Psych #1

Question 1

A 29-year-old man admits to drinking three pints of normal strength beer
every lunchtime, two 175 mL glasses of red wine and four single (25 mL)
measures of vodka each evening.
How many units of alcohol does he consume each day?

A. 10 units

B. 11.5 units

C. 12 units

D. 13 units

E. 17 units

Answer 1

Crap question

D – 13 units

A unit of alcohol is defined as 10 mL of ethanol (around 8 g). It is the equivalent
to the amount an adult can metabolize in one hour. The number of units per
given volume of drink is calculated using the percentage alcohol by volume

Units = (volume of drink(ml) * ABV%) / 1000

Question 2

A 46-year-old woman is brought into hospital by the police. She had been
found ‘behaving inappropriately’ in the town centre, walking around in
her underwear and declaring she was spending all her lottery winnings.
On examination, her speech is pressured and she is overly amorous
towards the doctor assessing her.
Which of the following symptoms is not consistent with mania?

A. Grandiose delusions

B. Flight of ideas

C. Increased need for sleep

D. Reckless spending

E. Reduced social inhibitions

Answer 2

C – Increased need for sleep

Manic episodes present with elevated mood in 70% of cases and an irritable
mood in 80% of cases. Biological symptoms of mania are decreased sleep,
increased energy and psychomotor agitation. Cognitive symptoms include
decreased concentration, flight of ideas and lack of insight. Manic patients
often display thought disorders, such as circumstantiality (where the speaker
eventually gets to the point in a very roundabout manner) and tangential
speech (where the speaker digresses further and further away from the initial
topic via a series of loose associations). Psychotic features include grandiose or
persecutory delusions, hyperacusis and hyperaesthesia. First-rank symptoms
occur in 20% of cases. In extreme cases there is manic stupor, in which the
patient is unresponsive, akinetic, mute and fully conscious, with elated facies

Question 3

A 32-year-old woman presents to the general practitioner complaining that
her periods have stopped. She has lost 20 kg from her normal healthy
weight over the past few months and is now 38 kg. She admits to strict
dieting and exercising excessively in an attempt to reduce her weight.
Her motivation is to change the way she looks; she says she is embarrassed
by her obesity.
Which of the following is the most likely cause for her weight loss?

A. Anorexia nervosa

B. Bulimia nervosa

C. Hyperthyroidism

D. Mania

E. Obsessive compulsive disorder

Answer 3

A – Anorexia nervosa

A diagnosis of anorexia nervosa requires all four of the following:
† Body weight 15% below expected, or body mass index (BMI) ,17.5
† Self-induced weight loss (by dieting, exercising, vomiting, etc.)
† Morbid fear of being fat (an overvalued idea rather than a delusion)
† Endocrine disturbance (e.g. amenorrhoea, pubertal delay, lanugo hair)
The incidence of anorexia is 4 per 100,000 with a peak age of 18 years. Around
10% of cases of anorexia occur in males. Risk factors include being Caucasian,
high social class, academic prowess and interests such as ballet or modelling.
Other common features are anaemia, expressing a high interest in preparing
or buying food, feeling tired and cold, bradycardia and hypotension. Treatment
options include cognitive behavioural therapy (CBT)/supportive therapy and
raising calorie intake. Hospitalization is indicated if there is a weight loss of
over 35%. Around 50% of people with anorexia nervosa eventually recover
completely. Mortality is 5%, usually from starvation or suicide.
A diagnosis of bulimia nervosa requires all three of the following:
† Binge eating
† Methods to prevent gaining weight (e.g. vomiting, purging, laxatives,
etc.)
† Morbid dread of fatness (overvalued idea, not a delusion)
The incidence of bulimia is 12 per 100,000 with females being affected 10 times
more commonly than males. Individuals tend to be of a normal or above-normal
weight. Complications are caused by starvation and vomiting, and include
hypokalaemia, dehydration, enlargement of the parotid glands, dental caries,
Mallory–Weiss tear, osteoporosis and Russell’s sign (thick skin on the dorsum
of the hands due to repeated-induced vomiting by stimulating the gag reflex
with the fingers). Treatment is similar to that of anorexia, but selective serotonin
reuptake inhibitors (SSRIs) may improve bingeing behaviour. Seventy percent of
cases recover within 5 years and there is no increase in mortality.

Question 4

A 21-year-old man is found wandering the streets by a police officer. He
appears distressed, disorientated and is muttering to himself. He becomes
instantly aggressive and states the police cannot touch him as he is the
son of God.
Under which Section of the Mental Health Act 1983 can the police officer
take the man from a public place to a place of safety?

A. Section 2

B. Section 3

C. Section 5(2)

D. Section 135

E. Section 136

Answer 4

E – Section 136

These are all sections from Part II of the Mental Health Act for England andWales
1983. They relate to compulsory detainment in hospital of patients with a psychiatric
disorder that requires treatment. Around 90% of psychiatric admissions
to hospital are on a voluntary (informal) basis. Patients and their nearest relatives
have the right to appeal against their section. This may go to Mental Health Act
managers or a mental health review tribunal which has the authority to discharge
patients. The Mental Health Act was updated in 2007, specifying one small alteration to
this section: ‘. . . it will not be possible for patients to be compulsorily detained or
their detention continued unless medical treatment which is appropriate to the
patient’s mental disorder and all other circumstances of the case is available to
that patient . . .’.
Sections 135 and 136 allow police to take someone from the community to a
hospital or other safe place. It lasts 72 hours and is granted by a magistrate.
Section 135 applies when a patient is in a private property and allows the
police to break in. Section 136 applies if the patient is in a public place.

Question 5

A 76-year-old man is seen on the ward round by the house officer a day after
his elective left knee replacement. She is surprised that the patient cannot
remember that he has had an operation.
Which of the following is suggestive of a diagnosis of dementia rather than
delirium?

