risks and benefits of SSRI use in patients at risk of bleeding and consider alternative antidepressants of gastroprotective measures when appropriate.
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This question is part of the following fields:
- Old Age Psychiatry
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Question 75
Incorrect
-
Which mental health issue has the strongest correlation with homicide rates?
Your Answer:
Correct Answer: Substance misuse
Explanation:When substance misuse is considered, the majority of harmful actions towards others are not attributed primarily to mental illness. Additionally, individuals with mental illness of intellectual disability are at a higher risk of being subjected to violence rather than being the ones who commit violent acts.
Homicide is classified into three categories in England and Wales: murder, manslaughter, and infanticide. Murder requires intent to kill of cause grievous bodily harm, while manslaughter can be voluntary of involuntary. Mental disorder is significantly associated with homicide, particularly in people diagnosed with schizophrenia and personality disorder. Homicide rates by people with a mental disorder are based on calculations of those with disposals such as ‘diminished responsibility’ and ‘not guilty by reason of insanity’. The age-standardised rate for homicide in people with schizophrenia is estimated to be around 0.1 / 100,000, which translates to about 20-30 mental disorder homicides each year in England and Wales. However, a significant proportion of these cases tend to have a secondary diagnosis of alcohol / drug dependence. Individuals with schizophrenia commit 5-6% of homicides in England.
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This question is part of the following fields:
- Forensic Psychiatry
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Question 76
Incorrect
-
A 28-year-old pregnant patient with a family history of bipolar disorder presents in a manic state. What is the recommended initial medication for treatment?
Your Answer:
Correct Answer: Haloperidol
Explanation:When a pregnant woman experiences mania of psychosis without taking any psychotropic medication, the first-line treatment option should be an antipsychotic. If the patient does not respond to the maximum dose of the antipsychotic of if the mania is severe, lithium can be considered as an alternative. However, if the patient does not respond to lithium, ECT may be considered, although the question specifically asks about pharmacological treatment. It is not recommended to use valproate to treat mental health problems in women of childbearing age due to the risk of fetal abnormalities. Diazepam is unlikely to be effective, and if benzodiazepines are necessary during pregnancy, drugs with a shorter half-life should be preferred to avoid the risk of ‘floppy baby’ syndrome.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 77
Incorrect
-
A woman in her 50s with refractory depression has been tried on several different SSRIs and tricyclic antidepressants and despite this has failed to respond. Which of the following is recommended as first choice by the Maudsley Guidelines in this situation?
Your Answer:
Correct Answer: Add quetiapine
Explanation:Depression (Refractory)
Refractory depression is a term used when two successive attempts at treatment have failed despite good compliance and adequate doses. There is no accepted definition of refractory depression. The following options are recommended as the first choice for refractory depression, with no preference implied by order:
– Add lithium
– Combined use of olanzapine and fluoxetine
– Add quetiapine to SSRI/SNRI
– Add aripiprazole to antidepressant
– Bupropion + SSRI
– SSRI (of venlafaxine) + mianserin (of mirtazapine)These recommendations are taken from the 13th edition of the Maudsley Guidelines.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 78
Incorrect
-
You begin treating a geriatric patient with depression with an SSRI and schedule a follow-up appointment six weeks later. What rating scale would be best to use in order to monitor changes in their symptoms?
Your Answer:
Correct Answer: Montgomery-Asberg Depression Rating Scale
Explanation:The Morgan-Russell Scale is specifically utilized for anorexia nervosa, while the Historical Clinical Risk 20 is a semi-structured tool employed by professionals to evaluate the likelihood of violent behavior. However, the MADRS is uniquely designed to detect changes in depression resulting from treatment.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 79
Incorrect
-
A 7 year old girl presents with persistent bed wetting. She has been able to stay dry during the day since she was 5 years old, but still wets the bed 2-3 nights per week. The girl and her parents are becoming increasingly worried about this issue. Urinalysis results are normal and there are no indications of an underlying medical cause. What recommendations would you make?
Your Answer:
Correct Answer: The parents should be encouraged to start a reward system
Explanation:NICE (CG111) recommends implementing a reward system and providing advice on fluid intake and using the toilet before sleep as initial measures for bedwetting. If these measures are unsuccessful of if bedwetting occurs less than 1-2 nights per week, alarms are suggested. Desmopressin should only be considered for children aged 7 and above if the alarm method has failed of is not preferred.
