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  • Question 1 - A 35-year-old male comes to your clinic at the suggestion of his partner....

    Correct

    • A 35-year-old male comes to your clinic at the suggestion of his partner. He has been experiencing hyperarousal to loud noises and difficulty concentrating at work since his stay in the ICU 4 weeks ago. His partner believes he may have acute stress disorder, but you diagnose him with PTSD and discuss treatment options. He asks you to explain the difference between the two to his partner. You explain that while the presentation is similar, the main difference is temporal.

      At what point after the event can you confirm a diagnosis of PTSD?

      Your Answer: 4 weeks

      Explanation:

      Acute stress disorder is characterized by an acute stress reaction that occurs within four weeks of a traumatic event, while PTSD is diagnosed after four weeks have passed. Symptoms presented within two weeks would suggest acute stress disorder. Both acute stress disorder and PTSD share similar features, including re-experiencing, avoidance, hyperarousal, and emotional numbing. Re-experiencing symptoms may include flashbacks, nightmares, and repetitive and distressing intrusive images. Avoidance symptoms may involve avoiding people, situations, or circumstances associated with the traumatic event. Hyperarousal symptoms may include hypervigilance for threat, exaggerated startle response, sleep problems, irritability, and difficulty concentrating. Emotional numbing may result in a lack of ability to experience feelings and feeling detached.

      Acute stress disorder is a condition that occurs within the first four weeks after a person has experienced a traumatic event, such as a life-threatening situation or sexual assault. It is characterized by symptoms such as intrusive thoughts, dissociation, negative mood, avoidance, and arousal. These symptoms can include flashbacks, nightmares, feeling disconnected from reality, and being hypervigilant.

      To manage acute stress disorder, trauma-focused cognitive-behavioral therapy (CBT) is typically the first-line treatment. This type of therapy helps individuals process their traumatic experiences and develop coping strategies. In some cases, benzodiazepines may be used to alleviate acute symptoms such as agitation and sleep disturbance. However, caution must be taken when using these medications due to their addictive potential and potential negative impact on adaptation. Overall, early intervention and appropriate treatment can help individuals recover from acute stress disorder and prevent the development of more chronic conditions such as PTSD.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 2 - A 26-year-old man is admitted to your psychiatric ward in a state of...

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    • A 26-year-old man is admitted to your psychiatric ward in a state of distress saying that he knows for certain that his colleagues are plotting to have him dismissed from work. He says they are spreading malicious rumours about his sexuality and, with the help of the CIA, have bugged his office. In the first week of his admission, he is observed to be responding to unseen stimuli when alone in his room. His family state that he is a lovely lad who never gets into any trouble with drink or drugs. They are very worried because in the last 3 months he has told them he can hear people talking about him to each other when he lies in bed at night. He has no significant medical history.
      Which one of the following courses of action would be most appropriate?

      Your Answer: Commence olanzapine with lorazepam and procyclidine as required

      Explanation:

      Treatment Options for Schizophrenia

      Schizophrenia is a serious mental disorder that requires prompt treatment. The following are some treatment options for schizophrenia:

      Commence Olanzapine with Lorazepam and Procyclidine as Required
      Olanzapine is an atypical anti-psychotic that carries a lower risk of extrapyramidal side-effects. However, it is appropriate to prescribe anticholinergic medication such as procyclidine to reduce the risk further. The anti-psychotic action of olanzapine may take up to 10 days to begin, so short-acting benzodiazepines such as lorazepam may be prescribed for sedation.

      Do Not Just Observe with Sedation as Required
      Observing with sedation is not a definitive treatment for schizophrenia. It is essential to commence anti-psychotic medication promptly.

      Commence Chlorpromazine
      Chlorpromazine is a typical anti-psychotic that carries a higher risk of extrapyramidal side-effects. Therefore, atypical anti-psychotics are usually preferred as first-line treatment.

      Commence Clozapine
      Clozapine is the most effective medication for treatment-resistant schizophrenia. However, it carries a small risk of serious complications such as fatal agranulocytosis, myocarditis or cardiomyopathy, and pulmonary embolus. Therefore, it is usually reserved for patients who have not responded to two anti-psychotics given at an appropriate dose for 6-8 weeks.

      Commence Chlorpromazine with Lorazepam and Procyclidine as Required
      Chlorpromazine is a typical anti-psychotic that carries a higher risk of extrapyramidal side-effects. Therefore, it is appropriate to prescribe anticholinergic medication such as procyclidine to reduce the risk. Short-acting benzodiazepines such as lorazepam may also be prescribed for sedation.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 3 - You are requested to assess a patient with generalized anxiety disorder (GAD) who...

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    • You are requested to assess a patient with generalized anxiety disorder (GAD) who has been on sertraline for the past 6 months. They have previously attempted citalopram with minimal improvement. The patient complains of persistent anxiety, chest tightness, and palpitations and wishes to explore a different medication. What would be the most suitable medication to recommend for this patient?

      Your Answer: Duloxetine

      Explanation:

      If sertraline is ineffective or not tolerated as a first-line SSRI for GAD, consider trying another SSRI or an SNRI. The recommended medication in this case would be duloxetine. Since the patient has already tried citalopram with little benefit, it would not be appropriate to prescribe it again. Clomipramine, a tricyclic antidepressant, is not typically recommended for GAD management. Diazepam, a benzodiazepine, is also not recommended for GAD treatment due to the risk of tolerance and addiction.

      Anxiety is a common disorder that can manifest in various ways. According to NICE, the primary feature is excessive worry about multiple events associated with heightened tension. It is crucial to consider potential physical causes when diagnosing anxiety disorders, such as hyperthyroidism, cardiac disease, and medication-induced anxiety. Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants, and caffeine.

      NICE recommends a step-wise approach for managing generalised anxiety disorder (GAD). This includes education about GAD and active monitoring, low-intensity psychological interventions, high-intensity psychological interventions or drug treatment, and highly specialist input. Sertraline is the first-line SSRI for drug treatment, and if it is ineffective, an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI) such as duloxetine or venlafaxine may be offered. If the patient cannot tolerate SSRIs or SNRIs, pregabalin may be considered. For patients under 30 years old, NICE recommends warning them of the increased risk of suicidal thinking and self-harm and weekly follow-up for the first month.

      The management of panic disorder also follows a stepwise approach, including recognition and diagnosis, treatment in primary care, review and consideration of alternative treatments, review and referral to specialist mental health services, and care in specialist mental health services. NICE recommends either cognitive behavioural therapy or drug treatment in primary care. SSRIs are the first-line drug treatment, and if contraindicated or no response after 12 weeks, imipramine or clomipramine should be offered.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 4 - A 32-year-old man comes to you seeking help as he feels like he...

    Correct

    • A 32-year-old man comes to you seeking help as he feels like he is not himself lately. He has been struggling since his divorce 8 months ago. For the past 5 weeks, he has been experiencing low moods for most of the day, particularly in the mornings when he wakes up early. He has lost interest in his usual hobbies, including going to the gym. He has not been to any of his regular workout classes. He has had thoughts of taking a bottle of pills to end it all, but he knows he won't do it because he has a supportive family. He has no significant medical or psychiatric history.

      Which of the following treatments would be the most appropriate?

