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Question 1
Correct
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A 28-year-old man visits his GP with complaints of poor memory. He works in a consulting company and recently faced trouble at work after missing a flight to a client in Tokyo. He has difficulty falling asleep and wakes up feeling exhausted. Sometimes he wakes up in the middle of the night screaming. When awake, he cannot relax and appears to be constantly on edge.
The patient has a history of attention-deficit hyperactivity disorder during childhood and one major depressive episode during his university years. He has not had any mental health-related complaints since then. He drinks one bottle of wine on Saturdays with his wife and admits to occasional past cocaine use. However, he stopped using cocaine after being ambushed and stabbed while dealing with a dealer during his last vacation in Thailand two months ago. His wife has recently complained that he appears emotionally unavailable.
Upon physical examination, no abnormalities are found. However, during the mental state examination, the patient exhibits low mood and an increased startle response. What is the most likely diagnosis?Your Answer: Post-traumatic stress disorder
Explanation:The individual is displaying common symptoms of PTSD, including re-experiencing the traumatic event through nightmares, avoiding triggers associated with the event, and experiencing hyperarousal such as hypervigilance and difficulty sleeping. It has been over a month since the traumatic event occurred, ruling out acute stress disorder. There are no signs of psychosis, and the individual has been sober from cocaine for two months. While anxiety is a symptom of PTSD, there is no indication of a generalized anxiety disorder or major depressive episode.
Understanding Post-Traumatic Stress Disorder (PTSD)
Post-traumatic stress disorder (PTSD) is a mental health condition that can develop in individuals of any age following a traumatic event. This can include experiences such as natural disasters, accidents, or even childhood abuse. PTSD is characterized by a range of symptoms, including re-experiencing the traumatic event through flashbacks or nightmares, avoidance of situations or people associated with the event, hyperarousal, emotional numbing, depression, and even substance abuse.
Effective management of PTSD involves a range of interventions, depending on the severity of the symptoms. Single-session interventions are not recommended, and watchful waiting may be used for mild symptoms lasting less than four weeks. Military personnel have access to treatment provided by the armed forces, while trauma-focused cognitive behavioral therapy (CBT) or eye movement desensitization and reprocessing (EMDR) therapy may be used in more severe cases.
It is important to note that drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used, venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline, should be tried. In severe cases, NICE recommends that risperidone may be used. Overall, understanding the symptoms and effective management of PTSD is crucial in supporting individuals who have experienced traumatic events.
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This question is part of the following fields:
- Psychiatry
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Question 2
Correct
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A 45-year-old man with a history of schizophrenia no longer reports hallucinations or delusions. However, he spends many hours doing nothing, has trouble reading a book or watching a film and rarely speaks spontaneously or fluently. His grooming is poor and he is socially withdrawn.
What is a positron emission tomography (PET) scan most likely to show?Your Answer: Hypoactivity of the prefrontal lobes, enlarged cerebral ventricles
Explanation:Brain Function and Psychiatric Disorders: PET Scan Findings
Major psychiatric syndromes, such as schizophrenia, mania, and depression, involve alterations in sensory processing, volitional behavior, environmental adaptation, and regulation of strong emotions. PET scans have shown that hypoactivity of the prefrontal lobes and enlarged cerebral ventricles are most likely to be associated with schizophrenia. On the other hand, hyperactivity of the prefrontal lobes is linked to obsessive-compulsive disorder (OCD). The prefrontal cortex plays a crucial role in planning, temporal sequencing, abstract thought, problem-solving, motility, attention, and the modulation of emotion. Lesions of these pathways impair pursuit of goal-oriented activity. PET scans have also revealed decreased metabolic activity in the temporal lobes in some patients with schizophrenia. However, increased occipital lobe activity is not likely to be seen on PET scans. Additionally, symmetrical enlargement of cerebral ventricles is a well-validated finding in patients suffering from schizophrenia.
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This question is part of the following fields:
- Psychiatry
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Question 3
Incorrect
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Sarah is a 30-year-old teacher who has been referred to the mental health team with suspected bipolar disorder. The psychiatrist has confirmed the diagnosis and prescribed lithium, which has stabilized her condition. They have requested that you take over the monitoring of her medication levels. When you call Sarah to advise her on when to have her lithium levels checked, she cannot recall the specific timing related to her medication. How would you recommend that her medication levels be monitored?
Your Answer: Blood test 12 hours post dose every month
Correct Answer: Blood test 12 hours post dose every 3 months
Explanation:According to NICE, lithium levels should be checked one week after starting treatment, one week after any dose changes, and weekly until stable levels are achieved. Once stable levels are reached, lithium levels should be checked every 3 months, with the sample taken 12 hours after the dose. It is important to note that a trough level taken immediately before a dose is only applicable for certain medications, such as twice-daily clozapine.
Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in treatment-resistant depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. The mechanism of action is not fully understood, but it is believed to interfere with inositol triphosphate and cAMP formation. Adverse effects may include nausea, vomiting, diarrhea, fine tremors, nephrotoxicity, thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, hyperparathyroidism, and hypercalcemia.
Monitoring of patients taking lithium is crucial to prevent adverse effects and ensure therapeutic levels. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until levels are stable. Once established, lithium levels should be checked every three months. Thyroid and renal function should be monitored every six months. Patients should be provided with an information booklet, alert card, and record book to ensure proper management of their medication. Inadequate monitoring of patients taking lithium is common, and guidelines have been issued to address this issue.
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This question is part of the following fields:
- Psychiatry
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Question 4
Correct
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You are advising a 35-year-old woman with major depressive disorder who is contemplating electroconvulsive therapy (ECT).
What is a temporary side effect of this treatment?Your Answer: Cardiac arrhythmias
Explanation:Knowing the side effects of ECT is crucial as it is a treatment that is often viewed with apprehension by the public. ECT is typically used to treat depression that is resistant to other treatments, as well as severe mania and catatonic schizophrenia. While it was once a feared treatment due to its use of high strengths and lack of anesthesia, it is now considered to be a relatively safe intervention. Short-term side effects of ECT include headaches, nausea, memory problems, and cardiac arrhythmias. There are few long-term effects, although some patients may experience long-term memory issues. ECT is used to treat mania and is being studied as a potential treatment for Parkinson’s disease. It induces a generalized seizure but is not associated with epilepsy or glaucoma.
