Past paper questions Flashcards
A young male with schizophrenia says the MI5 have been sending him secret messages through newspapers and radio broadcasts. He has a large folder full of newspaper clippings with no connection between them all and random words highlighted to form sentences.
What type of thought disorder is exhibited?
Delusional perception
Thought broadcasting
Thought insertion
Thought withdrawal
Thought blocking
Delusional perception
Delusional perception is when a patient attributes a false meaning to a true perception. An example of might be a TV presenter wearing a blue tie means that it is dangerous to go outside today.
A 16 year old girl attends the GP asking for laxatives. When asked why, she tells you that she has been constipated for some time. She refuses to be examined, but you notice calluses on her knuckles. On further questioning, she becomes tearful and eventually tells you that she needs the laxatives to lose weight because she is ‘fat and ugly’. She describes feeling like she ‘loses control’, eating large amounts of snack foods, and feels remorseful afterwards. She knows all her problems would go away if she could ‘just be skinny’. You calculate her BMI to be 25.
Which of the following clinical features points to a diagnosis of bulimia nervosa rather than anorexia nervosa?
Body mass index (BMI) of 25
Binge-eating
Russell’s sign
Lanugo hair
Hyperkalaemia
Body mass index (BMI) of 25
They key distinguishing feature between these conditions is BMI, with most guidelines using a BMI of 17.5 as a diagnostic feature of anorexia nervosa. Most individuals with bulimia nervosa are in the normal weight range (BMI: 18.5 - 30)
Emotional lability
refers to rapid, often exaggerated changes in mood, where strong emotions or feelings (uncontrollable laughing or crying, or heightened irritability or temper) occur.
tardive dyskinesia
a neurological disorder characterized by involuntary movements of the face and jaw.
A 15 year old physically well girl presents to A&E with new seizures and confusion. She is emotionally labile without obvious reason. She has no personal or family history of mental illness. She has no history of epilepsy or febrile seizures and regains full consciousness between seizures. What is the most appropriate next step?
MRI brain
Lumbar puncture
Routine blood tests
Full cardiovascular examination
Full neurological examination
Full neurological examination
This girl presents with neurological and psychiatric symptoms, including seizures, cognitive decline, emotional lability and memory impairment. The list of possible differential diagnoses is long, although it is likely that she has an encephalitis. A full neurological examination should be the first line investigation to determine which further investigations may be appropriate depending on the findings
A 24-year-old PhD student is under the care of a community mental health team for postpartum depression, after giving birth to her first child 4 months ago. She has experienced significant weight loss due to a lack of appetite, and feels she is struggling to bond with her baby due to her low mood. She has tried a course of psychological therapy, but this was unsuccessful, and she is keen to try medical treatment.
Which of the following antidepressants is preferred for the treatment of postpartum depression in breastfeeding patients?
Paroxetine
Mirtazapine
Citalopram
Venlafaxine
Fluoxetine
sertraline or paroxetine are the preferred selective serotonin reuptake inhibitors for a woman with postpartum depression who is breastfeeding
A 38-year-old male is found wandering around the ward. He seems very distant and is hard to interact with, but he allows nurses to sit with him for the evening. He talks about how life is a pointless pursuit, and now he is on the ‘other side’, everything suddenly makes sense. When asked what he means about being ‘on the other side’, he tells the nurses he died last week and has been living in the afterlife since. No amount of reasoning or demonstration from the nurses can convince him he is still alive.
What delusion is being demonstrated here?
Capgras delusion
Fregoli delusion
Cotard delusion
Charles Bonnet syndrome
Ekbom syndrome
Cotard delusion
Cotard delusion is a rare psychiatric delusion in which the patient believes they are dead or have had organs removed. It is associated with schizophrenia but can be found in patients with depression, brain tumours and migraine headaches.
Which of the following is the most common side effect of clozapine?
Paralytic ileus
Constipation
Agranulocytosis
Neuroleptic malignant syndrome
Sudden death
Constipation
Clozapine use is associated with impairment of intestinal peristalsis, thus causing constipation. This is a very common side effect of clozapine.
A 27 year old woman is brought into A&E after a paracetamol overdose.
She says she had an argument with her boyfriend and took the overdose as she “can’t live without him”. This is the third overdose she has taken in the past 18 months.