      Your Answer: Fluoxetine

      Explanation:

      Treatment Options for Depression: Choosing the Right Antidepressant

      Depression is a serious mental health condition that requires a comprehensive treatment plan. Antidepressants are often prescribed as part of this plan, along with high-intensity psychological interventions like cognitive behavioural therapy (CBT). However, not all antidepressants are created equal. Here are some of the most commonly used antidepressants and their indications:

      Fluoxetine: This selective serotonin reuptake inhibitor (SSRI) is the most suitable first-line treatment for depression due to its efficacy, patient acceptability, and lower toxicity in overdose.

      Imipramine: This tricyclic antidepressant is not usually used as a first-line treatment for depression but has a role in nocturnal enuresis.

      Lithium: While lithium has antidepressant properties, it is not a first-line treatment for unipolar depression due to its side-effects and the need for blood monitoring. It is commonly used in the treatment of bipolar affective disorder.

      Electroconvulsive therapy (ECT): ECT is reserved for more severe depression where there is an immediate risk to life or where other treatments have been ineffective.

      Phenelzine: This monoamine oxidase inhibitor (MAOI) is not commonly used as a first-line treatment for depression but is helpful in treatment-resistant depression.

      It’s important to work closely with a healthcare professional to determine the best treatment plan for your individual needs. Antidepressants may take several weeks to take effect, and patients should be aware of potential side-effects and the importance of adhering to their medication regimen.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 5 - A 54-year-old woman visited her primary care physician complaining of persistent polydipsia and...

    Incorrect

    • A 54-year-old woman visited her primary care physician complaining of persistent polydipsia and swollen legs for the past few months. She reported having a medical history of chronic obstructive pulmonary disease (COPD), schizophrenia, and hypertension. Her current medications include tiotropium inhaler, ipratropium bromide inhaler, olanzapine, and nifedipine. She had previously taken bendroflumethiazide, which was discontinued two years ago, and had a 5-day course of 30mg oral prednisolone six months ago due to a COPD exacerbation. Her fasting blood tests revealed:
      Fasting plasma glucose 7 mmol/L (3.9-5.4)
      Random plasma glucose 12 mmol/L (<7.8)
      Which medication is likely responsible for her abnormal blood results?

      Your Answer: Prednisolone

      Correct Answer: Olanzapine

      Explanation:

      Antipsychotics can cause metabolic side effects such as dysglycaemia, dyslipidaemia, and diabetes mellitus. In this case, the patient’s persistent hyperglycaemia in both fasting blood tests and HBA1c tests has led to a diagnosis of type 2 diabetes, likely caused by her regular medication, olanzapine. While the patient has also experienced swollen legs, this is likely due to nifedipine rather than the cause of her deranged blood result. A 5-day course of prednisolone given half a year ago is unlikely to be the cause of her diabetes. Ipratropium bromide is also an unlikely culprit, as it is not known to increase blood sugar levels. Thiazide diuretics, which can increase blood sugar levels, were stopped two years ago and are therefore unlikely to be the cause of her diabetes. Other potential metabolic side effects of thiazide diuretics include hypomagnesemia, hypokalemia, dyslipidemia, and hyperuricemia.

      Antipsychotics are a group of drugs used to treat schizophrenia, psychosis, mania, and agitation. They are divided into two categories: typical and atypical antipsychotics. The latter were developed to address the extrapyramidal side-effects associated with the first generation of typical antipsychotics. Typical antipsychotics work by blocking dopaminergic transmission in the mesolimbic pathways through dopamine D2 receptor antagonism. They are associated with extrapyramidal side-effects and hyperprolactinaemia, which are less common with atypical antipsychotics.

      Extrapyramidal side-effects (EPSEs) are common with typical antipsychotics and include Parkinsonism, acute dystonia, sustained muscle contraction, akathisia, and tardive dyskinesia. The latter is a late onset of choreoathetoid movements that may be irreversible and occur in 40% of patients. The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients, including an increased risk of stroke and venous thromboembolism. Other side-effects include antimuscarinic effects, sedation, weight gain, raised prolactin, impaired glucose tolerance, neuroleptic malignant syndrome, reduced seizure threshold, and prolonged QT interval.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 6 - A 29-year-old male with schizophrenia is being evaluated by his psychiatrist. He expresses...

    Correct

    • A 29-year-old male with schizophrenia is being evaluated by his psychiatrist. He expresses that he no longer takes pleasure in his usual pastimes. The patient used to enjoy playing video games and going to the gym, but now finds these activities uninteresting and lacks motivation to engage in them.

      Which symptom of schizophrenia is the patient exhibiting?

      Your Answer: Anhedonia

      Explanation:

      Symptoms of Schizophrenia

      Anhedonia, affective flattening, alogia, apathy, and delusions are all symptoms of schizophrenia. Anhedonia is the inability to experience pleasure from activities that were once enjoyable. Affective flattening is the loss of a normal range of emotional expression, making it difficult for individuals to express their emotions appropriately. Alogia is a lack of spontaneous speech, making it difficult for individuals to communicate effectively. Apathy is a sense of indifference and lack of interest in activities that were once enjoyable. Delusions are firmly held false beliefs that are not based in reality. These symptoms can significantly impact an individual’s ability to function in daily life and can lead to social isolation and difficulty maintaining relationships. It is important for individuals experiencing these symptoms to seek professional help and support.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 7 - A 50-year-old man with schizophrenia who is on chlorpromazine experiences a bilateral resting...

    Incorrect

    • A 50-year-old man with schizophrenia who is on chlorpromazine experiences a bilateral resting tremor. Which side effect of antipsychotic medication does this exemplify?

      Your Answer: Tardive dyskinesia

      Correct Answer: Parkinsonism

      Explanation:

      Antipsychotics are a group of drugs used to treat schizophrenia, psychosis, mania, and agitation. They are divided into two categories: typical and atypical antipsychotics. The latter were developed to address the extrapyramidal side-effects associated with the first generation of typical antipsychotics. Typical antipsychotics work by blocking dopaminergic transmission in the mesolimbic pathways through dopamine D2 receptor antagonism. They are associated with extrapyramidal side-effects and hyperprolactinaemia, which are less common with atypical antipsychotics.

      Extrapyramidal side-effects (EPSEs) are common with typical antipsychotics and include Parkinsonism, acute dystonia, sustained muscle contraction, akathisia, and tardive dyskinesia. The latter is a late onset of choreoathetoid movements that may be irreversible and occur in 40% of patients. The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients, including an increased risk of stroke and venous thromboembolism. Other side-effects include antimuscarinic effects, sedation, weight gain, raised prolactin, impaired glucose tolerance, neuroleptic malignant syndrome, reduced seizure threshold, and prolonged QT interval.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 8 - Sophie, a 22-year-old student, presents to her GP with a history of low...

    Correct

    • Sophie, a 22-year-old student, presents to her GP with a history of low mood lasting several months. She is struggling with her university studies due to poor concentration and constant fatigue. Despite waking up early every morning, she finds it difficult to fall back asleep. Sophie no longer enjoys spending time with her loved ones and feels hopeless about her future. She has sought medical attention as her symptoms are significantly impacting her academic performance.

      Sophie denies having any suicidal thoughts, and there is no evidence of psychotic features during the examination. She is in good health and denies any alcohol or drug use. Sophie is eager to begin treatment for her symptoms. What would be the most appropriate course of action?