Electroconvulsive therapy (ECT) is a viable treatment option for patients who suffer from severe depression that does not respond to medication, such as catatonia, or those who experience psychotic symptoms. The only absolute contraindication for ECT is when a patient has raised intracranial pressure.
Short-term side effects of ECT include headaches, nausea, short-term memory impairment, memory loss of events prior to the therapy, and cardiac arrhythmia. However, these side effects are typically temporary and resolve quickly.
Long-term side effects of ECT are less common, but some patients have reported impaired memory. It is important to note that the benefits of ECT often outweigh the potential risks, and it can be a life-changing treatment for those who have not found relief from other forms of therapy.
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This question is part of the following fields:
- Psychiatry
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Question 5
Correct
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A 28-year-old patient presents to her doctor with symptoms of low mood and anhedonia. She has previously undergone cognitive behavioural therapy and art therapy, but with limited success. The doctor prescribes citalopram and refers her for additional talk therapy.
What medication should be avoided while taking citalopram?Your Answer: Rasagiline
Explanation:Combining SSRIs and MAOIs is not recommended due to the potential danger of developing serotonin syndrome.
Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.
The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.
When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.
When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.
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This question is part of the following fields:
- Psychiatry
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Question 6
Correct
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A 50-year-old woman presents with complaints of lower back pain, constipation, headaches, low mood, and difficulty concentrating. Which medication is most likely responsible for her symptoms?
Your Answer: Lithium
Explanation:Hypercalcaemia, which is indicated by the presented signs and symptoms, can be a result of long-term use of lithium. The mnemonic ‘stones, bones, abdominal moans, and psychic groans’ can be used to identify the symptoms. The development of hyperparathyroidism and subsequent hypercalcaemia is believed to be caused by lithium’s effect on calcium homeostasis, leading to parathyroid hyperplasia. To diagnose this condition, a U&Es and PTH test can be conducted. Unlike lithium, other psychotropic medications are not associated with the development of hyperparathyroidism and hypercalcaemia.
Lithium is a medication used to stabilize mood in individuals with bipolar disorder and as an adjunct in treatment-resistant depression. It has a narrow therapeutic range of 0.4-1.0 mmol/L and is primarily excreted by the kidneys. The mechanism of action is not fully understood, but it is believed to interfere with inositol triphosphate and cAMP formation. Adverse effects may include nausea, vomiting, diarrhea, fine tremors, nephrotoxicity, thyroid enlargement, ECG changes, weight gain, idiopathic intracranial hypertension, leucocytosis, hyperparathyroidism, and hypercalcemia.
Monitoring of patients taking lithium is crucial to prevent adverse effects and ensure therapeutic levels. It is recommended to check lithium levels 12 hours after the last dose and weekly after starting or changing the dose until levels are stable. Once established, lithium levels should be checked every three months. Thyroid and renal function should be monitored every six months. Patients should be provided with an information booklet, alert card, and record book to ensure proper management of their medication. Inadequate monitoring of patients taking lithium is common, and guidelines have been issued to address this issue.
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This question is part of the following fields:
- Psychiatry
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Question 7
Correct
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A 47-year-old woman presents complaining of ‘flashbacks’. Seven months earlier, she had been standing at a bus stop when a car swerved off the road into the queue, killing instantly a child standing near to her. Every day she experiences intrusive images of the child’s face as it saw the car mount the curb. She has not been able to go to that part of town since the day and she has avoided taking the bus anywhere. She feels she is always on edge and jumps at the slightest noise around the house. She thinks things are getting worse, rather than better, and asks you whether there are any psychological treatments that might help her.
Which one of the following approaches is indicated?Your Answer: Trauma-focused cognitive behavioural therapy (CBT)
Explanation:Treatment Options for Post-Traumatic Stress Disorder: Focus on Trauma-Focused CBT
Post-traumatic stress disorder (PTSD) is a delayed and/or prolonged response to a traumatic event that can cause distress in almost anyone. Symptoms include intrusive flashbacks, avoidance of trauma-related triggers, emotional numbness, and hypervigilance. Trauma-focused cognitive behavioural therapy (CBT) is the recommended first-line treatment for PTSD, according to the National Institute for Health and Care Excellence (NICE) in the United Kingdom. Other therapies, such as psychodynamic therapy, supportive therapy, and hypnotherapy, may be helpful but are not first-line approaches. Watchful waiting is only appropriate for mild symptoms present for less than a month. It is important to seek help for PTSD, and trauma-focused CBT is a proven effective treatment option.
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This question is part of the following fields:
- Psychiatry
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Question 8
Incorrect
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A 30-year-old female with a diagnosis of bipolar disorder visits her doctor to discuss a headache. She starts explaining her issue with the following statement:
I came here to talk about this headache, but I can't stop thinking about the dream I had last night where I was flying over a rainbow. It's funny because I haven't eaten pizza in a week, and I really miss it.
What sign of thought disorder is evident in the patient's speech?Your Answer: Clang associations
Correct Answer: Knight's move
Explanation:The patient’s speech is indicative of thought disorder characterized by Knight’s move thinking, where there are illogical leaps from one idea to another without any discernible links between them. This is different from flight of ideas, where there are identifiable connections between ideas. It is important to note that the patient is not exhibiting neologisms or clang associations, and their speech is not a word salad.
Thought disorders can manifest in various ways, including circumstantiality, tangentiality, neologisms, clang associations, word salad, Knight’s move thinking, flight of ideas, perseveration, and echolalia. Circumstantiality involves providing excessive and unnecessary detail when answering a question, but eventually returning to the original point. Tangentiality, on the other hand, refers to wandering from a topic without returning to it. Neologisms are newly formed words, often created by combining two existing words. Clang associations occur when ideas are related only by their similar sounds or rhymes. Word salad is a type of speech that is completely incoherent, with real words strung together into nonsensical sentences. Knight’s move thinking is a severe form of loosening of associations, characterized by unexpected and illogical leaps from one idea to another. Flight of ideas is a thought disorder that involves jumping from one topic to another, but with discernible links between them. Perseveration is the repetition of ideas or words despite attempts to change the topic. Finally, echolalia is the repetition of someone else’s speech, including the question that was asked.
