James Bloomer Psych EMQs

Question 1

A. Electroconvulsive therapy (ECT)

B. The “squeeze” technique

C. Sensate focus therapy

D. Cognitive behavioural therapy (CBT)

E. Hormone replacement therapy

F. Phosphodiesterase 5 inhibitors

G. Vaginal trainers

H. Vacuum pump

A painful, involuntary spasm of the vaginal muscles when penetration is attempted.

Answer 1

G. Vaginal trainers

The problem described is vaginismus.

Question 2

A. Electroconvulsive therapy (ECT)

B. The “squeeze” technique

C. Sensate focus therapy

D. Cognitive behavioural therapy (CBT)

E. Hormone replacement therapy

F. Phosphodiesterase 5 inhibitors

G. Vaginal trainers

H. Vacuum pump

Low sex drive

Answer 2

C. Sensate focus therapy

This problem is also called low libido. Other causes of low libido (such as depression) should be excluded and treated (e.g. with CBT / antidepressants).

Question 3

A. Electroconvulsive therapy (ECT)

B. The “squeeze” technique

C. Sensate focus therapy

D. Cognitive behavioural therapy (CBT)

E. Hormone replacement therapy

F. Phosphodiesterase 5 inhibitors

G. Vaginal trainers

H. Vacuum pump

Unintentional ejaculation, leaving one or both partners unsatisfied.

Answer 3

B. The “squeeze” technique

This is premature ejaculation. Squeezing the glans penis postpones orgasm.

Question 4

A. Electroconvulsive therapy (ECT)

B. The “squeeze” technique

C. Sensate focus therapy

D. Cognitive behavioural therapy (CBT)

E. Hormone replacement therapy

F. Phosphodiesterase 5 inhibitors

G. Vaginal trainers

H. Vacuum pump

“Sex addiction”

Answer 4

D. Cognitive behavioural therapy (CBT)

This is hypersexuality or high libido. It can be difficult to treat, but CBT may help.

Question 5

A. Electroconvulsive therapy (ECT)

B. The “squeeze” technique

C. Sensate focus therapy

D. Cognitive behavioural therapy (CBT)

E. Hormone replacement therapy

F. Phosphodiesterase 5 inhibitors

G. Vaginal trainers

H. Vacuum pump

Vaginal dryness and shrinkage of oestrogen-dependent tissues

Answer 5

E. Hormone replacement therapy

The problem is atrophic vaginitis and is a problem in post-menopausal women.

Question 6

A. Parkinson’s disease
B. Delirium
C. Frontotemporal lobar degeneration
D. Huntington’s disease
E. Creutzfeldt-Jakob disease
F. HIV encephalopathy
G. Wilson’s disease
H. Tertiary neurosyphilis
I. Dementia with Lewy bodies
J. Alzheimer’s Disease

Instructions: For each of the pathological features below, choose the single most likely diagnosis from the above list of options.

Accumulations of insoluble prion protein

Answer 6

E. Creutzfeldt-Jakob disease

This is a florid plaque from the brain of a patient with variant Creutzfeldt-Jakob disease. It is not a common disease in old age, but should be considered in patients with early onset dementias.

Question 7

A. Parkinson’s disease
B. Delirium
C. Frontotemporal lobar degeneration
D. Huntington’s disease
E. Creutzfeldt-Jakob disease
F. HIV encephalopathy
G. Wilson’s disease
H. Tertiary neurosyphilis
I. Dementia with Lewy bodies
J. Alzheimer’s Disease

Instructions: For each of the pathological features below, choose the single most likely diagnosis from the above list of options.

B-amyloid protein aggregates into insoluble clumps surrounded by dystrophic neurites

Answer 7

J. Alzheimer’s Disease

This is a plaque from the brain of a patient with Alzheimer’s disease.

Question 8

A. Parkinson’s disease
B. Delirium
C. Frontotemporal lobar degeneration
D. Huntington’s disease
E. Creutzfeldt-Jakob disease
F. HIV encephalopathy
G. Wilson’s disease
H. Tertiary neurosyphilis
I. Dementia with Lewy bodies
J. Alzheimer’s Disease

Instructions: For each of the pathological features below, choose the single most likely diagnosis from the above list of options.

Eosinophilic, intracytoplasmic neuronal structures form in the cingulate gyrus and neocortex.

Answer 8

I. Dementia with Lewy bodies

This is a cortical Lewy body from a patient with Dementia with Lewy Bodies.