A. A score of 27 on the mini mental state examination

B. Abrupt onset

C. Clouding of consciousness

D. Concurrent infection

E. Insidious onset

Answer 5

E – Insidious onset

Dementia (meaning ’deprived of mind’) can be described as a non-specific syndrome
caused by several illnesses. Affected areas of cognition can be memory,
attention, language and problem solving. Symptoms are usually required to
be present for at least 6 months.
Delirium is characterized by fluctuating impairment of consciousness, mood
changes and abnormal perceptions. It affects 10–25% of people over 65
years on medical wards. The patient may be obviously confused, with disruptive
behaviour and expressing bizarre ideas, but it is important to recognize that it
can also cause a decreased level of activity and speech. It develops over a
short period of time and is caused by an underlying physical condition.
Common causes are infection, hypoxia, electrolyte disturbances, constipation,
drugs, and central nervous system disease. The main principle of management
is to investigate and treat the cause, but to concurrently help relieve distress to
the patient by optimizing their ability to orientate themselves. There should be a
calm environment with adequate lighting, even at night. Patients should be
wearing their glasses and hearing aids (if applicable), have continuity of staff
contact where possible, and ideally have family members or familiar belongings
around them. In some circumstances, oral or intramuscular haloperidol or
benzodiazepines can be used to relieve severe agitation, but they should be
avoided where possible. The average duration of delirium is 7 days. Around
40% of patients with delirium die of the underlying condition and 5% go on
to develop dementia

Question 6

A 54-year-old man sees his general practitioner complaining of gradually
worsening impotence over the last year. He is in debt and had found out
2 months ago that his wife was having an affair. He admitted to drinking
up to 40 units of alcohol per week. His past medical history includes hypertension,
for which he takes atenolol.
What is the most appropriate initial management plan?

A. Psychosexual counselling

B. Self-help exercises

C. Sildenafil

D. Stop atenolol and reduce alcohol consumption

E. Use of a vacuum constriction device

Answer 6

D – Stop atenolol and reduce alcohol consumption

Psychosexual disorders are non-organic problems preventing an individual from
participating in a satisfactory sexual relationship. However, there is frequently a
combination of physical and psychological factors contributing to an impairment
of function. In this scenario, these include marital difficulties, financial strain,
excessive alcohol use and prescription drugs (atenolol). Other drugs that can
cause erectile dysfunction include tricyclic antidepressants, benzodiazepines,
antihistamines, oestrogens, statins and anti-Parkinsonism medication Stopping atenolol and reducing alcohol consumption are sensible initial
measures in this case. Appropriate investigation will depend on the history.
Biological causes should be ruled out (e.g. neuropathy, ischaemic vascular
dysfunction, hypertension) and specialist referral may be needed. However, if
psychological factors are involved, referral to a sexual and relationship clinic
may be helpful. In cases of erectile failure (e.g. diabetic neuropathy), intracavernosal
injection of papaverine or prostaglandin E1 can be used. Other physical
treatments include vacuum device, nitrate creams and rod insertion.

Question 7

The recommended weekly consumption of alcohol for men should not
exceed:

A. 7 units

B. 14 units

C. 21 units

D. 28 units

E. 30 units

Answer 7

C – 21 units

In the UK, the recommended maximum weekly alcohol consumption is 21 units
in men and 14 units in women. Obviously these are general guidelines, and
certain people should limit their intake or abstain from alcohol altogether.
Examples include people with chronic liver disease, low body weight or poor
nourishment, at the extremes of age and those on certain medications (some
antibiotics, e.g. metronidazole, monoamine oxidase inhibitors, antihistamines,
benzodiazepines and opioids)

Question 8

A 68-year-old woman presents with sudden-onset loss of concentration and
worsening confusion. This has become progressively more severe on many
discrete occasions without recovery in between.
What is the most likely cause of her confusion?

A. Lewy body dementia

B. Normal pressure hydrocephalus

C. Parkinson’s disease

D. Pick’s disease

E. Vascular dementia

Answer 8

E – Vascular dementia

Vascular dementia is an ischaemic disorder characterized by multiple small cerebral
infarcts in the cortex and white matter. When .100 mL of infarcts have
occurred, dementia becomes clinically apparent. Vascular dementia begins in
the 60s with a step-wise deterioration of cognitive function. Other features
include focal neurology, fits and nocturnal confusion. Risk factors for vascular
dementia are as of any atherosclerotic disease (male sex, smoking, hypertension,
diabetes, hypercholesterolaemia). Death in vascular dementia often
occurs within 5 years, due to ischaemic heart disease or stroke.
Normal pressure hydrocephalus is characterized by the triad of dementia (mainly
memory problems), gait disturbance and urinary incontinence. It is caused by
an increased volume of cerebrospinal fluid (CSF), but with only a slightly
raised pressure (as the ventricles dilate to compensate). There is an underlying
obstruction in the subarachnoid space that prevents CSF from being reabsorbed
but allows it to flow from the ventricular system into the subarachnoid space.
Diagnosis is by lumbar puncture (to demonstrate a normal CSF opening
pressure) followed by head CT/MRI (showing enlarged ventricles). Treatment
is with ventriculoperitoneal shunting.
Pick’s disease is a form of frontotemporal dementia (it can only be differentiated
from other forms at autopsy, so ‘frontotemporal dementia’ is the preferred
term). Clinical features include disinhibition, inattention, antisocial behaviour
and personality changes. Later on, apathy, akinesia and withdrawal may predominate.
Memory loss and disorientation only occur late. Autopsy shows atrophy of the frontal and temporal lobes (knife blade atrophy) and Pick’s bodies (cytoplasmic
inclusion bodies of tau protein) in the substantia nigra. In advanced
cases the atrophy may be seen on MRI.

Question 9

A 20-year-old woman presents with evidence of delusions of a religious
nature, persecutory auditory hallucinations and thought broadcasting.
According to her mother, these symptoms have been present for the last
2 weeks.
According to ICD-10 criteria, how long should symptoms be present before
a probable diagnosis of schizophrenia can be made?

A. Greater than or equal to 2 weeks

B. Greater than or equal to 1 month

C. Greater than or equal to 2 months

D. Greater than or equal to 6 months

E. Unspecified duration

Answer 9

B – Greater than or equal to 1 month

Psychosis should only lead to the diagnosis of schizophrenia if symptoms have
been present for 1 month, and there is the absence of significant mood disorder,
overt brain disease, and drug intoxication/withdrawal. Important differential
diagnoses are organic psychotic disorder, substance induced psychotic disorder,
delusional disorder, schizoaffective disorder, transient psychosis and schizotypal
disorder.

Question 10

A 63-year-old man is admitted to hospital with an exacerbation of COPD.
On the third day, he complains of sweating and tremor. On examination
he is confused, anxious, tachycardic and appears to be responding to
visual hallucinations. He says he can see thousands of miniature soldiers
marching on the floor.
Which of the following is the most likely cause?