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This question is part of the following fields:
- Psychiatry
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Question 9
Correct
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A 16-year-old is brought to her General Practitioner by her parents after they noticed her eating habits had become irregular. The parents report that the patient eats large volumes of foods and is sometimes found vomiting shortly after eating dinner. This behaviour has been occurring for the past 6 months. On examination, the patient’s vital signs are normal and she has a body mass index (BMI) of 23. She has excoriations on the knuckles of her right hand. She also has erosions on her teeth and swelling bilaterally on the lateral aspects of the face along the mandibular rami.
What is the most likely diagnosis?Your Answer: Bulimia nervosa
Explanation:Common Mental Health Disorders: Symptoms and Characteristics
Bulimia Nervosa
Bulimia nervosa is an eating disorder characterized by binge eating followed by purging, usually in the form of vomiting. Patients with bulimia nervosa often have normal BMI, despite purging behavior. Symptoms associated with vomiting include teeth erosion, swelling along the mandibular rami (parotitis), and excoriations of the knuckles (Russell’s sign).Avoidant Personality Disorder
Avoidant personality disorder is characterized by a person who desires social connections but is too shy to form relationships due to fear of rejection. This is different from the schizoid personality, which prefers to be alone.Anorexia Nervosa
Anorexia nervosa is associated with decreased dietary intake, with or without purging behavior. Patients with anorexia nervosa tend to have extremely low BMI due to low calorie intake. They also suffer from early osteoporosis and electrolyte abnormalities due to malnutrition.Binge Eating Disorder
Binge eating disorder is characterized by purely binge eating, without purging behavior. Patients with binge eating disorder often experience distress and weight gain.Gender Dysphoria
Gender dysphoria is characterized by a strong identification with a gender other than that assigned at birth. This can be managed through social transition (living as their preferred gender) or medical transition (hormone or surgical treatments that are gender-affirming).Understanding Common Mental Health Disorders
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This question is part of the following fields:
- Psychiatry
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Question 10
Incorrect
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A 36-year-old man with a known history of severe depression has been in hospital for the past year. He was diagnosed with depression at the age of 23 and has been on antidepressants since. He has had multiple self-harm and suicide attempts in the past. For the past year, he has been receiving treatment in hospital and has been making some progress with regard to his mental health. He is not happy to be in hospital, but the doctors thought that it was in his best interests to keep him in hospital for treatment. He has been under a Section which allowed him to be kept in hospital for six months. At the end of the first six months, the doctors applied for a second time for him to be kept for another six months, as they feel he is not yet fit for discharge.
For how long can the relevant Section be renewed for this patient for the third time?Your Answer: Six months
Correct Answer: One year
Explanation:Understanding the Time Limits of Mental Health Detention in the UK
In the UK, mental health detention is governed by specific time limits depending on the type of detention and the purpose of the detention. Here are some of the key time limits to be aware of:
– Section 2: This is the Section used for assessment, and a patient can be kept in hospital for a maximum of 28 days under this Section. It cannot be extended.
– Section 3: This is the Section used for treatment, and a patient can be detained for up to six months initially. The Section can be renewed for another six months, and then for one year at a time. Treatment without consent can be given for the first three months, and then only with the approval of an ‘approved second-opinion doctor’ for the next three months.
– Two years: While a patient can be kept in hospital for up to two years for treatment, Section 3 cannot be renewed for two years at a time. The patient can also be discharged earlier if the doctor thinks the patient is well enough.
– Six months: This is the time for which an initial Section 3 can be applied for and the time for which it can be renewed for a second time. For a third time and onwards, Section 3 can be renewed for one year each time, but the patient can be discharged earlier if doctors think it is not necessary for the patient to be under Section anymore.Understanding these time limits is important for both patients and healthcare professionals involved in mental health detention in the UK.
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This question is part of the following fields:
- Psychiatry
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Question 11
Incorrect
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A 29-year-old man with bipolar disorder presents at the psychiatric outpatients clinic. He has been stable on lamotrigine for the past six months but is now reporting symptoms of elevated mood. How can you differentiate between symptoms of mania and hypomania in this case?
Your Answer: Increased daytime energy levels despite reduced sleep
Correct Answer: Delusional beliefs of being the leader of their own kingdom
Explanation:Mania is a state of elevated mood that persists and is accompanied by psychotic symptoms.
Bipolar disorder is characterized by highs that can be classified into two categories: mania and hypomania. Mania is the more severe form, and it is diagnosed based on two criteria: a prolonged time course (hypomania lasts less than 7-10 days) and the presence of psychotic symptoms. These symptoms can include mood congruent hallucinations or delusional beliefs related to the patient’s elevated mood and feelings of superiority. Delusions of grandeur, such as the belief of owning a kingdom, are common.
Symptoms of elevated mood include increased energy, reduced sleep, rapid or pressured speech, pressured thought, and a non-reactive affect or mood. These symptoms are seen in both hypomania and mania.
Understanding Bipolar Disorder
Bipolar disorder is a mental health condition that is characterized by alternating periods of mania/hypomania and depression. It typically develops in the late teen years and has a lifetime prevalence of 2%. There are two recognized types of bipolar disorder: type I, which involves mania and depression, and type II, which involves hypomania and depression.
Mania and hypomania both refer to abnormally elevated mood or irritability, but mania is more severe and can include psychotic symptoms for 7 days or more. Hypomania, on the other hand, involves decreased or increased function for 4 days or more. The presence of psychotic symptoms suggests mania.
Management of bipolar disorder may involve psychological interventions specifically designed for the condition, as well as medication. Lithium is the mood stabilizer of choice, but valproate can also be used. Antipsychotic therapy, such as olanzapine or haloperidol, may be used to manage mania/hypomania, while fluoxetine is the antidepressant of choice for depression. It is important to address any co-morbidities, as there is an increased risk of diabetes, cardiovascular disease, and COPD in individuals with bipolar disorder.
If symptoms suggest hypomania, routine referral to the community mental health team (CMHT) is recommended. However, if there are features of mania or severe depression, an urgent referral to the CMHT should be made. Understanding bipolar disorder and its management is crucial for healthcare professionals to provide appropriate care and support for individuals with this condition.
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This question is part of the following fields:
- Psychiatry
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Question 12
Correct
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A 50-year-old man has been hospitalized following an overdose. What is the most significant indicator of an increased likelihood of future suicide?
Your Answer: Making plans before the overdose to avoid discovery
Explanation:Factors indicating high risk of suicide
The concealment of an overdose indicates a serious intent to complete suicide, more so than other options. However, a previous history of overdoses does not necessarily imply a more serious intent. Other factors that may suggest a higher risk of suicide include being male, elderly, and having a mental illness.