Elimination Disorders
Elimination disorders refer to conditions that affect a child’s ability to control their bladder of bowel movements. Enuresis, of lack of control over the bladder, typically occurs between the ages of 1-3, while control over the bowel usually occurs before that of the bladder for most toddlers. Toilet training can be influenced by various factors, including intellectual capacity, cultural determinants, and psychological interactions between the child and their parents.
Enuresis is characterized by involuntary voiding of urine, by day and/of by night, which is abnormal in relation to the individual’s age and is not a result of any physical abnormality. It is not normally diagnosed before age 5 and may be primary (the child never having achieved continence) of secondary. Treatment options include reassurance, enuresis alarms, and medication.
Encopresis refers to repeated stool evacuation in inappropriate places in children over the age of four. The behavior can be either involuntary of intentional and may be due to unsuccessful toilet training (primary encopresis) of occur after a period of normal bowel control (secondary encopresis). Treatment generally involves bowel clearance, prevention of impaction, and behavioral therapy.
Before a diagnosis of encopresis is made, organic causes must be excluded. Hirschsprung’s disease is a condition that results from an absence of parasympathetic ganglion cells in the rectum, colon, and sometimes the small intestine. It leads to a colonic obstruction and is diagnosed in at least half of all cases in the first year of life. It is twice as common in boys than in girls.
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This question is part of the following fields:
- Child And Adolescent Psychiatry
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Question 80
Incorrect
-
What is the main focus of behavioural activation therapy?
Your Answer:
Correct Answer: Depression
Explanation:Understanding Behavioural Activation Therapy for Depression
Behavioural activation therapy is a formal treatment for depression that emphasizes activity scheduling to encourage patients to approach activities they are avoiding. Unlike traditional cognitive therapy, it involves less cognitive therapy and is easier to train staff in its use. The therapy was introduced by Martell in 2001 and has two primary focuses: the use of avoided activities as a guide for activity scheduling and functional analysis of cognitive processes that involve avoidance.
Behavioural activation theory suggests that when people become depressed, many of their activities function as avoidance and escape from aversive thoughts, feelings, of external situations. As a result, someone with depression engages less frequently in pleasant of satisfying activities and obtains less positive reinforcement than someone without depression. To address this, the patient is encouraged to identify activities and problems that they avoid and to establish valued directions to be followed. These are set out on planned timetables (activity schedules).
In behavioural activation therapy, therapists do not engage in the content of the patient’s thinking. Instead, they use functional analysis to focus on the context and process of the individual’s response. The most common cognitive responses are rumination, fusion, and self-attack. A typical session has a structured agenda to review homework and progress towards goals, discuss feedback on the previous session, and focus on one of two specific issues. The number of sessions required to treat depression is typically between 12 and 24.
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This question is part of the following fields:
- Psychotherapy
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Question 81
Incorrect
-
What is the most frequent symptom observed in individuals with Huntington's disease?
Your Answer:
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.
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This question is part of the following fields:
- Old Age Psychiatry
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Question 82
Incorrect
-
A client is referred with depression and is eager to begin medication. You find out that they have hypertension. What would be the most suitable treatment option?
Your Answer:
Correct Answer: Fluoxetine
Explanation:Antidepressants and Diabetes
Depression is a prevalent condition among patients with diabetes. It is crucial to select the appropriate antidepressant as some may have negative effects on weight and glucose levels. The first-line treatment for depression in diabetic patients is selective serotonin reuptake inhibitors (SSRIs), with fluoxetine having the most supporting data. Serotonin-norepinephrine reuptake inhibitors (SNRIs) are also likely to be safe, but there is less evidence to support their use. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) should be avoided. These recommendations are based on the Maudsley Guidelines 10th Edition.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 83
Incorrect
-
What substance is involved in the abnormal ingestion known as amylophagia in cases of pica?
Your Answer:
Correct Answer: Starch
Explanation:Pregnant women often exhibit a type of pica known as amylophagia.
Pica: Eating Non-Nutritive Substances
Pica is a condition where a person persistently eats non-nutritive substances for at least a month. The name pica comes from the Latin word for magpie, a bird known for its large and random appetite. To be diagnosed with pica, the behavior must be developmentally inappropriate, not culturally sanctioned, and severe enough to require clinical attention. It is more common in young people than adults and is often associated with mental retardation.