A. Alcohol use

B. Alcohol withdrawal

C. Amphetamine withdrawal

D. Sedative use

E. Sedative withdrawal

Answer 10

B – Alcohol withdrawal

Alcohol withdrawal usually occurs if blood alcohol concentration falls in
someone with alcohol dependence. Symptoms usually start approximately
12 hours after the last intake and include anxiety, insomnia, sweating, tachycardia
and tremor. Seizures may occur after 48 hours. Treatment is supportive
with a reducing dose of regular benzodiazepines (e.g. chlordiazepoxide) and
vitamin B supplements (intravenous or oral). Mortality is approximately 5%.
Delirium tremens may also be a feature of alcohol withdrawal and occurs after
48 hours, lasting for 5 days. There is tremor, restlessness and increased autonomic
activity, fluctuating consciousness with disorientation, a fearful affect
and hallucinations. Hallucinations may be auditory, tactile or visual, and delusions
may also be present. Lilliputian hallucinations (seeing little people) are
characteristic (named after the island of Lilliput in Jonathan Swift’s novel
Gulliver’s Travels, where the inhabitants were ‘not six inches high’).

Question 11

A 42-year-old woman is about to undergo electroconvulsive therapy. Her
family asks you about the possible side-effects.
Which of the following is recognized as a late side-effect of this therapy?

A. Death

B. Hallucinations

C. Headaches

D. Memory loss

E. Muscle aches

Answer 11

D – Memory loss

Electroconvulsive therapy (ECT) is the administration of an electric shock to the
head (under general anaesthesia) in order to induce a seizure. The indications
are severe depressive illness, especially if there is life-threatening behaviour,
puerperal depressive illness, mania and catatonic schizophrenia. The absolute
contraindication is raised intracranial pressure. Relative contraindications
include high anaesthetic risk and known cerebral aneurysm. Long-term
side-effects of ECT are largely unknown, but some patients have complained of long-term memory loss. Short-term side-effects are headaches, temporary
confusion, muscle aches and some short-term memory loss.

Question 12

A 62-year-old man has been taking haloperidol for schizophrenia since his
initial diagnosis 20 years ago. On examination, he displays continual facial
movements which look as though he is chewing his own mouth. These
movements have been present for some time.
From which of the following side-effects is he suffering?

A. Acute dystonia

B. Akathisia

C. Parkinsonism

D. Serotonin syndrome

E. Tardive dyskinesia

Answer 12

E – Tardive dyskinesia

Typical antipsychotics block dopamine D2 receptors in the central nervous
system in various pathways. This accounts for both their therapeutic and sideeffects.
The effect on the mesolimbic pathway improves psychotic symptoms,
but action on the mesocortical pathway worsens negative symptoms. The
effect on the tuberoinfundibular pathway causes the side-effect of hyperprolactinaemia
(! gynaecomastia, galactorrhoea, reduced sperm count, amenorrhoea
and reduced libido). Action on the chemoreceptor trigger zone has an
antiemetic property.
The consequence of nigrostriatal pathway blockade is the extrapyramidal sideeffects.
These include Parkinsonism (rigidity, bradykinesia and tremor, which
can begin within 1 month and are treated with anticholinergics, e.g. procyclidine);
acute dystonias (occur within 72 hours of treatment and include
trismus, tongue protrusion, spasmodic torticollis, opisthotonus, oculogyric
crisis and grimacing); akathisia (occurs within 60 days and features a subjective
feeling of inner tension and restless leg syndrome, but can be treated with
b-blockers and benzodiazepines); and tardive dyskinesia (affects 20% in the
long term and presents with chewing, grimacing, sucking and a darting
tongue).
Other side-effects of typical antipsychotics are anticholinergic effects, which
cause an increased QT interval, arrhythmias and cardiac arrest. a-adrenoreceptor
blocking action causes postural hypotension and antihistamine activity
causes sedation and weight gain. Chlorpromazine specifically causes greying
of the skin in response to sunlight, and a reduced seizure threshold.

Question 13

An 81-year-old man has a 10-month history of worsening forgetfulness. He
has however had frequent episodes of relative lucidness during this period.
He occasionally sees dogs running around his house, although he does not
own any, and his walking has slowed markedly. His sleeping pattern is now
irregular.
Which of the following descriptions suggests a clinical diagnosis of Lewy
body dementia?

A. Bradykinesia, limb rigidity, repeated falls

B. Fluctuating cognition, recurrent auditory hallucinations

C. Motor features of Parkinsonism, fluctuating cognition

D. Recurrent visual hallucinations, syncope

E. Transient loss of continence, visual hallucinations

Answer 13

C – Motor features of Parkinsonism, fluctuating cognition

Lewy body dementia is the second most common dementia after Alzheimer’s.
Characteristic features of Lewy body dementia include day-to-day fluctuating
levels of cognitive functioning, recurrent visual hallucinations (commonly involving
people or animals), sleep disturbance, transient loss of consciousness,
recurrent falls and Parkinsonian features (tremor, shuffling gait, hypokinesia,
rigidity and postural instability). Although people with Lewy body dementia
are prone to hallucination, antipsychotics should be avoided as they precipitate
severe Parkinsonism in 60%. A Lewy body is an abnormality of the cytoplasm
found within a neuron, containing clumps of a-synuclein and ubiquitin
protein. They are found in the cerebral cortex in patients with Lewy body
dementia postmortem, and they are also found in patients with Parkinson’s
disease.

Question 14

A 35-year-old man attends the general practice because he is concerned
about his partner. He has become very suspicious of her and feels he
cannot trust her. Although he does not know why he feels like this, he
has various possible conspiratorial explanations.
Which of the following personality disorders is most appropriate?

A. Dissocial

B. Emotionally unstable – impulsive type

C. Paranoid

D. Schizoid

E. Schizotypal

Answer 14

C – Paranoid

The ICD-10 definition of a personality disorder is ‘a severe disturbance in the
characterological constitution and behavioural tendencies of the individual,
usually involving several areas of the personality, and nearly always associated
with considerable personal and social disruption’. They often become apparent
during childhood or adolescence, and continue into adulthood. The prevalence
of personality disorders is probably under-reported. It is likely to affect around
10% of the population, but is higher in psychiatric settings. There are several
theories regarding personality and personality disorders; the dimensional
approach suggests that people with personality disorders exhibit traits which
feature as a spectrum in the population, but to an exaggerated degree.
Personality disorders may be categorized into clusters (DSM-IV):
† Cluster A (paranoid, schizoid, schizotypal) ! odd or eccentric
† Cluster B (antisocial, borderline, histrionic,
narcissistic)
! emotional or dramatic
† Cluster C (avoidant, dependent, anankastic) ! anxious or fearful
People with a paranoid personality disorder are often sensitive, suspicious of
others (including their own partners), preoccupied with conspiratorial explanations
and are very sensitive to rejection. They often bear grudges and misinterpret
the actions of others as malicious. Schizoid personalities have a preference
for one’s own company over that of others. They lack emotional expression and
may consequently be perceived by others as cold and disinterested. They may
not gain pleasure from many activities and have little interest in forming
sexual or confiding relationships. In schizotypal disorder people often have odd
ideas, perceptions, appearances and behaviours. Thought disorders and psychoses,
which are features of schizophrenia, are not present in schizoid personalities.
However, schizoid personalities are not exempt from developing
schizophrenia.
Antisocial (dissocial) personalities often display little feeling towards others. There
is a tendency to be aggressive, commit crimes and lack remorse. Affected
persons have difficulty in forming intimate relationships and the diagnosis is supported
by a previous childhood conduct disorder.
In DSM-IV, two further personality disorders are categorized: the narcissistic personality
(arrogant with a grandiose sense of self-importance, often lacking
empathy for others) and the schizotypal personality (eccentric behaviours, thinking,
speech and appearance, and lacking social confidence and close relationships
– think of your local nutty professor!).
Narcissism, from the Greek legend Narcissus, who was cursed into falling in love
with his own reflection after breaking the heart of the shy nymph Echo. (Incidentally,
Echo loved the sound of her voice so much, she was herself cursed into only
being able to repeat what others said.)