According to the Assessment of Suicide Risk clinical guide, protective factors against suicide include religious beliefs, social support, and being responsible for children. While being responsible for children is an important point to note in the management plan for a suicidal patient, it is not a factor that indicates a high risk of suicide.
It is crucial to identify the factors that suggest a high risk of suicide in order to provide appropriate care and management for the patient. However, it is also important to consider the patient’s wider circumstances and any protective factors that may be present. By taking a comprehensive approach, healthcare professionals can provide the best possible care for patients at risk of suicide.
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This question is part of the following fields:
- Psychiatry
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Question 13
Correct
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A 45-year-old woman who is currently an informal inpatient at a mental health hospital is being evaluated for electroconvulsive therapy (ECT), a treatment she has never undergone before. What is an appropriate indication for ECT?
Your Answer: Catatonia
Explanation:Electroconvulsive therapy is indicated for patients with treatment-resistant depression, as well as those experiencing manic episodes, moderate depression that has previously responded to ECT, and life-threatening catatonia. The Patient Health Questionnaire-9 (PHQ-9) is used by general practitioners to assess the severity of depression, with scores ranging from no depression to severe depression. However, the decision to pursue ECT is based on more than just the PHQ-9 score and requires a diagnosis of severe treatment-resistant depression.
Electroconvulsive therapy (ECT) is a viable treatment option for patients who suffer from severe depression that does not respond to medication, such as catatonia, or those who experience psychotic symptoms. The only absolute contraindication for ECT is when a patient has raised intracranial pressure.
Short-term side effects of ECT include headaches, nausea, short-term memory impairment, memory loss of events prior to the therapy, and cardiac arrhythmia. However, these side effects are typically temporary and resolve quickly.
Long-term side effects of ECT are less common, but some patients have reported impaired memory. It is important to note that the benefits of ECT often outweigh the potential risks, and it can be a life-changing treatment for those who have not found relief from other forms of therapy.
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This question is part of the following fields:
- Psychiatry
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Question 14
Correct
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A 28-year-old woman with a history of depression comes in 2 months postpartum with symptoms of low mood, lack of energy, and loss of pleasure for the past 3 weeks. She is currently breastfeeding. She has previously taken fluoxetine and found it effective but stopped during pregnancy. After a conversation, she has decided to resume her medication.
Which antidepressant would be the best choice to initiate treatment?Your Answer: Sertraline
Explanation:Understanding Postpartum Mental Health Problems
Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of more than 13 indicates a ‘depressive illness of varying severity’, with sensitivity and specificity of more than 90%. The questionnaire also includes a question about self-harm.
‘Baby-blues’ is seen in around 60-70% of women and typically occurs 3-7 days following birth. It is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Reassurance and support from healthcare professionals, particularly health visitors, play a key role in managing this condition. Most women with the baby blues will not require specific treatment other than reassurance.
Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features are similar to depression seen in other circumstances, and cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. Although these medications are secreted in breast milk, they are not thought to be harmful to the infant.
Puerperal psychosis affects approximately 0.2% of women and requires admission to hospital, ideally in a Mother & Baby Unit. Onset usually occurs within the first 2-3 weeks following birth, and features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). There is around a 25-50% risk of recurrence following future pregnancies. Paroxetine is recommended by SIGN because of the low milk/plasma ratio, while fluoxetine is best avoided due to a long half-life.
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This question is part of the following fields:
- Psychiatry
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Question 15
Correct
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A 38-year-old man presents to the Emergency Department complaining of epigastric pain. The patient reports that he developed acute abdominal pain 2 hours prior to presentation after eating a cheeseburger. The patient otherwise has no significant past medical history. He does not take any medications and denies smoking, alcohol consumption and drug use. He has been recently been released from prison and has not got stable living and has had to sleep outside since his release.
On examination, the patient has normal vital signs. His abdominal examination demonstrates normoactive bowel sounds, no tenderness to palpation in the epigastrium and no guarding or rebound tenderness. Rectal exam for stool occult blood is negative and a chest X-ray does not reveal free air under the diaphragm. A right upper quadrant ultrasound does not demonstrate stones. The doctor recommends antacids. When the doctor tells the patient that he is safe for discharge, the patient insists that he must be admitted to hospital for further tests.
Which of the following is the most likely diagnosis?Your Answer: Malingering
Explanation:Differentiating between Malingering, Factitious Disorder, Conversion Disorder, and Hypochondriasis
When a patient presents with physical symptoms but there are no physical or imaging signs of significant illness, the likely diagnosis is malingering. In such cases, it is important to investigate the patient’s history to see if there could be other factors impacting their symptoms. Malingering is often suspected when a patient insists on staying in the hospital despite negative test results.
Factitious disorder refers to a patient who assumes the sick role without any physical or organic disease. These patients find satisfaction in being taken care of and often seek frequent outpatient visits and psychotherapy.
Factitious or induced illness is similar to factitious disorder, but it involves a patient seeking the sick role vicariously through a second patient. For example, a mother suffering from factitious disorder may abuse her child so that she can bring the child to the doctor for treatment. The patient assumes the sick role by proxy through the child.
Conversion disorder refers to the manifestation of psychological illness as neurologic pathology. Patients with conversion disorder suffer from symptoms such as weakness, numbness, blindness, or paralysis as a result of underlying psychiatric illness. They are often not bothered by their symptoms, a condition known as la belle indifférence.
Hypochondriasis refers to the fear of having a medical illness despite negative tests and reassurance. It is not associated with secondary gain.
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This question is part of the following fields:
- Psychiatry
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Question 16
Correct
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A 28-year-old woman is brought to the Emergency Department after taking an overdose of paracetamol due to a recent breakup with her partner. She expresses remorse for her actions, denies any suicidal thoughts, and requests to be discharged. Her parents and a friend arrive at the hospital soon after. Paracetamol levels at 4 hours are below the treatment limit.
What should be the next course of action in managing her case?Your Answer: Arrange review by mental health liaison team prior to discharge
Explanation:Importance of Mental Health Liaison Team Review Prior to Discharge for Paracetamol Overdose Patients
Paracetamol overdose is a common presentation of self-harm in emergency departments. While medical management is crucial, patients may also require mental health support. A hospital-based mental health liaison team can provide advice on discharge and arrange follow-up if necessary. Discharging a patient without follow-up increases the risk of further self-harm. However, temporary compulsory detention under the Mental Health Act is not appropriate for low-risk patients. Prescribing N-acetyl-L-cysteine is unnecessary if the paracetamol levels are below treatment threshold. Emergency admission to an inpatient psychiatric unit is only necessary for high-risk patients. Therefore, mental health liaison team review prior to discharge is crucial for appropriate management of paracetamol overdose patients.