There are various causes of pica, including mental disorders such as autism and schizophrenia, iron and zinc deficiency (although this is rare and not clear if it is a cause of effect), and pregnancy. The DSM-5 requires a minimum age of 2 before a diagnosis can be made. Pregnant women have been reported to experience certain forms of pica, such as geophagia (clay eating) and amylophagia (starch eating).
Pica affects both sexes equally and is estimated to occur in up to 15% of those with severe intellectual disability. However, aside from cases of autistic spectrum disorder of intellectual disability, pica usually remits by adolescence.
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This question is part of the following fields:
- Child And Adolescent Psychiatry
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Question 84
Incorrect
-
What is the initial medication prescribed for a 9 year old boy with ADHD and no other medical conditions?
Your Answer:
Correct Answer: Methylphenidate
Explanation: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.
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This question is part of the following fields:
- Child And Adolescent Psychiatry
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Question 85
Incorrect
-
What is a known factor that can lead to inaccurate positive results for amphetamine on drug screening tests?
Your Answer:
Correct Answer: Pseudoephedrine
Explanation:Pseudoephedrine belongs to the phenethylamine and amphetamine chemical classes and acts as a sympathomimetic drug. Its primary purpose is to alleviate nasal and sinus congestion.
Drug Screening
Drug testing can be conducted through various methods, but urinalysis is the most common. Urine drug tests can be either screening of confirmatory. Screening tests use enzymatic immunoassays to detect drug metabolites of classes of drug metabolites in the urine. However, these tests have limitations, such as false positives due to cross-reactivity. Therefore, any positive test should be confirmed through gas chromatography of mass spectrometry.
People may try to manipulate drug testing procedures by adulterating the sample. Normal urine parameters, such as temperature, specific gravity, and pH, can assist in detecting adulterated samples. Adulterants include household items like vinegar, detergent, and ammonia, as well as commercially available products. Diluted urine may also yield false negatives.
Detection times vary from person to person, and the approximate drug detection time in urine can be found in a table provided by Nelson (2016). False positives can occur due to cross-reactivity, as illustrated by Moeller (2017). Clinicians should be aware of the limitations of urine drug tests and the potential for manipulation.
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This question is part of the following fields:
- Substance Misuse/Addictions
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Question 86
Incorrect
-
What is the recommended alternative for bipolar disorder prophylaxis when lithium and valproate are not viable options, according to NICE?
Your Answer:
Correct Answer: Olanzapine
Explanation:Bipolar Disorder: Diagnosis and Management
Bipolar disorder is a lifelong condition characterized by episodes of mania or hypomania and episodes of depressed mood. The peak age of onset is 15-19 years, and the lifetime prevalence of bipolar I disorders is estimated to be around 2.1%. The diagnosis of bipolar disorder is based on the presence of manic or hypomanic episodes, which are characterized by elevated of expansive mood, rapid speech, and increased activity of energy. Psychotic symptoms, such as delusions and hallucinations, may also be present.
Bipolar depression differs from unipolar depression in several ways, including more rapid onset, more frequent episodes, and shorter duration. Rapid cycling is a qualifier that can be applied to bipolar I of bipolar II disorder and 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.
The management of bipolar disorder involves acute and long-term interventions. Acute management of mania or hypomania may involve stopping antidepressants and offering antipsychotics of mood stabilizers. Long-term management may involve psychological interventions and pharmacological treatments such as lithium, valproate, of olanzapine.
It is important to note that valproate should not be offered to women of girls of childbearing potential for long-term bipolar disorder unless other options are ineffective of not tolerated and a pregnancy prevention program is in place. Aripiprazole is recommended as an option for treating moderate to severe manic episodes in adolescents with bipolar I disorder.
Overall, the diagnosis and management of bipolar disorder require a comprehensive approach that takes into account the individual’s symptoms, history, and preferences.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 87
Incorrect
-
What level of kappa score indicates complete agreement between two observers?
Your Answer:
Correct Answer: 1
Explanation:Understanding the Kappa Statistic for Measuring Interobserver Variation
The kappa statistic, also known as Cohen’s kappa coefficient, is a useful tool for quantifying the level of agreement between independent observers. This measure can be applied in any situation where multiple observers are evaluating the same thing, such as in medical diagnoses of research studies. The kappa coefficient ranges from 0 to 1, with 0 indicating complete disagreement and 1 indicating perfect agreement. By using the kappa statistic, researchers and practitioners can gain insight into the level of interobserver variation present in their data, which can help to improve the accuracy and reliability of their findings. Overall, the kappa statistic is a valuable tool for understanding and measuring interobserver variation in a variety of contexts.