Question 15

A 78-year-old woman is assessed in the emergency department following a
deliberate overdose of 70 paracetamol tablets. She mentions that she has
been feeling very under the weather this week and she had no one to talk to.
Which of the following features would suggest a good prognosis of her
mood in this case?

A. Acute onset

B. Associated personality disorder

C. Insidious onset

D. Lack of social support network

E. Older age group

Answer 15

A – Acute onset

The lifetime risk of depression is 10–25% in females and 5–12% in males.
Marital status affects the risk of depression: the highest risk group are those
who are divorced, followed by people who are separated, then single, then
married. Other risk factors are having three or more children below the age
of 14, unemployment, maternal death below the age of 11, and a lack of
confiding relationships. An adverse life event in the previous 6 months,
chronic illness, personality disorders and a family history of bipolar disorder
predispose to depression. Examples of medications which increase the risk of
depression include b-blockers, steroids, anticonvulsants, benzodiazepines, antipsychotics,
opiates and non-steroidal anti-inflammatory drugs.
Prognostic factors associated with a good outcome in depression include acute
onset, and an earlier age of onset. Prognostic factors associated with a poor
outcome include insidious onset, neurotic depression, being elderly, low self confidence,
co-morbidity (physical or psychological) and a lack of social support.

Question 16

An 18-year-old male with a previous diagnosis of schizophrenia complains
of auditory hallucinations. He has become socially withdrawn and feels he
does not talk or have as many thoughts as he did previously.
Which one of the following positive symptoms of schizophrenia does he
have?

A. Anhedonia

B. Blunted affect

C. Hallucinations

D. Poverty of speech

E. Poverty of thought

Answer 16

C.Hallucinations

Schizophrenia is characterized by distortions in thought and perception, with a
blunted, inappropriate affect. Intellect and clear consciousness are usually maintained.
The most important features are first-rank symptoms, thought disorder
and negative symptoms.
Positive symptoms of schizophrenia include:
† Hallucinations
† Delusions
† Thought withdrawal, insertion and broadcasting
Negative symptoms include:
† Loss of interest in others or initiative
† Anhedonia
† Blunted affect
† Reduced speech
There is a lifetime risk of 1% with a peak age of onset of 26 years in females and
23 years in males. There is a slightly higher incidence in males. Risk factors
include low socioeconomic class and exposure to a high level of expressed
emotion (over 35 hours/week). There is also a higher incidence in those with
a family history, winter/spring birthdays, maternal flu infection during the
second trimester of pregnancy, decreased brain volume and increased ventricle
size, adverse life events and lack of social interactions. The dopamine hypothesis
is a theory regarding the mechanism of schizophrenia. Briefly, it says that the
symptoms are caused in part by central dopaminergic hyperactivity in the mesolimbic–
mesocortical system.

Question 17

A 32-year-old man has begun to gain sexual excitement from soft materials
such as wool and cotton. He is now relying on it in order to become
aroused.
Which of the following words best describes his behaviour?

A. Exhibitionism

B. Fetishism

C. Sadomasochism

D. Transvestism

E. Voyeurism

Answer 17

B – Fetishism

Paraphilias are defined as disorders of sexual preference. Fetishism focuses on
inanimate objects that are not normally viewed as being of a sexual nature, as
a source of sexual stimulation, e.g. shoes, leather, etc. Transvestic fetishism is
the use of cross-dressing in order to gain sexual excitement. Exhibitionism is
the tendency to expose genitalia to strangers in public places with subsequent
gratification, particularly if there are reactions of shock or horror. Type 1 exhibitionism
(80% cases) occurs often in young men, showing a flaccid penis. There
is often remorse afterwards. Type 2 exhibitionism is the exposure of an erect
penis. This is more common in people with dissocial personality types and
there is often a lack of remorse. Voyeurism is the tendency to watch other
people engaging in sexual activity.

Question 18

A 29-year-old man complains to his general practitioner that a colleague at
work has been deleting the ideas from his head before he had time to say
them or write them down. He is referred to the psychiatrist with a presumptive
diagnosis of schizophrenia.
Which one of the following is also a first-rank symptom of schizophrenia?

A. Grandiose delusions

B. Nihilistic delusions

C. Second person auditory hallucinations

D. Thought broadcasting

E. Visual hallucinations

Answer 18

D – Thought broadcasting

Kurt Schneider listed symptoms that he felt distinguished schizophrenia from
other types of psychosis. He describes these ‘first-rank symptoms’ as being
highly suggestive of schizophrenia in the absence of organic brain disease.
However, they are absent in 20% of people with schizophrenia and can be
present in other psychiatric disorders, such as depression or mania. The presence
of first-rank symptoms in schizophrenia is not an indicator of prognosis.
The first-rank symptoms can be categorized as follows:
† Auditory hallucinations ! 3rd person, running commentary,
repeating thought
† Thought alienation ! thought insertion/withdrawal/broadcast
† Influences on the body ! made feelings/actions/impulses
† Other ! somatic passivity and delusional perception
In 3rd person auditory hallucinations, the patient hears the voices of more than
one person discussing matters between themselves. A running commentary is
one voice describing the patient’s every action. Finally, the patient can experience
thought sonorization (hearing their thoughts out aloud). These ‘audible
thoughts’ can occur either at the same time of the real thoughts (gedankenlautwerden)
or just afterwards (e´cho de la pense´e).
In thought insertion, the patient believes that thoughts are being put into the
mind by an outside agency. In thought withdrawal they feel as if their thoughts
are being removed. Thought broadcasting is where the patient feels their
thoughts are being made accessible to others (i.e. others can hear them).