When you go to speak with the patient you notice scars on both forearms consistent with self-harm. She says that you are “the best, kindest doctor she’s ever met” and that she previously had a row with one of the nurses who was “completely useless and needs to be fired”.
What personality disorder is this patient most likely to have?
Emotionally unstable
Narcissitic
Histrionic
Dependent
Anti-social
Emotionally unstable
This is correct. This patient is demonstrating the unstable relationships and self-injurous behaviour classically associated with BPD. She also employs ‘splitting’- where individuals are considered wholly good or bad
A 24 year old man, who has not had any previous contact with mental health services, presents to his GP saying he has been hearing voices for the last two months. The voices comment on his behaviour as he goes about his daily routine and can be derogatory in nature. He is certain that other people are putting thoughts into his mind and he cannot be persuaded otherwise. What is the most appropriate first-line treatment?
Lorazepam
Sertraline
Clozapine
Haloperidol
Risperidone
Risperidone
This is the correct answer. This man is experiencing auditory hallucinations which provide running commentary, as well as thought insertion, for more than one month, fitting diagnostic criteria for paranoid schizophrenia. This is treated first-line with atypical antipsychotics such as Risperidone
A 34-year-old man is reviewed by his GP after being recommenced on sertraline for a relapse of his mild depressive disorder. He had noticed low mood and anhedonia, which was making it difficult for him to concentrate at work and had previously found sertraline to be very helpful for these symptoms. He has now been taking daily sertraline for 2 months and notes that he has been feeling much more positive for the past month and has begun returning to his previous interests. He is not experiencing any side effects of the medication.
For how long should the sertraline be continued?
The sertraline should be continued lifelong, as this is his second episode of depression
He can now stop the sertraline, as he is now feeling better; it is likely that side effects will outweigh any possible further benefit of treatment
He can now stop the sertraline, as he has completed the recommended 2-month course
Minimum of a further 6 months
Minimum of a further 5 months
Minimum of a further 5 months
NICE recommends that antidepressants should be continued for at least 6 months following remission of symptoms, as this greatly reduces the risk of relapse.
The patient’s depression has been in remission for 1 month at this point. It is, therefore, necessary to continue the medication for a further 5 months. If he remains well at this point, the sertraline can be stopped.
A 64 year old man has been an inpatient in a psychiatric inpatient unit for three months with severe depression. He has a six month history of low mood, which has been getting gradually worse. He feels suicidal every day, although currently has no active plans to end his life. He only sleeps for two hours a night and feels exhausted all of the time. His appetite is so poor that he has gradually reduced his oral intake over the last few weeks and for the last two days he has not eaten or drunk anything except a few glasses of orange juice. He has no motivation to get better and wants to be discharged so that he can die. He has tried the antidepressants Sertraline, Fluoxetine and Venlafaxine with no improvement in his mood. He is offered Electroconvulsive Therapy and has a discussion with his psychiatrist about the possible side effects. Which of the following side effects is he most likely to experience?
Coma
Epilepsy
Memory loss
Dementia
Renal failure
Memory loss
This man has severe depression requiring urgent intervention, due to his poor oral intake. Electroconvulsive Therapy carries a risk of memory loss, which is usually temporary but in some cases can be persistent and last longer
first line SSRI
sertraline
- lowest burden of side effects
SNRI
can work well but have worse side effects - due to noradrenaline burden e.g. palpitations, sweating
which antidepressant for elderly
Mirtazapine - NASA - works on release of noradrenaline and serotonin
Side effects (histamine)
- sleep
- weight gain
lithium
mood stabiliser / antimanic agent
- reduces suicide
HOWEVER
- very narrow therapeutic range (0.5-1)
A 30 year old woman presents to the GP with low mood following the birth of her first child three months ago. Since her husband’s return to work last month she has had difficulty coping. She reports poor appetite and low energy levels, and only manages to get out of bed to breastfeed and take care of the baby. She becomes tearful during the consultation. When asked if she has thoughts of harming herself or the baby, she is visibly shocked and responds ‘never!’
Which of the following is the most appropriate intervention?
