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Question 1
Incorrect
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What is the most accurate approximation of how many children have attention deficit hyperactivity disorder?
Your Answer: 1%
Correct Answer: 5%
Explanation:ADHD (Diagnosis and Management in Children)
ADHD is a behavioural syndrome characterised by symptoms of inattention, hyperactivity, and impulsivity. The DSM-5 and ICD-11 provide diagnostic criteria for the condition, with both recognising three subtypes: predominantly inattentive, predominantly hyperactive-impulsive, and combined.
Treatment for children under 5 involves offering an ADHD-focused group parent-training programme as a first-line option. Medication should only be considered after obtaining advice from a specialist ADHD service. For children and young people aged 5-18, advice and support should be given, along with an ADHD-focused group parent-training programme. Medication should only be offered if ADHD symptoms persist after environmental modifications have been implemented and reviewed. Cognitive behavioural therapy may also be considered for those who have benefited from medication but still experience significant impairment.
NICE advises against elimination diets, dietary fatty acid supplementation, and the use of the ‘few foods diet’. Methylphenidate of lisdexamfetamine is the first-line medication option, with dexamphetamine considered for those who respond to lisdexamfetamine but cannot tolerate the longer effect profile. Atomoxetine of guanfacine may be offered for those who cannot tolerate methylphenidate of lisdexamfetamine. Clonidine and atypical antipsychotics should only be used with advice from a tertiary ADHD service.
Drug holidays may be considered for children and young people who have not met the expected height for their age due to medication. However, NICE advises that withdrawal from treatment is associated with a risk of symptom exacerbation.
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This question is part of the following fields:
- Child And Adolescent Psychiatry
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Question 2
Correct
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Anthony Ryle is credited with the development of which therapy?
Your Answer: Cognitive analytic therapy
Explanation:Fonagy and Bateman – Mentalisation-Based Treatment
Mentalisation-Based Treatment (MBT) was developed by Peter Fonagy and Anthony Bateman in the 1990s. It is a psychodynamic therapy that focuses on improving the patient’s ability to mentalise, which is the capacity to understand one’s own and others’ mental states. MBT is primarily used to treat borderline personality disorder, but it has also been used to treat other mental health conditions.
Fonagy and Bateman work on MBT was influenced by their research on attachment theory and the importance of early relationships in shaping mentalisation abilities. They believed that individuals with borderline personality disorder have difficulties with mentalisation due to early attachment disruptions, and that MBT could help them develop more stable and secure relationships.
MBT is typically delivered in a group of individual format, and it involves a combination of psychoeducation, cognitive-behavioral techniques, and psychodynamic interventions. The therapist helps the patient to identify and reflect on their thoughts, feelings, and behaviors, and to understand how these are influenced by their past experiences and relationships. The therapist also helps the patient to develop more adaptive coping strategies and to improve their interpersonal skills.
Overall, Fonagy and Bateman work on MBT has contributed to the development of psychodynamic therapies that are more focused on specific treatment goals and evidence-based practices.
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This question is part of the following fields:
- Psychotherapy
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Question 3
Incorrect
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A study is designed to assess a new proton pump inhibitor (PPI) in middle-aged patients who are taking aspirin. The new PPI is given to 120 patients whilst a control group of 240 is given the standard PPI. Over a five year period 24 of the group receiving the new PPI had an upper GI bleed compared to 60 who received the standard PPI. What is the absolute risk reduction?
Your Answer:
Correct Answer: 5%
Explanation:Measures of Effect in Clinical Studies
When conducting clinical studies, we often want to know the effect of treatments of exposures on health outcomes. Measures of effect are used in randomized controlled trials (RCTs) and include the odds ratio (of), risk ratio (RR), risk difference (RD), and number needed to treat (NNT). Dichotomous (binary) outcome data are common in clinical trials, where the outcome for each participant is one of two possibilities, such as dead of alive, of clinical improvement of no improvement.
To understand the difference between of and RR, it’s important to know the difference between risks and odds. Risk is a proportion that describes the probability of a health outcome occurring, while odds is a ratio that compares the probability of an event occurring to the probability of it not occurring. Absolute risk is the basic risk, while risk difference is the difference between the absolute risk of an event in the intervention group and the absolute risk in the control group. Relative risk is the ratio of risk in the intervention group to the risk in the control group.
The number needed to treat (NNT) is the number of patients who need to be treated for one to benefit. Odds are calculated by dividing the number of times an event happens by the number of times it does not happen. The odds ratio is the odds of an outcome given a particular exposure versus the odds of an outcome in the absence of the exposure. It is commonly used in case-control studies and can also be used in cross-sectional and cohort study designs. An odds ratio of 1 indicates no difference in risk between the two groups, while an odds ratio >1 indicates an increased risk and an odds ratio <1 indicates a reduced risk.
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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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A male patient with anorexia nervosa would likely have elevated levels of which of the following?
