Core clinical (MRCP) Flashcards
The majority of postpartum psychotic episodes are characterized by which of the following presentations? A. Schizophreniform presentation B. Affective–manic presentation C. Delirium–organic presentation D. Dissociative presentation E. Catatonic presentation
B. It is well known that postpartum psychosis is often an episode of bipolar manic illness.
A small minority have schizophreniform presentation or organic, delirious presentation. Another
episode of relapse occurs in the same year in nearly 70% and risk during subsequent pregnancy is
greater than 50%. In delirious presentations, ruling out organic cause, such as postpartum
pituitary apoplexy, is very important
Which of the following fi gures represent the correct estimate of the incidence of postpartum psychosis? A. Around 1–2 in 1000 B. Around 1 in 100 C. Around 1 in 10,000 D. Around 5 in 100 E. Around 1 in 2000
A. Postpartum psychosis affects 1 to 2 per 1000 childbirths. Initially, it was claimed that the
incidence was higher in the West but, currently, comparable rates have been obtained worldwide.
In contrast, postpartum depression affects 10 to 15% of all mothers, while postpartum blues
affects 50 to 70% of mothers
Which of the following postpartum disorders is correctly matched with its
time of onset?
A. Postpartum blues – within a few months of delivery
B. Postpartum depression – fi rst week of delivery
C. Postpartum psychosis – within 2 weeks of delivery
D. Postpartum pituitary apoplexy –12 months after delivery
E. All of the above are correct
C. Time of onset of symptoms is an important clue in postpartum illnesses, especially to aid
diagnosis during early presentation. Postpartum blues typically start 3 to 5 days after delivery;
postpartum psychosis is also of acute onset and can develop between 2 weeks and 2 months
after delivery; postpartum depression can occur anytime between 2 months and 1 year after
childbirth, most commonly in the third month.
Which of the following principle has guided the organization of disorders in ICD-10 Chapter V? A. Hierarchy B. Reversibility C. Treatment response D. Mode of onset E. Degree of disability
A. Jasperian hierarchy refers to the principle that, in psychiatric practice, some diagnoses
when made preclude using another diagnostic label even if a second diagnosis could account for
a constellation of symptoms. For example when a diagnosis of major depression is made,
symptoms of generalized anxiety are included in the description of depression itself; a separate
diagnosis of generalized anxiety disorder need not be entertained. Similarly, depressive symptoms
can be present during an acute psychotic episode of schizophrenia – they need not always
indicate a separate diagnosis of depression. The hierarchy is maintained in ICD-10, to some
extent, in the way the various chapters of ICD are organized. Organic disorders trump a
diagnosis of psychotic disorders, which in turn are more or less equally considered with affective
disorders. Affective disorders trump neuroses, which in turn trump personality disorders. DSM
has abandoned this hierarchy to a large extent, though the principle is retained. Different modes
of onset or degrees of disability will not yield differing diagnosis. Treatment response cannot be
considered as a principle for organization of ICD-10 Chapter V.
In ICD-10 schizoaffective disorder is included in the same chapter as which of the following disorders? A. Schizophrenia B. Affective disorders C. Organic disorders D. Stress disorders E. Personality disorders
A. Schizoaffective disorder is a diagnosis that lies between schizophrenia and affective
disorder. It is placed together with schizophrenia in section F20–29. ICD-10 stipulates that
schizophrenic and affective symptoms must be simultaneously present and both must be equally
prominent. In DSM-IV the concept of a continuum between psychosis and affective illness is
better highlighted. According to DSM-IV: (1) both schizophrenia and affective disorder categories
must be met simultaneously; (2) a period of psychosis (2 weeks) without prominent affective
symptoms must be present; and (3) the mood disturbance must be present for a substantial
period during active (psychotic) and residual periods. Note that in postschizophrenic depression
(classifi ed under schizophrenia in ICD-10) the psychotic symptoms must not be prominent (but
residual) when a depressive episode is present, and depression must be within 12 months of the
most recent psychotic episode. Schizophreniform disorder is a diagnosis used when
schizophrenia does not fulfi l the duration criteria in DSM-IV (<6 months). This diagnosis is not
included in ICD-10.
