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Question 1
Correct
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What is the ratio of the risk of stroke within a 3 year period for high-risk psychiatric patients taking the new oral antithrombotic drug compared to those taking warfarin, based on the given data below? Number who had a stroke within a 3 year period vs Number without stroke New drug: 10 vs 190 Warfarin: 10 vs 490
Your Answer: 2.5
Explanation:The relative risk (RR) of the event of interest in the exposed group compared to the unexposed group is 2.5.
RR = EER / CER
EER = 10 / 200 = 0.05
CER = 10 / 500 = 0.02
RR = EER / CER
= 0.05 / 0.02 = 2.5This means that the exposed group has a 2.5 times higher risk of experiencing the event compared to the unexposed group.
Measures of Effect in Clinical Studies
When conducting clinical studies, we often want to know the effect of treatments of exposures on health outcomes. Measures of effect are used in randomized controlled trials (RCTs) and include the odds ratio (of), risk ratio (RR), risk difference (RD), and number needed to treat (NNT). Dichotomous (binary) outcome data are common in clinical trials, where the outcome for each participant is one of two possibilities, such as dead of alive, of clinical improvement of no improvement.
To understand the difference between of and RR, it’s important to know the difference between risks and odds. Risk is a proportion that describes the probability of a health outcome occurring, while odds is a ratio that compares the probability of an event occurring to the probability of it not occurring. Absolute risk is the basic risk, while risk difference is the difference between the absolute risk of an event in the intervention group and the absolute risk in the control group. Relative risk is the ratio of risk in the intervention group to the risk in the control group.
The number needed to treat (NNT) is the number of patients who need to be treated for one to benefit. Odds are calculated by dividing the number of times an event happens by the number of times it does not happen. The odds ratio is the odds of an outcome given a particular exposure versus the odds of an outcome in the absence of the exposure. It is commonly used in case-control studies and can also be used in cross-sectional and cohort study designs. An odds ratio of 1 indicates no difference in risk between the two groups, while an odds ratio >1 indicates an increased risk and an odds ratio <1 indicates a reduced risk.
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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 2
Incorrect
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Who among these psychosurgeons received the Nobel Prize in medicine?
Your Answer: Kluver and Bucy
Correct Answer: Moniz
Explanation:The History of Psychosurgery
Psychosurgery, the surgical treatment of mental illness, has a long and controversial history. The modern era of psychosurgery began in the late 19th century with the pioneering work of Swiss neurosurgeon Burckhardt, who removed areas of cortex from the frontal and parietal regions of six patients.
In 1910, Russian neurosurgeon Puseep ablated the frontoparietal tracts of three bipolar patients. However, it was Egas Moniz who refined psychosurgical techniques and was awarded the Nobel Prize for Medicine in 1949 for his work in the treatment of psychiatric disorders.
American neurosurgeon Freeman also developed similar procedures and advocated for psychosurgery as a first-line treatment for mental illness. Luver and Bucy described the effect of temporal lobectomy on aggression, further advancing the field of psychosurgery. Despite its controversial history, psychosurgery continues to be used today in select cases as a treatment option for severe mental illness.
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This question is part of the following fields:
- Organisation And Delivery Of Psychiatric Services
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Question 3
Incorrect
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The Diagnostic Project between the UK and US revealed that the increased prevalence of schizophrenia in New York, as opposed to London, was due to what factor?
Your Answer: Reverse causality
Correct Answer: Bias
Explanation:The US-UK Diagnostic Project found that the higher rates of schizophrenia in New York were due to diagnostic bias, as US psychiatrists used broader diagnostic criteria. However, the use of standardised clinical interviews and operationalised diagnostic criteria greatly reduced the variability of both incidence and prevalence rates of schizophrenia. This was demonstrated in a study by Sartorius et al. (1986) which examined early manifestations and first-contact incidence of schizophrenia in different cultures.
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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 4
Incorrect
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NICE has made a recommendation for the treatment of antisocial personality disorder, but the specific recommendation is not provided in the given information.
Your Answer: Dialectic behavioural therapy
Correct Answer: Group based cognitive interventions
Explanation:NICE suggests that individuals with antisocial personality disorder, including those who struggle with substance misuse, who are receiving care in community and mental health services, should be offered group-based cognitive and behavioural interventions. These interventions aim to tackle issues such as impulsivity, interpersonal challenges, and antisocial behaviour.
