General Adult (MRCP)

Question 1

According to ICD-10 criteria which of the following is considered to be the
minimum required weight loss to be signifi cant as a diagnostic criteria for
somatic syndrome associated with depression?
A. Loss of 1% body weight in 1 month
B. Loss of 5% body weight in 3 months
C. Loss of 2% body weight in 2 weeks
D. Loss of 5% body weight in 1 month
E. Loss of 15% body weight in 1 week

Answer 1

D. Somatic syndrome is defi ned by a set of vegetative or biological features of depression.
The ICD-10 criteria for somatic syndrome of depression require at least four symptoms from
a list of eight. These are (1) marked loss of interest or pleasure; (2) loss of emotional reactions;
(3) early-morning awakening (2 hours before normal waking time); (4) diurnal worsening of
mood; (5) objective evidence of marked psychomotor retardation or agitation; (6) marked loss
of appetite; (7) loss of libido and (8) 5% or more of body weight lost unintentionally in the past
month. To diagnose anorexia nervosa, there must be a weight loss leading to a body weight at
least 15% below the normal expected weight for age and height

Question 2

The prevalence of catatonic phenomenon among patients with
schizophrenia is estimated to be around
A. 1–2%
B. 0.01–0.05%
C. 5–10%
D. 15–25%
E. 30–35%

Answer 2

C. According to the International Pilot Study of Schizophrenia (World Health Organization
1973), 7% of 811 schizophrenia patients exhibited one or other catatonic phenomenon. Further
studies that followed gave a figure of between 5% and 10%. Mannerisms are the most common
catatonic phenomenon in schizophrenia, followed by stereotypies, stupor, negativism, automatism
and echopraxia in order of frequency. About 10–15% of patients with catatonia meet the
criteria for schizophrenia. It is widely appreciated that catatonic symptoms are more prevalent
in the developing nations than in the West. When one includes all psychiatric patients, not just
schizophrenia, the prevalence of catatonia increases to 10–20%. This is because depression
contributes to most of the observed catatonia in practice. Immobility and mutism are the most
commonly observed catatonic symptoms among depressed patients

Question 3

Seasonal affective disorder (SAD) is a popular concept but not formally
considered as a separate category under current classifi catory systems.
Which of the following statements is true with regard to this condition?
A. Seasonal depression carries higher familial risk of affective disorders than non-seasonal
depression
B. In phototherapy for SAD, exposure to skin is more effective than exposure to eye
C. Early-morning light therapy is more effective than evening exposure
D. Side-effects of exposure are more intense with evening than morning therapy
E. Conventional antidepressants have no effect on seasonal depression

Answer 3

C. ICD-10 clinical guidelines do not include specifi c criteria for SAD. However, specifi c
criteria are included in DSM-IV (Text Revision) and the research version of ICD-10. ICD-10
provisional criteria for SAD specifi es the disorder as a subtype of mood disorder where three
or more episodes must occur with onset within the same 90-day period of the year for three
or more consecutive years; Remissions also occur within a particular 90-day period of the year.
Seasonal episodes must outnumber any non-seasonal episodes that may occur. Familial risks
of affective disorders in SAD are similar to those found in non-seasonal depressive illnesses.
Typical depressive symptoms of SAD respond better to bright-light therapy whereas atypical
symptoms respond to phototherapy at all intensities. In phototherapy retinal light exposure is
important; skin absorption is not suffi cient to modify circadian rhythms or depressive symptoms.
Early-morning phototherapy is superior but leads to more side-effects, such as easy startle,
gastrointestinal intolerance and headaches. Conventional antidepressants have also been
reported to have a therapeutic effect in SAD.

Question 4

The 1-year prevalence of dysthymia is estimated to be around
A. 15–20%
B. 20–25%
C. 1–6%
D. 0.1–0.6%
E. 10–15%

Answer 4

C. Dysthymia has a 1-year prevalence of 1–3%. The lifetime prevalence according to
the National Comorbidity Survey 1994 is 6%. Dysthymia has a high comorbidity with other
psychiatric disorders, particularly major depression. In one series, only about 25–30% of cases
were observed to occur over a lifetime in the absence of other psychiatric disorders. The
comorbidity of personality disorders seems to be very high (60–80%). Early-onset dysthymia is
defi ned as having onset before age 21.

Question 5

The most powerful predictors of recurrence of depressive episodes among
the following is
A. Previous episodes of depression and presence of residual symptoms
B. Non-bipolar diagnosis and later age of onset
C. Female gender and earlier age of onset
D. Higher degree of life events and family history of affective disorders
E. Male gender and past history of psychiatric admission

Answer 5

A. Follow-up studies in depression reveal two powerful predictors of recurrence: the
presence of residual symptoms after apparent recovery and history of previous episodes of
depression. The presence of residual symptoms increases the risk of recurrence nearly threefold,
whereas past history of depression doubles the risk, with each new episode increasing the
risk further. Other possible risk predictors for recurrence include somatic syndrome, reversed
vegetative signs, early age of onset, and family history of mood disorders. Recurrence risk is
higher in bipolar than in unipolar mood disorders.

Question 6

The proportion of patients who develop a depressive episode and then go
on to develop an episode of mania within 10 years is approximately
A. 1 in 2
B. 1 in 10
C. 1 in 4
D. 1 in 50
E. 1 in 200

Answer 6

B. In community studies, 1 in 10 patients who begin with a depressive episode go on to
develop an episode of mania within 10 years. If the illness begins at a younger age, the switch
happens earlier. This rate increases to nearly 50% if severely depressed hospitalized patients are
considered. Long-term follow-up studies blinded for severity and number of previous episodes
show much lower conversion rates (3.2%). It is known that the majority of bipolar patients,
particularly women, begin with depressive episodes. Among hospitalized depressed patients
followed up for nearly a decade, 1% a year converted to bipolar I and 0.5% a year converted to
bipolar II. However, this conversion rate is less for outpatients with depression. Factors associated
with a change of polarity from unipolar to bipolar were younger age, male sex, family history
of bipolarity, antidepressant-induced hypomania, hypersomnic and retarded phenomenology,
psychotic depression, and a postpartum episode. The mean age at which the switch occurs is
32 years. The average number of previous episodes in those who switch varies between two and
four. The huge differences in switch rates probably reflect the severity of the initial depression,
the length of follow-up, and the expanding definitions of bipolar II disorder

Question 7

Clinical depression and bereavement share many common features. Which
of the following clinical features points to clinical depression rather than
normal mourning?
A. Brief hallucinations
B. Somatic symptoms
C. Anxiety when reminded of loss
D. Psychomotor retardation
E. Angry pining

Answer 7

D. Parkes described features that may distinguish normal mourning from depression. Normal
mourning is characterized by pangs of grief, angry pining, and anxiety when reminded of the loss,
brief hallucinations, somatic symptoms, and identifi cation-related behaviours. The presence of
psychomotor retardation, generalized guilt and suicidal thoughts after the fi rst month suggest
development of depression.