Which of the following principles is not included in psychiatric classifi catory
systems (ICD and DSM) to defi ne specifi c psychiatric disorders?
A. Number of symptoms
B. Impairment criteria
C. Duration criteria
D. Prognostic criteria
E. Exclusion criteria
D. In general, both DSM and ICD use symptom count, age of onset, duration, impairment,
and exclusion criteria for many psychiatric diagnoses. Aetiological information and theoretical
speculations are avoided in classifi cation. Course specifi ers are used often in DSM-IV to aid in
subtyping a disorder. Good or poor prognostic typology is not employed as a classifi cation
principle in either of these systems.
Which of the following is a difference between DSM-IV and ICD-10?
A. Culture-bound syndromes are separately classifi ed in ICD
B. Comorbid diagnoses are allowed in DSM
C. DSM-IV has a dimensional approach to personality disorders
D. Length of illness is a criteria for diagnosing DSM-IV schizophrenia
E. Schizotypal disorder is a personality disorder in ICD-10
D. In DSM-IV a period of at least 6 months of observation is required before a reliable
diagnosis of schizophrenia could be made. In ICD-10 a period of 1 month is used instead. This
makes DSM-IV schizophrenia narrower than ICD-10 schizophrenia. Schizotypal disorder is a
personality disorder according to DSM-IV not ICD-10. Culture-bound syndromes are separately
coded in DSM, which is largely an American system. ICD-10 encompasses cultural differences in
various places throughout the text.
In the multiaxial system of DSM-IV, the fi fth axis refers to A. General medical condition B. Personality diffi culties C. Global assessment of functioning D. Psychosocial stress factors E. Intelligence level
C. DSM is multiaxial – it consists of fi ve axes:
Axis 1. Primary psychiatric diagnosis
Axis 2. Personality diffi culties or learning diffi culties; can include defence mechanism/ coping
strategy employed predominantly
Axis 3. General medical condition (may or may not be related to Axis 1 or 2)
Axis 4. Psychosocial stressor (both positive and negative)
Axis 5. Global assessment of functioning (highest score achieved over a few months in the last
year in various domains of life)
Note that ICD-10 also has a multiaxial version, which has three axes.
Two clinicians using the same checklist to aid clinical description come up with the same diagnosis. Which of the following properties of the checklist is involved in this outcome? A. Validity of the checklist B. Reliability of checklist C. Sensitivity of checklist D. Specifi city of checklist E. None of the above
B. Reliability of a test refers to its ability to produce the same results when tested at
different times (test–retest reliability) or tested by different observers at the same time
(observer reliability). Validity refers to the ability of a test to measure what it sets out or intends
to measure. Sensitivity refers to the ability of a test to pick the highest number of true patients
from a sample to whom it is administered. Specifi city refers to the ability to identify the correct
diagnosis among various different possibilities. Reliability of diagnostic classifi cations is enhanced
by using operationalized check lists. Field trials enhance the validity. Reliability and validity need
not always correlate. It is possible for many clinicians to make the same diagnosis which is not
really right (reliable but invalid). Validity has a ceiling set by reliability – very low reliability can
reduce validity though vice versa is not true
Which of the following could increase the validity of psychiatric diagnosis in the future? A. Cross-cultural studies B. Laboratory tests C. Operational criteria D. Cross-sectional studies E. Consensus statements
B. How can we know whether the diagnosis we make using a set of descriptions and
observation is the true condition that a patient has? Cross-sectional studies of even a huge
number of patients cannot answer this question. Longitudinal study of the patient in question can
improve claims about a diagnosis – but classifi cation systems are typically constructed to enable a
clinician to make a diagnosis after a time-sliced, cross-sectional interview rather than a lifelong
observation. We can ensure that everyone makes the same diagnosis by having a consensus