Question 9

A. Parkinson’s disease
B. Delirium
C. Frontotemporal lobar degeneration
D. Huntington’s disease
E. Creutzfeldt-Jakob disease
F. HIV encephalopathy
G. Wilson’s disease
H. Tertiary neurosyphilis
I. Dementia with Lewy bodies
J. Alzheimer’s Disease

Instructions: For each of the pathological features below, choose the single most likely diagnosis from the above list of options.

Deposits of abnormal protein cause atrophy of the basal ganglia and thalamus, cortical neurone loss, especially affecting frontal regions. Caudate nucleus atrophy may be visible on MRI / CT scan.

Answer 9

D. Huntington’s disease

The picture on the left is normal; that on the right is from a patient with Huntington’s disease, showing the flattened caudate nucleus.

Question 10

A. Parkinson’s disease
B. Delirium
C. Frontotemporal lobar degeneration
D. Huntington’s disease
E. Creutzfeldt-Jakob disease
F. HIV encephalopathy
G. Wilson’s disease
H. Tertiary neurosyphilis
I. Dementia with Lewy bodies
J. Alzheimer’s Disease

Instructions: For each of the pathological features below, choose the single most likely diagnosis from the above list of options.

Neurones contain ‘Pick bodies’ and neurofibrillary tangles

Answer 10

C. Frontotemporal lobar degeneration

Frontotemporal lobar degeneration is an umbrella term for a number of disorders united by asymmetrical frontal and / or anterior temporal lobe atrophy. The picture shows Pick bodies, seen in the Pick’s disease subtype. These dementias tend to affect younger patients (under 60).

Question 11

A. Dementia with Lewy Bodies
B. Metastatic breast carcinoma
C. Subdural haematoma
D. Vascular dementia
E. Normal pressure hydrocephalus
F. Extradural haematoma
G. Subarachnoid haemorrhage
H. Alzheimer’s disease
I. Normal CT head
J. Huntington’s disease

Answer 11

D. Vascular dementia

Non-contrast CT head in a patient multi-infarct dementia. Note the areas of lower density adjacent to the anterior and posterior horns of the lateral ventricles, due to chronic ischaemia.

Question 12

A. Dementia with Lewy Bodies
B. Metastatic breast carcinoma
C. Subdural haematoma
D. Vascular dementia
E. Normal pressure hydrocephalus
F. Extradural haematoma
G. Subarachnoid haemorrhage
H. Alzheimer’s disease
I. Normal CT head
J. Huntington’s disease

Answer 12

C. Subdural haematoma

Non-contrast CT head in a patient with a subdural haematoma. Note the collection of blood adjacent to the left frontal lobe.

Question 13

A. Dementia with Lewy Bodies
B. Metastatic breast carcinoma
C. Subdural haematoma
D. Vascular dementia
E. Normal pressure hydrocephalus
F. Extradural haematoma
G. Subarachnoid haemorrhage
H. Alzheimer’s disease
I. Normal CT head
J. Huntington’s disease

Answer 13

E. Normal pressure hydrocephalus

Head CT in a patient with normal pressure hydrocephalus. Note the dilated ventricles, out of proportion to the degree of involutional changes or cortical atrophy.

Question 14

A. Dementia with Lewy Bodies
B. Metastatic breast carcinoma
C. Subdural haematoma
D. Vascular dementia
E. Normal pressure hydrocephalus
F. Extradural haematoma
G. Subarachnoid haemorrhage
H. Alzheimer’s disease
I. Normal CT head
J. Huntington’s disease

Answer 14

B. Metastatic breast carcinoma

Head CT with contrast of a patient with metastatic breast carcinoma: note the ring-enhancing lesion and surrounding oedema causing a mass effect and some midline shift.

Question 15

A. Dementia with Lewy Bodies
B. Metastatic breast carcinoma
C. Subdural haematoma
D. Vascular dementia
E. Normal pressure hydrocephalus
F. Extradural haematoma
G. Subarachnoid haemorrhage
H. Alzheimer’s disease
I. Normal CT head
J. Huntington’s disease

Answer 15

I. Normal CT head

Non-contrast CT Head showing a normal brain. Note the difference between the grey and white matter appearances on CT, along with the symmetry of the ventricles.

Question 16

A. Depressive disorder
B. Postnatal depression
C. Baby blues
D. Schizophrenia
E. Puerperal psychosis
F. Bipolar affective disorder
G. Schizoid personality disorder
H. Adjustment reaction
I. Schizotypal disorder
J. Cyclothymia

Symptoms usually respond to treatment within a month but may persist.