      Your Answer: A trial of fluoxetine

      Explanation:

      Lucy is exhibiting symptoms typical of moderate/severe depression, including low mood, fatigue, anhedonia, difficulty concentrating, poor sleep, and feelings of hopelessness. According to NICE guidelines, the recommended first-line treatment for this level of depression is a combination of antidepressants and high-intensity psychological therapy, such as cognitive behavioural therapy or interpersonal therapy. As such, starting fluoxetine (an SSRI) would be the most appropriate course of action. Tricyclic antidepressants like amitriptyline are not recommended due to their potential side effects and overdose risk. Low-intensity psychological interventions like individual guided self-help are also not suitable for moderate/severe depression. While Lucy is not currently a risk to herself or others and is willing to try treatment in the community, urgent mental health review is not necessary. Given the severity of her symptoms and her desire for active treatment, watchful waiting is not recommended.

      In 2022, NICE updated its guidelines on managing depression and now classifies it as either less severe or more severe based on a patient’s PHQ-9 score. For less severe depression, NICE recommends discussing treatment options with patients and considering the least intrusive and resource-intensive treatment first. Antidepressant medication should not be routinely offered as first-line treatment unless it is the patient’s preference. Treatment options for less severe depression include guided self-help, group cognitive behavioral therapy, group behavioral activation, individual CBT or BA, group exercise, group mindfulness and meditation, interpersonal psychotherapy, SSRIs, counseling, and short-term psychodynamic psychotherapy. For more severe depression, NICE recommends a shared decision-making approach and suggests a combination of individual CBT and an antidepressant as the preferred treatment option. Other treatment options for more severe depression include individual CBT or BA, antidepressant medication, individual problem-solving, counseling, short-term psychodynamic psychotherapy, interpersonal psychotherapy, guided self-help, and group exercise.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 9 - A 16-year-old boy with Tourette's syndrome is brought to the GP by his...

    Correct

    • A 16-year-old boy with Tourette's syndrome is brought to the GP by his father as he is concerned about some unusual behaviors he has observed. During the appointment, you discover that he has been extremely anxious about his upcoming driving test. He feels compelled to check the locks on all the doors in the house repeatedly before leaving, as otherwise, he becomes more anxious about the test.

      What signs or symptoms would suggest a diagnosis of psychosis rather than obsessive-compulsive disorder?

      Your Answer: She truly believes that if she does not perform these acts that she will definitely fail her exams

      Explanation:

      The level of insight into their actions can differentiate obsessive-compulsive disorder from psychosis. OCD is characterized by obsessions and compulsions, where patients have intrusive thoughts and perform acts to reduce them. Patients with OCD typically have a good understanding of their condition and know that not performing the acts will not make their obsessive thoughts come true. However, they still feel the urge to perform them. If a patient lacks insight into their condition and believes that not performing the acts will lead to a negative outcome, it may indicate a delusional element and suggest a diagnosis other than OCD, such as psychosis. Gender is not linked to OCD, and Tourette’s is associated with OCD, not psychosis. Patients with untreated OCD may need to perform more acts over time, but this does not indicate psychosis. While there is a genetic link to OCD, the absence of a family history does not suggest another underlying diagnosis.

      Obsessive-compulsive disorder (OCD) is characterized by the presence of obsessions and/or compulsions that can cause significant functional impairment and distress. Risk factors include family history, age, pregnancy/postnatal period, and history of abuse, bullying, or neglect. Treatment options include low-intensity psychological treatments, SSRIs, and more intensive CBT (including ERP). Severe cases should be referred to the secondary care mental health team for assessment and may require combined treatment with an SSRI and CBT or clomipramine as an alternative. ERP involves exposing the patient to an anxiety-provoking situation and stopping them from engaging in their usual safety behavior. Treatment with SSRIs should continue for at least 12 months to prevent relapse and allow time for improvement.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 10 - A 36-year-old woman presents to her doctor with complaints of struggling to maintain...

    Correct

    • A 36-year-old woman presents to her doctor with complaints of struggling to maintain positive relationships with her coworkers. Upon further inquiry, it is revealed that the woman has a rigid value system and moral code, making it challenging for her to work with colleagues who have different beliefs and work practices. What personality disorder is most likely present in this patient?

      Your Answer: Obsessive-compulsive personality disorder

      Explanation:

      Patients with obsessive-compulsive personality disorder tend to be inflexible when it comes to morals, ethics, and values. They often have difficulty delegating tasks to others, as seen in this case. Other symptoms include an excessive focus on details, rules, lists, and order, as well as perfectionism that can interfere with completing tasks.

      Antisocial personality disorder is not applicable in this case. This disorder is characterized by aggressive and unlawful behavior, deception, and a lack of empathy.

      Borderline personality disorder is also not applicable. This disorder is characterized by unstable self-image, unstable relationships, fear of abandonment, and chronic feelings of emptiness.

      Paranoid personality disorder is not applicable. This disorder is characterized by a tendency to question the loyalty of friends, hypersensitivity to insult, and preoccupation with conspiracies and hidden meanings.

      Narcissistic personality disorder is not applicable. This disorder is characterized by a grandiose sense of self-importance, lack of empathy, sense of entitlement, and preoccupation with fantasies of success, power, or beauty.

      Personality disorders are a set of personality traits that are maladaptive and interfere with normal functioning in life. It is estimated that around 1 in 20 people have a personality disorder, which are typically categorized into three clusters: Cluster A, which includes Odd or Eccentric disorders such as Paranoid, Schizoid, and Schizotypal; Cluster B, which includes Dramatic, Emotional, or Erratic disorders such as Antisocial, Borderline (Emotionally Unstable), Histrionic, and Narcissistic; and Cluster C, which includes Anxious and Fearful disorders such as Obsessive-Compulsive, Avoidant, and Dependent.

      Paranoid individuals exhibit hypersensitivity and an unforgiving attitude when insulted, a reluctance to confide in others, and a preoccupation with conspiratorial beliefs and hidden meanings. Schizoid individuals show indifference to praise and criticism, a preference for solitary activities, and emotional coldness. Schizotypal individuals exhibit odd beliefs and magical thinking, unusual perceptual disturbances, and inappropriate affect. Antisocial individuals fail to conform to social norms, deceive others, and exhibit impulsiveness, irritability, and aggressiveness. Borderline individuals exhibit unstable interpersonal relationships, impulsivity, and affective instability. Histrionic individuals exhibit inappropriate sexual seductiveness, a need to be the center of attention, and self-dramatization. Narcissistic individuals exhibit a grandiose sense of self-importance, lack of empathy, and excessive need for admiration. Obsessive-compulsive individuals are occupied with details, rules, and organization to the point of hampering completion of tasks. Avoidant individuals avoid interpersonal contact due to fears of criticism or rejection, while dependent individuals have difficulty making decisions without excessive reassurance from others.

      Personality disorders are difficult to treat, but a number of approaches have been shown to help patients, including psychological therapies such as dialectical behavior therapy and treatment of any coexisting psychiatric conditions.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 11 - Samantha is a 38-year-old female who has come to the crisis team with...

    Correct

    • Samantha is a 38-year-old female who has come to the crisis team with suicidal thoughts. Upon further inquiry, Samantha also reveals experiencing low mood, lack of energy, early morning awakenings, and difficulty concentrating. She reports that these symptoms are persistent, but she has both good and bad days. Samantha has no prior psychiatric history. What medication would be the most suitable to initiate treatment for Samantha?