Your Answer:
Correct Answer: Liver enzymes
Explanation:In individuals with anorexia, the majority of their blood test results are typically below normal levels, with the exception of growth hormone, cholesterol, and cortisol.
Eating Disorders: Lab Findings and Medical Complications
Eating disorders can lead to a range of medical complications, including renal failure, peripheral edema, sinus bradycardia, QT-prolongation, pericardial effusion, and slowed GI motility. Other complications include constipation, cathartic colon, esophageal esophagitis, hair loss, and dental erosion. Blood abnormalities are also common in patients with eating disorders, including hyponatremia, hypokalemia, hypophosphatemia, and hypoglycemia. Additionally, patients may experience leucopenia, anemia, low albumin, elevated liver enzymes, and vitamin deficiencies. These complications can cause significant morbidity and mortality in patients with eating disorders. It is important for healthcare providers to monitor patients for these complications and provide appropriate treatment.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 5
Incorrect
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What is the name of the harmful substance produced by the body when someone takes too much paracetamol, leading to liver damage?
Your Answer:
Correct Answer: Benzoquinoneimine
Explanation:Paracetamol’s main byproduct is benzoquinoneimine, a highly reactive substance that typically binds with glutathione. However, when glutathione levels are low, it can bind to liver protein and result in liver damage.
Self-Harm and its Management
Self-harm refers to intentional acts of self-poisoning of self-injury. It is prevalent among younger people, with an estimated 10% of girls and 3% of boys aged 15-16 years having self-harmed in the previous year. Risk factors for non-fatal repetition of self-harm include previous self-harm, personality disorder, hopelessness, history of psychiatric treatment, schizophrenia, alcohol abuse/dependence, and drug abuse/dependence. Suicide following an act of self-harm is more likely in those with previous episodes of self-harm, suicidal intent, poor physical health, and male gender.
Risk assessment tools are not recommended for predicting future suicide of repetition of self-harm. The recommended interventions for self-harm include 4-10 sessions of CBT specifically structured for people who self-harm and considering DBT for adolescents with significant emotional dysregulation. Drug treatment as a specific intervention to reduce self-harm should not be offered.
In the management of ingestion, activated charcoal can help if used early, while emetics and cathartics should not be used. Gastric lavage should generally not be used unless recommended by TOXBASE. Paracetamol is involved in 30-40% of acute presentations with poisoning. Intravenous acetylcysteine is the treatment of choice, and pseudo-allergic reactions are relatively common. Naloxone is used as an antidote for opioid overdose, while flumazenil can help reduce the need for admission to intensive care in benzodiazepine overdose.
For superficial uncomplicated skin lacerations of 5 cm of less in length, tissue adhesive of skin closure strips could be used as a first-line treatment option. All children who self-harm should be admitted for an overnight stay at a pediatric ward.
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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 the recommended safe amount of alcohol to consume during pregnancy, as stated by the UK Department of Health?
Your Answer:
Correct Answer: No amount of alcohol is considered safe at any point in pregnancy
Explanation:Pregnancy and Alcohol
The advice on safe drinking levels during pregnancy varies, but the most recent recommendation is to abstain from alcohol completely. According to NICE, pregnant women of those planning a pregnancy should avoid alcohol altogether to minimize risks to the fetus. This aligns with the UK Chief Medical Officers’ Alcohol Guidelines Review from 2016. It is recommended to follow this guideline to ensure the safety of the developing baby.
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This question is part of the following fields:
- Substance Misuse/Addictions
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Question 7
Incorrect
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For what purpose is the GRADE approach used in the field of evidence based medicine?
Your Answer:
Correct Answer: Assessing the quality of evidence
Explanation:Levels and Grades of Evidence in Evidence-Based Medicine
To evaluate the quality of evidence on a subject of question, levels of grades are used. The traditional hierarchy approach places systematic reviews of randomized control trials at the top and case-series/report at the bottom. However, this approach is overly simplistic as certain research questions cannot be answered using RCTs. To address this, the Oxford Centre for Evidence-Based Medicine introduced their 2011 Levels of Evidence system, which separates the type of study questions and gives a hierarchy for each.
The grading approach to be aware of is the GRADE system, which classifies the quality of evidence as high, moderate, low, of very low. The process begins by formulating a study question and identifying specific outcomes. Outcomes are then graded as critical of important. The evidence is then gathered and criteria are used to grade the evidence, with the type of evidence being a significant factor. Evidence can be promoted of downgraded based on certain criteria, such as limitations to study quality, inconsistency, uncertainty about directness, imprecise of sparse data, and reporting bias. The GRADE system allows for the promotion of observational studies to high-quality evidence under the right circumstances.
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This question is part of the following fields:
- Research Methods, Statistics, Critical Review And Evidence-Based Practice
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Question 8
Incorrect
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What is the term used to describe a test that initially appears to measure what it is intended to measure?
Your Answer:
Correct Answer: Good face validity
Explanation:A test that seems to measure what it is intended to measure has strong face validity.