Question 8

Which of the following is an early sign of prolonged grief?
A. Self-blame regarding the death
B. Shock and disbelief
C. Clinging behaviour
D. Anxiety when reminded of loss
E. Brief hallucinations

Answer 8

C. Clinging behaviour and inordinate pining may be early signs of prolonged grief as
described by Parkes. More recently, childhood experiences of early parental death or divorce,
sudden or violent death of a loved one, and high levels of dependency on the deceased for
a sense of personal well-being are thought to be associated with prolonged grief. Several of
these factors suggest the role of attachment insecurity in increasing a person’s vulnerability to
complicated bereavement.

Question 9

The term ‘specifi er’ is used when describing psychiatric diagnoses. Which of
the following is correct with regard to this term?
A. It is used in ICD-10 only
B. It is used in DSM-IV only
C. It refers to treatment response
D. It is used in both DSM IV and ICD 10
E. It refers to number of previous episodes

Answer 9

B. Specifi ers are extensions to a diagnosis that further clarify the course, severity, or special
features of the diagnosis. Note that while subtypes are mutually exclusive and jointly exhaustive
patterns of diagnostic description, specifi ers merely provide an opportunity to defi ne a more
homogeneous subgrouping based on observable clinical phenomenon. DSM-IV uses specifi ers
extensively while dealing with mood disorders. These include specifi ers of the most recent
episode and the longitudinal course. Specifi ers of current clinical severity, psychotic features, and
remission status are the most commonly used. Other descriptive specifi ers include catatonic
features, melancholic features, atypical features, and postpartum onset. The longitudinal course
specifi ers include a seasonal pattern and the presence of rapid cycling. ICD-10 does not use the
term ‘specifi ers’ separately, although the majority are discussed in the core text.

Question 10

Which of the following is true with regard to the longitudinal course of
bipolar disorder?
A. The duration of mood episodes decreases progressively
B. Initial episodes have more rapid onset than later episodes
C. The interval between episodes decreases progressively
D. Seasonal pattern is more common in bipolar type 1 than type 2
E. Later episodes are more likely to be triggered by life events than the initial episodes

Answer 10

C. In any patient with bipolar disorder, the duration of individual mood episodes tends to
be relatively stable throughout the course, with mania generally lasting for a shorter time than
depression. But the onset may become more rapid with age. The interval from one episode to
the next tends to decrease through the course of illness, although some evidence suggests a
tendency for the inter-episode intervals to stabilize after approximately fi ve episodes. Patients
with seasonal patterns are more commonly of bipolar II subtype than bipolar I. The fi rst episode
is more likely to be triggered by life events than later episodes. Ambelas confirmed the strong
correlation between stressful life events and first manic admissions; this association weakens as
the illness progresses. This is particularly true for younger bipolar patients with mania rather than
depression. This is consistent with the hypothesis of kindling phenomenon in bipolar disorders

Question 11

The most common psychiatric disturbance associated with Cushing’s
disease is
A. Depression
B. Mania
C. Mixed affective state
D. Schizophreniform psychosis
E. Dementia

Answer 11

A. Cushing’s syndrome is very frequently, although not invariably, associated with depression.
Nearly 40% of cases in one series of observation had depression whereas only 3% had mania.
It is claimed that the predominance of pure depressive disorders may be a result of publication
bias; controlling for this yields mixed anxiety and depression as the most common psychiatric
disturbance in Cushing’s syndrome. Depression in Cushing’s syndrome may occur as a prodrome
even before the medical disorder is diagnosed; the phenomenology may differ from primary
major depression in that the symptoms are intermittent when associated with Cushing’s
syndrome. Psychosis occurs more commonly in association with affective states; isolated
schizophreniform psychosis is rare. Delirium may occur in 15–20% of patients

Question 12

Polyuria can be a troublesome side-effect with lithium therapy. Which of the
following is NOT correct with response to lithium-related polyuria?
A. It is seen in one-third of those treated with lithium
B. It is usually reversible
C. Once-daily dose produces more polyuria than multiple doses a day
D. Amiloride is a useful intervention
E. Dose reduction may alleviate polyuria

Answer 12

C. Lithium-related polyuria and polydipsia are seen in nearly one-third of those treated.
Polyuria is usually reversible in the early stages but may become obstinate the longer the therapy
lasts. When a once-daily preparation of lithium is used instead of multiple divided doses, the
frequency of polyuria seems to be less, but a direct correlation between plasma peaks and
polyuria is not clearly demonstrated in clinical samples. Dose reduction or use of amiloride
can be tried in those who have troublesome levels of polyuria. Amiloride has relatively less
propensity to cause electrolyte disturbances when co-prescribed with lithium than with other
diuretics.

Question 13

Which of the following electrolyte disturbances simulate lithium-induced
changes in electrocardiogram?
A. Hyperkalaemia
B. Hypocalcaemia
C. Hypomagnesaemia
D. Hypokalaemia
E. Hyponatraemia

Answer 13

D. Lithium exerts minimal cardiac effects at therapeutic doses in most patients. It most
commonly produces benign reversible T-wave changes (including inversion and fl attening) in the
resting electrocardiogram (ECG). These hypokalaemia-like changes are seen in approximately
20–30% of patients treated with lithium. ECG abnormalities of clinical signifi cance are mainly
documented at toxic levels: they include all kinds of arrhythmias (sinus node dysfunction is well
documented) and QTc prolongation. SA node dysfunction is the characteristic complication of
lithium therapy and can manifest clinically as sinus bradycardia or atrioventricular conduction
disturbances. Other parameters such as PR and QRS intervals often remain normal. Combining
carbamazepine with lithium increases the risk for cardiac arrhythmias.

Question 14

Lithium is associated with thyroid dysfunction in some cases. Which of the
following is false with respect to this association?
A. 5–10% of patients on lithium develop clinical hypothyroidism
B. Thyroid enlargement is the most common clinical presentation
C. Presence of thyroid antibodies increases the risk
D. Family history of thyroid disease increases the risk
E. Increased TSH is the most sensitive laboratory index

Answer 14

B. Nearly one-fi fth of lithium-treated patients show increased plasma thyroid-stimulating
hormone (TSH). About 5% show thyroid enlargement (goitre) whereas 5–10% have clinical
hypothyroidism. Weight gain and lethargy are the most common clinical features. These effects
are dependent on dose and the duration of lithium therapy. Middle-aged women with a preexisting
propensity for hypothyroidism in the form of autoantibodies against the thyroid are the
most susceptible clinical group.