      Your Answer: Sertraline

      Explanation:

      When managing a patient with depression, it is important to consider several factors according to NICE guidelines. These include managing suicide risk, safeguarding concerns for vulnerable individuals, and any comorbid conditions such as substance abuse. If the patient exhibits psychotic symptoms or eating disorders, seeking expert advice is recommended. For those with mild depression or subthreshold symptoms, active monitoring and follow-up appointments are suggested. Psychological interventions through IAPT are recommended for persistent subthreshold or mild-to-moderate depression, while antidepressants and high-intensity psychological interventions are recommended for moderate or severe depression. When prescribing antidepressants, it is important to consider the patient’s history and any chronic physical health problems, with sertraline being preferred in such cases due to its lower risk of drug interactions. Practical solutions to stressors contributing to depression should also be discussed.

      In 2022, NICE updated its guidelines on managing depression and now classifies it as either less severe or more severe based on a patient’s PHQ-9 score. For less severe depression, NICE recommends discussing treatment options with patients and considering the least intrusive and resource-intensive treatment first. Antidepressant medication should not be routinely offered as first-line treatment unless it is the patient’s preference. Treatment options for less severe depression include guided self-help, group cognitive behavioral therapy, group behavioral activation, individual CBT or BA, group exercise, group mindfulness and meditation, interpersonal psychotherapy, SSRIs, counseling, and short-term psychodynamic psychotherapy. For more severe depression, NICE recommends a shared decision-making approach and suggests a combination of individual CBT and an antidepressant as the preferred treatment option. Other treatment options for more severe depression include individual CBT or BA, antidepressant medication, individual problem-solving, counseling, short-term psychodynamic psychotherapy, interpersonal psychotherapy, guided self-help, and group exercise.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 12 - A 54-year-old man visits his General Practitioner (GP) with his wife. Since retiring...

    Incorrect

    • A 54-year-old man visits his General Practitioner (GP) with his wife. Since retiring from the navy, he has been struggling with anger issues. This is affecting his marriage, and he has been drinking more heavily to help him to relax. He also reports feeling low in mood and having frequent nightmares, including flashbacks from his past experiences while fighting in Afghanistan.
      Which one of the following psychological therapies would be most appropriate to manage this condition?

      Your Answer: Eye movement desensitisation and reprocessing (EMDR)

      Correct Answer: Trauma-focused cognitive behavioural therapy

      Explanation:

      Different Approaches to Treating PTSD in Combat-Related Trauma

      When it comes to treating post-traumatic stress disorder (PTSD) caused by combat-related trauma, there are several approaches available. Trauma-focused cognitive behavioural therapy is often recommended, which involves educating the patient about their reactions to trauma and providing strategies for managing symptoms. Anger management may also be appropriate if the patient is only experiencing anger without other PTSD symptoms. However, eye movement desensitisation and reprocessing (EMDR) is not the most suitable treatment for combat-related trauma. Psychoanalytic therapy, which involves exploring the unconscious to resolve underlying conflicts, is also not recommended. Finally, psychologically focused debriefing is not recommended for treating PTSD in combat- or non-combat-related trauma. It’s important to consider the specific needs of each patient and tailor treatment accordingly.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 13 - You are about to prescribe fluoxetine, a selective serotonin reuptake inhibitor (SSRI) to...

    Correct

    • You are about to prescribe fluoxetine, a selective serotonin reuptake inhibitor (SSRI) to a 50-year-old man who has just started a new relationship. He asks about common side-effects.
      Which of the below is a common side-effect that it would be most important to council this patient about?

      Your Answer: Sexual dysfunction

      Explanation:

      Understanding the Side-Effects of SSRIs: Sexual Dysfunction, Constipation, Sedation, Urinary Retention, and Dry Mouth

      Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for major depressive and generalized anxiety disorders. These drugs work by increasing serotonin concentration in the synaptic cleft, which stimulates post-synaptic neurons and improves mood. However, SSRIs can also cause several side-effects that patients should be aware of.

      One of the most important side-effects to keep in mind is sexual dysfunction. Patients may feel uncomfortable discussing this issue, so it is important for healthcare providers to ask about it specifically. Sildenafil can be useful in treating this side-effect.

      SSRIs can also cause gastrointestinal upset, including dyspepsia, nausea, abdominal pain, diarrhea, and constipation. However, given the patient’s age, it would be most appropriate to counsel regarding sexual dysfunction.

      While SSRIs are associated with insomnia, restlessness, and general agitation, they are not typically associated with sedation. Urinary disorders can be associated with SSRIs, but they are more commonly seen with the use of tricyclic antidepressants. Dry mouth is a common side-effect of SSRIs, but it is less important to counsel patients about than sexual dysfunction.

      In summary, patients taking SSRIs should be aware of the potential side-effects, including sexual dysfunction, gastrointestinal upset, insomnia, urinary disorders, and dry mouth. Healthcare providers should ask about sexual dysfunction specifically and provide appropriate treatment options.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 14 - You are asked to obtain consent from a pediatric patient for electroconvulsive therapy...

    Correct

    • You are asked to obtain consent from a pediatric patient for electroconvulsive therapy (ECT).

      Which of the following is not a risk associated with ECT?

      Your Answer: Induction of dementia

      Explanation:

      Side Effects and Memory Loss Associated with Electroconvulsive Therapy (ECT)

      Electroconvulsive therapy (ECT) is a medical treatment that involves passing electrical currents through the brain to induce a seizure. While side effects of ECT are rare, some patients may experience memory loss. During the course of ECT, patients may have difficulty remembering newly learned information, but this typically improves in the days and weeks following treatment. However, some patients may experience partial loss of memory for events that occurred before ECT, which may take longer to recover.

      Despite these potential memory issues, some patients report improved memory ability following ECT, as it can remove the amnesia associated with severe depression. It is important to note that cardiac arrhythmia may be stimulated by the electrical shock of ECT, but musculoskeletal injury is rare with adequate anesthesia.

      It is also important to dispel the myth that ECT can cause dementia. Dementia is an organic illness that is not induced by ECT. Research has not found a link between ECT and dementia, but this remains an area of focus for further study. Overall, while ECT may have some potential side effects, it can be a highly effective treatment for severe depression and other mental health conditions.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 15 - A 50-year-old male with schizophrenia is being evaluated by his psychiatrist. During the...

    Correct

    • A 50-year-old male with schizophrenia is being evaluated by his psychiatrist. During the consultation, the psychiatrist observes that the patient appears disinterested and unresponsive when discussing recent and upcoming events in his life, such as his upcoming trip to Hawaii and his recent separation from his spouse.

      What is the most appropriate term to describe the abnormality exhibited by the patient?

      Your Answer: Blunting of affect

      Explanation:

      Emotional and Cognitive Symptoms in Mental Health

      Blunting of affect is a condition where an individual experiences a loss of normal emotional expression towards events. This can be observed in people with schizophrenia, depression, and post-traumatic stress disorder. Anhedonia, on the other hand, is the inability to derive pleasure from activities that were once enjoyable. Depersonalisation is a feeling of detachment from oneself, where an individual may feel like they are not real. Labile affect is characterized by sudden and inappropriate changes in emotional expression. Lastly, thought blocking is a sudden interruption in the flow of thought.