Validity in statistics refers to how accurately something measures what it claims to measure. There are two main types of validity: internal and external. Internal validity refers to the confidence we have in the cause and effect relationship in a study, while external validity refers to the degree to which the conclusions of a study can be applied to other people, places, and times. There are various threats to both internal and external validity, such as sampling, measurement instrument obtrusiveness, and reactive effects of setting. Additionally, there are several subtypes of validity, including face validity, content validity, criterion validity, and construct validity. Each subtype has its own specific focus and methods for testing validity.
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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
Incorrect
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What is the term used to describe the proposed idea that a researcher is attempting to validate?
Your Answer:
Correct Answer: Alternative hypothesis
Explanation:Understanding Hypothesis Testing in Statistics
In statistics, it is not feasible to investigate hypotheses on entire populations. Therefore, researchers take samples and use them to make estimates about the population they are drawn from. However, this leads to uncertainty as there is no guarantee that the sample taken will be truly representative of the population, resulting in potential errors. Statistical hypothesis testing is the process used to determine if claims from samples to populations can be made and with what certainty.
The null hypothesis (Ho) is the claim that there is no real difference between two groups, while the alternative hypothesis (H1 of Ha) suggests that any difference is due to some non-random chance. The alternative hypothesis can be one-tailed of two-tailed, depending on whether it seeks to establish a difference of a change in one direction.
Two types of errors may occur when testing the null hypothesis: Type I and Type II errors. Type I error occurs when the null hypothesis is rejected when it is true, while Type II error occurs when the null hypothesis is accepted when it is false. The power of a study is the probability of correctly rejecting the null hypothesis when it is false, and it can be increased by increasing the sample size.
P-values provide information on statistical significance and help researchers decide if study results have occurred due to chance. The p-value is the probability of obtaining a result that is as large of larger when in reality there is no difference between two groups. The cutoff for the p-value is called the significance level (alpha level), typically set at 0.05. If the p-value is less than the cutoff, the null hypothesis is rejected, and if it is greater or equal to the cut off, the null hypothesis is not rejected. However, the p-value does not indicate clinical significance, which may be too small to be meaningful.
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This question is part of the following fields:
- Research Methods, Statistics, Critical Review And Evidence-Based Practice
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Question 10
Incorrect
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What is the most appropriate approach to handling a situation where a man discloses a dream about sexually abusing his daughter during a session of psychodynamic psychotherapy?
Your Answer:
Correct Answer: Ask him to elaborate on the dream
Explanation:The abstract meanings from the unconscious mind are represented in people’s dreams, which can provide important therapeutic information when patients are asked to reflect on their own understanding of their dreams.
As an AI language model, I do not have personal opinions of beliefs. However, I can provide a summary of the information presented in the text. The text discusses different models of dream interpretation in psychodynamic therapy, including Freudian interpretation, compensatory theory, content analysis, the Five Star Method, and the cognitive-experiential model. Each model has its own approach to understanding the meaning of dreams, with some focusing on unconscious desires and motivations, while others emphasize personal experiences and attitudes. The text provides an overview of each model and their key assumptions and techniques.
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This question is part of the following fields:
- Psychotherapy
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Question 11
Incorrect
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What is another term used to refer to a type II error in hypothesis testing?
Your Answer:
Correct Answer: False negative
Explanation:Hypothesis testing involves the possibility of two types of errors: type I and type II errors. A type I error occurs when the null hypothesis is wrongly rejected of the alternative hypothesis is wrongly accepted. This error is also referred to as an alpha error, error of the first kind, of a false positive. On the other hand, a type II error occurs when the null hypothesis is wrongly accepted. This error is also known as the beta error, error of the second kind, of the false negative.
Understanding Hypothesis Testing in Statistics
In statistics, it is not feasible to investigate hypotheses on entire populations. Therefore, researchers take samples and use them to make estimates about the population they are drawn from. However, this leads to uncertainty as there is no guarantee that the sample taken will be truly representative of the population, resulting in potential errors. Statistical hypothesis testing is the process used to determine if claims from samples to populations can be made and with what certainty.
The null hypothesis (Ho) is the claim that there is no real difference between two groups, while the alternative hypothesis (H1 of Ha) suggests that any difference is due to some non-random chance. The alternative hypothesis can be one-tailed of two-tailed, depending on whether it seeks to establish a difference of a change in one direction.
Two types of errors may occur when testing the null hypothesis: Type I and Type II errors. Type I error occurs when the null hypothesis is rejected when it is true, while Type II error occurs when the null hypothesis is accepted when it is false. The power of a study is the probability of correctly rejecting the null hypothesis when it is false, and it can be increased by increasing the sample size.
P-values provide information on statistical significance and help researchers decide if study results have occurred due to chance. The p-value is the probability of obtaining a result that is as large of larger when in reality there is no difference between two groups. The cutoff for the p-value is called the significance level (alpha level), typically set at 0.05. If the p-value is less than the cutoff, the null hypothesis is rejected, and if it is greater or equal to the cut off, the null hypothesis is not rejected. However, the p-value does not indicate clinical significance, which may be too small to be meaningful.