Personality Disorder (Antisocial / Dissocial)
Antisocial personality disorder is characterized by impulsive, irresponsible, and often criminal behavior. The criteria for this disorder differ somewhat between the ICD-11 and DSM-5. The ICD-11 abolished all categories of personality disorder except for a general description of personality disorder. This diagnosis can be further specified as “mild,” “moderate,” of “severe.” Patient behavior can be described using one of more of five personality trait domains; negative affectivity, dissociality, anankastic, detachment, and disinhibition. Clinicians may also specify a borderline pattern qualifier.
The core feature of dissociality is a disregard for the rights and feelings of others, encompassing both self-centeredness and lack of empathy. Common manifestations of Dissociality include self-centeredness and lack of empathy. The DSM-5 defines antisocial personality disorder as a pervasive pattern of disregard for and violation of the rights of others, occurring since age 15, as indicated by three (of more) of the following: failure to conform to social norms with respect to lawful behaviors, deceitfulness, impulsivity of failure to plan ahead, irritability and aggressiveness, reckless disregard for safety of self of others, consistent irresponsibility, and lack of remorse.
Prevalence estimates are between 1%-6% in men and between 0.2-0.8% in women. Antisocial behaviors typically have their onset before age 8 years. Nearly 80% of people with ASPD developed their first symptom by age 11 years. Boys develop symptoms earlier than girls, who may not develop symptoms until puberty. An estimated 25% of girls and 40% of boys with Conduct Disorder will later meet criteria for ASPD.
The 2009 NICE Guidelines essentially make two recommendations on treatment: consider offering group-based cognitive and behavioral interventions and pharmacological interventions should not be routinely used for the treatment of antisocial personality disorder of associated behaviors of aggression, anger, and impulsivity. A Cochrane review found that there is not enough good quality evidence to recommend of reject any psychological treatment for people with a diagnosis of AsPD.
The term psychopathy has varied meanings. Some use the term synonymously with APD and consider it to represent the severe end of the spectrum of APD. Others maintain a clear distinction between psychopathy and APD. Psychopathy has been said to be a richer (broader) concept than APD. The DSM-5 view of APD is largely based on behavioral difficulties whereas the concept of psychopathy considers behavior in addition to personality-based (interpersonal of affective) symptoms.
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This question is part of the following fields:
- Forensic Psychiatry
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Question 5
Correct
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What is the most consistently identified risk factor for the development of schizophrenia?
Your Answer: Family history
Explanation:A family history of schizophrenia is the most significant and extensively documented risk factor associated with the onset of the disorder.
Schizophrenia: Understanding the Risk Factors
Social class is a significant risk factor for schizophrenia, with people of lower socioeconomic status being more likely to develop the condition. Two hypotheses attempt to explain this relationship, one suggesting that environmental exposures common in lower social class conditions are responsible, while the other suggests that people with schizophrenia tend to drift towards the lower class due to their inability to compete for good jobs.
While early studies suggested that schizophrenia was more common in black populations than in white, the current consensus is that there are no differences in rates of schizophrenia by race. However, there is evidence that rates are higher in migrant populations and ethnic minorities.
Gender and age do not appear to be consistent risk factors for schizophrenia, with conflicting evidence on whether males of females are more likely to develop the condition. Marital status may also play a role, with females with schizophrenia being more likely to marry than males.
Family history is a strong risk factor for schizophrenia, with the risk increasing significantly for close relatives of people with the condition. Season of birth and urban versus rural place of birth have also been shown to impact the risk of developing schizophrenia.
Obstetric complications, particularly prenatal nutritional deprivation, brain injury, and influenza, have been identified as significant risk factors for schizophrenia. Understanding these risk factors can help identify individuals who may be at higher risk for developing the condition and inform preventative measures.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 6
Incorrect
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What is a true statement about vigabatrin?
Your Answer: The risk of visual loss is not dose related
Correct Answer: Vision loss can worsen despite discontinuation
Explanation:Vigabatrin has the potential to cause permanent visual field constriction, leading to tunnel vision and disability. It may also harm the central retina and reduce visual acuity. The risk of vision loss increases with higher doses and prolonged use. The onset of vision loss is unpredictable and can occur shortly after starting treatment of at any point during treatment, even after several months of years. Unfortunately, once vision loss is detected, it cannot be reversed.