      These symptoms are commonly observed in individuals with mental health conditions and can significantly impact their daily lives. It is important to recognize and address these symptoms to provide appropriate treatment and support. By these symptoms, mental health professionals can better assess and diagnose their patients, leading to more effective treatment plans. Additionally, individuals experiencing these symptoms can seek help and support to manage their condition and improve their quality of life.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 16 - A 20-year-old individual presents with obsessive thoughts about causing harm to others since...

    Correct

    • A 20-year-old individual presents with obsessive thoughts about causing harm to others since moving away from home to attend college. They are particularly anxious about using the shared kitchen in their dormitory and tend to prepare and eat meals during the night to avoid contact with their roommates. After completing a Yale-Brown Obsessive Compulsive Scale (Y-BOCS), they are diagnosed with mild OCD. What treatment option would be most suitable for this individual?

      Your Answer: Cognitive behavioural therapy

      Explanation:

      For patients with mild symptoms of obsessive-compulsive disorder (OCD) and mild impairment, the recommended first-line treatment is cognitive behavioural therapy (CBT) with exposure and response prevention (ERP). While clomipramine, a tricyclic antidepressant, may be used in some cases, it is not typically the first choice. Dialectical behaviour therapy is not commonly used in the treatment of OCD, as CBT and ERP are more effective. Fluoxetine, an SSRI antidepressant, may also be used in the treatment of OCD, but is not typically the first-line treatment for mild cases.

      Obsessive-compulsive disorder (OCD) is characterized by the presence of obsessions and/or compulsions that can cause significant functional impairment and distress. Risk factors include family history, age, pregnancy/postnatal period, and history of abuse, bullying, or neglect. Treatment options include low-intensity psychological treatments, SSRIs, and more intensive CBT (including ERP). Severe cases should be referred to the secondary care mental health team for assessment and may require combined treatment with an SSRI and CBT or clomipramine as an alternative. ERP involves exposing the patient to an anxiety-provoking situation and stopping them from engaging in their usual safety behavior. Treatment with SSRIs should continue for at least 12 months to prevent relapse and allow time for improvement.

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      • Psychiatry
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  • Question 17 - A 67-year-old man is prescribed duloxetine for a major depressive episode after having...

    Correct

    • A 67-year-old man is prescribed duloxetine for a major depressive episode after having no response to citalopram or fluoxetine.

      What is the mechanism of action of the newly added drug?

      Your Answer: Serotonin and noradrenaline reuptake inhibitor

      Explanation:

      The mechanism of action of duloxetine involves inhibiting the reuptake of both serotonin and noradrenaline, making it a member of the antidepressant class known as serotonin and noradrenaline reuptake inhibitors. When selecting an antidepressant, patient preference, previous sensitization, overdose risk, and cost are all factors to consider. SSRIs are typically the first-line treatment due to their favorable risk-to-benefit ratio and comparable efficacy to other antidepressants.

      Understanding Serotonin and Noradrenaline Reuptake Inhibitors

      Serotonin and noradrenaline reuptake inhibitors (SNRIs) are a type of antidepressant medication that work by increasing the levels of serotonin and noradrenaline in the brain. These neurotransmitters are responsible for regulating mood, emotions, and anxiety levels. By inhibiting the reuptake of these chemicals, SNRIs help to maintain higher levels of serotonin and noradrenaline in the synaptic cleft, which can lead to improved mood and reduced anxiety.

      Examples of SNRIs include venlafaxine and duloxetine, which are commonly used to treat major depressive disorders, generalised anxiety disorder, social anxiety disorder, panic disorder, and menopausal symptoms. These medications are relatively new and have been found to be effective in treating a range of mental health conditions. SNRIs are often preferred over other types of antidepressants because they have fewer side effects and are less likely to cause weight gain or sexual dysfunction.

      Overall, SNRIs are an important class of medication that can help to improve the lives of people struggling with mental health conditions. By increasing the levels of serotonin and noradrenaline in the brain, these medications can help to regulate mood and reduce anxiety, leading to a better quality of life for those who take them.

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      • Psychiatry
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  • Question 18 - A 47-year-old woman presents complaining of ‘flashbacks’. Seven months earlier, she had been...

    Correct

    • A 47-year-old woman presents complaining of ‘flashbacks’. Seven months earlier, she had been standing at a bus stop when a car swerved off the road into the queue, killing instantly a child standing near to her. Every day she experiences intrusive images of the child’s face as it saw the car mount the curb. She has not been able to go to that part of town since the day and she has avoided taking the bus anywhere. She feels she is always on edge and jumps at the slightest noise around the house. She thinks things are getting worse, rather than better, and asks you whether there are any psychological treatments that might help her.
      Which one of the following approaches is indicated?

      Your Answer: Trauma-focused cognitive behavioural therapy (CBT)

      Explanation:

      Treatment Options for Post-Traumatic Stress Disorder: Focus on Trauma-Focused CBT

      Post-traumatic stress disorder (PTSD) is a delayed and/or prolonged response to a traumatic event that can cause distress in almost anyone. Symptoms include intrusive flashbacks, avoidance of trauma-related triggers, emotional numbness, and hypervigilance. Trauma-focused cognitive behavioural therapy (CBT) is the recommended first-line treatment for PTSD, according to the National Institute for Health and Care Excellence (NICE) in the United Kingdom. Other therapies, such as psychodynamic therapy, supportive therapy, and hypnotherapy, may be helpful but are not first-line approaches. Watchful waiting is only appropriate for mild symptoms present for less than a month. It is important to seek help for PTSD, and trauma-focused CBT is a proven effective treatment option.

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      • Psychiatry
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  • Question 19 - A 78-year-old woman complains of feeling down, having low energy, and losing interest...

    Correct

    • A 78-year-old woman complains of feeling down, having low energy, and losing interest in activities. She has been experiencing poor sleep for the past 2 weeks and has had no appetite. Her physician prescribes mirtazapine. What category of medications does mirtazapine fall under?

      Your Answer: Noradrenergic and specific serotonergic antidepressants

      Explanation:

      By blocking alpha2 adrenoreceptors, mirtazapine increases the release of neurotransmitters and functions as a noradrenergic and specific serotonergic antidepressant.

      Mirtazapine: An Effective Antidepressant with Fewer Side Effects

      Mirtazapine is an antidepressant medication that functions by blocking alpha2-adrenergic receptors, which leads to an increase in the release of neurotransmitters. Compared to other antidepressants, mirtazapine has fewer side effects and interactions, making it a suitable option for older individuals who may be more susceptible to adverse effects or are taking other medications.

      Mirtazapine has two side effects that can be beneficial for older individuals who are experiencing insomnia and poor appetite. These side effects include sedation and an increased appetite. As a result, mirtazapine is typically taken in the evening to help with sleep and to stimulate appetite.

      Overall, mirtazapine is an effective antidepressant that is well-tolerated by many individuals. Its unique side effects make it a valuable option for older individuals who may have difficulty sleeping or eating.

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      • Psychiatry
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  • Question 20 - A 32-year-old man with a diagnosis of bipolar disorder is brought in by...

    Correct

    • A 32-year-old man with a diagnosis of bipolar disorder is brought in by police under section 136 of the mental health act. His psychiatrist has recently adjusted his medication. He was found dancing in the middle of a busy street claiming to be the king of the world.