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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 12
Incorrect
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What is the correct statement about therapeutic alliance?
Your Answer:
Correct Answer: The strength of the therapeutic bond is not highly correlated with the duration of the treatment
Explanation:Therapeutic Alliance
The therapeutic alliance is a collaborative partnership between the doctor and the patient that is crucial for successful treatment outcomes. Research has shown that the client’s perception of the relationship with their therapist is a stronger predictor of treatment success than the therapist’s perception. The strength of the therapeutic bond is not necessarily related to the length of service, as a strong relationship can be established in a short amount of time. Therapist self-awareness can also positively impact the development of a therapeutic alliance. It is important to maintain a positive working relationship when dealing with family members of the client. Additionally, the presence of hope can significantly impact how individuals cope with stress, difficulty, and problems.
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This question is part of the following fields:
- Psychotherapy
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Question 13
Incorrect
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Which feature is not included in Kernberg's description of 'borderline personality organisation'?
Your Answer:
Correct Answer: Negative automatic thoughts
Explanation:The psychoanalyst Kernberg introduced the idea of ‘borderline personality organization’ and played a role in advancing the Transference-Focused Therapy approach to treatment.
Personality Disorder (Borderline)
History and Terminology
The term borderline personality disorder originated from early 20th-century theories that the disorder was on the border between neurosis and psychosis. The term borderline was coined by Adolph Stern in 1938. Subsequent attempts to define the condition include Otto Kernberg’s borderline personality organization, which identified key elements such as ego weakness, primitive defense mechanisms, identity diffusion, and unstable reality testing.
Features
The DSM-5 and ICD-11 both define borderline personality disorder as a pervasive pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity. Symptoms include efforts to avoid abandonment, unstable relationships, impulsivity, suicidal behavior, affective instability, chronic feelings of emptiness, difficulty controlling temper, and transient dissociative symptoms.
Abuse
Childhood abuse and neglect are extremely common among borderline patients, with up to 87% having suffered some form of trauma. The effect of abuse seems to depend on the stage of psychological development at which it takes place.
comorbidity
Borderline PD patients are more likely to receive a diagnosis of major depressive disorder, bipolar disorder, panic disorder, PTSD, OCD, eating disorders, and somatoform disorders.
Psychological Therapy
Dialectical Behavioral Therapy (DBT), Mentalization-Based Treatment (MBT), Schema-Focused Therapy (SFT), and Transference-Focused Psychotherapy (TFP) are the main psychological treatments for BPD. DBT is the most well-known and widely available, while MBT focuses on improving mentalization, SFT generates structural changes to a patient’s personality, and TFP examines dysfunctional interpersonal dynamics that emerge in interactions with the therapist in the transference.
NICE Guidelines
The NICE guidelines on BPD offer very little recommendations. They do not recommend medication for treatment of the core symptoms. Regarding psychological therapies, they make reference to DBT and MBT being effective but add that the evidence base is too small to draw firm conclusions. They do specifically say Do not use brief psychotherapeutic interventions (of less than 3 months’ duration) specifically for borderline personality disorder of for the individual symptoms of the disorder.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 14
Incorrect
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What factor increases the risk of developing neutropenia as a result of taking clozapine?
Your Answer:
Correct Answer: Afro-Caribbean race
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 15
Incorrect
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Which of the following is characterised by fluent, empty speech?
Your Answer:
Correct Answer: Semantic dementia
Explanation:Frontotemporal Lobar Degeneration
Frontotemporal lobar degeneration (FTLD) is a group of neurodegenerative disorders that involve the atrophy of the frontal and temporal lobes. The disease is characterized by progressive dysfunction in executive functioning, behavior, and language, and can mimic psychiatric disorders due to its prominent behavioral features. FTLD is the third most common form of dementia across all age groups and a leading type of early-onset dementia.
The disease has common features such as onset before 65, insidious onset, relatively preserved memory and visuospatial skills, personality change, and social conduct problems. There are three recognized subtypes of FTLD: behavioral-variant (bvFTD), language variant – primary progressive aphasia (PPA), and the language variant is further subdivided into semantic variant PPA (aka semantic dementia) and non-fluent agrammatic variant PPA (nfvPPA).
As the disease progresses, the symptoms of the three clinical variants can converge, as an initially focal degeneration becomes more diffuse and spreads to affect large regions in the frontal and temporal lobes. The key differences between the subtypes are summarized in the table provided. The bvFTD subtype is characterized by poor personal and social decorum, disinhibition, poor judgment and problem-solving, apathy, compulsive/perseverative behavior, hyperorality of dietary changes, and loss of empathy. The nfvPPA subtype is characterized by slow/slurred speech, decreased word output and phrase length, word-finding difficulties, apraxia of speech, and spared single-word comprehension. The svPPA subtype is characterized by intact speech fluency, word-finding difficulties (anomia), impaired single-word comprehension, repetitive speech, and reduced word comprehension.