Antiepileptic drugs (AEDs) are commonly used for the treatment of epilepsy, but many of them also have mood stabilizing properties and are used for the prophylaxis and treatment of bipolar disorder. However, some AEDs carry product warnings for serious side effects such as hepatic failure, pancreatitis, thrombocytopenia, and skin reactions. Additionally, some AEDs have been associated with an increased risk of suicidal behavior and ideation.
Behavioral side-effects associated with AEDs include depression, aberrant behaviors, and the development of worsening of irritability, impulsivity, anger, hostility, and aggression. Aggression can occur before, after, of in between seizures. Some AEDs are considered to carry a higher risk of aggression, including levetiracetam, perampanel, and topiramate. However, data on the specific risk of aggression for other AEDs is lacking of mixed. It is important for healthcare providers to carefully consider the potential risks and benefits of AEDs when prescribing them for patients with epilepsy of bipolar disorder.
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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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What is the lowest amount of olanzapine needed to effectively treat a patient experiencing their first episode of schizophrenia?
Your Answer: 5 mg
Explanation:Antipsychotics: Minimum Effective Doses
The Maudsley Guidelines provide a table of minimum effective oral doses for antipsychotics in schizophrenia. The following doses are recommended for first episode and relapse (multi-episode) cases:
– Chlorpromazine: 200mg (first episode) and 300mg (relapse)
– Haloperidol: 2mg (first episode) and 4mg (relapse)
– Sulpiride: 400mg (first episode) and 800mg (relapse)
– Trifluoperazine: 10mg (first episode) and 15mg (relapse)
– Amisulpride: 300mg (first episode) and 400mg (relapse)
– Aripiprazole: 10mg (first episode and relapse)
– Olanzapine: 5mg (first episode) and 7.5mg (relapse)
– Quetiapine: 150mg (first episode) and 300mg (relapse)
– Risperidone: 2mg (first episode) and 4mg (relapse)The minimum effective doses may vary depending on individual patient factors and response to treatment. It is important to consult with a healthcare professional before making any changes to medication dosages.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 8
Incorrect
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What is a correct statement about funnel plots?
Your Answer: They allow for the visual inspection of attrition bias
Correct Answer: Studies with a smaller standard error are located towards the top of the funnel
Explanation:Funnel plots are utilized in meta-analyses to visually display the potential presence of publication bias. However, it is important to note that an asymmetric funnel plot does not necessarily confirm the existence of publication bias, as other factors may contribute to its formation.
Stats Publication Bias
Publication bias refers to the tendency for studies with positive findings to be published more than studies with negative findings, leading to incomplete data sets in meta-analyses and erroneous conclusions. Graphical methods such as funnel plots, Galbraith plots, ordered forest plots, and normal quantile plots can be used to detect publication bias. Funnel plots are the most commonly used and offer an easy visual way to ensure that published literature is evenly weighted. The x-axis represents the effect size, and the y-axis represents the study size. A symmetrical, inverted funnel shape indicates that publication bias is unlikely, while an asymmetrical funnel indicates a relationship between treatment effect and study size, indicating either publication bias of small study 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 9
Correct
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What factors are known to contribute to false positive outcomes for cannabis on drug screening tests?
Your Answer: Efavirenz, promethazine, and ibuprofen
Explanation: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 10
Correct
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How would you rephrase the question to refer to the test's capacity to identify a person with a disease as positive?
Your Answer: Sensitivity
Explanation: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 11
Correct
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A 65-year-old patient on clozapine has a white blood cell count of 4 10^9/L. Which of the following does this correspond to?
Your Answer: This is a normal blood result
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 12
Correct
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Out of the options provided, which one is the least probable cause of postural hypotension?
Your Answer: Aripiprazole
Explanation:Antipsychotics: Common Side Effects and Relative Adverse Effects
Antipsychotics are medications used to treat various mental health conditions, including schizophrenia and bipolar disorder. However, they can also cause side effects that can be bothersome of even serious. The most common side effects of antipsychotics are listed in the table below, which includes the adverse effects associated with their receptor activity.
Antidopaminergic effects: These effects are related to the medication’s ability to block dopamine receptors in the brain. They can cause galactorrhoea, gynecomastia, menstrual disturbance, lowered sperm count, reduced libido, Parkinsonism, dystonia, akathisia, and tardive dyskinesia.
Anticholinergic effects: These effects are related to the medication’s ability to block acetylcholine receptors in the brain. They can cause dry mouth, blurred vision, urinary retention, and constipation.
Antiadrenergic effects: These effects are related to the medication’s ability to block adrenaline receptors in the body. They can cause postural hypotension and ejaculatory failure.