Answer 16

B. Postnatal depression

The treatment of postanatal depression is the same as for regular depression - but extra care in the choice of antidepressants should be taken if the mother is breast-feeding.

Question 17

A. Depressive disorder
B. Postnatal depression
C. Baby blues
D. Schizophrenia
E. Puerperal psychosis
F. Bipolar affective disorder
G. Schizoid personality disorder
H. Adjustment reaction
I. Schizotypal disorder
J. Cyclothymia

Most patients recover within 6-12 weeks

Answer 17

E. Puerperal psychosis

Puerperal psychosis is a frightening and devastating illness, and treatment should match the presentation (delirium / affective / schizophreniform).

Question 18

A. Depressive disorder
B. Postnatal depression
C. Baby blues
D. Schizophrenia
E. Puerperal psychosis
F. Bipolar affective disorder
G. Schizoid personality disorder
H. Adjustment reaction
I. Schizotypal disorder
J. Cyclothymia

Mary is a 36 year old woman who had her third child 3 days ago, her husband is concerned as she seems irritable and cries often. Her aunt suffered from depression.

Answer 18

C. Baby blues

Given the time scale the “blues” is the most likely diagnosis.

Question 19

A. Depressive disorder
B. Postnatal depression
C. Baby blues
D. Schizophrenia
E. Puerperal psychosis
F. Bipolar affective disorder
G. Schizoid personality disorder
H. Adjustment reaction
I. Schizotypal disorder
J. Cyclothymia

The risk of this condition is increased by younger maternal age, poor social support, recent adverse life events or a personal history of depression.

Answer 19

B. Postnatal depression

These are all risk factors for post natal depression.

Question 20

A. Depressive disorder
B. Postnatal depression
C. Baby blues
D. Schizophrenia
E. Puerperal psychosis
F. Bipolar affective disorder
G. Schizoid personality disorder
H. Adjustment reaction
I. Schizotypal disorder
J. Cyclothymia

1/3 of patients will relapse in subsequent pregnancies.

Answer 20

E. Puerperal psychosis

A third of mothers who have suffered a puerperal psychosis will relapse in future pregnancies - so being aware of this history is important for the team caring for her and her baby in the puerperium.

Question 21

A. Epilepsy
B. Obsessive compulsive disorder
C. Foetal alcohol syndrome
D. Fragile X
E. Neglect
F. Asperger’s syndrome
G. Autism
H. Down syndrome
I. Schizophrenia
J. Mild depression

Elongated face, high arched palate, “autistic type” behaviour, large testes.

Answer 21

D. Fragile X

These are all symptoms associated with Fragile X. Others include prominent ears and hyperextensible joints.

Question 22

A. Epilepsy
B. Obsessive compulsive disorder
C. Foetal alcohol syndrome
D. Fragile X
E. Neglect
F. Asperger’s syndrome
G. Autism
H. Down syndrome
I. Schizophrenia
J. Mild depression

Single palmar crease, early-onset Alzheimer’s

Answer 22

H. Down syndrome

These are associated with Down syndrome. Other features include upward-slanting palpebral fissures, epicanthic folds, protruding tongue and hypotonia.

Question 23

A. Epilepsy
B. Obsessive compulsive disorder
C. Foetal alcohol syndrome
D. Fragile X
E. Neglect
F. Asperger’s syndrome
G. Autism
H. Down syndrome
I. Schizophrenia
J. Mild depression

Poor language and social skills, usually reversible

Answer 23

E. Neglect

Neglect in early childhood will stunt the social and linguistic development of a child. Except in the most severe and prolonged cases, this is usually recoverable if the child is placed with a loving and supportive family.

Question 24

A. Epilepsy
B. Obsessive compulsive disorder
C. Foetal alcohol syndrome
D. Fragile X
E. Neglect
F. Asperger’s syndrome
G. Autism
H. Down syndrome
I. Schizophrenia
J. Mild depression

Reduced social functioning, speech disorders, auditory hallucinations.

Answer 24

I. Schizophrenia

These would fit with a diagnosis of schizophrenia. Auditory hallucinations differentiate this from autism, where hallucinations would be unexpected.

Question 25

A. Epilepsy
B. Obsessive compulsive disorder
C. Foetal alcohol syndrome
D. Fragile X
E. Neglect
F. Asperger’s syndrome
G. Autism
H. Down syndrome
I. Schizophrenia
J. Mild depression

Wide palpebral fissure, foetal growth retardation, smooth philtrum

Answer 25

C. Foetal alcohol syndrome

These are signs of foetal alcohol syndrome, and other signs include a thin top lip.