In conclusion, FTLD is a progressive, heterogeneous, neurodegenerative disorder that affects the frontal and temporal lobes. The disease is characterized by dysfunction in executive functioning, behavior, and language, and can mimic psychiatric disorders due to its prominent behavioral features. There are three recognized subtypes of FTLD, and as the disease progresses, the symptoms of the three clinical variants can converge.
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This question is part of the following fields:
- Old Age Psychiatry
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Question 16
Incorrect
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Which factor poses the greatest risk to children born to women with anorexia nervosa?
Your Answer:
Correct Answer: Low APGAR score
Explanation:Risks to Children of Mothers with Eating Disorders
Children of mothers with eating disorders are at risk of various complications, including premature birth, increased perinatal mortality, cleft lip and cleft palate, epilepsy, developmental delays, abnormal growth, food fussiness, feeding difficulties, low birth weight, microcephaly, and low APGAR scores. Previous exam questions have focused on low APGAR scores.
Eating disorders in pregnancy can also lead to associated complications, such as inadequate of excessive weight gain, hyperemesis gravidarum, hypotension (in anorexia) of hypertension (in bulimia), syncope/presyncope from cardiac arrhythmias and electrolyte disturbances, anemia (in anorexia), pregnancy termination (spontaneous of therapeutic), small for term infant, stillbirth, breech pregnancy, pre-eclampsia, cesarean section, post-episiotomy suture tearing, vaginal bleeding, increased rate of perinatal difficulties, postpartum depression risk, cardiac changes, and refeeding syndrome (occurs primarily in patients who are aggressively refed).
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This question is part of the following fields:
- General Adult Psychiatry
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Question 17
Incorrect
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What is a true statement about complex post traumatic stress disorder?
Your Answer:
Correct Answer: Significant problems in affect regulation are an essential feature in the diagnosis
Explanation:Complex PTSD includes all the necessary criteria for PTSD, but it also involves severe challenges in regulating emotions, persistent negative self-beliefs, and ongoing struggles in maintaining relationships. While some individuals with Complex PTSD may also meet the criteria for a personality disorder, it is not considered a personality disorder itself.
Stress disorders, such as Post Traumatic Stress Disorder (PTSD), are emotional reactions to traumatic events. The diagnosis of PTSD requires exposure to an extremely threatening of horrific event, followed by the development of a characteristic syndrome lasting for at least several weeks, consisting of re-experiencing the traumatic event, deliberate avoidance of reminders likely to produce re-experiencing, and persistent perceptions of heightened current threat. Additional clinical features may include general dysphoria, dissociative symptoms, somatic complaints, suicidal ideation and behaviour, social withdrawal, excessive alcohol of drug use, anxiety symptoms, and obsessions of compulsions. The emotional experience of individuals with PTSD commonly includes anger, shame, sadness, humiliation, of guilt. The onset of PTSD symptoms can occur at any time during the lifespan following exposure to a traumatic event, and the symptoms and course of PTSD can vary significantly over time and individuals. Key differentials include acute stress reaction, adjustment disorder, and complex PTSD. Management of PTSD includes trauma-focused cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and supported trauma-focused computerized CBT interventions. Drug treatments, including benzodiazepines, are not recommended for the prevention of treatment of PTSD in adults, but venlafaxine of a selective serotonin reuptake inhibitor (SSRI) may be considered for adults with a diagnosis of PTSD if the person has a preference for drug treatment. Antipsychotics such as risperidone may be considered in addition if disabling symptoms and behaviors are present and have not responded to other treatments. Psychological debriefing is not recommended for the prevention of treatment of PTSD. For children and young people, individual trauma-focused CBT interventions of EMDR may be considered, but drug treatments are not recommended.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 18
Incorrect
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Which study design is susceptible to making the erroneous assumption that relationships observed among groups also hold true for individuals?
Your Answer:
Correct Answer: Ecological study
Explanation:An ecological fallacy is a potential error that can occur when generalizing relationships observed among groups to individuals. This is a concern when conducting analyses of ecological studies.
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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A 28-year-old woman confides in you that she experienced protracted and recurrent childhood sexual abuse. Which one of the following features is not a characteristic feature of post-traumatic stress disorder?
Your Answer:
Correct Answer: Loss of inhibitions
Explanation:PTSD can develop from a single traumatic event, such as a car accident, of from ongoing and repeated trauma, such as childhood abuse. The latter is known as complex PTSD. However, there is some discussion about whether complex PTSD and borderline personality disorder are distinct conditions, as they have many similar symptoms.