Question 19

A 38-year-old man attends the general practice for monitoring of his antipsychotic
medication. The ‘traffic light’ notification system is used for
the monitoring of which antipsychotic drug?

A. Chlorpromazine

B. Clozapine

C. Olanzapine

D. Quetiapine

E. Risperidone

Answer 19

B – Clozapine

Clozapine is an atypical antipsychotic. NICE guidelines1 recommend that clozapine
should be used in treatment-resistant schizophrenia after sequential use of
at least two antipsychotics for 6–8 weeks, at least one of which should be an
‘atypical’ antipsychotic. Patients on clozapine must be registered with a
central monitoring agency and have regular full blood counts – the drug
must be stopped if there is evidence of neutropenia, as episodes of fatal agranulocytosis
have previously been reported. All patents must be registered with the
Clozaril Patient Monitoring Service (CPMS) and a normal leucocyte count must
be confirmed before treatment can be started. Each time a blood sample is sent
to the CPMS, the results will be telephoned through if urgent, or posted if not. A
traffic light system is sometimes used:
† Green light Normal, clozapine can be given
† Amber light Caution, further sampling advised
† Red light Stop clozapine immediately, then take daily blood
samples

Question 20

A 72-year-old man is being assessed by a psychiatrist for memory impairment.
He scores 20 on the mini mental state examination.
Which of the following scores is suggestive of cognitive impairment?

A. Less than 30

B. Less than 28

C. Less than 25

D. Less than 20

E. Less than 15

Answer 20

C – Less than 25

The mini mental state examination (or Folstein test) permits a standardized
assessment of orientation (maximum 10 points), registration/concentration/
recall (maximum 11 points), and concentration and language/drawing
(maximum 9 points). It is scored out of a total of 30 points. A score of .27 is
normal. A score of ,25 suggests cognitive impairment, graded as mild
(21–24), moderate (10–20) or severe (,10).

Question 21

A 22-year-old woman complains of problems staying awake during the day.
She often falls asleep at inappropriate moments, and has occasionally collapsed
when she has fallen asleep in a standing position. The periods of
sleep are of a sudden onset but only last a few minutes.
Which of the following terms best describes this sleep disorder?

A. Hypersomnia

B. Insomnia

C. Narcolepsy

D. Sleep apnoea

E. Somnambulism

Answer 21

C – Narcolepsy

Narcolepsy affects ,0.1% of the population. It is a neurological condition
caused by a loss of inhibition of rapid eye movement (REM). It has four main features:
irresistible attacks of sleep at inappropriate times, cataplexy (sudden loss
of muscle tone when intense emotion occurs, leading to collapse), hypnogogic/
hypnopompic hallucinations (hallucinations that occur on falling asleep and
waking, respectively), and sleep paralysis. Not all cases of narcolepsy have all
four features. When forming the diagnosis, factors that point to hypersomnia
are sleeps that have a gradual onset, are worse in the mornings and rarely
occur in unusual places. Factors that suggest narcolepsy are a short duration
of sleep (10–20 minutes,) the inability to control sleep attacks and interrupted
night-time sleep, as well as the four main features. Management falls under the
remit of neurologists.
Insomnia is a condition describing a reduced quantity or quality of sleep for a
prolonged period. This may involve difficulty getting to sleep/staying asleep,
and early morning wakening. If there is an underlying cause this should be
treated. Drug treatments are limited and include short-acting benzodiazepines
such as temazepam (which have less of a hangover effect compared with
longer-acting ones like diazepam) or zopiclone (which is similar). However,
these drugs should be used for a limited duration and use for longer than
2 weeks increases the risk of addiction. Insomnia is more common in the elderly.
Hypersomnia is defined as either excessive daytime sleepiness with sleep attacks,
or an abnormal length of time taken to reach full arousal after sleeping (in the
absence of an organic disorder). It affects between 0.3% and 4% of the population.
Somnambulism (sleep walking) is a state of altered consciousness in which
there are some features of wakefulness and some of sleep. The individual usually
arises from bed (during the first third of nocturnal sleep) and begins walking, but
with reduced awareness, reactivity and motor skill. Upon awakening there is
usually no recollection of the event. It is more common in children. Management
is by reassurance, simple safety measures and gentle encouragement to
return to bed by the family.
Sleep apnoea is a physical condition in which the upper respiratory tract
becomes partially occluded during sleep. This can cause transient cessation in
breathing which causes the patient to wake repeatedly during the night, reducing
the quality of sleep. Sleep apnoea results in daytime tiredness. It is more
common in overweight males who snore. Treatment is by continuous positive
airway pressure via face mask during sleep.

Question 22

A 34-year-old woman with severe mania was found in her hospital bedroom
sitting on the floor. She was staring towards one of the walls with an elated
look on her face, but did not respond to the commands of the nursing staff.
Which of the following terms best describes her behaviour?

A. Echopraxia

B. Hyperkinesis

C. Motor tic

D. Negativism

E. Stupor

Answer 22

E – Stupor

Stupor describes the state of being unresponsive, akinetic and mute, but fully
conscious. Stupor can occur in mania (this case), depression, catatonia, epilepsy
and hysteria. Obsessional slowness is a reduced rate of activity due to repeated
doubts and compulsive rituals in obsessive–compulsive disorder (OCD).

Hyperkinesis is often seen in children and teenagers. It comprises overactivity,
distractibility, impulsivity and excitability. Motor tics are repeated involuntary
movements involving a group of muscles. Parkinsonism describes a group of
characteristic movements that occur in Parkinson’s disease and other conditions.
These include resting tremor, cogwheel rigidity, festinant gait (an involuntary
tendency to making short, accelerated steps when walking) and posture
abnormalities.
Movements seen in schizophrenia. Ambitendency involves making tentative
incomplete movements, apparent when shaking hands. Echopraxia is the
copying of another person’s movements, even when asked to stop. Mannerisms
are repeated involuntary movements that appear goal directed, e.g. flicking
hair. Stereotypies are repeated patterns of movement that are not goal directed,
e.g. moving head from side to side. Negativism is the motiveless resistance to
commands and attempts to be moved. Posturing is where a bizarre body position
is adopted for an inappropriately long time. Waxy flexibility is when the
patient remains motionless, but allows their limbs to be moved by someone
else. The limbs then remain in the new posture.

Question 23

A 33-year-old man living in Malaysia had a gun in his house which used to
belong to his father. One day, he grabbed it, shot his family and ran outside
shooting passers-by before finally taking his own life. He had no previous
psychiatric history, and there was no obvious motive.
Which of the following terms describes this condition?