Question 15

Compared with the general population, the risk of Ebstein’s anomaly
in children of mothers exposed to lithium during the fi rst trimester of
pregnancy is
A. 2–3 times higher
B. 10–20 times higher
C. 50–80 times higher
D. 100–120 times higher
E. 4–5 times higher

Answer 15

B. The risk of major congenital anomalies in children exposed to lithium in the uterus is
4–12%. This is nearly three times higher than non-exposed fetuses. The UK National Teratology
Information Service has concluded that lithium increases the risk of cardiac malformations
by approximately eightfold. First trimester exposure to lithium increases the risk of Ebstein’s
anomaly by nearly 10–20 times, bringing the absolute risk to 0.05–0.1%.

Question 16

A 48-year-old man is prescribed sodium valproate for prophylaxis against
bipolar mania. He develops a confusional state despite liver function tests
being within the normal range. Which of the following conditions related to
valproate use is most likely to be associated with the above presentation?
A. Hyperammonaemia
B. Hepatic failure
C. Pancreatitis
D. Hypertensive encephalopathy
E. Ketoacidosis

Answer 16

A. Valproate is associated with elevated plasma ammonia. In some people,
hyperammonaemia may be clinically signifi cant, resulting in hyperammonaemic encephalopathy
characterized by varied clinical presentation, including irritability, agitation, drowsiness, asterixis,
coma, and paradoxical seizures. Other symptoms may include loss of appetite, nausea, and
vomiting. Valproic acid-induced hyperammonaemic encephalopathy may occur in people with
normal liver function, despite normal doses and serum levels. It is more common in children with
urea cycle enzyme defi ciencies. Other risk factors include concomitant antiepileptic prescriptions
(especially topiramate), underlying liver disease or hypoalbuminaemia, initiation of high-dose and
long-term therapy. Propionate, a metabolite of valproate reduces the hepatic N-acetylglutamate
concentration, which is an obligatory activator of carbamoyl phosphate synthetase 1 (CPS-1),
the fi rst enzyme of the urea cycle. Another potential mechanism may be via valproate-induced
reduction in hepatic carnitine levels.

Question 17

All of the following patients are under carbamazepine therapy for bipolar
disorder. In which of the following patients will you discontinue the
carbamazepine treatment immediately?
A. A 34-year-old man developing dizziness
B. A 50-year-old man with blood carbamazepine levels 9 mg/L
C. A 44-year-old woman with neutrophil count less than 1000 per mm3
D. A 37-year-old man with sodium levels 129 mEq/dL
E A 48-year-old woman with elevation of thyroid-stimulating hormone (TSH) levels

Answer 17

C. Nausea, ataxia, and dizziness are common side-effects of carbamazepine; usually, none
of these in isolation warrants a cessation of therapy. A maculopapular rash is noted in nearly
1 in 10 patients receiving carbamazepine. This usually occurs within 2 weeks of therapy and
often requires cessation of treatment if associated with an abnormal blood count. Although
leucopenia is seen in 1–2% of patients, serious agranulocytosis occurs rarely (about eight per
million prescriptions). This bone marrow toxicity warrants a cessation of therapy and is indicated
by a total white blood cell (WBC) count of less than 3000 per mm3 or a neutrophil count less
than 1500 per mm3. Hyponatraemia is a common side-effect but levels up to 125 mEq/L can be
managed conservatively without requiring sudden cessation of treatment. Elevation of
thyroid-stimulating hormone does not necessitate stopping carbamazepine

Question 18

Which of the following predicts a good prophylactic effect of lithium in
bipolar disorder?
A. Absence of family history of bipolar disorder
B. Presence of neurological signs
C. ‘Depression–mania–well interval’ pattern of bipolar course
D. Good antimanic effi cacy during acute episode
E. Absence of complete inter-episode recovery

Answer 18

D. Various clinical, biological, and genetic factors that predict lithium responsiveness in
prophylaxis of bipolar disorder have been studied. The presence of typical features of bipolar
disorder, good inter-episode clinical recovery, a family history of bipolar disorder, experiencing
mania as the fi rst bipolar episode, and a good response to lithium in the acute manic phase
predict lithium responsiveness. The presence of neurological signs, comorbid substance use,
and the presence of rapid cycling predict a poor response to lithium. The lithium response in a
sample composed of relatives of lithium responder probands was 67% compared with 30% in the
control group; this indicates that lithium responsiveness may have a certain degree of heritability

Question 19

Which of the following situations associated with parental loss carries the
highest risk of developing depression as an adult?
A. Children born to single mothers
B. Children of divorced mothers
C. Children of remarried mothers with confl icts after remarriage
D. Childhood bereavement with loss of one parent
E. Children living with divorced parent after confl ictual relationship

Answer 19

C. Parental divorce between birth and age 7, regardless of subsequent remarriage, was
predictive of a twofold higher depression risk. The relative risk of depression was highest for
children whose single parent remarried into a confl ictual relationship following divorce. It was
shown that the quality of parental relationship, especially in relation to continuing confl ict among
those taking parental responsibilities, has a major effect on the subsequent risk of depression.
Although childhood socioeconomic status was found to be a signifi cant predictor of later
depression, the risk for depression associated with parental divorce was found to be of a similar
magnitude across categories of childhood socioeconomic status. There is little evidence that
childhood bereavement itself predisposes to adult depression.

Question 20

Adverse life events are consistently associated with depression. Which of
the following statements with respect to the above relationship is
NOT true?
A. 30% of those with depression have no history of preceding signifi cant life events
B. Suicide attempters have a higher amount of life events than depressed patients
C. Loss or humiliation events are highly correlated with depression
D. The impact of life events depends on the contextual threat posed by them
E. No reverse causality exists between depression and life events

Answer 20

E. Only 30% of those with depression give no history of signifi cant life events. Depression
itself may generate negative life events (reverse causality). Similarly, there may be a genetic
contribution to the experience of adverse life events, making the gene–environment interaction
more complex. The Life Events and Diffi culties Scale is considered to be the standard life events
assessment instrument. This scale is based on contextual measurement of the threat posed by life
events (i.e. an event can be considered as signifi cant only in accordance with social and cultural
backgrounds and the life situation in which it occurs). It is shown that suicide attempters have a
higher rate of life events than those with depression. Loss, humiliation, or separation events highly
correlate with depression.