statement or cross-cultural studies. Defi nite laboratory measures that are objective can, if
developed, increase the validity of a diagnosis
Which of the following is a benefi t of a categorical classifi cation over dimensional classifi cation? A. Easy to communicate B. Increased validity C. Prognostic information D. Informs qualitative research E. All of the above
A. Categorical classifi cation refers to the current ICD-10 and DSM-IV approach of using
mutually exclusive labels for diagnosis in an ‘all or none’ fashion. A diagnosis is either present or
absent according to this system, very similar to the medical model – pneumonia is either present
or absent. Relative advantages of a categorical system are (1) it is very familiar and not complex
to construct; (2) it is easy to remember and communicate; and (3) it informs management
decisions readily (e.g. if there is malaria, give chloroquine). A dimensional approach considers a
continuum of diagnostic issues; it uses degrees of severity of a particular dimension (say mood,
anxiety) rather than mutually exclusive ‘boxes’ of diagnosis. In this way various dimensions can be
employed simultaneously to describe a patient’s diffi culties. Relative advantages of a dimensional
system include: (1) more information is conveyed and this may include valuable information of
prognostic importance that can be missed using plain categories; (2) it is very fl exible; (3) it does
not impose strict, artifi cial boundaries between disorders and so has better validity; and (4) it is
more holistic and less labelling, thus informing qualitative research.
Which of the following disorders has the most evidence for existing as a
continuum in the population, making a dimensional approach more rational?
A. Delusional disorders
B. Personality disorders
C. Developmental disorders
D. Affective disorders
E. Cognitive disorders
B. It has been argued that personality disorders are better considered in a continuum with
normalcy and so a dimensional approach is tipped for personality disorders in future DSM
classifi cations. Note that contemporary cognitive psychologists consider delusions to exist in a
continuum of normal beliefs and so a modular approach is criticized. But this does not imply that
delusional disorders, as defi ned currently, exist in such a continuum
By defi nition, the nature of delirium that differentiates it from dementia includes which of the following? A. Insidious onset B. Acute onset C. Deteriorating course D. Familial onset E. Irreversible progression
B. Delirium is an acute confusional state by defi nition. It may or may not be reversible
depending on the aetiology. Most cases are reversible and have a non-deteriorating episodic
course. Both dementia and delirium have an impact on global cognitive abilities, including
memory
Which of the following best describes the nature of cognitive impairment required to diagnose dementia? A. Focal, progressive defi cits B. Focal, static defi cits C. Global, progressive defi cits D. Global, static defi cits E. None of the above
C. Dementia is an organic syndrome wherein progressive, global cognitive disturbance is
noted. Dementia is often irreversible. Cognitive disturbances include memory diffi culties
(amnesia), aphasia, agnosia, apraxia, impaired executive function, and personality changes.
Signifi cant psychosocial impairment must be present to warrant a diagnosis of dementia. Clouding
of consciousness, impaired attention, wide diurnal fl uctuation, presence of autonomic signs, and a
high degree of reversibility on treating the potential cause are other differentiating features that
point towards delirium.
The most common cause of presenile dementia is A. Vascular dementia B. Pick’s dementia C. Alzheimer’s dementia D. Lewy body dementia E. Prion dementia
C. Alzheimer’s dementia is the most common dementia in both older and younger patients.
Risk of Alzheimer’s increases with age. About 1% risk at age 60 years then doubles every 5 years
becoming nearly 40% of those aged 85 years. Women are affected three times more often.
Down’s syndrome, previous head injury, hypothyroidism, family history of dementia, and
supposedly low educational attainment are other risk factors. Alzheimer’s is implicated in up to
two-thirds of all senile dementia.