      Upon assessment, he appears elated, his speech is rapid and he appears easily distracted. He believes he has been chosen by a higher power to save the world from destruction and hasn't slept for days as a result.

      The patient is sectioned and admitted to the mental health ward.

      What is the most appropriate course of action?

      Your Answer: Stop sertraline and start olanzapine

      Explanation:

      When managing mania or hypomania in patients who are taking antidepressants, it may be necessary to discontinue the use of the antidepressant and initiate treatment with antipsychotic medication.

      Understanding Bipolar Disorder

      Bipolar disorder is a mental health condition that is characterized by alternating periods of mania/hypomania and depression. It typically develops in the late teen years and has a lifetime prevalence of 2%. There are two recognized types of bipolar disorder: type I, which involves mania and depression, and type II, which involves hypomania and depression.

      Mania and hypomania both refer to abnormally elevated mood or irritability, but mania is more severe and can include psychotic symptoms for 7 days or more. Hypomania, on the other hand, involves decreased or increased function for 4 days or more. The presence of psychotic symptoms suggests mania.

      Management of bipolar disorder may involve psychological interventions specifically designed for the condition, as well as medication. Lithium is the mood stabilizer of choice, but valproate can also be used. Antipsychotic therapy, such as olanzapine or haloperidol, may be used to manage mania/hypomania, while fluoxetine is the antidepressant of choice for depression. It is important to address any co-morbidities, as there is an increased risk of diabetes, cardiovascular disease, and COPD in individuals with bipolar disorder.

      If symptoms suggest hypomania, routine referral to the community mental health team (CMHT) is recommended. However, if there are features of mania or severe depression, an urgent referral to the CMHT should be made. Understanding bipolar disorder and its management is crucial for healthcare professionals to provide appropriate care and support for individuals with this condition.

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      • Psychiatry
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  • Question 21 - A 50-year-old man has been hospitalized following an overdose. What is the most...

    Correct

    • A 50-year-old man has been hospitalized following an overdose. What is the most significant indicator of an increased likelihood of future suicide?

      Your Answer: Making plans before the overdose to avoid discovery

      Explanation:

      Factors indicating high risk of suicide

      The concealment of an overdose indicates a serious intent to complete suicide, more so than other options. However, a previous history of overdoses does not necessarily imply a more serious intent. Other factors that may suggest a higher risk of suicide include being male, elderly, and having a mental illness.

      According to the Assessment of Suicide Risk clinical guide, protective factors against suicide include religious beliefs, social support, and being responsible for children. While being responsible for children is an important point to note in the management plan for a suicidal patient, it is not a factor that indicates a high risk of suicide.

      It is crucial to identify the factors that suggest a high risk of suicide in order to provide appropriate care and management for the patient. However, it is also important to consider the patient’s wider circumstances and any protective factors that may be present. By taking a comprehensive approach, healthcare professionals can provide the best possible care for patients at risk of suicide.

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      • Psychiatry
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  • Question 22 - A worried parent comes to your clinic with concerns that their 14-year-old son...

    Correct

    • A worried parent comes to your clinic with concerns that their 14-year-old son may be purging after meals. They have noticed that he has become increasingly preoccupied with his appearance and often disappears after eating. They want to know more about purging. What information can you provide them about this behavior?

      Purging is a behavior that involves getting rid of food and calories from the body after eating. This can be done through self-induced vomiting, using laxatives or diuretics, or excessive exercise. Purging is often associated with eating disorders such as bulimia nervosa. It is important to note that purging can have serious health consequences, including dehydration, electrolyte imbalances, and damage to the digestive system. If their son is indeed purging, it is important to seek medical and psychological help as soon as possible.

      Your Answer: Purging behaviours can include exercising, laxatives or diuretics

      Explanation:

      Bulimia nervosa involves purging behaviors that go beyond just vomiting, and can also include the use of laxatives or diuretics, as well as excessive exercising. Binging episodes are followed by these purgative behaviors, which occur on average once a week and do not necessarily happen after every meal. Fasting, which involves restricting or stopping food intake, is more commonly associated with anorexia nervosa.

      Bulimia Nervosa: An Eating Disorder Characterized by Binge Eating and Purging

      Bulimia nervosa is a type of eating disorder that involves recurrent episodes of binge eating followed by purging behaviors such as self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise. The DSM 5 diagnostic criteria for bulimia nervosa include recurrent episodes of binge eating, a sense of lack of control over eating during the episode, and recurrent inappropriate compensatory behaviors to prevent weight gain. These behaviors occur at least once a week for three months and are accompanied by an undue influence of body shape and weight on self-evaluation.

      Management of bulimia nervosa involves referral for specialist care and the use of bulimia-nervosa-focused guided self-help or individual eating-disorder-focused cognitive behavioral therapy (CBT-ED). Children should be offered bulimia-nervosa-focused family therapy (FT-BN). While pharmacological treatments have a limited role, a trial of high-dose fluoxetine is currently licensed for bulimia. It is important to seek appropriate care for bulimia nervosa to prevent the physical and psychological consequences of this eating disorder.

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      • Psychiatry
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  • Question 23 - A 32-year-old woman confides in you that she experienced childhood sexual abuse. Which...

    Correct

    • A 32-year-old woman confides in you that she experienced childhood sexual abuse. Which one of the following features is not a characteristic feature of post-traumatic stress disorder?

      Your Answer: Loss of inhibitions

      Explanation:

      Understanding Post-Traumatic Stress Disorder (PTSD)

      Post-traumatic stress disorder (PTSD) is a mental health condition that can develop in individuals of any age following a traumatic event. This can include experiences such as natural disasters, accidents, or even childhood abuse. PTSD is characterized by a range of symptoms, including re-experiencing the traumatic event through flashbacks or nightmares, avoidance of situations or people associated with the event, hyperarousal, emotional numbing, depression, and even substance abuse.

      Effective management of PTSD involves a range of interventions, depending on the severity of the symptoms. Single-session interventions are not recommended, and watchful waiting may be used for mild symptoms lasting less than four weeks. Military personnel have access to treatment provided by the armed forces, while trauma-focused cognitive behavioral therapy (CBT) or eye movement desensitization and reprocessing (EMDR) therapy may be used in more severe cases.

      It is important to note that drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used, venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline, should be tried. In severe cases, NICE recommends that risperidone may be used. Overall, understanding the symptoms and effective management of PTSD is crucial in supporting individuals who have experienced traumatic events.

    • This question is part of the following fields:

      • Psychiatry
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  • Question 24 - A 35-year-old man is brought to his GP by his partner who is...

    Incorrect

    • A 35-year-old man is brought to his GP by his partner who is concerned he may have developed bipolar disorder over the last few months.
      The man experiences periods of elevated mood, where he spends a lot of money and sleeps very little. He denies having any delusions of grandeur. These episodes usually last for a few days, and he has never put himself or others in danger.
      The man also has episodes of severe depression, where he feels suicidal, loses interest in his hobbies, and sleeps excessively. He is referred to a psychiatrist for further evaluation.
      What is the most probable diagnosis?