Urgent admission to mental health unit
Referral for cognitive behavioural therapy (CBT)
Start Fluoxetine
Reassurance
Electroconvulsive therapy (ECT)
Referral for cognitive behavioural therapy (CBT)
This patient is experiencing mild to moderate postpartum depression, which is managed the same as depression in other circumstances. Options include CBT, starting a Selective Serotonin re-uptake inhibitor (SSRI), or both - but there is a higher threshold for starting SSRIs post-partum due to contamination of breastmilk, and so are reserved for more severe cases
The police are called to see a young, dishevelled-looking man in the duck pond of a local park. He appears distressed, shouting and is responding to unseen stimuli. This is causing concern for members of the public. When approached, the man is reluctant to speak to the police and declines to attend A&E.
Under what section of the Mental Health Act can the police move the patient to A&E for assessment?
Section 5(4)
Section 2
Section 136
Section 135
Section 5(2)
Section 136
Section 136 allows the police to bring an individual who appears to have a mental disorder from a public place to a Place of Safety. This can either be a police station or, as in this case, A&E.
A 22-year-old therapy assistant is reviewed by her community mental health team following concerns raised by her neighbours. They report loud music coming from her flat throughout the day and night for the past 4 weeks, and numerous daily shopping deliveries. She is already known to the team for treatment of depression, for which she takes sertraline. During the assessment, she is noted to be speaking very quickly, and is easily distracted by cars driving past the window. She describes her mood as ‘the best it’s ever been’.
Which of the following medication regimes would be most appropriate for this patient?
Commence olanzapine only
Commence sodium valporate, stop sertraline
Commence olanzapine, stop sertraline
Commence sodium valproate and a combined oral contraceptive pill
Switch sertraline to fluoxetine
Commence olanzapine, stop sertraline
This patient appears to be experiencing mania. Key symptoms demonstrated here include reduced need for sleep, increased speech rate and distractibility. The deliveries also hint at changes in spending habits, which can be seen in mania. NICE recommends that if a patient develops mania and is not already taking an antipsychotic or mood stabiliser, an antipsychotic medication such as haloperidol, olanzapine, quetiapine or risperidone should be commenced.
NICE also recommends that clinicians should consider stopping any antidepressants the patient is already taking if a patient develops mania. As depression is not currently a problem for this patient, it would be most appropriate to stop the sertraline.
schizophrenia vs schizoid vs schizotypal
Schizoid
This patient is not experiencing disturbances in thought or any hallucinations and has a logical thought pattern that enables him to have conversations with family. He is choosing to withdraw from others by not participating in university activities, avoiding his family and not showing affection towards them. The indifference to praise is another significant symptom.
Schizotypal
Schizoid and schizotypal personality disorders do overlap; however, schizotypal personality disorders display odd thought and behaviour patterns. His family may notice eccentric dressing and may not be able to hold a logical conversation with him.
Schizophrenia
Schizophrenia presents with disordered thought and hallucinations. It is likely the family would have noticed odd behaviour patterns or eccentric dressing and may have picked up on his hallucinations, such as talking when he is on his own or claiming to hear things that aren’t there. Schizophrenia patients are often out of touch with reality, so they are unlikely to succeed in jobs or education without treatment.
Fregoli delusion
Fregoli delusion describes where a patient believes that everyone they meet is the same person but with different disguises. It can be associated with injury to the right frontal area, left temporoparietal areas and the fusiform gyrus.
Capgras delusion
Capgras delusion is a misidentification syndrome in which the patient believes that someone close to them has been replaced by a clone.
Cotard delusion
Cotard delusion is a rare psychiatric delusion in which the patient believes they are dead or have had organs removed. It is associated with schizophrenia but can be found in patients with depression, brain tumours and migraine headaches.
Ekbom syndrome
In Ekbom syndrome, the patient believes they have been infested with parasites. The patient will complain of crawling sensations on the skin and can be due to a psychological or organic reason such as B12 deficiency.
Charles Bonnet syndrome
Charles Bonnet syndrome is an organic brain syndrome of the elderly associated with visual field defects. Cortical input from other areas (eg. memory association areas) closely involved with the occipital lobe are hypothesised to fill in for a visual deficit, producing a hallucinogenic effect.
A 22-year-old man is under the care of a community mental health team for monitoring of his anorexia nervosa. He undergoes a physical examination and measurement of his vital signs to assess for acute deterioration in his physical health.