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This question is part of the following fields:
- Research Methods, Statistics, Critical Review And Evidence-Based Practice
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Question 88
Incorrect
-
Which client group experiences the most intense transference during therapy?
Your Answer:
Correct Answer: Borderline personality disorder
Explanation:Transference and Countertransference
Transference is the unconscious transfer of feelings, attitudes, thoughts, desires, fantasies, of behaviors from past significant relationships to a current interpersonal relationship. It is often observed in therapy, and the therapist interprets its meaning and source to help the patient understand how their past experiences affect their current relationships. Factors that increase transference include anxiety, frequent contact with a key worker, and borderline personality disorder. Effective management of transference involves recognizing the importance of the relationship to the patient, maintaining professional boundaries, interpreting the transference, and being a reliable therapist.
Countertransference, on the other hand, refers to the therapist’s emotional, cognitive, of behavioral response to the patient, triggered by some characteristic of the patient but ultimately resulting from unresolved conflicts within the therapist. There are different conceptions of countertransference, including the classical definition, the totalistic conception, the complementary conception, and the relational perspective. However, a working definition suggests that countertransference is a response to the patient triggered by unresolved conflicts within the therapist. Effective management of countertransference involves understanding the patient’s interpersonal style of relating and framing therapeutic interventions accordingly.
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This question is part of the following fields:
- Psychotherapy
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Question 89
Incorrect
-
Which of the following is not a recommendation by NICE for the treatment of PTSD?
Your Answer:
Correct Answer: Debriefing
Explanation:According to the NICE guidelines of 2005 on post-traumatic stress disorder (PTSD), debriefing is not recommended.
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.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 90
Incorrect
-
What can be done to distinguish between paranoid personality disorder and schizotypal personality disorder?
Your Answer:
Correct Answer: Hypersensitivity to criticism
Explanation:All personality disorders typically develop during childhood of adolescence and share symptoms such as paranoid thoughts and difficulty forming close relationships. However, individuals with schizotypal personality disorder do not typically exhibit an excessive sensitivity to criticism.
Schizotypal Personality Disorder: Symptoms and Diagnostic Criteria
Schizotypal personality disorder is a type of personality disorder that is characterized by a pervasive pattern of discomfort with close relationships, distorted thinking and perceptions, and eccentric behavior. This disorder typically begins in early adulthood and is present in a variety of contexts. To be diagnosed with schizotypal personality disorder, an individual must exhibit at least five of the following symptoms:
1. Ideas of reference (excluding delusions of reference).
2. Odd beliefs of magical thinking that influences behavior and is inconsistent with subcultural norms.
3. Unusual perceptual experiences, including bodily illusions.
4. Odd thinking and speech.
5. Suspiciousness of paranoid ideation.
6. Inappropriate or constricted affect.
7. Behavior of appearance that is odd, eccentric, of peculiar.
8. Lack of close friends of confidants other than first-degree relatives.
9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.It is important to note that the ICD-11 does not have a specific category for schizotypal personality disorder, as it has abandoned the categorical approach in favor of a dimensional one.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 91
Incorrect
-
If a woman with a history of mild depression comes to the clinic and reports that she is pregnant, and has been in remission for 5 months after taking sertraline 50mg, what would you suggest?
Your Answer:
Correct Answer: Withdraw the sertraline and monitor
Explanation:Although sertraline can be used to treat depression during pregnancy, it is important to note that no psychotropic medication is completely safe. Therefore, it is recommended to avoid medication if possible and carefully consider the risk versus benefit. In cases of mild depression, it may be reasonable to explore non-medication options.
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.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 92
Incorrect
-
What is the most accurate approximation of the occurrence rate of schizophrenia among adults who have a learning disability?
Your Answer:
Correct Answer: 3%
Explanation:As mentioned in previous questions, the number found in the general population is one-third of what is found here.
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.
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This question is part of the following fields:
- Learning Disability
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Question 93
Incorrect
-
A 38-year-old lady attends clinic for a medication review. She has been established on lithium carbonate, once daily, for prophylaxis of recurrent depression for several years and has had stable levels. She also suffers from ankylosing spondylitis for which she has been prescribed celecoxib for many years. Her lithium level was checked three days prior to her appointment and was 0.6 mmol/L.