      Your Answer: Type 1 bipolar disorder

      Correct Answer: Type 2 bipolar disorder

      Explanation:

      The woman’s alternating episodes of hypomania and severe depression suggest that she has type 2 bipolar disorder. There are no indications of an anxiety disorder, and the severity of her symptoms is not consistent with cyclothymia. Major depressive disorder is also not a likely diagnosis, as she experiences ‘highs’ consistent with hypomania. Type 1 bipolar disorder is also unlikely, as her ‘high’ periods are more in line with hypomania rather than full-blown mania.

      Understanding Bipolar Disorder

      Bipolar disorder is a mental health condition that is characterized by alternating periods of mania/hypomania and depression. It typically develops in the late teen years and has a lifetime prevalence of 2%. There are two recognized types of bipolar disorder: type I, which involves mania and depression, and type II, which involves hypomania and depression.

      Mania and hypomania both refer to abnormally elevated mood or irritability, but mania is more severe and can include psychotic symptoms for 7 days or more. Hypomania, on the other hand, involves decreased or increased function for 4 days or more. The presence of psychotic symptoms suggests mania.

      Management of bipolar disorder may involve psychological interventions specifically designed for the condition, as well as medication. Lithium is the mood stabilizer of choice, but valproate can also be used. Antipsychotic therapy, such as olanzapine or haloperidol, may be used to manage mania/hypomania, while fluoxetine is the antidepressant of choice for depression. It is important to address any co-morbidities, as there is an increased risk of diabetes, cardiovascular disease, and COPD in individuals with bipolar disorder.

      If symptoms suggest hypomania, routine referral to the community mental health team (CMHT) is recommended. However, if there are features of mania or severe depression, an urgent referral to the CMHT should be made. Understanding bipolar disorder and its management is crucial for healthcare professionals to provide appropriate care and support for individuals with this condition.

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      • Psychiatry
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  • Question 25 - A 27-year-old man is brought to the emergency department by police after being...

    Incorrect

    • A 27-year-old man is brought to the emergency department by police after being found naked in the street and shouting about the government's plan to infect the population with a virus through the water supply. He is not known to secondary care services and a drug screen is negative. The psychiatry liaison team admits him under Section 2 of the Mental Health Act for assessment of a first psychosis. What is the most significant risk factor for this patient's condition?

      Your Answer: Prolonged cannabis use

      Correct Answer: Uncle with schizophrenia

      Explanation:

      The most significant risk factor for psychotic disorders is a person’s family history.

      Understanding the Epidemiology of Schizophrenia

      Schizophrenia is a psychotic disorder that affects a significant portion of the population. The strongest risk factor for developing this condition is having a family history of the disorder. Individuals with a parent who has schizophrenia have a relative risk of 7.5. Additionally, monozygotic twins have a 50% chance of developing schizophrenia, while siblings have a 10% chance. In contrast, individuals without relatives with schizophrenia have a 1% chance of developing the disorder.

      Aside from family history, other factors can increase the risk of developing schizophrenia. Black Caribbean ethnicity has a relative risk of 5.4, while migration and living in an urban environment have relative risks of 2.9 and 2.4, respectively. Cannabis use also increases the risk of developing schizophrenia, with a relative risk of 1.4.

      Understanding the epidemiology of schizophrenia is crucial in identifying individuals who may be at risk of developing the disorder. By recognizing these risk factors, healthcare professionals can provide early interventions and support to prevent or manage the onset of schizophrenia.

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      • Psychiatry
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  • Question 26 - A 28-year-old man visits his GP with complaints of poor memory. He works...

    Correct

    • A 28-year-old man visits his GP with complaints of poor memory. He works in a consulting company and recently faced trouble at work after missing a flight to a client in Tokyo. He has difficulty falling asleep and wakes up feeling exhausted. Sometimes he wakes up in the middle of the night screaming. When awake, he cannot relax and appears to be constantly on edge.

      The patient has a history of attention-deficit hyperactivity disorder during childhood and one major depressive episode during his university years. He has not had any mental health-related complaints since then. He drinks one bottle of wine on Saturdays with his wife and admits to occasional past cocaine use. However, he stopped using cocaine after being ambushed and stabbed while dealing with a dealer during his last vacation in Thailand two months ago. His wife has recently complained that he appears emotionally unavailable.

      Upon physical examination, no abnormalities are found. However, during the mental state examination, the patient exhibits low mood and an increased startle response. What is the most likely diagnosis?

      Your Answer: Post-traumatic stress disorder

      Explanation:

      The individual is displaying common symptoms of PTSD, including re-experiencing the traumatic event through nightmares, avoiding triggers associated with the event, and experiencing hyperarousal such as hypervigilance and difficulty sleeping. It has been over a month since the traumatic event occurred, ruling out acute stress disorder. There are no signs of psychosis, and the individual has been sober from cocaine for two months. While anxiety is a symptom of PTSD, there is no indication of a generalized anxiety disorder or major depressive episode.

      Understanding Post-Traumatic Stress Disorder (PTSD)

      Post-traumatic stress disorder (PTSD) is a mental health condition that can develop in individuals of any age following a traumatic event. This can include experiences such as natural disasters, accidents, or even childhood abuse. PTSD is characterized by a range of symptoms, including re-experiencing the traumatic event through flashbacks or nightmares, avoidance of situations or people associated with the event, hyperarousal, emotional numbing, depression, and even substance abuse.

      Effective management of PTSD involves a range of interventions, depending on the severity of the symptoms. Single-session interventions are not recommended, and watchful waiting may be used for mild symptoms lasting less than four weeks. Military personnel have access to treatment provided by the armed forces, while trauma-focused cognitive behavioral therapy (CBT) or eye movement desensitization and reprocessing (EMDR) therapy may be used in more severe cases.

      It is important to note that drug treatments for PTSD should not be used as a routine first-line treatment for adults. If drug treatment is used, venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline, should be tried. In severe cases, NICE recommends that risperidone may be used. Overall, understanding the symptoms and effective management of PTSD is crucial in supporting individuals who have experienced traumatic events.

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      • Psychiatry
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  • Question 27 - An 18-year-old boy takes an overdose of 12 paracetamol tablets after a fight...

    Correct

    • An 18-year-old boy takes an overdose of 12 paracetamol tablets after a fight with his best friend. He is found by his roommate and rushed to the hospital.

      What is the most significant factor that suggests a high likelihood of a successful suicide attempt?

      Your Answer: Making efforts to not be found

      Explanation:

      The risk of completed suicide is heightened when attempts are made to avoid being discovered. Additionally, factors such as writing a note, making plans, sorting out affairs, and using violent methods also increase the risk. However, an overdose of paracetamol and alcohol has not been found to increase the risk of completed suicide. While a history of deliberate self-harm does increase the risk of suicide, it does not necessarily increase the risk of completed suicide. Furthermore, an impulsive suicide attempt is considered less concerning than a meticulously planned one.

      Suicide Risk Factors and Protective Factors

      Suicide risk assessment is a common practice in psychiatric care, with patients being stratified into high, medium, or low risk categories. However, there is a lack of evidence on the positive predictive value of individual risk factors. A review in the BMJ concluded that such assessments may not be useful in guiding decision-making, as 50% of suicides occur in patients deemed low risk. Nevertheless, certain factors have been associated with an increased risk of suicide, including male sex, history of deliberate self-harm, alcohol or drug misuse, mental illness, depression, schizophrenia, chronic disease, advancing age, unemployment or social isolation, and being unmarried, divorced, or widowed.