Question 21

All of the following are characteristic features of a depression-prone
individual except
A. Perceiving higher probability for aversive outcomes
B. Believing that aversive events are uncontrollable
C. Attributing negative events to external, unstable but specifi c causes
D. Fragile self-esteem
E. Harbouring high amount of information processing biases

Answer 21

C. If negative events are ascribed to external, unstable, and specifi c causes, one may come
to believe that they are modifi able; this will also induce less self-blame and guilt and will not
induce feelings of helplessness or hopelessness. In contrast, individuals whose locus of control
for negative events is internal, global, and non-specifi c show a higher degree of self-blame and
depression-prone attitude. These individuals possess a high degree of information-processing
biases characterized by the perception of a higher than possible probability for aversive events
and belief that such events are uncontrollable (fatalistic). They also have a fragile self-esteem.

Question 22

Anti-obesity drug rimonabant is associated with signifi cant psychiatric
adverse effects. Which of the following correctly describes the mechanism
of action of rimonabant?
A. Cannabinoid CB1-receptor antagonist
B. Cannabinoid CB2-receptor antagonist
C. Monoclonal antibody against GABAA subunits
D. NMDA receptor antagonist
E. Cholecystokinin antagonist

Answer 22

A. Rimonabant was approved in Europe as an anti-obesity agent in 2006. Rimonabant is a
selective antagonist of the cannabinoid type 1 receptor, and it is the first member of a new class
of compounds that targets the endocannabinoid system. But concerns have been raised regarding
the psychiatric adverse effects of this drug. A meta-analysis by the American Food and Drug
Administration showed that 26% of people given rimonabant 20 mg versus 14% of those given
placebo had a psychiatric symptom reported as an adverse event. The side-effects range from
depressed mood to anxiety and often led to co-prescription of a psychotropic or withdrawal
of the drug. The relative risk for psychiatric adverse events in the rimonabant group was twice
higher than the placebo group.

Question 23

Which of the following neurotransmitters is proposed to be involved in
increasing the signifi cance (salience) of external stimuli in patients with
schizophrenia?
A. GABA
B. Glutamate
C. Endocannabinoids
D. Dopamine
E. Noradrenaline

Answer 23

D. Kapur proposed that in the normal individual, the role of mesolimbic dopamine is to
attach signifi cance or ‘salience’ to an external stimulus or an internal thought. This converts a
neutral piece of information into attention-grabbing information. In acute psychosis where a
hyperdopaminergic state is noted in the mesolimbic system, insignificant events and perceptions
receive inappropriate salience. For example, an innocuous smile of a stranger may be given a
high degree of ‘aberrant salience’ leading to delusional elaborations. On a similar note, when
such aberrant salience is attached to internally generated self-speech, hallucinations may be
experienced. Antipsychotics are claimed to ‘dampen the salience’ of these abnormal experiences
rather than erase the symptoms, and provide the platform for a process of psychological
resolution.

Question 24

All of the following are diagnostic features of neuroleptic malignant
syndrome (NMS) except
A. Diaphoresis
B. Fluctuant blood pressure
C. Myoclonus
D. Tachycardia
E. Mutism

Answer 24

C. DSM-IV-TR research criteria require both severe muscle rigidity and elevated
temperature to be present following recent administration of an antipsychotic. In addition, at
least two associated signs, symptoms, or laboratory fi ndings must be present. The associated
symptoms listed in DSM research criteria include diaphoresis, dysphagia, tremors, incontinence,
mutism, tachycardia, elevated blood pressure, leucocytosis, changes in the level of consciousness,
and laboratory evidence of muscle injury. NMS must be distinguished from serotonin syndrome.
NMS is an idiosyncratic reaction to therapeutic dosages of neuroleptic agents, whereas serotonin
syndrome is a toxic reaction due to overstimulation of 5-HT2a receptors; distinguishing features
include bradykinesia and lead pipe rigidity in NMS, whereas hyperkinesia and myoclonus are
evident in serotonin syndrome.

Question 25

The most common phase of sleep when nocturnal panic attacks appear is
A. Transition between stage 2 and stage 3
B. Transition between stage 1 and stage 2
C. REM sleep
D. Transition between REM sleep and awake state
E. Stage 1 sleep

Answer 25

A. Nocturnal panic refers to waking from sleep with an abrupt and discrete sense of
intense fear accompanied by cognitive and physical symptoms of arousal. It does not differ
signifi cantly from panic attacks that occur during wakeful states. Most patients with nocturnal
panic experience panic attacks during wakeful states too. But a small subset with predominantly
circumscribed nocturnal panic has been described. Most patients report that nocturnal panic
occurs between 1 and 3 hours after sleep onset. It is a non-REM event, usually occurring in
late Stage II or early Stage III sleep. It is not accompanied by any electroencephalographic
abnormalities.

Question 26

All of the following are sleep changes associated with depression except
A. Reduced REM latency
B. Reduced REM density
C. Increased duration of fi rst REM period
D. Low arousal threshold
E. Reduced stage 3 and 4 sleep

Answer 26

B. Disrupted sleep architecture is a long-recognized feature of mood disorders. Several
sleep-related electroencephalogram (EEG) changes have been noted in around 90% of those with
depression. Short REM latency, increased amount of REM sleep, increased REM density, especially
in the fi rst REM episode, prolonged sleep latency, increased frequency of awakenings with low
arousal threshold, reduced slow-wave sleep, and shifting of delta sleep to second-stage NREM
sleep are some of the notable changes. Some reports have suggested that bipolar depression may
be atypical with respect to sleep changes in that daytime sleepiness and increased sleep effi ciency
are reported. In hypomania/mania, short REM latency, inability to fall asleep, short sleep duration,
and reduced delta sleep are seen. In patients who have secondary depression due to a chronic
medical condition, REM sleep may be reduced.

Question 27

A 60-year-old man has episodes of disturbed sleep. He experiences unusual
movements associated with singing and talking to unseen people during
some of these episodes. He recalls vivid dreams when he wakes up. The
most appropriate diagnosis would be
A. Sleep-walking
B. Sleep terrors
C. REM sleep behavioural disorder
D. Periodic limb movement disorder
E. Restless legs syndrome

Answer 27

C. Normally REM sleep is associated with loss of muscle tone (atonia) and dreaming.
In some patients, as an isolated condition or as a prodrome for later neurodegenerative disorders
such as Lewy body dementia/Parkinson’s disease, this normal atonia is absent. This then leads to
‘dreams being acted out’ with uncontrolled limb movements. This is called REM sleep behavioural
disorder. Patients can recall dreams when awakened, unlike sleep terror. The behaviours may be
more complex than simple sleepwalking. Periodic limb movement disorder is characterized by
periodic episodes of repetitive and stereotyped limb movements that occur during sleep. These
movements can cause clinical sleep disturbance expressed by insomnia or excessive daytime
sleepiness. This is not a dream-related behaviour, unlike REM sleep behavioural disorder. Restless
legs syndrome, in simplistic terms, is the daytime extension of periodic limb movement disorder
wherein episodic akathisia and motor restlessness are seen during the day and at night.