When should her next lithium levels be checked?Your Answer:
Correct Answer: In three months
Explanation:Patients taking lithium should be cautious when using celecoxib, an NSAID that has the potential to elevate lithium levels.
Lithium – Clinical Usage
Lithium is primarily used as a prophylactic agent for bipolar disorder, where it reduces the severity and number of relapses. It is also effective as an augmentation agent in unipolar depression and for treating aggressive and self-mutilating behavior, steroid-induced psychosis, and to raise WCC in people using clozapine.
Before prescribing lithium, renal, cardiac, and thyroid function should be checked, along with a Full Blood Count (FBC) and BMI. Women of childbearing age should be advised regarding contraception, and information about toxicity should be provided.
Once daily administration is preferred, and various preparations are available. Abrupt discontinuation of lithium increases the risk of relapse, and if lithium is to be discontinued, the dose should be reduced gradually over a period of at least 4 weeks.
Inadequate monitoring of patients taking lithium is common, and it is often an exam hot topic. Lithium salts have a narrow therapeutic/toxic ratio, and samples should ideally be taken 12 hours after the dose. The target range for prophylaxis is 0.6–0.75 mmol/L.
Risk factors for lithium toxicity include drugs altering renal function, decreased circulating volume, infections, fever, decreased oral intake of water, renal insufficiency, and nephrogenic diabetes insipidus. Features of lithium toxicity include GI and neuro symptoms.
The severity of toxicity can be assessed using the AMDISEN rating scale.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 94
Incorrect
-
What evidence would be most indicative of a diagnosis of mania?
Your Answer:
Correct Answer: Mood congruent delusions
Explanation:Mania: Features and Characteristics
Mania is a mental state characterized by a range of symptoms that can significantly impact an individual’s behavior, thoughts, and emotions. Some of the key features of mania include an elated of irritable mood, restlessness, and overactivity. People experiencing mania may also exhibit disinhibited and reckless behavior, such as excessive spending of engaging in risky activities. They may have over-ambitious plans for the future and experience a flight of ideas and pressured speech. Additionally, mania can involve mood congruent delusions, increased libido, and a decreased need for sleep. Overall, mania can be a challenging and disruptive condition that requires professional treatment and support.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 95
Incorrect
-
What proportion of individuals with severe mental illness are responsible for committing violent crimes?
Your Answer:
Correct Answer: 1 in 20
Explanation:Mental Health Risk in Sweden: Data on Violent Crimes Committed by People with Severe Mental Illness
According to data from Sweden’s national register, 2.4% of violent crimes were committed by individuals with severe mental illness. This suggests that there is a mental health risk associated with violent crime in Sweden. However, it is important to note that this percentage only accounts for a small portion of all violent crimes.
The population attributable risk fraction of patients was found to be 5%, indicating that patients with severe mental illness are responsible for 1 in 20 violent crimes. This highlights the need for effective mental health treatment and support for individuals with severe mental illness to reduce the risk of violent behavior.
Overall, the data from Sweden’s national register provides important insights into the relationship between mental illness and violent crime. While the percentage of violent crimes committed by individuals with severe mental illness is relatively low, it is still a significant concern that requires attention and action from mental health professionals and policymakers.
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This question is part of the following fields:
- Forensic Psychiatry
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Question 96
Incorrect
-
You are seeing a 6-year-old child in clinic. His parents are very concerned that over the past three months he does not seem to understand what they are saying, and has stopped talking. He has some behavioural problems, and had one seizure a few weeks prior. Previously his language skills were normal, and he has achieved his developmental milestones on time. Your neurological examination is grossly normal.
What investigation would be the most helpful to request?Your Answer:
Correct Answer: EEG
Explanation:The patient’s symptoms suggest Landau-Kleffner syndrome, which requires an EEG for diagnosis. This rare disorder causes a child to lose both expressive and receptive language, despite previously developing normally. EEG abnormalities over Broca and Wernicke’s area, particularly during sleep, are common. Seizures may also occur before of after the onset of aphasia. While prognosis varies, Landau-Kleffner syndrome is typically not life-threatening. About two-thirds of children experience a receptive language deficit, while one-third recover completely. Treatment involves antiepileptic medication. CT and MRI scans, as well as CSF analysis, are typically normal. Speech and language therapy may be recommended as part of a multidisciplinary approach. However, EEG testing is essential for diagnosis.
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This question is part of the following fields:
- Psychiatry Of Learning Disability
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Question 97
Incorrect
-
What is a common observation regarding the sleep patterns of individuals diagnosed with schizophrenia?