Which of the following is a red-flag sign in patients with anorexia nervosa?
Concurrent generalised anxiety disorder
A blood pressure of 150/60 mmHg
A heart rate of 80 bpm
Concurrent depressive disorder
They are unable to stand up from a chair without using their hands
They are unable to stand up from a chair without using their hands
The sit-up–squat–stand (SUSS) test is a method used to assess muscle wasting in patients with anorexia nervosa. In the sit-up test, the patient lies flat on a firm surface such as the floor and attempts to sit up without using their hands. In the squat test, the patient is asked to rise from a squatting position without using their hands.
An inability to stand up from a chair without using their hands indicates failure of the squat test, which is a red-flag sign indicating severe muscle wasting.
A 34-year-old man presents to his GP, requesting support with his heroin dependency. He wishes to stop taking the drug, but struggles to cope with the unpleasant withdrawal effects that occur when he abstains. He asks whether there is anything that can be prescribed to help reduce these symptoms. He has not tried anything in the past.
What medication(s) should be prescribed first line to support detoxification from heroin?
Naloxone
Chlorphenamine
Buprenorphine
Methamphetamine
Methadone
Methadone
NICE states that both methadone or buprenorphine are equally effective as an opioid substitution therapy; however, there may be specific reasons for choosing one above the other. For example, if a patient has had a previous overdose on methadone, then buprenorphine should be given. However, if both drugs are equally suitable, as they appear to be in this patient, then methadone should be prescribed first line.
A 30 year old interior designer with bipolar affective disorder presents to the GP. She has been stable on Lithium for the past 6 months, but attends now complaining of irritable mood.
Which of the following clinical features suggests mania as opposed to hypomania?
Symptom length of five days
Belief that she will be awarded a Nobel prize for her discovery of the cure for Coronavirus
Increased energy levels despite reduced sleep
Flight of ideas
Pressured speech
Belief that she will be awarded a Nobel prize for her discovery of the cure for Coronavirus
This is a delusion of grandeur. The presence of psychotic symptoms (delusions or hallucinations) is a feature of mania, not hypomania. Hypomania can be thought of as a less severe form of mania
> 7 for mania
5 for hypomania
A 47-year-old man presents to his GP for a routine health check. When asked, he admits to an average alcohol intake of around 90 units per week, which has been ongoing for the past 15 years. He is notably malnourished, and reports having dropped three clothes sizes in the past 6 months. Neurological examination is normal.
Which vitamin supplementation should be prescribed?
Vitamin C
Vitamin B1
Vitamin B6
Vitamin D
Vitamin B12
Vitamin B1
Vitamin B1 (thiamine) should be prescribed in those with chronic alcohol misuse and signs of malnutrition. There is evidence that this can prevent the development of Wernicke’s encephalopathy, and prevent the progression of Wernicke’s encephalopathy to Korsakoff syndrome. Thiamine should be given parenterally for those with features of Wernicke’s encephalopathy. Oral thiamine should be given to those with a harmful alcohol intake if they are malnourished, have decompensated liver disease, or if they are undergoing medically assisted alcohol withdrawal.
______
management of psychosis
- Antipsychotics can be broadly divided into typical and atypical.
-
Atypical antipsychotics are first-line, e.g. risperidone and olanzapine.
–>Depot formulations should be considered if the patient prefers or
there is a problem with non-compliance. - Clozapine is the most effective antipsychotic and used for
treatment-resistant schizophrenia (failure to respond to two other antipsychotics).
A 17 year old girl comes to the GP surgery complaining of absent periods for the past 6 months. She denies being sexually active and previously had a regular 28 day cycle since the age of 13.
On examination she is wearing multiple layers of clothing, and appears underweight and malnourished. You notice a fine layer of hair covering her skin.
Which of the following blood results when you expect to find, given the most likely diagnosis?