Question 26

A. Attention deficit hyperactivity disorder (ADHD; hyperkinetic disorder)
B. Autism
C. Learning disability
D. Conduct disorder
E. Enuresis
F. Encopresis
G. Oppositional defiant disorder
H. Antisocial personality disorder
I. Simple tics
J. Complex tics
K. Asperger’s syndrome
L. Gilles de la Tourette Syndrome

Rob is three years old and hasn’t spoken his first word yet. He’s not really interested in other children and prefers to play alone, spending most of his time playing with aluminium foil. He suffers from epilepsy.

Answer 26

B. Autism

In Autism, there are abnormalities of communication (including speech delay), reciprocal social interaction (e.g. playing alone, disinterested in others), and have restricted behaviours and interests (e.g. aluminium foil).

Question 27

A. Attention deficit hyperactivity disorder (ADHD; hyperkinetic disorder)
B. Autism
C. Learning disability
D. Conduct disorder
E. Enuresis
F. Encopresis
G. Oppositional defiant disorder
H. Antisocial personality disorder
I. Simple tics
J. Complex tics
K. Asperger’s syndrome
L. Gilles de la Tourette Syndrome

Jake is only thirteen, but like his older brother, is already well known to the local police as a member of a local gang involved in vandalism and theft. He has the reputation of being a troublemaker and bully at school and was recently suspended after assaulting a teacher. Jake brags to his friends that he broke into a neighbour’s house and killed all their fish by turning up the thermostat on the aquarium.

Answer 27

D. Conduct disorder

In conduct disorder there is persistently antisocial behaviour, e.g. vandalism, theft, bullying, assault, cruelty to animals. Jake’s behaviour is more than simple rebelliousness or “naughtiness”.

Question 28

A. Attention deficit hyperactivity disorder (ADHD; hyperkinetic disorder)
B. Autism
C. Learning disability
D. Conduct disorder
E. Enuresis
F. Encopresis
G. Oppositional defiant disorder
H. Antisocial personality disorder
I. Simple tics
J. Complex tics
K. Asperger’s syndrome
L. Gilles de la Tourette Syndrome

Five year old Andy started potty training early and initially seemed to be doing well, gaining bowel control by the age of three. However, since the recent birth of his sister, Lisa, he has been having frequent accidents, soiling himself. His GP tells his parents that there is nothing physically wrong with him.

Answer 28

F. Encopresis

This is a case of secondary encopresis, since normal function has been previously gained and now lost. Primary encopresis describes the situation of never having gained bowel control by the age of four.

Question 29

A. Attention deficit hyperactivity disorder (ADHD; hyperkinetic disorder)
B. Autism
C. Learning disability
D. Conduct disorder
E. Enuresis
F. Encopresis
G. Oppositional defiant disorder
H. Antisocial personality disorder
I. Simple tics
J. Complex tics
K. Asperger’s syndrome
L. Gilles de la Tourette Syndrome

Robin is seven, boisterous and regarded by his teacher as a trouble maker. He is very disruptive in class and seems unable to take turns or leave the other students alone, interfering in their work and distracting those around him with his “attention seeking” antics. He never finishes his own work, and always seems to be wandering around the classroom, despite being told to sit quietly. The other children find him irritating and this sometimes causes him to get into fights with the other boys. He becomes tearful when he is told off, and repeatedly promises to “try to be good” but never manages to maintain his “good behaviour” for more than a couple of hours. His teacher states that Robin “just doesn’t take his work seriously” and his reading and writing are well below average.

Answer 29

A. Attention deficit hyperactivity disorder (ADHD; hyperkinetic disorder)

The main features of attention deficit hyperactivity disorder (or hyperkinetic disorder) are hyperactivity, inattention and impulsivity.

Question 30

A. Attention deficit hyperactivity disorder (ADHD; hyperkinetic disorder)
B. Autism
C. Learning disability
D. Conduct disorder
E. Enuresis
F. Encopresis
G. Oppositional defiant disorder
H. Antisocial personality disorder
I. Simple tics
J. Complex tics
K. Asperger’s syndrome
L. Gilles de la Tourette Syndrome

Ray is 10 years old and has been brought to the GP by his mother. For the past 2 months, he has been blinking repeatedly, in a rather strange manner, squeezing his eyes tightly twice. His mother is concerned that an eye infection may be the cause. Eye examination is normal and there is no evidence of infection from the history. Ray explains that he feels better when he blinks and although he can repress his “double blink”, it makes him feel very uncomfortable until he gives in to it.