Your Answer:
Correct Answer: Reduced REM latency
Explanation:Schizophrenia and Sleep
Sleep disturbances are a common feature of schizophrenia, as research has shown. Specifically, individuals with schizophrenia tend to have a shorter amount of time until the onset of rapid eye movement (REM) sleep, known as decreased REM latency. Additionally, they have a lower proportion of slow wave sleep. These findings were reported in a 2008 article by Rajiv T. titled Schizophrenia, ‘Just the facts’, What we know in 2008 in the journal Schizophrenia Research.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 98
Incorrect
-
Among the listed herbal remedies, which one has the strongest evidence to back up its efficacy in treating depression?
Your Answer:
Correct Answer: Hypericum perforatum
Explanation:Herbal Remedies for Depression and Anxiety
Depression can be treated with Hypericum perforatum (St John’s Wort), which has been found to be more effective than placebo and as effective as standard antidepressants. However, its use is not advised due to uncertainty about appropriate doses, variation in preparations, and potential interactions with other drugs. St John’s Wort can cause serotonin syndrome and decrease levels of drugs such as warfarin and ciclosporin. The effectiveness of the combined oral contraceptive pill may also be reduced.
Anxiety can be reduced with Piper methysticum (kava), but it cannot be recommended for clinical use due to its association with hepatotoxicity.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 99
Incorrect
-
What is true about acamprosate?
Your Answer:
Correct Answer: It acts as a glutamatergic NMDA antagonist
Explanation:Anticonvulsants are not recommended for relapse prevention in alcohol dependence. While some studies have shown potential benefits for certain anticonvulsants, such as carbamazepine and valproate, the evidence is not strong enough to support their routine use. Additionally, these drugs can have significant side effects, including liver toxicity and blood disorders, and require careful monitoring. Therefore, they are not recommended by NICE for this indication.
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This question is part of the following fields:
- Substance Misuse/Addictions
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Question 100
Incorrect
-
What is a true statement about maintenance therapy for individuals with opioid dependence?
Your Answer:
Correct Answer: There is evidence that buprenorphine maintenance therapy is more effective at retaining people in treatment than placebo of no therapy
Explanation:According to a NICE Health Technology Assessment, buprenorphine maintenance therapy is more effective in retaining individuals in treatment compared to placebo of no therapy. However, buprenorphine can be abused if injected and is more expensive than methadone. Methadone may be more suitable for individuals who use large amounts of heroin, as they may not respond as well to high dose buprenorphine. On the other hand, buprenorphine may be a better option for individuals on long-term treatment with drugs that induce of inhibit liver enzymes, as it is less affected by these enzymes compared to methadone.
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.
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This question is part of the following fields:
- Substance Misuse/Addictions
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Question 101
Incorrect
-
What is the maximum duration of psychotic symptoms required for a diagnosis of acute and transient psychotic disorder according to the ICD-11?
Your Answer:
Correct Answer: 3 months
Explanation:– Schizophrenia and other primary psychotic disorders are characterized by impairments in reality testing and alterations in behavior.
– Schizophrenia is a chronic mental health disorder with symptoms including delusions, hallucinations, disorganized speech of behavior, and impaired cognitive ability.
– The essential features of schizophrenia include persistent delusions, persistent hallucinations, disorganized thinking, experiences of influence, passivity of control, negative symptoms, grossly disorganized behavior, and psychomotor disturbances.
– Schizoaffective disorder is diagnosed when all diagnostic requirements for schizophrenia are met concurrently with mood symptoms that meet the diagnostic requirements of a moderate or severe depressive episode, a manic episode, of a mixed episode.
– Schizotypal disorder is an enduring pattern of unusual speech, perceptions, beliefs, and behaviors that are not of sufficient intensity of duration to meet the diagnostic requirements of schizophrenia, schizoaffective disorder, of delusional disorder.
– Acute and transient psychotic disorder is characterized by an acute onset of psychotic symptoms, which can include delusions, hallucinations, disorganized thinking, of experiences of influence, passivity of control, that emerge without a prodrome, progressing from a non-psychotic state to a clearly psychotic state within 2 weeks.