Stress disorders, such as Post Traumatic Stress Disorder (PTSD), are emotional reactions to traumatic events. The diagnosis of PTSD requires exposure to an extremely threatening of horrific event, followed by the development of a characteristic syndrome lasting for at least several weeks, consisting of re-experiencing the traumatic event, deliberate avoidance of reminders likely to produce re-experiencing, and persistent perceptions of heightened current threat. Additional clinical features may include general dysphoria, dissociative symptoms, somatic complaints, suicidal ideation and behaviour, social withdrawal, excessive alcohol of drug use, anxiety symptoms, and obsessions of compulsions. The emotional experience of individuals with PTSD commonly includes anger, shame, sadness, humiliation, of guilt. The onset of PTSD symptoms can occur at any time during the lifespan following exposure to a traumatic event, and the symptoms and course of PTSD can vary significantly over time and individuals. Key differentials include acute stress reaction, adjustment disorder, and complex PTSD. Management of PTSD includes trauma-focused cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), and supported trauma-focused computerized CBT interventions. Drug treatments, including benzodiazepines, are not recommended for the prevention of treatment of PTSD in adults, but venlafaxine of a selective serotonin reuptake inhibitor (SSRI) may be considered for adults with a diagnosis of PTSD if the person has a preference for drug treatment. Antipsychotics such as risperidone may be considered in addition if disabling symptoms and behaviors are present and have not responded to other treatments. Psychological debriefing is not recommended for the prevention of treatment of PTSD. For children and young people, individual trauma-focused CBT interventions of EMDR may be considered, but drug treatments are not recommended.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 20
Incorrect
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A middle-aged patient is referred to secondary care due to issues with depression. You see the man several times and his depression responds well to treatment with an SSRI.
During consultations, you are struck by the man’s excessive formality and seriousness. On further enquiry you identify that he has significant difficulties at work. He explains that he is overworked and feels he can't ask colleagues for help as they are unable to do the job properly. He feels that despite all his hard work he is still underperforming in his job. He reports also feeling that he is an inadequate father and reports that his children complain about his refusal to spend money and enjoy himself.
Which of the following ICD-11 conditions do you most suspect?:Your Answer:
Correct Answer: Personality disorder with anankastic
Explanation:Personality Disorder (Obsessive Compulsive)
Obsessive-compulsive personality disorder is characterized by a preoccupation with orderliness, perfectionism, and control, which can hinder flexibility and efficiency. This pattern typically emerges in early adulthood and can be present in various contexts. The estimated prevalence ranges from 2.1% to 7.9%, with males being diagnosed twice as often as females.
The DSM-5 diagnosis requires the presence of four of more of the following criteria: preoccupation with details, rules, lists, order, organization, of agenda to the point that the key part of the activity is lost; perfectionism that hampers completing tasks; extreme dedication to work and efficiency to the elimination of spare time activities; meticulous, scrupulous, and rigid about etiquettes of morality, ethics, of values; inability to dispose of worn-out of insignificant things even when they have no sentimental meaning; unwillingness to delegate tasks of work with others except if they surrender to exactly their way of doing things; miserly spending style towards self and others; and rigidity and stubbornness.
The ICD-11 abolished all categories of personality disorder except for a general description of personality disorder, which can be further specified as “mild,” “moderate,” of “severe.” The anankastic trait domain is characterized by a narrow focus on one’s rigid standard of perfection and of right and wrong, and on controlling one’s own and others’ behavior and controlling situations to ensure conformity to these standards. Common manifestations of anankastic include perfectionism and emotional and behavioral constraint.
Differential diagnosis includes OCD, hoarding disorder, narcissistic personality disorder, antisocial personality disorder, and schizoid personality disorder. OCD is distinguished by the presence of true obsessions and compulsions, while hoarding disorder should be considered when hoarding is extreme. Narcissistic personality disorder individuals are more likely to believe that they have achieved perfection, while those with obsessive-compulsive personality disorder are usually self-critical. Antisocial personality disorder individuals lack generosity but will indulge themselves, while those with obsessive-compulsive personality disorder adopt a miserly spending style toward both self and others. Schizoid personality disorder is characterized by a fundamental lack of capacity for intimacy, while in obsessive-compulsive personality disorder, this stems from discomfort with emotions and excessive devotion to work.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 21
Incorrect
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Aaron Beck is credited with developing which therapy?
Your Answer:
Correct Answer: Cognitive therapy
Explanation:Cognitive Therapy and Negative Automatic Thoughts
Cognitive therapy is a present-focused approach that aims to help clients overcome difficulties by identifying and changing dysfunctional thinking. This therapy is based on collaboration between the client and therapist and on testing beliefs through collaborative empiricism. One of the techniques used in cognitive therapy is Socratic questioning, which helps elicit false beliefs called negative automatic thoughts.
Negative automatic thoughts, also known as cognitive distortions, can be categorized into different types. Dichotomous thinking is the tendency to see things as black and white rather than shades of grey. Personalization is the incorrect assumption that things happen due to us, while overgeneralization involves coming to a general conclusion based on a single piece of evidence. Arbitrary inference is drawing an unjustified conclusion, while selective abstraction involves concentrating on the negative while ignoring the positives. Catastrophizing is expecting disaster from relatively trivial events, while filtering involves selecting out only negative aspects of a situation and leaving out the positive.