Which one of the following is NOT a risk factor for developing dementia? A. Smoking B. Boxing C. Ageing D. Drinking alcohol E. Living alone
E. Smoking is a risk factor for dementia especially of the vascular type, though controversies
exist as to whether smoking could prevent Alzheimer’s disease. A large survey of UK male
doctors followed up from 1951 has demonstrated that smoking in fact increases the risk of
Alzheimer’s. Also in a prospective, population-based cohort study of 6868 participants >55 years
followed up for an average of 7 years, smoking was associated with increased risk of any
dementia in general, and Alzheimer’s in particular. Ageing increases the risk of dementia. Boxing is
associated with dementia pugilistica wherein neurofi brillary tangles are observed. Alcoholic
dementia occurs in excessive drinkers. Living alone does not increase the risk of dementia
The best option for preventing dementia available currently is A. Regular NSAIDs B. Vitamin E C. Low salt diet D. Early retirement E. None of the above
E. Evidence for dementia preventive strategies has emerged recently though this is largely
concerned with delaying the onset rather than abolishing the risk. Sustained use of NSAIDs is
associated with a reduced risk of developing AD. Some NSAIDs appear to modulate the amyloid
load in the brain. But NSAIDs have signifi cant adverse effects that might limit their potential as
primary preventive agents in AD. Oestrogens and HRT cannot be recommended and the
potential of statins remains to be fully assessed. Evidence for using antioxidant supplements such
as vitamin E and vitamin C is far from clear cut and there are safety concerns about higher doses
of vitamin E. Strategies to target mid-life vascular risk factors are likely to have an important
effect on the age of presentation of AD, though as of now none of the given options are
recommended to prevent dementia.
Which one of the following genetic factor is associated with senile dementia of Alzheimer’s type? A. Presenilin 1 only B. Presenilin 1 and 2 C. Amyloid precursor protein D. APOE4 allele E. Defective tau protein
D. Of patients with Alzheimer’s, 40% have a positive family history of Alzheimer’s. This is
especially true if the patient is younger (<55). Among various genes implicated, Chromosome 21
carries the gene for amyloid precursor protein (APP) which when mutant increases amyloid
deposition even before senility, so it is associated with younger-onset dementia. Trisomy 21 acts
via the same mechanism in Down’s. The APO gene on chromosome 19 codes for apolipoprotein
(apo). People with one copy of the APOE4 allele have Alzheimer’s three times more frequently
than do those with no APOE4 allele, and people with two APOE4 alleles have the disease eight
times more frequently. Diagnostic testing for APOE4 is not recommended because it is seen in
more patients without Alzheimer’s than those with the disease and so accounts only for 50% of
genetic variance. E3 is the most common APOE allele and E2 may be protective. It is possible that
apoE4 mediates Alzheimer’s risk via lipid metabolism as the presence of apoE4 increases
cholesterol levels in blood. Chromosome 14 (presenilin 1) and chromosome 1 (presenilin 2) are
also implicated in early-onset Alzheimer’s via increased beta amyloid deposition.
With respect to the major classifi catory systems ICD and DSM, the term
‘operational defi nition’ refers to which of the following?
A. Defi nition arrived at by a consensus
B. Defi nition with precise inclusion and exclusion criteria
C. Defi nition validated by fi eld trials
D. Defi nition with strict duration of illness criteria
E. Defi nitions with multilingual translation
B. The term operational defi nition refers to a defi nition that is specifi ed by a series of
precise, unambiguous inclusion and exclusion criteria. In other words, an operational defi nition is
arrived at by using a checklist. This improves the reliability of a classifi catory system tremendously.