– Delusional disorder is diagnosed when there is a presence of a delusion of set of related delusions, typically persisting for at least 3 months and often much longer, in the absence of a depressive, manic, of mixed episode. -
This question is part of the following fields:
- General Adult Psychiatry
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Question 102
Incorrect
-
On an MRI, the region of the brain that is commonly observed to be abnormal in Alzheimer's dementia is:
Your Answer:
Correct Answer: Medial temporal lobe
Explanation:Medial temporal lobe atrophy is associated with Alzheimer’s disease.
Dementia is a condition that can be diagnosed and supported with the use of neuroimaging techniques. In Alzheimer’s disease, MRI and CT scans are used to assess volume changes in specific areas of the brain, such as the mesial temporal lobe and temporoparietal cortex. SPECT and PET scans can also show functional changes, such as hypoperfusion and glucose hypometabolism. Vascular dementia can be detected with CT and MRI scans that show atrophy, infarcts, and white matter lesions, while SPECT scans reveal a patchy multifocal pattern of hypoperfusion. Lewy body dementia tends to show nonspecific and subtle changes on structural imaging, but SPECT and PET scans can reveal posterior deficits and reduced D2 receptor density. Frontotemporal dementia is characterized by frontal lobe atrophy, which can be seen on CT and MRI scans, while SPECT scans show anterior perfusion deficits. NICE recommends the use of MRI for early diagnosis and detection of subcortical vascular changes, SPECT for differentiating between Alzheimer’s disease, vascular dementia, and frontotemporal dementia, and DaTscan for establishing a diagnosis of dementia with Lewy bodies.
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This question is part of the following fields:
- Old Age Psychiatry
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Question 103
Incorrect
-
Which vitamin is administered for the treatment of the Wernicke-Korsakoff syndrome?
Your Answer:
Correct Answer: Vitamin B1
Explanation:Wernicke’s Encephalopathy: Symptoms, Causes, and Treatment
Wernicke’s encephalopathy is a serious condition that is characterized by confusion, ophthalmoplegia, and ataxia. However, the complete triad is only present in 10% of cases, which often leads to underdiagnosis. The condition results from prolonged thiamine deficiency, which is commonly seen in people with alcohol dependency, but can also occur in other conditions such as anorexia nervosa, malignancy, and AIDS.
The onset of Wernicke’s encephalopathy is usually abrupt, but it may develop over several days to weeks. The lesions occur in a symmetrical distribution in structures surrounding the third ventricle, aqueduct, and fourth ventricle. The mammillary bodies are involved in up to 80% of cases, and atrophy of these structures is specific for Wernicke’s encephalopathy.
Treatment involves intravenous thiamine, as oral forms of B1 are poorly absorbed. IV glucose should be avoided when thiamine deficiency is suspected as it can precipitate of exacerbate Wernicke’s. With treatment, ophthalmoplegia and confusion usually resolve within days, but the ataxia, neuropathy, and nystagmus may be prolonged of permanent.
Untreated cases of Wernicke’s encephalopathy can lead to Korsakoff’s syndrome, which is characterized by memory impairment associated with confabulation. The mortality rate associated with Wernicke’s encephalopathy is 10-20%, making early diagnosis and treatment crucial.
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This question is part of the following fields:
- Substance Misuse/Addictions
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Question 104
Incorrect
-
What is the approximate occurrence rate of conduct disorder among male children aged 5 to 10 years in England?
Your Answer:
Correct Answer: 7%
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.
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This question is part of the following fields:
- Child And Adolescent Psychiatry
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Question 105
Incorrect
-
Which condition is believed to be linked to puerperal psychosis?
Your Answer:
Correct Answer: Bipolar affective disorder
Explanation:Psychiatric Issues in the Postpartum Period
The period following childbirth, known as the postpartum period, can be a time of significant psychiatric challenges for women. Many women experience a temporary mood disturbance called baby blues, which is characterized by emotional instability, sadness, and tearfulness. This condition typically resolves within two weeks.
However, a minority of women (10-15%) experience postpartum depression, which is similar to major depression in its clinical presentation. In contrast, a very small number of women (1-2 per 1000) experience postpartum psychosis, also known as puerperal psychosis. This is a severe form of psychosis that occurs in the weeks following childbirth.
Research suggests that there may be a link between puerperal psychosis and mood disorders, as approximately 50% of women who develop the condition have a family history of mood disorder. Puerperal psychosis typically begins within the first two weeks following delivery. It is important for healthcare providers to be aware of these potential psychiatric issues and to provide appropriate support and treatment to women during the postpartum period.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 106
Incorrect
-
What is the main cannabinoid responsible for the psychoactive effects of cannabis?