A. Amok

B. Dhat

C. Koro

D. Latah

E. Susto

Answer 23

A – Amok

Amok is seen in South-East Asia, usually in Malaysian men. The features are
acquisition of a weapon followed by a series of frenzied attacks, killing or
seriously injuring anyone within reach. The attacks can last several hours and
are frequently only terminated by the attacker being killed by someone else
or himself. If he is not killed, amok is followed by a stupor/sleep lasting one
day, followed by amnesia of the event. It is thought to be a form of dissociative
disorder.
Koro is seen in Asian men, especially of Chinese origin. It is the fear that the penis
is retracting into the abdomen. Some have a secondary worry that full retraction
will lead to death. Koro is more common in people who have limited access to
education.
Dhat occurs in young Indian males. It is associated with anxiety and a belief that
semen is being lost in the urine. It often accompanies excessive guilt about masturbation.
There may be a belief that semen is ‘vital fluid’, more so than blood,
and the loss of it leads to fatigue.
Latah is a culture-bound condition found in women in North Africa and the Far
East. There is an exaggerated startle response, in which women sometimes start
repeating the words of another person (echolalia), or obeying their commands.
There is frequently amnesia after the event.
Susto usually occurs in people living in South America. It is a severe depressive
episode usually occurring after a traumatic event. There are often physical symptoms
such as diarrhoea and nervous tics. It is thought (within the culture in which it exists) to be caused by separation of the soul from the body. It has some
features in common with acute stress reaction.
Amok, from Malay amuk ¼ mad with rage. It is the origin of the phrase ‘to run
amok’.

Question 24

A 21-year-old man is found break-dancing in a fast food restaurant. He says
that he is the best in the world at it and he felt it was only right that everyone
should be able to share his talents. He has been up for the last 60 hours
practising at home. This is his second such episode in a month.
Which of the following is the first-line drug for stabilizing his mood?

A. Fluoxetine

B. Haloperidol

C. Lithium

D. Olanzapine

E. Sodium valproate

Answer 24

C – Lithium

Bipolar affective disorder is characterized by two or more episodes in which
mood and activity levels are significantly disturbed. This should include at
least one episode of elevation of mood and increased energy and activity (hypomania
or mania) although on other occasions there may be a lowering of mood
and decreased energy and activity (depression). There is a 1% lifetime risk, with
the average age of onset being in the mid-20s. Males and females have an equal
risk of developing bipolar disorder, and higher social classes have a higher risk.
Acute episodes of mania are managed with neuroleptic drugs (e.g. olanzipine or
haloperidol) with benzodiazepines for agitation. Long-term prophylaxis (mood
stabilizers) is most often given in the form of lithium. (carbamazepine and
sodium valproate may also be effective). Mood stabilizers are prescribed only
if there has been more than one episode of mania. Lithium causes sustained
remission in 80% of cases. Psychotherapies have a supportive role and can
improve concordance with therapy. Electroconvulsive therapy is used for
manic stupor and resistant mania but, if used during a depressive episode in a
patient with bipolar disorder, it can precipitate mania.

Question 25

A 32-year-old man with schizophrenia has recently had an increase in his
dose of clozapine. He presented to the emergency department unconscious
with muscle rigidity. Initial blood tests revealed a raised white cell count
and a creatine kinase of 5000 iu/L.
Which of the following is not a common feature of neuroleptic malignant
syndrome?

A. Altered consciousness

B. Hypothermia

C. Increased creatine kinase

D. Muscle rigidity

E. Tachycardia

Answer 25

B – Hypothermia

Neuroleptic malignant syndrome is a life-threatening neurological condition
that can occur with the use of typical and atypical antipsychotics, particularly
after an increase in dosage. Symptoms include pyrexia, fluctuating consciousness,
muscle rigidity and autonomic dysfunction. Investigations may reveal a
raised creatine kinase, raised white cell count and abnormal liver function
tests. Management includes benzodiazepines, stopping the precipitating
agent, and supportive measures such as oxygen, maintaining fluid balance
and reducing core body temperature. Intravenous sodium bicarbonate can be
used in cases of rhabdomyolysis, and dantrolene or lorazepam can be used to
reduce rigidity.

Question 26

A 35-year-old woman is admitted to a psychiatric unit with a probable diagnosis
of postpartum psychosis. She is very distressed, states she is not ill and
threatens to leave the ward.
Under which Section of the Mental Health Act 1983 may a doctor prevent
her from leaving hospital?

A. Section 2

B. Section 4

C. Section 5(2)

D. Section 5(4)

E. Section 136

Answer 26

C – Section 5(2)

Section 5(2) is doctor holding power. It allows the detention of hospital inpatients
(under any speciality) by the doctor responsible for their care. It lasts
72 hours (long enough to arrange a Section 2). Note that in even more acute
situations patients can be stopped under common law for a short time if there
is an immediate threat to their health. Section 5(4) is nurse holding power.
This allows detention of informal psychiatry inpatients by nurses if there is no
doctor available. It lasts 6 hours, allowing time for a more permanent Section
to be administered.
Section 2 is compulsory detention for assessment; when the exact diagnosis and
response to treatment is unknown. Its duration is 28 days. Application for detention
under this Section can be made by the patient’s nearest relative or approved
social worker. It must be agreed by two doctors (one of whom must be Section
12 approved). To become approved under Section 12(2) you have to attend
a specific Section 12 training course and be recommended to do so by two
psychiatry consultants. Before attending training, doctors must usually hold
membership to the Royal College of Psychiatrists or have at least 3 years
experience in psychiatry.
Section 3 allows compulsory detention for treatment when the diagnosis is
already known. It lasts for 6 months, but may be renewed if necessary. It must
be agreed by two doctors (one of whom must be Section 12 approved).
Section 4 allows an emergency admission to hospital when there is not enough
time to organize a Section 2. Its duration is 72 hours and there is no right of
appeal against it. It can be arranged by one doctor.
Sections 35 to 37 can be requested by a court on advice of a Section 12 approved
doctor when a patient has been charged with an offence that may lead to imprisonment.
Section 35 is for the purpose of producing a medical report on the
psychiatric illness of the offender. The duration is 28 days. Section 36 allows
treatment of the patient. It also lasts 28 days, but requires two doctors to
agree on it. Section 37 is for the detention and treatment of a patient already
convicted of an imprisonable offence. This also requires two doctors’ agreement
and lasts 6 months.
Section 17 allows for set periods of leave from the inpatient unit (with a responsible
adult) to be granted by the responsible medical officer

Question 27

A 32-year-old woman attends the general practitioner in tears. She is upset
because she thinks that the man at home with her is not her husband but
someone in disguise as her husband. Her sister, who is with her, tells the
doctor that this is not true.
From which of the following conditions is she suffering?