Histaminergic effects: These effects are related to the medication’s ability to block histamine receptors in the brain. They can cause drowsiness.
The Maudsley Guidelines provide a rough guide to the relative adverse effects of different antipsychotics. The table below summarizes their findings, with +++ indicating a high incidence of adverse effects, ++ indicating a moderate incidence, + indicating a low incidence, and – indicating a very low incidence.
Drug Sedation Weight gain Diabetes EPSE Anticholinergic Postural Hypotension Prolactin elevation
Amisulpride – + + + – – +++
Aripiprazole – +/- – +/- – – –
Asenapine + + +/- +/- – – +/-
Clozapine +++ +++ +++ – +++ +++ –
Flupentixol + ++ + ++ ++ + +++
Fluphenazine + + + +++ ++ + +++
Haloperidol + + +/- +++ + + +++
Olanzapine ++ +++ +++ +/- + + +
Paliperidone + ++ + + + ++ +++
Pimozide + + – + + + +++
Quetiapine ++ ++ ++ – + ++ –
Risperidone + ++ + + + ++ +++
Zuclopenthixol ++ ++ + ++ ++ + +++Overall, it is important to discuss the potential side effects of antipsychotics with a healthcare provider and to monitor for any adverse effects while taking these medications.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 13
Correct
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Based on the AUCs shown below, which screening test had the highest overall performance in differentiating between the presence of absence of bulimia?
Test - AUC
Test 1 - 0.42
Test 2 - 0.95
Test 3 - 0.82
Test 4 - 0.11
Test 5 - 0.67Your Answer: Test 2
Explanation:Understanding ROC Curves and AUC Values
ROC (receiver operating characteristic) curves are graphs used to evaluate the effectiveness of a test in distinguishing between two groups, such as those with and without a disease. The curve plots the true positive rate against the false positive rate at different threshold settings. The goal is to find the best trade-off between sensitivity and specificity, which can be adjusted by changing the threshold. AUC (area under the curve) is a measure of the overall performance of the test, with higher values indicating better accuracy. The conventional grading of AUC values ranges from excellent to fail. ROC curves and AUC values are useful in evaluating diagnostic and screening tools, comparing different tests, and studying inter-observer variability.
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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 14
Incorrect
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What is the most efficient medication for managing Parkinson's-related psychosis?
Your Answer: Aripiprazole
Correct Answer: Clozapine
Explanation:In Parkinson’s disease, only clozapine and quetiapine are appropriate antipsychotic medications, and if one is not well-tolerated, the other may be considered.
Parkinson’s Disease: Presentation, Aetiology, Medical Treatment, and Psychiatric Aspects
Parkinson’s disease is a degenerative disease of the brain that is characterised by motor symptoms such as rigidity, bradykinesia, and tremor. It has a long prodromal phase and early symptoms generally present asymmetrically. The tremor associated with Parkinson’s disease is classically described as ‘pill rolling’. The principle abnormality is the degeneration of dopaminergic neurons in the pars compacta of the substantia nigra, which leads to an accumulation of alpha-synuclein in these abnormal dopaminergic cells. The majority of cases of Parkinson’s disease are idiopathic, but single gene mutations occur in a minority of cases. Pesticide, herbicide, and heavy metal exposures are linked to an increased risk of Parkinson’s disease in some epidemiologic studies, whereas smoking and caffeine use are associated with decreased risks.
Treatment for Parkinson’s disease predominantly focuses on symptomatic relief with drugs aiming to either restore the level of dopamine in the striatum of to act on striatal postsynaptic dopamine receptors. However, as dopamine is not the only neurotransmitter involved in Parkinson’s disease, many other drugs are also being used to target specific symptoms, such as depression of dementia. Psychiatric symptoms are common in Parkinson’s disease and range from mild to severe. Factors associated with severe symptoms include age, sleep disturbance, dementia, and disease severity. Hallucinations are common in Parkinson’s disease and tend to be visual but can be auditory of tactile. In the majority of patients, psychotic symptoms are thought to be secondary to dopaminergic medication rather than due to the Parkinson’s disease itself. Anticholinergics and dopamine agonists seem to be associated with a higher risk of inducing psychosis than levodopa of catechol-O-methyltransferase inhibitors. Medications used for psychotic symptoms may worsen movement problems. Risperidone and the typicals should be avoided completely. Low dose quetiapine is the best tolerated. Clozapine is the most effective antipsychotic drug for treating psychosis in Parkinson’s disease but its use in clinical practice is limited by the need for monitoring and the additional physical risks.