Before the popular use of ICD and DSM systems, the cross-national agreement for psychiatric
diagnosis was very poor, as exemplifi ed by the US–UK diagnostic study. In the UK, the rate of
manic depression was ten times higher and the rate of schizophrenia was two times lower than
the prevalence in the US (Cooper, 1972). Operational defi nitions paved the way for the wider
use of standardized diagnostic instruments, increasing the reliability of classifi cation
Dementia secondary to which of the following is not reversible? A. Nutritional defi ciencies B. Hypothyroidism C. Stroke D. Normal pressure hydrocephalus E. Depression
C. Reversible causes constitute nearly 15% of initial diagnoses of dementia. The proportion
is higher in younger patients. The reversible causes are commonly subdural haematoma, normal
pressure hydrocephalus (NPH), vitamin B12 defi ciency, metabolic causes, and hypothyroidism.
Stroke causes vascular dementia which is irreversible.
Which of the following produce a rapidly evolving dementia with neurological features? A. Viruses B. Prions C. Bacteria D. Helminths E. Drugs
B. Creutzfeldt–Jakob disease (CJD) is a prion disease that presents with rapidly evolving
dementia with multiple neurological features. Prions are virus-like transmissible agents but
without any nucleic acid. They are simple, mutated proteins originating from the normal human
prion protein gene (PRNP), which is located on the short arm of chromosome 20. When mutant
PrPSc is formed it is partially protease-resistant with a capacity to change further normal PrP to
PrPSc, initiating a cascade. CJD presents non-specifi cally with fatigue and fl u-like symptoms with
rapid development of neurological fi ndings such as aphasia, cerebellar signs, myoclonus, apraxia
with emotional lability, depression, delusions, hallucinations, or marked personality changes. The
disease is rapidly progressive with dementia, akinetic mutism, coma, and death occurring within
few months of onset.
Prion dementia is caused by all of the following EXCEPT A. Hormone extracts B. Corneal transplants C. Organ donations D. Peritoneal dialysis E. Contaminated meat
D. Sporadic onset accounts for 85% of cases with CJD, while 10% result from genetic
mutation. The remaining 5% result from iatrogenic transmission during transplant surgery of dura
and corneal grafts, and pituitary growth hormone. vCJD is a variant form of human CJD that is
transmitted by eating contaminated meat of an animal with bovine spongiform encephalopathy.
Peritoneal dialysis does not involve foreign tissue
The probability of developing Korsakoff ’s syndrome is related to which of the following features? A. Amount of alcohol consumed B. Nutritional deprivation C. Age of onset of drinking D. Type of alcoholic drink E. Level of tolerance
B. Wernicke–Korsakoff syndrome is considered to be a nutritional illness seen in alcoholics.
Thiamine defi ciency can occur secondary to gastrectomy, carcinoma stomach, anorexia,
haemodialysis, hyperemesis gravidarum, prolonged intravenous hyperalimentation, and alcoholism.
This produces neuronal damage with small vessel hyperplasia and occasional haemorrhages
especially in diencephalic structures such as mamillary bodies and medial dorsal thalamus. There
is no clear correlation between amount, type, or duration of alcohol consumption and incidence
of Korsakoff ’s syndrome. It is thought that patients who develop Korsakoff ’s may have abnormal
transketolase enzyme, involved in thiamine metabolism
Korsakoff ’s syndrome is characterized by all EXCEPT A. Dense anterograde amnesia B. Impaired procedural memory C. Apathy D. Confabulation E. Executive deficits
B. In Korsakoff ’s syndrome recent memory tends to be affected more than is remote
memory. Confabulation, apathy, and executive dysfunction are prominent. The length of
retrograde amnesia is variable. Working memory and attention are preserved. The implicit
emotional learning and procedural memory are preserved, facilitating rehabilitation; 75% of these
patients show some degrees of improvement, whilst 25% show no change.
Which of the following best describes the triad characteristic of normal
pressure hydrocephalus?