Question 28

All of the following are recognized treatment options for restless legs
syndrome except
A. Levodopa
B. Pergolide
C. Pramipexole
D. Amitriptyline
E. Clonazepam

Answer 28

D. Pharmacological treatment options for restless leg syndrome include dopaminergic
agents (L-dopa, pergolide, pramipexole), anticonvulsants (gabapentin, carbamazepine), certain
opioid drugs, and clonazepam. Amitriptyline has no role in the management of restless leg
syndrome. An increase in periodic limb movements observed during sleep has been reported
as a side-effect of tricyclics. Some patients may report new-onset restless leg syndrome in
association with SSRIs or tricyclics when treated for depression.

Question 29

A 29-year-old man presents with erectile dysfunction. His history reveals
excessive stress at work. Which of the following indicates a psychogenic
rather than an organic cause for his sexual dysfunction?
A. Sudden onset of the erectile problem
B. Erectile dysfunction occurs in all settings
C. Loss of early-morning erections
D. Preserved ejaculation despite impaired erection
E. Complete lack of tumescence

Answer 29

A. It is important to realize that clear-cut demarcations between psychogenic or organic
erectile dysfunctions are diffi cult to ascertain in clinical practice. But certain clues that may
favour a psychogenic origin/overlay of erectile dysfunction include sudden onset of the problem,
early collapse of erection (as against complete absence of tumescence), preserved spontaneous
(early morning) and self-stimulated erections, antecedent (temporally related) problems or
changes in relationship, a history of signifi cant preceding or ongoing life events, and evidence
of psychological problems. Clues that may indicate an organic aetiology include preserved
ejaculation in spite of impaired erection, unperturbed libido (in the early stages), and a history of
antecedent physical injury, surgeries, or vascular risk factors in the medical history, smoking, and
other prescribed or recreational drug use.

Question 30

Which of the following drugs used for erectile dysfunction acts via the
dopaminergic mechanism?
A. Sildenafi l
B. Vardenafi l
C. Alprostadil
D. Apomorphine
E. Yohimbine

Answer 30

D. Apomorphine is a dopamine receptor agonist which stimulates both dopamine D1 and
D2 receptors and is sometimes used in male erectile dysfunction. Phosphodiesterase-5 (PDE-5)
is an enzyme found in the trabecular smooth muscle of the penis. It catalyses the degradation
of cGMP, which results in an elevated cytosolic calcium concentration and muscular contraction
leading to erection. PDE-5 inhibitors such as sildenafi l, vardenafi l, and tadalafi l block this
biochemical pathway to promote erection. Sildenafi l and vardenafi l must be taken 1 hour before
sexual activity to enable their action. Alprostadil is prostaglandin E1, which causes smooth muscle
relaxation and subsequent vasodilation by acting on adenylate cyclase to increase the intracellular
cyclic adenosine monophosphate (cAMP) concentration. Yohimbine is not commonly used for
erectile dysfunction; it is an adrenergic antagonist relatively selective for alpha-2 receptors. The
site of action of yohimbine when used for erectile dysfunction is suspected to be central rather
than peripheral as the predominant subtype of alpha-adrenoceptor in penile erectile tissue is
alpha-1 type rather than alpha-2 type.

Question 31

Which of the following instruments is validated for predictive screening for
chronic post-traumatic stress disorder (PTSD) in those who are exposed to
traumatic events?
A. Holmes and Rahe Social Adjustment scale
B. Life Events and Diffi culties Scale
C. Trauma Screening Questionnaire
D. Appraisal of Life Events Scale
E. Abbreviated Injury Scale

Answer 31

C. Not everyone who experiences a traumatic event goes on to develop PTSD. It is
diffi cult to predict exactly who will go on to develop PTSD. Two factors most associated with
future risk of PTSD in those exposed to trauma are perceived lack of social support and peritraumatic
dissociation. The possibility of predicting PTSD has led to designing of predictive
screening instruments to be used shortly after a traumatic event. The 10-item Trauma Screening
Questionnaire (TSQ) is one of the best validated. The TSQ is a predictive screening instrument
for victims of violent crime 1–3 weeks after the assault. In spite of high rates of sensitivity and
specificity, a lower positive predictive value (around 0.48) means that although the TSQ can
detect the vast majority of PTSD sufferers at 1 month, 50% of those who screened positive will
not develop PTSD. Other scales listed in the question are not used directly for predicting PTSD.
The Holmes and Rahe Social Adjustment Scale is used to measure the impact of life events by
means of arbitrary values attached to different types of common life events. The Life Events
and Diffi culties scale is used to measure the contextual threat posed by life events. Appraisal of
the Life Events Scale is designed to provide an index of the three primary appraisal dimensions
(threat, challenge, and loss) described in Lazarus and Folkman’s transactional model of stress.
The Abbreviated Injury Scale is an anatomical scoring system used to classify motor accident
victims to enable emergency physical interventions.

Question 32

Reduced fl ush response to nicotinic acid (niacin) skin patches has been
demonstrated in
A. Depression
B. Bipolar disorder
C. Schizophrenia
D. Autism
E. Anorexia nervosa

Answer 32

C. Niacin (nicotinic acid) is a water-soluble vitamin used as a drug for hyperlipidaemia.
It can induce a visible skin fl ush response that is caused by prostaglandin-mediated cutaneous
vasodilatation. This normal fl ush response is reduced in patients with schizophrenia. The use of
niacin challenge as a simple biochemical test for schizophrenia has been proposed. Depending
on the criteria used, the prevalence rates of attenuated or absent response to a niacin skin patch
in patients with schizophrenia ranged from 49% to 90%, compared with 8% to 23% in healthy
control subjects. This abnormal fl ush response has also been reported in fi rst-degree relatives
of schizophrenia patients. The estimated heritability ranges from 47% to 54%. The attenuated
fl ush response to a niacin patch seen in schizophrenia patients was not observed in patients
with depression, bipolar disorder or autism. The reduced niacin fl ush response in patients with
schizophrenia was not affected by medication status, antipsychotic drug doses, or substances such
as cigarette, coffee, or alcohol consumption.