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This question is part of the following fields:
- Psychiatry
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Question 17
Correct
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You are a Foundation Year 2 doctor in Psychiatry. During the ward round, you are asked to perform a mental state examination of a patient who has been on the ward for a month.
In which part of the mental state examination would you report neologisms, pressure, or poverty?Your Answer: Speech
Explanation:Assessing Mental State: Key Components to Consider
When assessing a patient’s mental state, there are several key components to consider. These include speech rate, rhythm, and volume, as well as the presence of neologisms, which may indicate a thought disorder. Poverty of speech may suggest reduced speech content, often seen in depression, while pressure of speech may indicate an increased rate, often seen in mania.
Insight is another important factor to consider, as it reflects the patient’s understanding of their condition and their willingness to accept treatment. Under the heading of Appearance and behaviour, it is important to note the patient’s level of self-care, rapport, and any non-verbal cues. Abnormal movements and level of motor activity should also be observed.
Mood and affect are subjective and objective measures of the patient’s emotional state. Mood refers to the patient’s internal experience, while affect refers to the external manifestation of that emotion. Thought content should also be assessed, including any preoccupations, obsessions, overvalued ideas, ideas of reference, delusions, or suicidal thoughts. By considering these key components, clinicians can gain a comprehensive understanding of a patient’s mental state.
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This question is part of the following fields:
- Psychiatry
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Question 18
Correct
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What is the mechanism of action of venlafaxine for elderly patients?
Your Answer: Serotonin and noradrenaline reuptake inhibitor
Explanation:The mechanism of action of venlafaxine involves inhibiting the reuptake of both serotonin and noradrenaline, making it a type of antidepressant known as a serotonin and noradrenaline reuptake inhibitor. When choosing an antidepressant, factors such as patient preference, previous sensitization, overdose risk, and cost should be considered, although SSRIs are typically the first-line treatment due to their favorable risk-to-benefit ratio.
Understanding Serotonin and Noradrenaline Reuptake Inhibitors
Serotonin and noradrenaline reuptake inhibitors (SNRIs) are a type of antidepressant medication that work by increasing the levels of serotonin and noradrenaline in the brain. These neurotransmitters are responsible for regulating mood, emotions, and anxiety levels. By inhibiting the reuptake of these chemicals, SNRIs help to maintain higher levels of serotonin and noradrenaline in the synaptic cleft, which can lead to improved mood and reduced anxiety.
Examples of SNRIs include venlafaxine and duloxetine, which are commonly used to treat major depressive disorders, generalised anxiety disorder, social anxiety disorder, panic disorder, and menopausal symptoms. These medications are relatively new and have been found to be effective in treating a range of mental health conditions. SNRIs are often preferred over other types of antidepressants because they have fewer side effects and are less likely to cause weight gain or sexual dysfunction.
Overall, SNRIs are an important class of medication that can help to improve the lives of people struggling with mental health conditions. By increasing the levels of serotonin and noradrenaline in the brain, these medications can help to regulate mood and reduce anxiety, leading to a better quality of life for those who take them.
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This question is part of the following fields:
- Psychiatry
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Question 19
Incorrect
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A 38-year-old woman, who lived alone, scheduled a follow-up appointment with her GP. She had been self-isolating at home for several months due to the COVID-19 pandemic and continued to feel anxious about going out even after the lockdown was lifted.
Prior to the pandemic, she had experienced a traumatic event and was struggling with post-traumatic stress disorder (PTSD). She had also recently lost her job and was facing financial difficulties.
During a telephone consultation with her GP 4 weeks ago, she was diagnosed with moderate depression and referred for computerised cognitive behavioural therapy. She was also advised to increase her physical activity levels.
However, her mental health had since deteriorated, and she was experiencing difficulty sleeping, early morning awakening, and occasional thoughts of self-harm. She expressed reluctance to engage in one-to-one psychological treatments.
The GP discussed the next steps in managing her depression and PTSD.
What treatment options should be considered for this patient?Your Answer: Refer to the local crisis resolution team
Correct Answer: Commence citalopram
Explanation:For patients with ‘less severe’ depression, SSRIs are the recommended first-line antidepressant. However, in the case of a patient with moderate depression who is not responding well to low-level therapy and has refused psychological treatments, an antidepressant should be offered. While mirtazapine and venlafaxine are valid options, they are not considered first-line. NICE recommends considering the higher likelihood of patients stopping treatment with venlafaxine due to side effects and its higher cost compared to SSRIs, which are equally effective. Mirtazapine and venlafaxine are typically reserved as second-line agents when the response to an SSRI has been poor. NICE advises offering an SSRI first-line as they have fewer side effects than other antidepressants and are just as effective. In this patient’s case, referral to a crisis team is unlikely as he has not expressed any true suicidal plans or intent.
In 2022, NICE updated its guidelines on managing depression and now classifies it as either less severe or more severe based on a patient’s PHQ-9 score. For less severe depression, NICE recommends discussing treatment options with patients and considering the least intrusive and resource-intensive treatment first. Antidepressant medication should not be routinely offered as first-line treatment unless it is the patient’s preference. Treatment options for less severe depression include guided self-help, group cognitive behavioral therapy, group behavioral activation, individual CBT or BA, group exercise, group mindfulness and meditation, interpersonal psychotherapy, SSRIs, counseling, and short-term psychodynamic psychotherapy. For more severe depression, NICE recommends a shared decision-making approach and suggests a combination of individual CBT and an antidepressant as the preferred treatment option. Other treatment options for more severe depression include individual CBT or BA, antidepressant medication, individual problem-solving, counseling, short-term psychodynamic psychotherapy, interpersonal psychotherapy, guided self-help, and group exercise.
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This question is part of the following fields:
- Psychiatry
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Question 20
Incorrect
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A 25-year-old male is diagnosed with schizophrenia. He lives at home with his mother and two younger siblings. Although the patient has shown no signs of violence so far, his mother is very concerned for her own safety and that of her other two children. She wishes to discuss this with the psychiatry team.