Control fallacies involve believing that we are responsible for everything (internal control fallacy) of nothing (external control fallacy). The fallacy of fairness is believing that life is fair, while blaming involves holding others responsible for our distress. Shoulds are preconceived rules we believe (often incorrect) which makes us angry when others don’t obey them. Magnification is a tendency to exaggerate the importance of negative information of experiences, while trivializing of reducing the significance of positive information of experiences. Minimization involves an undervaluation of positive attributes, while emotional reasoning is believing what we feel must be true.
The fallacy of change involves expecting others to change just because it suits us, while global labeling involves exaggerating and labeling behavior (e.g. when you fail at something, saying ‘I’m a loser’). Always being right is when the need to be right dominates all other needs, while the heaven’s reward fallacy involves expecting our sacrifices will pay off. Finally, magical thinking is incorrectly believing that our actions influence the outcomes.
Overall, cognitive therapy helps individuals identify and challenge negative automatic thoughts to improve their mental health and well-being.
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This question is part of the following fields:
- Psychotherapy
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Question 22
Incorrect
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A woman with bipolar disorder presents as manic. She is taking lithium and you request levels which come back as 1.1 mmol/L. Which of the following should you do?:
Your Answer:
Correct Answer: Add in olanzapine
Explanation:Achieving a level of 1.1 mmol/L indicates that the appropriate therapeutic level of lithium has been reached, and any further increase in dosage would be unsafe (as per the Maudsley 14th guidelines, which recommend a level between 1.0-1.2). To address this, the guidelines suggest adding an antipsychotic medication, preferably one that is licensed for bipolar disorder, such as olanzapine, risperidone, quetiapine, of aripiprazole.
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 23
Incorrect
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A 38-year-old man with schizophrenia requests to stop taking his chlorpromazine medication after hearing from another patient that it is outdated. Despite the fact that chlorpromazine has effectively managed his symptoms since he was diagnosed at age 20, the patient insists on switching to a newer and more modern medication. Which of the following atypical antipsychotics would be the least appropriate for him to start taking next?
Your Answer:
Correct Answer: Clozapine
Explanation:Before starting clozapine, it is recommended to try at least two other antipsychotic medications. However, in this particular case, the individual has only been treated with one antipsychotic.
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 24
Incorrect
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What is a common observation regarding the sleep patterns of individuals diagnosed with schizophrenia?
Your Answer:
Correct Answer: Reduced REM latency
Explanation:Schizophrenia and Sleep
Sleep disturbances are a common feature of schizophrenia, as research has shown. Specifically, individuals with schizophrenia tend to have a shorter amount of time until the onset of rapid eye movement (REM) sleep, known as decreased REM latency. Additionally, they have a lower proportion of slow wave sleep. These findings were reported in a 2008 article by Rajiv T. titled Schizophrenia, ‘Just the facts’, What we know in 2008 in the journal Schizophrenia Research.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 25
Incorrect
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What is true about strategies for prevention?
Your Answer:
Correct Answer: Indicated interventions might be reasonable even if the intervention entails some risk
Explanation:Prevention measures can be classified into different levels, depending on the stage at which they are implemented. The first model, developed in the 1960s, includes primary, secondary, and tertiary prevention. Primary prevention aims to intervene before a disease of problem begins, and can be universal (targeted to the general public), selective (targeted to a high-risk population), of indicated (targeted to individuals with minimal but detectable signs of a disorder). Secondary prevention aims to detect and treat disease that has not yet become symptomatic, while tertiary prevention involves the care of established disease.
A newer model, developed in 1992, focuses on prevention interventions used before the initial onset of a disorder. This model also includes three levels: universal prevention (targeted to the general population), selective prevention (targeted to a high-risk population), and indicated prevention (targeted to individuals with minimal but detectable signs of a disorder). Examples of prevention measures include cognitive interventions for adolescents with cognitive deficits to prevent the later phases of schizophrenia, screening procedures for early detection and treatment of disease, and the use of low-dose atypical antipsychotics and CBT for patients with prodromal symptoms of schizophrenia to delay of prevent disease onset.
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This question is part of the following fields:
- Organisation And Delivery Of Psychiatric Services
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Question 26
Incorrect
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Which antidepressants are recommended by the Maudsley guidelines for breastfeeding women?
Your Answer:
Correct Answer: Sertraline of mirtazapine
Explanation:Paroxetine Use During Pregnancy: Is it Safe?