Question 33

Oral administration of a tryptophan-free amino acid mixture can lead to
tryptophan depletion. This can trigger relapse of depression in patients
being treated for depression. The above phenomenon is most likely seen in
those on
A. Selective serotonin reuptake inhibitors (SSRIs)
B. Tricyclic antidepressants
C. Reboxetine
D. Cognitive behavioural therapy
E. Maintenance electroconvulsive therapy

Answer 33

A. Tryptophan depletion is used as an intervention to deplete serotonin (5-HT) in humans.
It is noted to reverse the antidepressant effects of SSRIs and monoamine oxidase inhibitors
(MAOIs) in patients in remission with a history of depression but not in patients treated with
antidepressants that promote catecholaminergic rather than serotonergic neurotransmission
(such as tricyclic antidepressants, reboxetine, or buproprion). Patients who are either
unmedicated and/or fully remitted are much less likely to experience relapse than patients who
are recently medicated and partially remitted. Recently remitted patients who have been treated
with non-pharmacological therapies such as total sleep deprivation, electroconvulsive therapy,
or phototherapy and possibly CBT do not commonly show full clinical relapse with tryptophan
depletion.

Question 34

All of the following receptor changes are correctly paired except
A. Increased cortical 5HT2A: depressed patients
B. Increased cortical 5 HT1A: depressed patients
C. Increased cortical 5HT2A: ECT treatment
D. Increased cortical 5HT2A: suicide victims
E. Decreased β receptors: antidepressant therapy

Answer 34

B. An increased density of 5HT2 binding sites has been shown in post-mortem studies
of depressed/suicidal patients. The increase in 5HT2A receptors is most prominent in the
dorsolateral prefrontal cortex and in platelets of medication naïve patients. A reduction in 5HT1A
receptors has also been noted in the cortex. In contrast, long-term antidepressant treatment
has been shown to reduce 5HT2 receptors and increase 5HT1A function. But these changes may
not be causative in antidepressant action as they pre-date any clinical response in those who
have started antidepressant therapy. Of note, ECT treatment actually increases 5HT2A receptors.
Most directly acting 5HT1A agonists have poor antidepressant activity. Chronic antidepressant
treatment induces a reduction in β adrenoreceptor density around 2 weeks after starting
antidepressants; this correlates with therapeutic effects. Unmedicated suicide victims show a
greater density of β adrenoreceptors.

Question 35

Which of the following is true with regard to lithium toxicity?
A. Severity is highly correlated with serum levels
B. Neurotoxicity occurs only above therapeutic serum levels
C. Fine tremor is a sign of toxicity
D. Lithium levels often rise even after cessation of treatment
E. Most patients are left with some residual neurological damage

Answer 35

D. The severity of lithium toxicity has a feeble relationship, if any, with levels of serum
lithium. Neurotoxicity can occur even within therapeutic levels of lithium. The symptoms of
lithium toxicity can be grouped into gastrointestinal symptoms such as nausea, diarrhoea,
vomiting; neurological symptoms such as severe tremors (coarse), cerebellar ataxia, slurred
speech, myoclonus, and spasticity; mental symptoms such as drowsiness, disorientation, and
apathy. Most patients make a full recovery when lithium is stopped but serum levels may continue
to rise due to intracellular lithium release even after cessation of treatment. Rarely, persistent
cerebellar damage and cognitive impairment are reported following lithium toxicity.

Question 36

Which of the following antidepressants demonstrate the highest affi nity for
muscarinic acetylcholine receptors of the human brain?
A. Amitriptyline
B. Clomipramine
C. Amoxapine
D. Trazodone
E. Desipramine

Answer 36

A. Amitriptyline has the highest affi nity for central muscarinic acetylcholine receptors
among various antidepressants. Its affi nity is nearly one-tenth of the affi nity shown by atropine.
This is followed by protriptyline and clomipramine. Trazodone has very low muscarinic affi nity.
Anticholinergic side-effects of tricyclics include dry mouth, blurred vision, urinary retention,
constipation, memory impairment, and confusion especially in elderly people.

Question 37

The number of patients who die from hypertensive crises (including
fatal ‘cheese reaction’) when monoamine oxidase inhibitors such as
tranylcypromine are prescribed is approximately
A. 1 in 1000 patients
B. 1 in 100 patients
C. 1 in 10 000 patients
D. 1 in 100 000 patients
E. 1 in 10 patients

Answer 37

D. One in every 100 000 patients treated with monoamine oxidase inhibitors such as
tranylcypromine die due to fatal hypertensive reaction. The fatality rate can also be expressed as
1 in every 8000 hypertensive reactions. The so-called ‘cheese reaction’ is mainly characterized by
skin fl ushing, tachycardia, dyspnoea, sweating, hypertension, conjunctival injection, and headache.
The reaction is usually self-limiting, with signs and symptoms lasting from few minutes to a
few hours. Tyramine is formed by the decarboxylation of the amino acid tyrosine; it is mainly
catabolized via oxidation by monoamine oxidase-A (MAO-A) in man. Thus MAO-A acts as a
protective barrier against high tyramine levels in the nervous system. Unmetabolized tyramine
is transported into adrenergic nerve terminals where it displaces noradrenaline, causing
hypertension.

Question 38

Which of the following antidepressants has been found to be as lethal as
tricyclic antidepressants (TCAs) in cases of overdose?
A. Citalopram
B. Mirtazapine
C. Venlafaxine
D. Moclobemide
E. Escitalopram

Answer 38

C. Data from the Offi ce of National Statistics from 1993–2002 have demonstrated a
signifi cantly higher rate of fatal overdose (fatal toxicity index) with the antidepressant venlafaxine
than with SSRIs. Venlafaxine has a similar lethality to TCAs in cases of overdose; most deaths are
ascribed to cardiac effects of the drug. Overall, approximately 10% of venlafaxine overdoses that
are reported have proven fatal. Blood pressure increases are common in therapeutic doses but
severe increases do not appear to be a signifi cant feature of overdose. Fatal toxicity indices (FTIs)
are calculated using recorded deaths attributed to drug overdose obtained from prescribing data.
TCAs (in particular dothiepin) have been associated with a higher FTI than venlafaxine, which in
turn has been associated with a higher FTI than SSRIs.