Which of the following statements is true about the relationship between schizophrenia and violence?Your Answer: People with schizophrenia are under-represented in the perpetrators of homicide
Correct Answer: People with schizophrenia are responsible for about a twentieth of homicides in the UK
Explanation:The Complex Association Between Schizophrenia and Homicide in the UK
The relationship between mental illness, specifically schizophrenia, and violence is a complex and sensitive topic. While there have been high-profile cases of homicides committed by individuals with mental illness, it is important to keep this association in perspective. In fact, the vast majority of homicides in the UK are committed by individuals who are not mentally ill.
However, research from the National Confidential Inquiry into Suicides and Homicides by People with Mental Illness has found that individuals with schizophrenia are responsible for around 5% of homicides, compared to a population prevalence of around 1%. This over-representation suggests that there may be a connection between schizophrenia and violence.
It is important to note that this increased association with homicide is still relatively rare, with only around 30 homicides a year in the UK committed by individuals with schizophrenia. Additionally, the stigma surrounding mental illness should not be further perpetuated by this association.
In contrast, there is no significant association between obsessional-compulsive disorder (OCD) and violence. It is crucial to approach the topic of mental illness and violence with care and understanding, while also acknowledging the potential risks and challenges that individuals with schizophrenia may face.
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This question is part of the following fields:
- Psychiatry
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Question 21
Incorrect
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A 24-year-old man is brought into the emergency department by his friends. They report that for the past 6 days, he has not slept or eaten, and he believes that aliens are communicating with him through his phone.
During the examination, he speaks rapidly and loudly. When asked about his condition, he describes in detail what the aliens have been telling him, including the frequency and duration of the calls, as well as the tone and pitch of their voices. He also expresses feelings of anxiety and paranoia.
What type of thought disorder is present in this man?Your Answer: Flight of ideas
Correct Answer: Circumstantiality
Explanation:Circumstantiality is when a person provides excessive and unnecessary detail when answering a question. This can be a symptom of a manic episode, which is likely the case for this patient. The woman has been experiencing irrational thoughts for the past 5 days, which has resulted in a lack of sleep and eating. Her speech is loud and pressured, and she has a delusion that the government has given her a special mission to stop global warming. This delusion is a sign of a formal thought disorder, which is further demonstrated by her circumstantiality. She is unable to answer a question without providing excessive detail, such as describing the color of the television before finally expressing that she feels stressed. Echolalia, the repetition of someone else’s speech, is not observed in this woman. Flight of ideas, which involves accelerated speech and wandering ideas, is also not present. Knight’s move thinking, which involves poor associations to the previous topic, is also not observed.
Thought disorders can manifest in various ways, including circumstantiality, tangentiality, neologisms, clang associations, word salad, Knight’s move thinking, flight of ideas, perseveration, and echolalia. Circumstantiality involves providing excessive and unnecessary detail when answering a question, but eventually returning to the original point. Tangentiality, on the other hand, refers to wandering from a topic without returning to it. Neologisms are newly formed words, often created by combining two existing words. Clang associations occur when ideas are related only by their similar sounds or rhymes. Word salad is a type of speech that is completely incoherent, with real words strung together into nonsensical sentences. Knight’s move thinking is a severe form of loosening of associations, characterized by unexpected and illogical leaps from one idea to another. Flight of ideas is a thought disorder that involves jumping from one topic to another, but with discernible links between them. Perseveration is the repetition of ideas or words despite attempts to change the topic. Finally, echolalia is the repetition of someone else’s speech, including the question that was asked.
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This question is part of the following fields:
- Psychiatry
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Question 22
Correct
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A 65-year-old-male presents to his GP with a chief complaint of forgetfulness over the past 3 months. He reports difficulty recalling minor details such as where he parked his car and the names of acquaintances. He is a retired accountant and reports feeling bored and unstimulated. He also reports difficulty falling asleep at night. His MMSE score is 27 out of 30. When asked to spell WORLD backwards, he hesitates before correctly spelling the word. His medical history includes hyperlipidemia and osteoarthritis. What is the most likely diagnosis?
Your Answer: Depression
Explanation:The patient’s symptoms suggest pseudodementia caused by depression rather than dementia. Managing the depression should reverse the cognitive impairment.
Differentiating between Depression and Dementia
Depression and dementia are two conditions that can have similar symptoms, making it difficult to distinguish between the two. However, there are certain factors that can suggest a diagnosis of depression over dementia.
One of the key factors is the duration and onset of symptoms. Depression often has a short history and a rapid onset, whereas dementia tends to develop slowly over time. Additionally, biological symptoms such as weight loss and sleep disturbance are more commonly associated with depression than dementia.
Patients with depression may also express concern about their memory, but they are often reluctant to take tests and may be disappointed with the results. In contrast, patients with dementia may not be aware of their memory loss or may not express concern about it.
The mini-mental test score can also be variable in patients with depression, whereas in dementia, there is typically a global memory loss, particularly in recent memory.
In summary, while depression and dementia can have overlapping symptoms, careful consideration of the duration and onset of symptoms, biological symptoms, patient concerns, and cognitive testing can help differentiate between the two conditions.
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This question is part of the following fields:
- Psychiatry
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Question 23
Incorrect
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You are about to prescribe fluoxetine, a selective serotonin reuptake inhibitor (SSRI) to a 50-year-old man who has just started a new relationship. He asks about common side-effects.
Which of the below is a common side-effect that it would be most important to council this patient about?Your Answer: Sedation
Correct Answer: Sexual dysfunction
Explanation:Understanding the Side-Effects of SSRIs: Sexual Dysfunction, Constipation, Sedation, Urinary Retention, and Dry Mouth
Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for major depressive and generalized anxiety disorders. These drugs work by increasing serotonin concentration in the synaptic cleft, which stimulates post-synaptic neurons and improves mood. However, SSRIs can also cause several side-effects that patients should be aware of.
One of the most important side-effects to keep in mind is sexual dysfunction. Patients may feel uncomfortable discussing this issue, so it is important for healthcare providers to ask about it specifically. Sildenafil can be useful in treating this side-effect.
SSRIs can also cause gastrointestinal upset, including dyspepsia, nausea, abdominal pain, diarrhea, and constipation. However, given the patient’s age, it would be most appropriate to counsel regarding sexual dysfunction.