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This question is part of the following fields:
- Old Age Psychiatry
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Question 15
Incorrect
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What is the Royal College of Psychiatrists' recommended maximum frequency for administering ECT, except in emergency situations?
Your Answer: Every other day
Correct Answer: Twice weekly
Explanation:The ECTAS Guidelines 2019 recommend a frequency of two times per week.
ECT (Treatment) – Summary of Effectiveness and Recommendations
ECT (Electroconvulsive Therapy) is a treatment that induces a therapeutic seizure through the application of electrical current under general anesthesia and muscle relaxation. It is prescribed as a course and is usually administered twice weekly for 6 to 12 treatments. ECT is the most effective short-term treatment for major depression, with remission rates of around 60-80% when used as first-line treatment in a severe depressive episode. However, without maintenance treatment, the relapse rate is extremely high (over 80%) in the 6 months after successful ECT.
Cognitive effects are the main limitation to the wider use of ECT, particularly acute confusion shortly after the treatment, retrograde amnesia, and some losses in autobiographical memory longer term. The current state of evidence does not allow the general use of ECT in the management of schizophrenia. Bilateral ECT is more effective than unilateral ECT but may cause more cognitive impairment. With unilateral ECT, a higher stimulus dose is associated with greater efficacy but also increased cognitive impairment compared with a lower stimulus dose.
NICE (National Institute for Health and Care Excellence) recommends that ECT is used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/of when the condition is considered to be potentially life-threatening. ECT is recommended for individuals with severe depression (that is life-threatening and when a rapid response is required, of when other treatments have failed), moderate depression (consider it if their depression has not responded to multiple drug treatments and psychological treatment), catatonia, and a prolonged of severe manic episode.
The RCPsych (Royal College of Psychiatrists) position on ECT recommends it as a first-line treatment for individuals with high suicidal risk, severe psychomotor retardation and associated problems of compromised eating and drinking and/of physical deterioration, treatment-resistant depression that has responded to ECT in a previous episode of illness, pregnant individuals with severe depression, of severe mixed affective states, mania of catatonia and whose physical health of that of the fetus is at serious risk, and those who prefer this form of treatment. ECT is recommended as a second-line treatment for individuals with treatment-resistant depression, severe side-effects from medication, and persistent of life-threatening symptoms in severe of prolonged mania. ECT is indicated in some circumstances for individuals with bipolar depression, postnatal psychosis, treatment-resistant schizophrenia, treatment-resistant catatonia, and frequent relapses and recurrences of depression (maintenance).
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This question is part of the following fields:
- Organisation And Delivery Of Psychiatric Services
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Question 16
Incorrect
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What is the recommended pharmacological intervention for insomnia in a pregnant woman, as advised by NICE?
Your Answer: Olanzapine
Correct Answer: Promethazine
Explanation:NICE recommends that promethazine may be considered for pregnant women experiencing insomnia, but only after non-medication options such as sleep hygiene measures and psychological interventions have been attempted. It is important to note that promethazine is licensed for sedation and not specifically for insomnia in pregnancy, except in cases where it is associated with urticaria of pruritus. Therefore, its use for insomnia in pregnancy would be considered off-label, although it is supported by NICE.
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 17
Correct
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A 35-year-old woman with a diagnosis of bipolar affective disorder has had four episodes of depression and one episode of hypomania over the past 12 months. What should be used as maintenance therapy?
Your Answer: Lithium monotherapy
Explanation:The patient is experiencing rapid cycling bipolar disorder, which NICE recommends managing similarly to conventional bipolar disorder. Lithium monotherapy is the preferred first-line treatment for long-term management, while valproate should be avoided due to the patient’s potential for childbearing.
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 18
Correct
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A pediatrician becomes interested in a newly identified and rare pediatric syndrome. They are interested to investigate if previous exposure to herpes viruses may put children at increased risk. Which of the following study designs would be most appropriate?
Your Answer: Case-control study
Explanation:Case-control studies are useful in studying rare diseases as it would be impractical to follow a large group of people for a long period of time to accrue enough incident cases. For instance, if a disease occurs very infrequently, say 1 in 1,000,000 per year, it would require following 1,000,000 people for ten years of 1000 people for 1000 years to accrue ten total cases. However, this is not feasible. Therefore, a case-control study provides a more practical approach to studying rare diseases.