Question 39

The lorazepam challenge test is used in the diagnosis of
A. Dissociative amnesia
B. Transient global amnesia
C. Catatonia
D. Panic disorder
E. Endogenous depression

Answer 39

C. In the ‘lorazepam challenge test’ (coined by George Bidder), an intravenous line is
established and a syringe containing 2–4 mg of lorazepam in 2 mL of solution is prepared, and
1 mg is injected. In the next 2–5 minutes if no reduction is observed in catatonic features, the
second 1 mg of lorazepam is injected, and the assessment is repeated. It is noted that more
than 80% of patients with catatonia have a rapid reduction in symptoms with an intravenous
lorazepam challenge. Such a response to lorazepam typically results in a lorazepam treatment
trial, followed by electroconvulsive therapy if substantial relief is not maintained. Fink and Taylor
suggest that adhering to this algorithm achieves remission of catatonia in almost all patients.
Amytal interview using intravenous barbiturates/benzodiazepines has been used in dissociative
amnesia/fugue.

Question 40

Which of the following laboratory abnormalities is associated with
malignant catatonia?
A. High serum magnesium
B. Low serum iron
C. Low liver enzymes
D. High serum amylase
E. Low creatinine phosphokinase

Answer 40

B. The syndrome of malignant catatonia is severe form of catatonia characterized by fever,
muscle rigidity and autonomic instability and can be fatal (through renal failure, pulmonary
embolism or arrhythmias) if not treated promptly. It is indistinguishable from neuroleptic
malignant syndrome. ECT is the treatment of choice. Laboratory studies often help to assess
the overall health of a catatonic patient; they rarely help in identifying the cause or confi rm the
diagnosis of catatonia in isolation. Elevated levels of creatinine phosphokinase (CPK), elevated
liver enzymes, and leucocytosis are some of the changes noted in patients with malignant
catatonia. Low serum iron levels are associated with malignant catatonia; it is also observed in
some patients with neuroleptic malignant syndrome. Serum calcium and magnesium levels are
either normal or low in catatonia

Question 41

All of the following indicate a better treatment response to ECT except
A. Shorter illness duration
B. Past response to antidepressant treatment
C. Signifi cant post-ictal suppression on EEG
D. High ictal amplitude on EEG
E. Past history of mania

Answer 41

E. Medication resistance and chronicity of depression are two often noted factors that
predict lower response rates to ECT. Though ECT can provide signifi cant benefi t for patients who
are resistant to medication, the degree of response may be less than in depressed patients who
are not considered to have such resistance. Similarly, patients with longer durations of continuous
depressive illness are less likely to respond to ECT. Post-ictal suppression and ictal amplitude
are two main EEG-related features during ECT treatment that are associated with positive
effi cacy. Post-ictal suppression refers to the acute fall in EEG amplitude immediately after the
ECT-induced seizure terminates. Ictal EEG amplitude or power measured as voltage is felt to be
related to seizure strength or intensity. Bipolar depression does not respond to ECT differently
from unipolar depression when other variables are controlled for.

Question 42

While treating social anxiety disorder with SSRIs, an adequate treatment
trial should probably extend to
A. 4 weeks
B. 6 weeks
C. 12 weeks
D. 24 weeks
E. 18 months

Answer 42

C. SSRIs are now widely used as fi rst-line agents in social anxiety disorder – both limited
and generalized subtypes. An adequate trial of treatment with SSRIs in social anxiety must extend
to 12 weeks, with a minimum of 6–8 weeks at the highest tolerated doses administered before
considering a switch. It may take many months to consolidate a full treatment response and
achieve a full remission. If the treatment is effective, it is recommended that it be continued for at
least for a year, and then very gradually tapered off.

Question 43

A 32-year-old woman presents with concerns regarding her ‘ugly
appearance’. She had been convinced for a long time that her appearance
was defective and was particularly worried about her ‘streak’ eyes. She
admitted spending at least 14–16 hours a day thinking about her appearance
and comparing herself with other people or seeking reassurance from
others. Which of the following is true with regard to the treatment of this
condition?
A. She may respond to higher than usual antidepressant doses of serotonin re-uptake
inhibitors (SSRIs)
B. There is a good evidence for response to ECT in this condition
C. She has a comparable likelihood of response to SSRIs and non-SSRID antidepressants
D. She will require a shorter than usual duration of treatment trial with SSRIs
E. Cognitive behavioural therapy (CBT) has no role in the treatment

Answer 43

A. The amount of evidence for treatment of body dysmorphic disorder (BDD) is limited,
but it is accepted that serotonin reuptake inhibitors (SSRIs) and cognitive–behavioural therapy
(CBT) are the treatments of choice. Antidepressants, antipsychotics, or electroconvulsive therapy
are not effi cacious for BDD, even though the data are limited. BDD symptoms of delusional
patients appear as likely as symptoms of non-delusional patients to respond to an SSRI. SSRIs
improve preoccupations, distress, and insight with an associated reduction in BDD-related
behaviours such as mirror-checking, etc. The patient need not have depression to experience the
benefi cial effect. Although data are limited with respect to dose-fi nding studies, it is accepted that
BDD often requires higher SSRI doses than those typically used in the treatment of depression,
with variable response times ranging from 4–5 weeks to 9 weeks. Many patients may thus require
longer than the usual treatment trial.

Question 44

A 17-year-old girl is admitted to a medical unit following a prolonged
period of repeated bingeing and vomiting. She induces vomiting at least six
times a day but does not use laxatives or diuretics. Which of the following
laboratory fi nding is most likely in this patient?
A. Low urea levels
B. High potassium levels
C. Low bicarbonate levels
D. Increased thyroxine levels
E. High amylase levels

Answer 44

E. Elevations of serum amylase have been reported in 25–60% of anorexic/bulimic patients
who repeatedly vomit. This amylase appears to derive from the salivary fraction and not the
pancreas. Thus it may be associated with a clinical fi nding of parotid gland enlargement. The use
of serum amylase measurement as an index of clinical symptomatology in eating disorders is
currently limited as the correlation between amylase levels and symptom severity is poor. Low
urea levels are seen in restricting the type of anorexia; they may be increased in those who vomit
repeatedly. Hypokalaemia is a feature of laxative abuse or repeated vomiting in anorexia. High
bicarbonate levels are associated with vomiting whereas low levels are seen in laxative abuse.
Thyroid hormone (T3) is reduced in anorexia; basal TSH values and thyroxine levels may be
normal (low T3 syndrome).