Answer 30

I. Simple tics

Blinking is a common example of a simple tic disorder.

Question 31

A. Parenting skills training
B. Hypnotics
C. Laxatives
D. Cognitive behavioural therapy
E. Anger management
F. Reassurance and stress management
G. Positive reinforcement using star charts
H. Speech and language therapy

Moderate childhood depression

Answer 31

D. Cognitive behavioural therapy

Cognitive Behavioural Therapy is the treatment of choice in all but the most severe cases of childhood depression.

Question 32

A. Parenting skills training
B. Hypnotics
C. Laxatives
D. Cognitive behavioural therapy
E. Anger management
F. Reassurance and stress management
G. Positive reinforcement using star charts
H. Speech and language therapy

Enuresis

Answer 32

G. Positive reinforcement using star charts

Star charts celebrate each dry night and work via positive reinforcement. They should be used in combination with reassurance for both family and child that no-one is at fault for the enuresis. Stressors should be reviewed and dealt with, as appropriate.

Question 33

A. Parenting skills training
B. Hypnotics
C. Laxatives
D. Cognitive behavioural therapy
E. Anger management
F. Reassurance and stress management
G. Positive reinforcement using star charts
H. Speech and language therapy

Attention deficit hyperactivity disorder (ADHD; hyperkinetic disorder)

Answer 33

A. Parenting skills training

Parenting skills training is essential - not because the parents’ skills are bad, but because children with ADHD are extra challenging - and even the best parents would struggle.

Question 34

A. Parenting skills training
B. Hypnotics
C. Laxatives
D. Cognitive behavioural therapy
E. Anger management
F. Reassurance and stress management
G. Positive reinforcement using star charts
H. Speech and language therapy

Autism

Answer 34

H. Speech and language therapy

In autism, the ability to obtain useful speech is an important factor in improving prognosis.

Question 35

A. Parenting skills training
B. Hypnotics
C. Laxatives
D. Cognitive behavioural therapy
E. Anger management
F. Reassurance and stress management
G. Positive reinforcement using star charts
H. Speech and language therapy

Tic disorder

Answer 35

F. Reassurance and stress management

Reassurance and stress management are the key to treating the majority of tic disorders. Stress worsens tics.

Question 36

A. Paranoid

B. Schizoid

C. Histrionic

D. Emotionally Unstable

E. Anankastic

F. Anxious (avoidant)

G. Dependent

Do you lose your temper easily?

Would you say you were impulsive?

Answer 36

D. Emotionally Unstable

Along with dissocial personality disorder these characteristics are suggestive of emotionally unstable personality disorder. Further confirmation during the interview should be sought.

Question 37

A. Paranoid

B. Schizoid

C. Histrionic

D. Emotionally Unstable

E. Anankastic

F. Anxious (avoidant)

G. Dependent

Do you tend to daydream?

Do you prefer to spend most of your time alone?

Answer 37

B. Schizoid

Further history and exclusion of mental illness, including autistic spectrum disorder would be needed following these two prompts.

Question 38

A. Paranoid

B. Schizoid

C. Histrionic

D. Emotionally Unstable

E. Anankastic

F. Anxious (avoidant)

G. Dependent

Are you wary of trusting others?

Do you worry about what other people think of you?

Answer 38

F. Anxious (avoidant)

Not unusual characteristics in themselves, but may point towards anxious (avoidant) personality disorder. There is fear of rejection and a sense of inferiority to others. In paranoid personality disorder these could also apply, although the reasons why the patient worries about what other people think about them are very different.

Question 39

A. Paranoid

B. Schizoid

C. Histrionic

D. Emotionally Unstable

E. Anankastic

F. Anxious (avoidant)

G. Dependent

Are you generally quite suspicious of other people?

Do you tend to bear grudges?

Answer 39

A. Paranoid

May also overlap with dissocial personality disorder from these two answers alone. Persecutory delusions would be suggestive of paranoid schizophrenia or a persistent delusional disorder.

Question 40

A. Paranoid

B. Schizoid

C. Histrionic

D. Emotionally Unstable

E. Anankastic

F. Anxious (avoidant)

G. Dependent

Do you tend to follow rules carefully?

Do you take a lot of time over the detail in a task?

Answer 40

E. Anankastic

Although these may be entirely normal responses, people with anankastic personality disorder will have these traits. Need to also consider obsessive compulsive disorder and autistic spectrum disorder in the differential diagnosis.