While SSRIs are associated with insomnia, restlessness, and general agitation, they are not typically associated with sedation. Urinary disorders can be associated with SSRIs, but they are more commonly seen with the use of tricyclic antidepressants. Dry mouth is a common side-effect of SSRIs, but it is less important to counsel patients about than sexual dysfunction.
In summary, patients taking SSRIs should be aware of the potential side-effects, including sexual dysfunction, gastrointestinal upset, insomnia, urinary disorders, and dry mouth. Healthcare providers should ask about sexual dysfunction specifically and provide appropriate treatment options.
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This question is part of the following fields:
- Psychiatry
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Question 24
Correct
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Sarah, a 15-year-old girl is brought to the GP by her father as Sarah has not had her first period. She is 1.50m tall and weighs 40 Kg. Her heart rate is 60 beats per minute. Blood pressure is 120/90 mmHg. She has not developed any secondary sexual characteristics. There is a strong family history of eating disorder. You suspect that the delayed puberty may be due to anorexia nervosa.
What evidence supports the diagnosis of anorexia nervosa in Sarah?Your Answer: Lanugo hair
Explanation:The presence of lanugo hair, which is fine and downy hair that grows in response to body fat loss, can be a characteristic physical finding that supports the diagnosis of anorexia nervosa. However, this should be considered alongside other features such as the failure of secondary sexual characteristics, bradycardia, cold intolerance, and a yellow tinge on the skin (hypercarotenaemia). Anosmia is not typically associated with anorexia nervosa, but it may be relevant in patients with Kallmann syndrome, which involves anosmia and delayed or absent puberty. Hirsutism, which is excessive hair growth, is indicative of elevated testosterone levels and is not compatible with anorexia nervosa. Hyperkalaemia is an incorrect feature, as hypokalaemia is the most common electrolyte abnormality in anorexia. Patients with anorexia nervosa often have high cholesterol levels in their blood.
Characteristics of Anorexia Nervosa
Anorexia nervosa is a disorder that is characterized by a number of clinical signs and physiological abnormalities. The most notable feature of this disorder is a reduced body mass index, which is often accompanied by bradycardia and hypotension. In addition, individuals with anorexia nervosa may experience enlarged salivary glands, which can cause discomfort and difficulty swallowing.
Physiological abnormalities associated with anorexia nervosa include hypokalaemia, which is a deficiency of potassium in the blood, as well as low levels of FSH, LH, oestrogens, and testosterone. Individuals with anorexia nervosa may also have raised levels of cortisol and growth hormone, impaired glucose tolerance, hypercholesterolaemia, hypercarotinaemia, and low T3.
Overall, anorexia nervosa is a complex disorder that can have a significant impact on an individual’s physical and emotional well-being. It is important for individuals who are struggling with this disorder to seek professional help in order to receive the support and treatment they need to recover.
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This question is part of the following fields:
- Psychiatry
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Question 25
Correct
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A 42-year-old man visits his doctor's office and reports that his partner of many years passed away recently. He shares that when he woke up this morning, he believed he was lying next to her and heard her voice calling his name. Despite knowing that this is impossible, it has caused him considerable anguish. He is concerned that he may be losing his mind. He has no other significant psychiatric history.
What is the probable diagnosis?Your Answer: Pseudohallucination
Explanation:Pseudohallucinations, which are characterized by the patient’s awareness that the voice or feeling is coming from their own mind, are not indicative of psychosis or serious psychiatric conditions. This makes schizophrenia and other psychotic options less likely, and there are no signs of schizoid personality disorder in the patient. Pseudohallucinations are often observed in individuals who have experienced bereavement.
Understanding Pseudohallucinations
Pseudohallucinations are false sensory perceptions that occur in the absence of external stimuli, but with the awareness that they are not real. While not officially recognized in the ICD 10 or DSM-5, there is a general consensus among specialists about their definition. Some argue that it is more helpful to view hallucinations on a spectrum, from mild sensory disturbances to full-blown hallucinations, to avoid misdiagnosis or mistreatment.
One example of a pseudohallucination is a hypnagogic hallucination, which occurs during the transition from wakefulness to sleep. These vivid auditory or visual experiences are fleeting and can happen to anyone. It is important to reassure patients that these experiences are normal and do not necessarily indicate the development of a mental illness.
Pseudohallucinations are particularly common in people who are grieving. Understanding the nature of these experiences can help healthcare professionals provide appropriate support and reassurance to those who may be struggling with them. By acknowledging the reality of pseudohallucinations and their potential impact on mental health, we can better equip ourselves to provide compassionate care to those who need it.
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This question is part of the following fields:
- Psychiatry
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Question 26
Incorrect
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Which statement about the causation and dynamics of schizophrenia is accurate?
Your Answer: In monozygotic twins the risk of the second twin developing schizophrenia if the first is affected is of the order of 10%
Correct Answer: Schizophrenia is commoner in individuals not in stable relationships
Explanation:Schizophrenia Risk Factors
Schizophrenia is a mental disorder that affects a person’s ability to think, feel, and behave clearly. The risk of developing schizophrenia is influenced by various factors, including heavy cannabis use, marital status, socioeconomic status, and genetics.
According to the Swedish conscript study, heavy cannabis users have a sevenfold increase in the risk of developing schizophrenia. However, it is unclear whether cannabis use directly causes schizophrenia or if there are other underlying factors at play.
Marital status also appears to be a factor in schizophrenia risk, with unmarried and divorced individuals being twice as likely to develop the disorder compared to married or widowed individuals. This may be due to the alienating effects of schizophrenia rather than any causal relationship with being single.
Additionally, people with schizophrenia are more likely to be in the lowest socioeconomic groups. While poverty may not directly cause schizophrenia, it may increase the risk of exposure to biological factors or social stressors that could trigger the illness in susceptible individuals.
Finally, genetics also play a significant role in schizophrenia risk, with monozygotic twins having a 50% concordance rate and 10% of offspring being affected. This suggests a strong inheritance component to the disorder.
Overall, while the exact causes of schizophrenia are not fully understood, it is clear that multiple factors contribute to its development.
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This question is part of the following fields:
- Psychiatry
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Question 27
Correct
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A 25-year-old man has been admitted to the psychiatric ward due to concerns from his GP about experiencing symptoms of psychosis. The psychiatric team is contemplating a diagnosis of schizophrenia. What aspect of his medical history would be most indicative of this diagnosis?