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 19
Incorrect
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What is the correct approach to managing generalised anxiety disorder?
Your Answer: Self-help strategies should be based on the principles of DBT
Correct Answer: Suicidal thinking should be monitored weekly for the first month for all people under 30 prescribed SNRIs
Explanation:For individuals under 30 with GAD who are prescribed SSRIs of SNRIs, it is recommended to monitor their suicidal thoughts on a weekly basis during the first month. Non-facilitated self-help typically includes limited therapist interaction, such as brief phone calls lasting no more than 5 minutes.
Anxiety (NICE guidelines)
The NICE Guidelines on Generalised anxiety disorder and panic disorder were issued in 2011. For the management of generalised anxiety disorder, NICE suggests a stepped approach. For mild GAD, education and active monitoring are recommended. If there is no response to step 1, low-intensity psychological interventions such as CBT-based self-help of psychoeducational groups are suggested. For those with marked functional impairment of those who have not responded to step 2, individual high-intensity psychological intervention of drug treatment is recommended. Specialist treatment is suggested for those with very marked functional impairment, no response to step 3, self-neglect, risks of self-harm or suicide, of significant comorbidity. Benzodiazepines should not be used beyond 2-4 weeks, and SSRIs are first line. For panic disorder, psychological therapy (CBT), medication, and self-help have all been shown to be effective. Benzodiazepines, sedating antihistamines, of antipsychotics should not be used. SSRIs are first line, and if they fail, imipramine of clomipramine can be used. Self-help (CBT based) should be encouraged. If the patient improves with an antidepressant, it should be continued for at least 6 months after the optimal dose is reached, after which the dose can be tapered. If there is no improvement after a 12-week course, an alternative medication of another form of therapy should be offered.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 20
Correct
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A 16 year old girl comes to the clinic with her parents. They report a history of strange behaviors and social isolation for the past 18 months. During your examination, you observe hallucinations and delusions. She has a positive family history of schizophrenia. She was previously treated with olanzapine for 6 months, but it did not show any significant improvement. Currently, she is taking risperidone 5 mg twice daily for the past 10 weeks, but there is no noticeable improvement. What would be the appropriate course of action in this case?
Your Answer: Offer clozapine
Explanation:According to NICE guidance, clozapine should be offered to children and young people with schizophrenia if their illness has not responded adequately to at least two different antipsychotic drugs, each used for 6-8 weeks. The BNF (Children) recommends that risperidone can be used for children aged 12-17 years under expert supervision, with a starting dose of 2mg daily for day 1, followed by 4 mg daily for day 2, and a usual dose of 4-6 mg daily. Doses above 10 mg daily should only be used if the benefit is considered to outweigh the risk, and the maximum daily dose is 16mg. Slower titration may be appropriate for some patients.
Schizophrenia in children and young people is treated similarly to adults, according to the NICE Guidelines. The Maudsley Guidelines suggest avoiding first generation antipsychotics and using olanzapine, aripiprazole, and risperidone, which have been proven effective in randomized controlled trials. In cases where treatment resistance is present, clozapine should be considered.
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This question is part of the following fields:
- Child And Adolescent Psychiatry
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Question 21
Incorrect
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Which of the following behavioral signs is absent in individuals with semantic dementia?
Your Answer: Complex routines
Correct Answer: Reduced sociability
Explanation:FTD is more likely to impact social behavior, resulting in decreased sociability. Meanwhile, SD primarily affects conceptual knowledge.
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This question is part of the following fields:
- Old Age Psychiatry
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Question 22
Incorrect
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After a hospitalization for mania, a female patient with a history of hepatitis C presents with abnormal liver function. Which medication would be appropriate for long-term management of her mania?
Your Answer: Valproate
Correct Answer: Lithium
Explanation:Hepatic Impairment: Recommended Drugs
Patients with hepatic impairment may experience reduced ability to metabolize drugs, toxicity, enhanced dose-related side effects, reduced ability to synthesize plasma proteins, and elevated levels of drugs subject to first-pass metabolism due to reduced hepatic blood flow. The Maudsley Guidelines 14th Ed recommends the following drugs for patients with hepatic impairment:
Antipsychotics: Paliperidone (if depot required), Amisulpride, Sulpiride
Antidepressants: Sertraline, Citalopram, Paroxetine, Vortioxetine (avoid TCA and MAOI)
Mood stabilizers: Lithium
Sedatives: Lorazepam, Oxazepam, Temazepam, Zopiclone 3.75mg (with care)
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This question is part of the following fields:
- General Adult Psychiatry
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Question 23
Incorrect
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What is a true statement about Transient Global Amnesia?