Prescribing medication during pregnancy and breastfeeding is challenging due to the potential risks to the fetus of baby. No psychotropic medication has a UK marketing authorization specifically for pregnant of breastfeeding women. Women are encouraged to breastfeed unless they are taking carbamazepine, clozapine, of lithium. The risk of spontaneous major malformation is 2-3%, with drugs accounting for approximately 5% of all abnormalities. Valproate and carbamazepine are associated with an increased risk of neural tube defects, and lithium is associated with cardiac malformations. Benzodiazepines are associated with oral clefts and floppy baby syndrome. Antidepressants have been linked to preterm delivery and congenital malformation, but most findings have been inconsistent. TCAs have been used widely without apparent detriment to the fetus, but their use in the third trimester is known to produce neonatal withdrawal effects. Sertraline appears to result in the least placental exposure among SSRIs. MAOIs should be avoided in pregnancy due to a suspected increased risk of congenital malformations and hypertensive crisis. If a pregnant woman is stable on an antipsychotic and likely to relapse without medication, she should continue the antipsychotic. Depot antipsychotics should not be offered to pregnant of breastfeeding women unless they have a history of non-adherence with oral medication. The Maudsley Guidelines suggest specific drugs for use during pregnancy and breastfeeding. NICE CG192 recommends high-intensity psychological interventions for moderate to severe depression and anxiety disorders. Antipsychotics are recommended for pregnant women with mania of psychosis who are not taking psychotropic medication. Promethazine is recommended for insomnia.
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This question is part of the following fields:
- General Adult Psychiatry
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Question 27
Incorrect
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What is the term used to refer to the act of deriving pleasure from touching and rubbing against someone who has not given their consent?
Your Answer:
Correct Answer: Frotteurism
Explanation:Paraphilias are intense and persistent sexual interests other than sexual interest in genital stimulation of preparatory fondling with phenotypically normal, physically mature, consenting human partners. They are divided into those relating to erotic activity and those relating to erotic target. In order to become a disorder, paraphilias must be associated with distress of impairment to the individual of with harm to others. The DSM-5 lists 8 recognised paraphilic disorder but acknowledges that there are many more. Treatment modalities for the paraphilias have limited scientific evidence to support their use. Psychological therapy (especially CBT) is often used (with extremely variable results). Pharmacological options include SSRI, Naltrexone, Antipsychotics, GnRH agonists, and Anti-androgens and progestational drugs (e.g. cyproterone acetate).
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This question is part of the following fields:
- Forensic Psychiatry
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Question 28
Incorrect
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Which statement accurately describes the use of cholinesterase inhibitors for treating dementia caused by Parkinson's disease?
Your Answer:
Correct Answer: They are more effective than placebo in treating cognitive problems
Explanation:Dementia with Parkinson’s Disease: Understanding Cognitive Symptoms
Dementia with Parkinson’s disease is a syndrome that involves a decline in memory and other cognitive domains, leading to social and occupational dysfunction. Along with motor problems, non-motor symptoms such as cognitive, behavioral, and psychological issues can also arise. There is debate over whether Lewy body dementia and dementia due to Parkinson’s are different conditions. Drugs used to treat Parkinson’s can interfere with cognitive function, and people with this type of dementia tend to have marked problems with executive function. Cholinesterase inhibitors can improve cognitive performance, but they are not well tolerated and can cause side effects. Understanding the cognitive symptoms of dementia with Parkinson’s disease is crucial for effective clinical management.
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This question is part of the following fields:
- Old Age Psychiatry
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Question 29
Incorrect
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Which statement accurately describes IPT?
Your Answer:
Correct Answer: It focuses mainly on current rather than past relationships
Explanation:Cognitive Analytic Therapy (CAT) was developed by Anthony Ryle.
Interpersonal Therapy: A Structured Approach to Addressing Social Functioning Problems
Interpersonal therapy (IPT) is a structured form of psychotherapy that is often used to treat depression. It is based on the belief that social functioning problems have a significant impact on psychological problems. IPT is a time-limited therapy that typically runs for 10-16 one hour sessions. The therapy is organized into three phases, with the first phase involving data collection and formulation. The remaining sessions explore the formulation in more detail.
IPT focuses on four areas of social functioning problems: grief, role transitions, interpersonal deficits, and interpersonal disputes. The therapy aims to intervene at the level of social functioning, rather than focusing on personality. The therapy has been found to be effective in treating depression, particularly in patients with severe depression. However, it may be less effective in treating people with depression and comorbid personality disorders.
The evidence base for IPT is most developed for eating disorders, and the intervention is recommended in NICE guidelines for eating disorders. Overall, IPT is a structured approach to addressing social functioning problems that can be effective in treating depression and other psychological problems.
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This question is part of the following fields:
- Psychotherapy
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Question 30
Incorrect
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Which neuroanatomical structure has been the primary focus of studies examining the effectiveness of deep brain stimulation (DBS) for treating depression that does not respond to other treatments?
Your Answer:
Correct Answer: Subgenual cingulate gyrus
Explanation:Studies investigating the effectiveness of DBS in treating depression have most commonly focused on the subgenual cingulate gyrus. A review conducted in 2012 found that out of the six studies (with a total of 65 patients) that were analyzed, all of them targeted this area. Other areas that were targeted in smaller studies included the ventral capsule/ventral striatum (two studies with 32 patients) and the nucleus accumbens (three studies with 24 patients). There were also individual case reports that looked at the inferior thalamic peduncle and lateral habenula.
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This question is part of the following fields:
- Organisation And Delivery Of Psychiatric Services
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