Your Answer:
Correct Answer: Tetrahydrocannabinol
Explanation:Cannabis, also known as marijuana, grass, pot, weed, tea, of Mary Jane, is a plant that contains over 60 unique cannabinoids. The primary psychoactive component of cannabis is delta-9-tetrahydrocannabinol (Delta 9-THC), which is rapidly converted into 11-hydroxy-delta 9-THC, the active metabolite in the central nervous system. Specific cannabinoid receptors, including CB1 and CB2 receptors, have been identified in the body. CB1 receptors are found mainly at nerve terminals, where they inhibit transmitter release, while CB2 receptors occur mainly on immune cells and modulate cytokine release. The cannabinoid receptor is found in highest concentrations in the basal ganglia, hippocampus, and cerebellum, with lower concentrations in the cerebral cortex. Cannabis use has been associated with the amotivational syndrome, characterized by apathy, anergy, weight gain, and a lack of persistence in tasks requiring prolonged attention of tenacity.
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This question is part of the following fields:
- Substance Misuse/Addictions
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Question 107
Incorrect
-
For what purpose was the SUSS test created to assess?
Your Answer:
Correct Answer: Anorexia nervosa
Explanation:The SUSS test was created to aid in the evaluation and assessment of anorexia nervosa by providing a more precise method of measuring power. Traditional neurological examinations of anorexia patients often miss significant power deficiencies caused by muscle loss. The test requires patients to transition from lying down to sitting up, then squatting, and finally standing up again, with a structured scoring system in place.
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.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 108
Incorrect
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Which receptors are believed to be hypersensitive and responsible for causing tardive dyskinesia?
Your Answer:
Correct Answer: D2
Explanation:The development of tardive dyskinesia is thought to be caused by an increased sensitivity of postsynaptic D2 receptors in the nigrostriatal pathway. Therefore, clozapine is recommended as a treatment option since it has minimal binding affinity for D2 receptors.
Tardive Dyskinesia: Symptoms, Causes, Risk Factors, and Management
Tardive dyskinesia (TD) is a condition that affects the face, limbs, and trunk of individuals who have been on neuroleptics for months to years. The movements fluctuate over time, increase with emotional arousal, decrease with relaxation, and disappear with sleep. The cause of TD remains theoretical, but the postsynaptic dopamine (D2) receptor supersensitivity hypothesis is the most persistent. Other hypotheses include the presynaptic dopaminergic/noradrenergic hyperactivity hypothesis, the cholinergic interneuron burnout hypothesis, the excitatory/oxidative stress hypothesis, and the synaptic plasticity hypothesis. Risk factors for TD include advancing age, female sex, ethnicity, longer illness duration, intellectual disability and brain damage, negative symptoms in schizophrenia, mood disorders, diabetes, smoking, alcohol and substance misuse, FGA vs SGA treatment, higher antipsychotic dose, anticholinergic co-treatment, and akathisia.
Management options for TD include stopping any anticholinergic, reducing antipsychotic dose, changing to an antipsychotic with lower propensity for TD, and using tetrabenazine, vitamin E, of amantadine as add-on options. Clozapine is the antipsychotic most likely to be associated with resolution of symptoms. Vesicular monoamine transporter type 2 (VMAT2) inhibitors are agents that cause a depletion of neuroactive peptides such as dopamine in nerve terminals and are used to treat chorea due to neurodegenerative diseases of dyskinesias due to neuroleptic medications (tardive dyskinesia).
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This question is part of the following fields:
- General Adult Psychiatry
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Question 109
Incorrect
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What is a fact about self-harm among youth?
Your Answer:
Correct Answer: It is more common in girls than boys
Explanation:Self-harm is a common issue among young people, particularly girls, with rates appearing to have risen over the past decade. It is most likely to occur between the ages of 12 and 15 years and is associated with a range of psychiatric problems. Short-term management involves a psychosocial assessment and consideration of activated charcoal for drug overdose. Longer-term management may involve psychological interventions, but drug treatment should not be offered as a specific intervention to reduce self-harm. Risk assessment tools should not be used to predict future suicide of repetition of self-harm, but certain factors such as male gender, substance misuse, and parental mental disorder may be associated with a higher risk of completed suicide. It is important to seek professional help if you of someone you know is engaging in self-harm.
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This question is part of the following fields:
- Child And Adolescent Psychiatry
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