Your Answer: Cognition is characteristically impaired during an attack
Correct Answer: Attacks are often precipitated by a Valsalva manoeuvres
Explanation:Transient global amnesia typically affects individuals aged 40 to 80 and can be triggered by physical activities such as swimming, heavy lifting, of straining to defecate, as well as psychological stressors like arguments. The condition is characterized by sudden onset of severe anterograde amnesia, accompanied by repetitive questioning, but without any focal neurological symptoms. Patients remain alert and attentive, but disoriented to time and place. Episodes usually last between 1 to 8 hours, but no longer than 24 hours. There is no specific treatment for a typical episode. During an episode, patients are unable to form new memories, resulting in profound anterograde amnesia, while retrograde amnesia may also be present, lasting from a few hours to years.
Transient Global Amnesia: Definition, Diagnostic Criteria, and Possible Causes
Transient global amnesia (TGA) is a clinical syndrome characterized by sudden and severe amnesia, often accompanied by repetitive questioning, that lasts for several hours. The term was first coined in 1964 by Fisher and Adams. To diagnose TGA, the following criteria have been established: (1) the attack must be witnessed, (2) there must be clear anterograde amnesia, (3) clouding of consciousness and loss of personal identity must be absent, (4) there should be no accompanying focal neurological symptoms, (5) epileptic features must be absent, (6) attacks must resolve within 24 hours, and (7) patients with recent head injury of known active epilepsy are excluded.
Epidemiological studies have shown that thromboembolic cerebrovascular disease does not play a role in the causation of TGA. However, the incidence of migraine in patients with TGA is higher than in the general population. A small minority of cases with unusually brief and recurrent attacks eventually manifest temporal lobe epilepsy. EEG recording is typically normal after an attack, even when performed during the attack.
Possible causes of TGA include venous congestion with Valsalva-like activities before symptom onset, arterial thromboembolic ischemia, and vasoconstriction due to hyperventilation. Precipitants of TGA often include exertion, cold, pain, emotional stress, and sexual intercourse.
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This question is part of the following fields:
- Old Age Psychiatry
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Question 24
Incorrect
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What is true about the 2014 Adult Psychiatric Morbidity Survey?
Your Answer: The sample included people living in Wales
Correct Answer: People in prisons were not included in the sample
Explanation:The APMS has a significant drawback in that it solely relies on household data and does not incorporate data from institutions like prisons.
Adult Psychiatric Morbidity Survey
The Adult Psychiatric Morbidity Survey (APMS), also known as the National Psychiatric Morbidity Survey, is conducted every 7 years to monitor the prevalence of mental illness and access to treatment in the general population of England. The survey obtains a stratified random sample representative of the population living in private households by using postcodes. The information is gathered through questionnaires and interviews to screen for a range of mental disorders and risk factors. However, the survey does not collect data on individuals under the age of 16. The study does not include people living in institutional settings such as prisons of care homes, of those who are homeless of living in temporary housing.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 25
Incorrect
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What is a true statement about frontotemporal lobar degeneration?
Your Answer: The mean age of onset of behavioural-variant frontotemporal dementia is 70
Correct Answer: In semantic dementia, speech is characteristically fluent
Explanation:Frontotemporal Lobar Degeneration
Frontotemporal lobar degeneration (FTLD) is a group of neurodegenerative disorders that involve the atrophy of the frontal and temporal lobes. The disease is characterized by progressive dysfunction in executive functioning, behavior, and language, and can mimic psychiatric disorders due to its prominent behavioral features. FTLD is the third most common form of dementia across all age groups and a leading type of early-onset dementia.
The disease has common features such as onset before 65, insidious onset, relatively preserved memory and visuospatial skills, personality change, and social conduct problems. There are three recognized subtypes of FTLD: behavioral-variant (bvFTD), language variant – primary progressive aphasia (PPA), and the language variant is further subdivided into semantic variant PPA (aka semantic dementia) and non-fluent agrammatic variant PPA (nfvPPA).