Question 45

A 54-year-old African-Caribbean man had systematized persecutory
delusions that prevented him from eating for 5 weeks. Following admission
to a medical unit he was started on realimentation, despite which he
developed diplopia, bilateral horizontal nystagmus and right sixth cranial
nerve palsy. He had no past history of alcohol use. On transfer to a
psychiatric ward, he was started on a normal diet but soon his phosphate
levels were markedly reduced (0.26 mmol/L). The most likely diagnosis is
A. Normal pressure hydrocephalus
B. Olanzapine overdose
C. Refeeding syndrome
D. Laxative abuse
E. Hepatic failure

Answer 45

C. Refeeding syndrome refers to severe electrolyte and fl uid shift associated with metabolic
abnormalities in patients with malnutrition undergoing realimentation. Refeeding syndrome
can occur in people with eating disorders and alcoholism but it is often missed in psychiatric
units. This patient has developed features of low phosphate and thiamine defi ciency following
realimentation. The clinical features are related to the shift in metabolism that occurs on
refeeding. A change from fat to carbohydrate-based energy production occurs. A glucose load
stimulates insulin release, causing increased cellular uptake of glucose, phosphate, potassium,
magnesium, and water. This will result in hypophosphataemia, which in turn may cause a defi cit in
adenosine triphosphate (ATP) with widespread neuromuscular and haematolgical consequences.
Thiamine defi ciency occurs due to increased cellular utilization of thiamine in response to
carbohydrate refeeding and is associated with the precipitation of Wernicke’s encephalopathy.

Question 46

A 17-year-old girl presents with sudden-onset blindness while preparing
for her school exit examinations. Which of the following suggests an ocular
rather than a psychogenic cause for blindness?
A. Normal visual evoked potentials
B. Presence of tubular vision
C. Spiral changes in visual fi elds
D. Absence of optokinetic nystagmus
E. Disturbances in tests for proprioception

Answer 46

D. Non-organic visual loss may be psychogenic (conversion phenomenon) or secondary to
malingering. It is more common among younger age groups and females, with the most frequently
reported complaints being a reduction of visual acuity with or without loss of field. Absence
of underlying optic nerve pathology is suggested by the demonstration of normal evoked
potentials. On visual fi eld testing the patients may have an inconsistent spiral fi eld. When the
patient acknowledges sighting the stimulus at some point on a horizontal axis, the examiner then
moves around the fi eld in a circle (clockwise or anticlockwise). This will produce a progressively
constricting fi eld and when the same horizontal axis is reached again, the stimulus will only
be sighted at a much closer point to the centre. Some patients may have tubular vision. In the
presence of true visual fi eld loss, the area of constricted field expands with increasing distance
of the testing screen. In non-organic visual loss such field defects remain unchanged in width
when tangent screen testing is performed at varying distances. This produces what is known as
‘tubular fields’. Simple tests of proprioception such as the fi nger–nose test are easily performed
by blind patients; in non-organic visual loss, patients may be incapable of carrying out these tests.
Intact vision (acuity at least 6/60) will elicit a positive optokinetic nystagmus (eyes moving with a
black/white striped drum rolling in front of the eyes). The absence of such nystagmus indicates an
ocular rather than psychogenic cause for visual loss.

Question 47

Which of the following culture-bound syndromes is closely associated with
social phobia?
A. Brain fag syndrome in West Africa
B. Dhat syndrome in South Asia
C. Frigophobia in China
D. Taijin kyofusho in Japan
E. Arctic hysteria in Greenland

Answer 47

D. Taijin Kyofusho (or anthropophobia: a fear of interpersonal relationships) could be
considered as a cultural expression of social phobia among Japanese. Hikikomori, manifest by
complete withdrawal from social life, is very closely related. Patients show severe obsession and
fear of social contact with extreme self-consciousness regarding appearance, blushing, stuttering,
or emitting offensive odours. Brain fag syndrome (known as studiation madness in the Caribbean)
is characterized by variety of medically unexplained somatic symptoms, anxiety, depression, and
fatigue. Symptoms may be triggered by the effort of reading; it is seen in students from a West
African background. Dhat syndrome is characterized by complaints of discharge of semen in
urine with no urological cause; this may be associated with fatigue and anxiety of loss of fertility
and reproductive potency. Frigophobia (Pa-Leng) is a chronic anxiety state with phobia for cold;
the patients may dress compulsively in heavy clothes and may become housebound for the
fear of ‘cold attack’. Arctic hysteria or Piboloktoq is an acute dissociative episode of disruptive
behaviour characterized by an irritable prodromal period and subsequent wild, excited, and risky
behaviour.

Question 48

Which of the following mechanisms is proposed to underlie hypersalivation
seen in patients taking clozapine?
A. Muscarinic M1 blockade
B. Muscarinic M4 stimulation
C. Histaminic H1 blockade
E. Serotonergic 5HT2C blockade
F. Noradrenergic α1 blockade

Answer 48

B. Both muscarinic M3 and M4 receptors are expressed in salivary glands. In general,
stimulation of these receptors leads to increased salivation. Clozapine has antagonistic properties
at muscarinic receptors (M1 to M3, and M5) but acts as an agonist at the M4 receptor.
Olanzapine also has direct M4-agonistic properties and can produce hypersalivation; pirenzepine,
an M4 antagonist, alleviates hypersalivation. In addition, clozapine may exacerbate salivation
through its alpha-2 antagonism.

Question 49

Which of the following can increase levels of clozapine via alterations in
hepatic metabolism?
A. Rifampicin
B. Phenytoin
C. Carbamazepine
D. Cigarette smoking
E. Erythromycin

Answer 49

E. Clozapine is mostly metabolized via the CYP1A2, 3A4, and 2C19 enzymes. Cigarette
smoking and caffeine induce CYP1A2; this can reduce clozapine levels in plasma. Rifampicin,
carbamazepine, and phenytoin induce CYP3A4 and thus reduce clozapine levels. Erythromycin
inhibits CYP3A4 and ciprofl oxacin inhibits CYP1A2; both increase clozapine levels.

Question 50

All of the following neuroendocrine changes are noted in depression
EXCEPT
A. Raised salivary cortisol measures
B. Abnormal dexamethasone suppression test
C. Reduced Corticotropin-releasing hormone (CRH) in cerebrospinal fluid
D. Downregulated CRH receptors
E. Reduced adrenocorticotropic hormone (ACTH) response to CRH infusion

Answer 50

C. Depression is associated with many neuroendocrine changes in hypothalamic-pituitaryadrenal
cortex axis. Raised cortisol (measured in blood or saliva), abnormal dexamethasone
suppression test (non-suppression of cortisol levels after overnight dexamethasone
administration), and abnormal dexamethasone–corticotrophin releasing hormone (CRH)
response (mediated via reduced ACTH response to CRH infusion), raised CRH levels in
cerebrospinal fluid and down regulated CRH receptors are some of the reported changes.