A. Capgras’ syndrome

B. Couvade syndrome

C. de Cle´rambault’s syndrome

D. Folie a` deux

E. Fregoli syndrome

Answer 27

A – Capgras’ syndrome

Capgras’ syndrome is a delusional belief that a close acquaintance has been
replaced by an identical double. It is most commonly seen in schizophrenia.
Fregoli syndrome is a delusion that a persecutor is able to change into many
forms and disguise themself to look like different people, much like an actor. It is named after Leopold Fregoli, an Italian actor (1867–1936) who was famous
for being able to make quick changes of appearance during stage acts. Folie a deux is when a delusion in one person becomes shared by someone close to them. A similar effect can occur in three or more people (folie a trios, folie a` plusieurs).
de Cle´rambault’s syndrome (erotomania) is a delusional belief that someone of
higher social status is in love with them. It is more common in women.
Couvade syndrome occurs in males around the time of the birth of their child.
They experience symptoms similar to those of pregnancy, like nausea and dyspepsia.
They may even suffer abdominal distension and labour-like contraction
pains. The cause is not well understood, but symptoms usually resolve soon
after birth.

Question 28

A 30-year-old soldier returns from 6 months’ duty in Afghanistan, during
which time he witnessed a close friend being killed by a landmine
explosion. He now describes poor sleep, ‘flashbacks’ of the event and irritability.
Which of the following is a risk factor for developing this condition?

A. Caucasian ethnicity

B. Low self-esteem

C. Higher social class

D. Male sex

E. Psychopathic traits

Answer 28

B – Low self-esteem

This man has developed post-traumatic stress disorder (PTSD). PTSD (shell
shock) occurs secondary to a traumatic stressor (i.e. one that any ‘normal’
person would find stressful). Diagnostic features include:
† Experience of a major traumatic event
† Re-experiencing the trauma (nightmares, flashbacks)
† Avoidance behaviour
† Increased arousal (hypervigilance, insomnia, enhanced startle reaction)
† Onset is delayed (but within 6 months) and the features should last
1 month
The usual course is recovery, but occasionally symptoms become chronic.
Risk factors for PTSD include:
† Low education
† Lower social class
† Afro-Caribbean/Hispanic ethnicity
† Female sex
† Low self-esteem
† Personal or family history of psychiatric problems
† Prior traumatic events

Question 29

A 23-year-old woman has had a string of intense and unstable relationships.
She is often unpredictable. She also has a history of deliberate self-harm.
From which of the following personality disorders is she most likely
suffering?

A. Anankastic

B. Avoidant

C. Emotionally unstable, borderline type

D. Emotionally unstable, impulsive type

E. Histrionic

Answer 29

C – Emotionally unstable, borderline type

The emotionally unstable personality disorder (borderline type) is characterized by
emotional instability, disturbed views of self-image, feelings of emptiness and
intense, but easily broken, relationships. Self-harm is a common feature, often
in an attempt to avoid abandonment. The emotionally unstable (impulsive
type) personality disorder is similar, but a lack of self-control and violent outbursts
are more prominent features. Histrionic individuals crave attention, are
preoccupied with appearance and are inappropriately flirtatious. They may
display theatrical expressions of emotions, from excessive excitement to unexpected,
manipulative tantrums.

Question 30

A 56-year-old man has been referred by his psychiatrist for electroconvulsive
therapy.
Which of the following is not an indication for such intervention?
A. Catatonia
B. Neuroleptic malignant syndrome
C. Prolonged manic episode
D. Severe depression
E. Treatment-resistant dementia

Answer 30

E – Treatment-resistant dementia

Electroconvulsive therapy (ECT) may be considered as a treatment option for
depression when there are severe biological features, marked psychomotor
retardation or when the patient is at high risk of harm to themselves or
others. Other indications for ECT include catatonia, prolonged or severe
mania and neuroleptic malignant syndrome.

Question 31

A 62-year-old man with a history of depression presents to his general practitioner
with weight loss and lethargy. He has lost 10 kg in the last month
but he denies any desire to do so. He says that he has had increasing difficulty
swallowing solid foods and a reduced appetite.
Which of the following is the most likely cause of his weight loss?

A. Anorexia nervosa

B. Bulimia nervosa

C. Depression

D. Hyperthyroidism

E. Malignancy

Answer 31

E – Malignancy

Malignancy is a common cause of weight loss and should always be considered,
particularly in older people who complain of tiredness and a reduced appetite. A
full examination and systems review should be carried out to determine a possible
site of malignancy.
Thyroid dysfunction is associated with weight change. Hyperthyroidism can
lead to weight loss despite a good appetite and hypothyroidism can cause
weight gain without increased intake.

Question 32

A 30-year-old woman gave birth to her first child 3 days ago. It was a
planned pregnancy and there were no physical problems with the delivery
or baby. She has no past psychiatric history, but has become inconsolably
tearful, anxious and low in mood today.
Which of the following is the most likely diagnosis?

A. Maternity blues

B. Postnatal depression

C. Premenstrual syndrome

D. Pseudocyesis

E. Puerperal psychosis

Answer 32

A – Maternity blues

Maternity blues affects two-thirds of women postpartum. It begins 3 to 5 days
after birth, and lasts no longer than 10 days. It is characterized by low mood and
tearfulness, and usually recovers spontaneously. Management is by reassurance.
Postnatal depression starts within 3 months of giving birth, and usually lasts less
than 6 months. It affects 10% of women. Features are similar to those of
depressive episodes, but some symptoms of depression (insomnia, tiredness
and low libido) are normal postpartum. There may be obsessional thoughts,
particularly intrusive thoughts about harming the baby. There may be an excessive
concern about the baby’s health and the mother’s own adequacy as a
parent. Treatment may be solely supportive or include antidepressants.
The puerperium is defined as the first 6 weeks after childbirth. This is a high-risk
period for developing psychiatric illness. Puerperal psychosis affects one pregnancy
in 500 and has a rapid onset during the first 3 weeks after birth. There
may be a prodrome of insomnia and irritability, followed by acute confusion
and psychosis. It should be treated as a medical emergency in a specialist
centre because there is a suicide risk of 5% and an infanticide risk of 4%.
Seventy percent of cases recover fully. The aims of treatment are to keep the
mother and child together in a safe environment, and electroconvulsive
therapy is sometimes required
Pseudocyesis describes the presence of the signs and symptoms of pregnancy in
the non-pregnant woman (e.g. amenorrhoea, breast enlargement and significant
abdominal distension).