Your Answer: Insomnia
Explanation:Schizophrenia is often accompanied by disruptions in circadian rhythm, which can lead to sleep problems such as insomnia. However, low appetite, psoriasis, and foreign travel are not typically linked to this condition. While a family history of certain psychiatric disorders may increase the likelihood of schizophrenia, a family history of Alzheimer’s does not pose a significant risk factor.
Schizophrenia is a mental disorder that is characterized by various symptoms. Schneider’s first rank symptoms are divided into four categories: auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions. Auditory hallucinations can include hearing two or more voices discussing the patient in the third person, thought echo, or voices commenting on the patient’s behavior. Thought disorders can involve thought insertion, thought withdrawal, or thought broadcasting. Passivity phenomena can include bodily sensations being controlled by external influence or actions/impulses/feelings that are imposed on the individual or influenced by others. Delusional perceptions involve a two-stage process where a normal object is perceived, and then there is a sudden intense delusional insight into the object’s meaning for the patient.
Other features of schizophrenia include impaired insight, incongruity/blunting of affect (inappropriate emotion for circumstances), decreased speech, neologisms (made-up words), catatonia, and negative symptoms such as incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), and avolition (poor motivation). It is important to note that schizophrenia can manifest differently in each individual, and not all symptoms may be present.
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This question is part of the following fields:
- Psychiatry
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Question 28
Incorrect
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A 20-year-old female has presented to the emergency department with a history of diarrhoea for the past week. She denies any blood in her stool or exposure to infectious agents. The patient reports feeling more fatigued and sleeping more than usual.
The patient has a history of depression and was prescribed sertraline. However, she stopped taking the medication two weeks ago as she felt she no longer needed it. Her mental state is currently stable and euthymic.
During the general examination, the patient's pupils are noted to be bilaterally dilated, which was also observed during her childhood. What is the most likely feature in this patient that is a result of discontinuing her medication?Your Answer: Hypersomnia
Correct Answer: Diarrhoea
Explanation:Diarrhoea is the correct answer as the patient’s protracted diarrhoea, abdominal cramping, and vomiting are common symptoms of SSRI discontinuation syndrome, which she stopped taking two weeks prior to her presentation. Occam’s razor suggests that this syndrome is more likely than inflammatory bowel disease or gastroenteritis, given the timeline and normal blood results. Euthymia is incorrect as SSRI discontinuation syndrome more commonly results in mood changes, and hypersomnia is incorrect as insomnia is more commonly seen. Generalised weakness is also incorrect as it is likely due to diarrhoea, and there are no focal neurology symptoms to suggest otherwise. Additionally, SSRI discontinuation syndrome can result in paraesthesias rather than a general feeling of fatigue and weakness.
Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.
The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.
When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.
When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.
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This question is part of the following fields:
- Psychiatry
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Question 29
Incorrect
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A 35-year-old woman presents to her general practitioner complaining of a backache that has persisted for the last two weeks. The doctor diagnoses her with a muscle strain and recommends rest with paracetamol for pain as needed. The patient requested narcotic pain medicine, but the doctor refused to prescribe the drug because she thought a medicine of that strength was unnecessary. The patient left the examination room angrily and yelled at the reception staff on her way out.
Which of the following defence mechanisms was the patient demonstrating?Your Answer: Splitting
Correct Answer: Displacement
Explanation:Defense Mechanisms in Psychology
Defense mechanisms are psychological strategies that individuals use to cope with stressful situations or emotions. These mechanisms can be conscious or unconscious and can be adaptive or maladaptive. Here are some common defense mechanisms:
Displacement: This occurs when a person redirects their emotions or impulses from the original source to a neutral or innocent person or object.
Projection: This is when a person attributes their own unacceptable thoughts or feelings to someone else.
Denial: This is when a person refuses to accept reality or a diagnosis, often to avoid the pain or discomfort associated with it.
Fixation: This is when a person becomes overly focused on a particular thought, idea, or object as a way of coping with stress.
Splitting: This is a characteristic of borderline personality disorder, where a person sees others as either all good or all bad, and may switch between these views rapidly.
Understanding these defense mechanisms can help individuals recognize when they are using them and work towards more adaptive coping strategies.
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This question is part of the following fields:
- Psychiatry
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Question 30
Incorrect
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Sarah is a 38-year-old female who was diagnosed with post-traumatic stress disorder (PTSD) following a car accident two years ago. Similar to Steven, Sarah has been experiencing difficulty with sleep since the accident. She frequently wakes up in the middle of the night due to nightmares and struggles to fall back asleep. This has been affecting her daily life as she no longer has the energy to keep up with her young children.
Sarah has undergone several sessions of cognitive behavioural therapy (CBT), but unfortunately, she has not seen any significant improvement in her symptoms.
What would be the appropriate medication to manage Sarah's condition?Your Answer: Zopiclone
Correct Answer: Venlafaxine
Explanation:If CBT or EMDR therapy prove ineffective in treating PTSD, the recommended first-line drug treatments are venlafaxine or a SSRI. Tricyclic antidepressants like amitriptyline may also be used under the supervision of a mental health specialist, but they are not currently part of NICE guidance. Diazepam and zopiclone are only recommended for short-term management of severe symptoms or acute exacerbations of insomnia, and do not address the underlying cause of PTSD. Risperidone may be considered for patients with disabling symptoms or behaviors that have not responded to other treatments.
Understanding Post-Traumatic Stress Disorder (PTSD)
Post-traumatic stress disorder (PTSD) is a mental health condition that can develop in individuals of any age following a traumatic event. This can include experiences such as natural disasters, accidents, or even childhood abuse. PTSD is characterized by a range of symptoms, including re-experiencing the traumatic event through flashbacks or nightmares, avoidance of situations or people associated with the event, hyperarousal, emotional numbing, depression, and even substance abuse.
Effective management of PTSD involves a range of interventions, depending on the severity of the symptoms. Single-session interventions are not recommended, and watchful waiting may be used for mild symptoms lasting less than four weeks. Military personnel have access to treatment provided by the armed forces, while trauma-focused cognitive behavioral therapy (CBT) or eye movement desensitization and reprocessing (EMDR) therapy may be used in more severe cases.
It is important to note that drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used, venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline, should be tried. In severe cases, NICE recommends that risperidone may be used. Overall, understanding the symptoms and effective management of PTSD is crucial in supporting individuals who have experienced traumatic events.
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This question is part of the following fields:
- Psychiatry
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