As the disease progresses, the symptoms of the three clinical variants can converge, as an initially focal degeneration becomes more diffuse and spreads to affect large regions in the frontal and temporal lobes. The key differences between the subtypes are summarized in the table provided. The bvFTD subtype is characterized by poor personal and social decorum, disinhibition, poor judgment and problem-solving, apathy, compulsive/perseverative behavior, hyperorality of dietary changes, and loss of empathy. The nfvPPA subtype is characterized by slow/slurred speech, decreased word output and phrase length, word-finding difficulties, apraxia of speech, and spared single-word comprehension. The svPPA subtype is characterized by intact speech fluency, word-finding difficulties (anomia), impaired single-word comprehension, repetitive speech, and reduced word comprehension.
In conclusion, FTLD is a progressive, heterogeneous, neurodegenerative disorder that affects the frontal and temporal lobes. The disease is characterized by dysfunction in executive functioning, behavior, and language, and can mimic psychiatric disorders due to its prominent behavioral features. There are three recognized subtypes of FTLD, and as the disease progresses, the symptoms of the three clinical variants can converge.
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This question is part of the following fields:
- Old Age Psychiatry
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Question 26
Incorrect
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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: 95.4% of values lie between 4.3 and 4.9 mmol/l
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 27
Incorrect
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What drug is classified as a schedule 3 controlled substance?
Your Answer: Fentanyl
Correct Answer: Temazepam
Explanation:Temazepam falls under the category of drugs classified as schedule 3.
Drug Misuse (Law and Scheduling)
The Misuse of Drugs Act (1971) regulates the possession and supply of drugs, classifying them into three categories: A, B, and C. The maximum penalty for possession varies depending on the class of drug, with Class A drugs carrying a maximum sentence of 7 years.
The Misuse of Drugs Regulations 2001 further categorizes controlled drugs into five schedules. Schedule 1 drugs are considered to have no therapeutic value and cannot be lawfully possessed of prescribed, while Schedule 2 drugs are available for medical use but require a controlled drug prescription. Schedule 3, 4, and 5 drugs have varying levels of restrictions and requirements.
It is important to note that a single drug can have multiple scheduling statuses, depending on factors such as strength and route of administration. For example, morphine and codeine can be either Schedule 2 of Schedule 5.
Overall, the Misuse of Drugs Act and Regulations aim to regulate and control the use of drugs in the UK, with the goal of reducing drug misuse and related harm.
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This question is part of the following fields:
- Substance Misuse/Addictions
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Question 28
Correct
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What is a true statement about eating disorders?
Your Answer: Laxative misuse is ineffective at reducing calorie absorption
Explanation:When an imbalance in electrolytes is identified, the first step is to address the behavior causing it. In rare cases where supplementation is necessary to restore balance, oral administration is preferred over intravenous, unless there are issues with absorption in the gastrointestinal tract.
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 29
Incorrect
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What is the name of the opioid antagonist that is utilized to prevent relapse in individuals who were previously dependent on opioids?
Your Answer: Buprenorphine
Correct Answer: Naltrexone
Explanation:By acting as an antagonist to opioid receptors, naltrexone inhibits the pleasurable effects of opiates when consumed.
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 30
Incorrect
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Which option below represents a variable that belongs to an interval scale?
Your Answer: The age at which a patient developed schizophrenia
Correct Answer: The acidity of a group of patient's urine measured with a urine pH test
Explanation:The categorization of patients on a hospital ward based on their diagnosis = nominal
Scales of Measurement in Statistics
In the 1940s, Stanley Smith Stevens introduced four scales of measurement to categorize data variables. Knowing the scale of measurement for a variable is crucial in selecting the appropriate statistical analysis. The four scales of measurement are ratio, interval, ordinal, and nominal.
Ratio scales are similar to interval scales, but they have true zero points. Examples of ratio scales include weight, time, and length. Interval scales measure the difference between two values, and one unit on the scale represents the same magnitude on the trait of characteristic being measured across the whole range of the scale. The Fahrenheit scale for temperature is an example of an interval scale.
Ordinal scales categorize observed values into set categories that can be ordered, but the intervals between each value are uncertain. Examples of ordinal scales include social class, education level, and income level. Nominal scales categorize observed values into set categories that have no particular order of hierarchy. Examples of nominal scales include genotype, blood type, and political party.
Data can also be categorized as quantitative of qualitative. Quantitative variables take on numeric values and can be further classified into discrete and continuous types. Qualitative variables do not take on numerical values and are usually names. Some qualitative variables have an inherent order in their categories and are described as ordinal. Qualitative variables are also called categorical of nominal variables. When a qualitative variable has only two categories, it is called a binary variable.
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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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