A. Ataxia, dementia, confabulation
B. Incontinence, dementia, confabulation
C. Headaches, visual disturbances, dementia
D. Headaches, ataxia, dementia
E. Ataxia, dementia, incontinence
E. Normal pressure hydrocephalus or NPH is a syndrome of cerebral ventricular dilatation
with normal CSF pressure. The changes are prominent in the third ventricle, affecting the
pyramidal tract representing legs. This leads to a triad of: dementia, gait ataxia, and urinary
incontinence. The dementia is reversible if NPH is treated promptly with shunt or repeated
lumbar puncture.
Which one of the following clinical signs and diseases is correctly paired? A. Wilson’s disease–chorea B. Huntington’s disease–dystonia C. Parkinson’s disease–tremors D. Pseudobulabr palsy–past pointing E. Motor neuron disease–ataxia
C. In Wilson’s disease athetosis with wing beating movements are noted. Huntington’s
disease is characterized by chorea while a patient with pseudobulbar palsy shows exaggerated
jaw jerk and emotional lability. In motor neurone disease combined upper and lower motor
neurone signs are noted. Ataxia typically occurs in posterior column, cerebellar, or vestibular
damage. The tremor in Parkinson’s is described as pill rolling tremor
A 40-year-old man develops irritability and depressed mood with signifi cant
personality change. His father committed suicide at age of 45 and
grandmother suffered from memory problems before she died at age 57.
Which is the most important diagnosis to consider in this case?
A. Parkinson’s disease
B. Wilson’s disease
C. Huntington’s disease
D. Sydenham’s chorea
E. Fahr’s disease
C. The clues in this case are young age of onset, presence of irritability, and personality
change with family history including a degree of ‘anticipation’ over generations. Premature death,
suicide, and psychiatric problems point to Huntington’s disease in family members. The onset is
usually during the fourth decade with signifi cant numbers showing juvenile presentation with
successive generations. The course is almost always a deteriorating pattern with death occurring
around 10–12 years after diagnosis. Fahr’s disease refers to idiopathic bilateral basal ganglia
calcifi cation.
A 45-year-old man develops auditory hallucinations that are initially
fragmented but later turns into second person derogatory. The most
important aspect of personal history in this case is
A. Stimulant use
B. Alcohol use
C. Relationship difficulties
D. Psychosexual history
E. Employment history
B. In alcoholic hallucinosis, psychotic symptoms start either during intoxication or
withdrawal, but in a clear sensorium. The most common symptoms are auditory hallucinations;
these are usually unstructured voices which can develop into persecutory or derogatory content.
The hallucinations usually last for a short period and any persistence beyond 6 months is a strong
suspicion for other psychotic illnesses such as schizophrenia
Mr Smith considers himself as an alcoholic. He uses the same brand of
whisky everyday and drinks at the same pub around the same time. Which
of the following features is he exhibiting?
A. Salience
B. Tolerance
C. Narrow repertoire
D. Loss of control
E. Relief drinking
C. Narrowed repertoire of drinking was included as one of the criteria for alcohol
dependence by Griffi th Edwards and Milton Gross in 1976. Heavy drinkers may have a wide
drinking repertoire. This narrows as dependence advances. The dependent person may start to
drink in a restricted pattern and manner every day, which would ensure a constant blood-alcohol
level avoiding any symptoms of alcohol withdrawal. This is different from salience wherein priority
is given to alcohol over other important areas of life and even painful consequences are
disregarded.
Which of the following clinical feature of schizophrenia adds support to a neurodevelopmental hypothesis? A. Age of onset B. Stress-induced relapses C. Increased incidence among migrants D. Association with cannabis E. Response to antipsychotics
A. The peak ages of onset are 10 to 25 years for men and 25 to 35 years for women. Age of
onset of schizophrenia is quoted as a supporting feature of neurodevelopmental hypothesis. A
substantial reorganization of cortical connections, involving a programmed synaptic pruning, takes
place during adolescence in humans. An excessive pruning of the prefrontal synapses, perhaps
involving the excitatory glutamatergic inputs to pyramidal neurones, may underlie schizophrenia.
This is called the Feinberg hypothesis