      If a patient has attempted suicide, there are additional risk factors to consider, such as efforts to avoid discovery, planning, leaving a written note, final acts such as sorting out finances, and using a violent method. On the other hand, there are protective factors that can reduce the risk of suicide, such as family support, having children at home, and religious belief. It is important to consider both risk and protective factors when assessing suicide risk and developing a treatment plan.

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      • Psychiatry
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  • Question 28 - As a healthcare professional, you are asked to evaluate a patient in their...

    Correct

    • As a healthcare professional, you are asked to evaluate a patient in their early 30s who is experiencing chest pain and is awaiting assessment by the psychiatry team. Upon examination and investigations, no abnormalities are found. However, you observe that the patient is exhibiting unusual behavior, avoiding eye contact and being hesitant to answer questions. After building a rapport with the patient, they reveal that they have never been in a romantic relationship and prefer to be alone to avoid embarrassment. They have no friends and do not communicate with their family due to constant criticism. What type of personality disorder is the patient likely experiencing?

      Your Answer: Avoidant

      Explanation:

      Patients diagnosed with avoidant personality disorder exhibit a strong fear of criticism, rejection, ridicule, and being disliked. This fear often leads to social isolation and avoidance of activities that may result in embarrassment or negative judgment from others. It is important to note that this disorder is distinct from other personality disorders such as antisocial, borderline, and histrionic, which have their own unique symptoms and characteristics.

      Personality disorders are a set of personality traits that are maladaptive and interfere with normal functioning in life. It is estimated that around 1 in 20 people have a personality disorder, which are typically categorized into three clusters: Cluster A, which includes Odd or Eccentric disorders such as Paranoid, Schizoid, and Schizotypal; Cluster B, which includes Dramatic, Emotional, or Erratic disorders such as Antisocial, Borderline (Emotionally Unstable), Histrionic, and Narcissistic; and Cluster C, which includes Anxious and Fearful disorders such as Obsessive-Compulsive, Avoidant, and Dependent.

      Paranoid individuals exhibit hypersensitivity and an unforgiving attitude when insulted, a reluctance to confide in others, and a preoccupation with conspiratorial beliefs and hidden meanings. Schizoid individuals show indifference to praise and criticism, a preference for solitary activities, and emotional coldness. Schizotypal individuals exhibit odd beliefs and magical thinking, unusual perceptual disturbances, and inappropriate affect. Antisocial individuals fail to conform to social norms, deceive others, and exhibit impulsiveness, irritability, and aggressiveness. Borderline individuals exhibit unstable interpersonal relationships, impulsivity, and affective instability. Histrionic individuals exhibit inappropriate sexual seductiveness, a need to be the center of attention, and self-dramatization. Narcissistic individuals exhibit a grandiose sense of self-importance, lack of empathy, and excessive need for admiration. Obsessive-compulsive individuals are occupied with details, rules, and organization to the point of hampering completion of tasks. Avoidant individuals avoid interpersonal contact due to fears of criticism or rejection, while dependent individuals have difficulty making decisions without excessive reassurance from others.

      Personality disorders are difficult to treat, but a number of approaches have been shown to help patients, including psychological therapies such as dialectical behavior therapy and treatment of any coexisting psychiatric conditions.

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  • Question 29 - A 75-year-old male comes in for his routine check-up without specific concerns. During...

    Correct

    • A 75-year-old male comes in for his routine check-up without specific concerns. During the examination, no abnormalities were detected. However, upon reviewing the blood test results sent by the nurse before the appointment, the following values were noted:
      Na+ 130 mmol/l
      K+ 3.5 mmol/l
      Urea 4 mmol/l
      Creatinine 85 µmol/l
      The patient's medications are now being reviewed. Which medication is the most probable cause of the electrolyte abnormality?

      Your Answer: Sertraline

      Explanation:

      Hyponatraemia is a known side effect of SSRIs, but not of aspirin or bisoprolol. Bisoprolol may cause bradycardia, while aspirin may cause dyspepsia. Ramipril, an ACE inhibitor, is associated with hyperkalaemia in patients with reduced renal function.

      Understanding the Side-Effects and Interactions of SSRIs

      SSRIs, or selective serotonin reuptake inhibitors, are commonly prescribed antidepressants that can have various side-effects and interactions with other medications. The most common side-effect of SSRIs is gastrointestinal symptoms, and patients taking these medications are at an increased risk of gastrointestinal bleeding. To mitigate this risk, a proton pump inhibitor should be prescribed if the patient is also taking a NSAID. Hyponatraemia, or low sodium levels, can also occur with SSRIs, and patients should be vigilant for increased anxiety and agitation after starting treatment.

      Fluoxetine and paroxetine have a higher propensity for drug interactions, and citalopram has been associated with dose-dependent QT interval prolongation. The Medicines and Healthcare products Regulatory Agency (MHRA) has advised that citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram has been reduced for certain patient populations.

      SSRIs can also interact with other medications, such as NSAIDs, warfarin/heparin, aspirin, and triptans. It is important to review patients after starting antidepressant therapy and to gradually reduce the dose when stopping treatment to avoid discontinuation symptoms. These symptoms can include mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.

      In summary, understanding the potential side-effects and interactions of SSRIs is crucial for safe and effective treatment of depression and other mental health conditions. Patients should be closely monitored and counseled on the risks and benefits of these medications.

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      • Psychiatry
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  • Question 30 - A 25-year-old male has been taking antipsychotics for a few months and is...

    Incorrect

    • A 25-year-old male has been taking antipsychotics for a few months and is experiencing a severe side-effect that causes repetitive involuntary movements such as grimacing and sticking out the tongue. This side-effect is known to occur only in individuals who have been on antipsychotics for an extended period. What medication is the most appropriate for treating this side-effect?

      Your Answer: Procyclidine

      Correct Answer: Tetrabenazine

      Explanation:

      Tetrabenazine is an effective treatment for moderate to severe tardive dyskinesia, which is the condition that this patient is experiencing. Propranolol is typically used to alleviate symptoms of akathisia, while procyclidine and benztropine are commonly prescribed for acute dystonia.

      Antipsychotics are a group of drugs used to treat schizophrenia, psychosis, mania, and agitation. They are divided into two categories: typical and atypical antipsychotics. The latter were developed to address the extrapyramidal side-effects associated with the first generation of typical antipsychotics. Typical antipsychotics work by blocking dopaminergic transmission in the mesolimbic pathways through dopamine D2 receptor antagonism. They are associated with extrapyramidal side-effects and hyperprolactinaemia, which are less common with atypical antipsychotics.

      Extrapyramidal side-effects (EPSEs) are common with typical antipsychotics and include Parkinsonism, acute dystonia, sustained muscle contraction, akathisia, and tardive dyskinesia. The latter is a late onset of choreoathetoid movements that may be irreversible and occur in 40% of patients. The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients, including an increased risk of stroke and venous thromboembolism. Other side-effects include antimuscarinic effects, sedation, weight gain, raised prolactin, impaired glucose tolerance, neuroleptic malignant syndrome, reduced seizure threshold, and prolonged QT interval.

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      • Psychiatry
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SESSION STATS - PERFORMANCE PER SPECIALTY

Psychiatry (24/30) 80%
Passmed