Hypercholesterolaemia
Raised serum B-hCG
Low levels of growth hormone
Hyperkalaemia
High testosterone
Hypercholesterolaemia
This is correct. Patients with anorexia nervosa exhibit hypercholesterolaemia. The pathophysiology is unclear, however it is thought to be due to alterations in the metabolic pathway
also hypokalaemia
A 33 year old man has been experiencing auditory and somatic hallucinations for six months. He believes he is the cousin of the Queen of England and cannot understand why he has been refused entry to Buckingham Palace on the numerous times he has tried to visit her without an invitation. His family members accompany him to an outpatient appointment with his psychiatrist, expressing concern that his symptoms persist, despite being treated currently with Olanzapine and, before that, Risperidone, both at maximum doses. What is the next best treatment?
Clozapine
Paliperidone
Lithium
Quetiapine
Fluoxetine
Clozapine
This man has treatment-resistant paranoid schizophrenia (i.e. schizophrenia which has not responded to sequential treatment with two different antipsychotics) and should be offered Clozapine. This is a second-generation antipsychotic but should be offered at this stage according to NICE guidelines
A 19 year old female with a long history of anorexia is admitted to the hospital.
She is severely malnourished and the consultants have decided that she needs re-feeding via a nasogastric tube. The patient declines treatment.
Which of the following is true regarding the next steps?
This patient cannot be treated under the Mental Health Act, and so a capacity assessment must be undertaken
As there is discord between the opinions of the patient and doctor, this case must be seen before a tribunal
The nearest relative can consent to treatment on behalf of the patient
Treatment cannot go ahead as the patient has declined
This patient can be treated under the Mental Health Act as her physical problem is a result of her mental disorder
This patient can be treated under the Mental Health Act as her physical problem is a result of her mental disorder
This is correct. Re-feeding is permitted under the MHA as her physical problem is a result of her mental disorder
A 50-year-old man presents with agitation in the medical ward. He is pacing around and wanting to leave the ward. He is drenched in sweat. He says that a member of the nursing staff is a spy and is going to harm him with needles. He hears voices that tell him to leave the ward because it is unsafe to be here. He was admitted 3 days ago with pneumonia. He is taking acamprosate and co-amoxiclav.
His observations are as follows:
Temperature 38.0 °C
Heart rate 118 bpm
Respiratory rate 20 breaths/min
Blood pressure 122/84 mmHg
Which is the most appropriate initial pharmacotherapy?
IM (intramuscular) olanzapine
IV thiamine (Pabrinex)
Oral lorazepam
IM haloperidol
IV chlordiazepoxide
Oral lorazepam
This man has paranoid delusions and auditory hallucinations, together with symptoms of agitation and diaphoresis. He is having pyrexia and tachycardia. He is taking acamprosate for alcohol dependence. The most likely diagnosis here is delirium tremens. This is likely to occur when a patient with alcohol dependence is abstinent from alcohol for a few days. The first-line treatment for this medical emergency is oral lorazepam. Lorazepam is a short-acting benzodiazepine. If oral medication is declined or the symptoms persist, give parenteral lorazepam or haloperidol. This is an off-label use of lorazepam and haloperidol.
A 24-year-old man is detained under section 2 of the Mental Health Act for assessment of his first presentation of psychosis. This lasts for 28 days, at the end of which he wishes to leave the hospital. However, his medical team feel he needs a further period of treatment in hospital, and therefore recommend a Mental Health Act assessment.
Which professionals are required to detain a patient for treatment under Section 3 of the Mental Health Act?
An approved mental health professional (AMPH) and two doctors
A junior doctor and consultant psychiatrist
An AMPH or one doctor
Two consultant psychiatrists
One consultant psychiatrist
An AMHP and two doctors are required to detain a patient under Section 3 of the Mental Health Act. In addition, both doctors must have seen the patient in the past 24 hours.
72%
first rank symptoms
Auditory hallucinations
- NOT visual
- running commentary
- third person
- thoughts being spoken out loud
Broadcasting
- thoughts: insertion, withdrawal and broadcasting
Control
- somatic hallucinations- things are crawling on your skin or touching you
- delusions that you are being controlled
Delusional perception
- Delusional perception designates a sudden, idiosyncratic, and often self-referential delusion triggered by a neutral perceptual content (e.g. the traffic light)
- e.g. the traffic lught changes colour and that means that they are going to be killed
waxy flexibility
Waxy flexibility is a psychomotor symptom of catatonia as associated with schizophrenia, bipolar disorder, or other mental disorders which leads to a decreased response to stimuli and a tendency to remain in an immobile posture.