Question 33

A 37-year-old man is brought to the general practitioner by his wife as he is
becoming less socially responsive and motivated. She feels he has declined
gradually over the last year, but has become much worse in the last few
days. When asked what his name is, he stares blankly at the floor and
says ‘I don’t know’. Similar responses are given for other simple questions,
and he claims it is because he has lost his memory. He has previously been
fit and well and has no other symptoms.
What is the most likely cause of his symptoms?

A. Creutzfeldt–Jakob disease

B. HIV dementia

C. Huntington’s disease

D. Pseudodementia

E. Vascular dementia

Answer 33

D – Pseudodementia

Pseudodementia is recognized in people with severe depression. Their apparent
cognitive dysfunction is heavily affected by their lack of motivation. The mood
disturbance precedes the cognitive impairment and patients may not try to
answer during formal assessments, often providing ‘don’t know’ responses to
questions asked. They are more likely to complain of memory loss whereas
someone with true dementia is more likely to confabulate and try to hide it.
Depressive pseudodementia is a diagnosis of exclusion in someone with
depression, and management aims to treat the underlying mood disorder.
Creutzfeldt–Jakob disease (CJD) is a rapidly progressive dementia caused by
prions (an infectious agent composed only of protein). The prion proteins can
be transmitted by neurosurgical instruments and human-derived pituitary hormones.
Features of CJD include rapid cognitive impairment, which may be preceded
by anxiety and depression. Eventually physical features become
prominent, including muscle disturbance (rigidity, tremor, wasting, spasticity fasciculations, cyclonic jerks, choreoathetoid movements). Convulsions may
also occur. The EEG is characteristic (showing stereotyped sharp wave complexes).
Death occurs within 6 to 8 months.
HIV-related dementia (also known as AIDS dementia complex) occurs years after
initial infection. It presents with reduced cognitive function, low energy and
libido, general apathy and eventually muscle spasticity with hyperreflexia,
incontinence and ataxia. It is caused by the virus itself rather than an opportunistic
infection. Diagnosis is based on clinical probability

Question 34

A 34-year-old woman presents to her general practitioner complaining of
feeling sad all the time, difficulty sleeping, and weight gain. She has a
history of severe asthma and is taking medication regularly for frequent
exacerbations.
Which of the following conditions is most likely to be causing her mood
problems?

A. Cushing’s syndrome

B. Delirium

C. Hypothyroidism

D. Neurosyphilis

E. Space-occupying lesion

Answer 34

A – Cushing’s syndrome

The features of Cushing’s syndrome are caused by raised levels of glucocorticoids
from any source. Causes include steroid use (as in this case), ectopic
ACTH secretion and a pituitary tumour (Cushing’s disease). In addition to the
physical features (weight gain, hirsutism, striae, acne, plethora, bruising, thin
skin, cataracts) psychological features include depression, insomnia, reduced
libido and occasionally psychosis.

Question 35

A 32-year-old man is brought to the general practitioner by his wife because
he is always distressed. He worries excessively over trivial issues at work and
home and his muscles always feel tense. His mother died last year after a
long illness, but there has been no recent change in his circumstances.
From which of the following conditions is he most likely suffering?

A. Acute stress reaction

B. Generalized anxiety disorder

C. Panic disorder

D. Social phobia

E. Undifferentiated somatoform disorder

Answer 35

B – Generalized anxiety disorder

Generalized anxiety disorder is defined as generalized, excessive worry for more
than 6 months. It is twice as common in females and occurs frequently in early
adulthood. Sufferers of generalized anxiety disorder feel anxious or nervous
most of the time. There is not one particular trigger, and it can be described
as ‘free-floating’. There is an underlying worry that ‘something bad may
happen’. Physical symptoms include trembling, sweating, light-headedness,
palpitations, dizziness, abdominal discomfort and muscle tension. Genetic predisposition
overlaps with the predisposition to depression. Management
options include psychological therapies, selective serotonin reuptake inhibitors
(SSRIs), benzodiazepines for rapid anxiolysis and b-blockers for autonomic
symptoms. The disease course is usually chronic and fluctuating.
Panic disorder is characterized by sudden-onset, severe panic attacks that are not
limited to one particular situation. Panic attacks last a few minutes and are often
accompanied by a fear of going mad or dying. Physical symptoms include
nausea, hyperventilation, palpitations, chest pain, sweating and light-headedness.
Affected people are symptom-free in between attacks. Panic disorder is
only diagnosed if there is no underlying disorder such as depression. First-line
management is with cognitive behavioural therapy. Panic disorder is most
common in young female adults.

Question 36

According to ICD-10 criteria, which of the following options describe the
key features of hebephrenic schizophrenia?

A. Delusions and hallucinations

B. Disorganized speech and behaviour and flat affect

C. Meets the criteria for schizophrenia, but no specific symptom
subtype predominates

D. Previous positive symptoms, now less marked, with prominent
negative symptoms

E. Psychomotor disturbance

Answer 36

B – Disorganized speech and behaviour and flat affect

Key symptoms of hebephrenic schizophrenia are disorganized speech and
behaviour and flat or inappropriate affect. It has an earlier age of onset and a
worse prognosis than the paranoid type.
In paranoid schizophrenia there are predominantly positive symptoms (delusions
and hallucinations) with an increased suicide risk. Paranoid schizophrenia has
the best prognosis. Simple schizophrenia is a gradual decline in functioning.
There are negative symptoms without positive symptoms. Chronic schizophrenia
can be diagnosed if negative symptoms persist one year after positive symptoms.
In delusional disorder, it is delusions alone that make up the clinical
picture, although very occasional and transient hallucinations do not exclude
the diagnosis. It usually starts in middle age. Transient psychotic disorder
usually reaches a crescendo of symptoms within 2 weeks with complete resolution
within 3 months. It may be precipitated by a stressful life event. Catatonic
schizophrenia has a prominence of catatonic symptoms. These are stupor, excitement,
posturing, negativism, rigidity, waxy flexibility, perseveration of words
and mutism.

Question 37

A 42-year-old woman is described by her husband to be increasingly preoccupied
with order and control. She is often doubtful, indecisive, cautious
and pedantic.
From which of the following personality disorders is she most likely
suffering?

A. Anankastic

B. Anxious (avoidant)

C. Antisocial

D. Paranoid

E. Schizoid

Answer 37

A – Anankastic

People with anankastic personality disorder frequently display an inflexible preoccupation
with rules, order and attention to detail (almost like an obsessive–
compulsive). They may be very cautious and stubborn, and may try to
enforce their ways on others. Anxious (avoidant) personality disorder is characterized
by a tendency to worry, extreme anxiety, feelings of inferiority and a
fear of criticism/disapproval to the point of avoiding people/situations where
this might happen. Dependent personality types are often passive, relying on
others to make decisions. They fear abandonment and find it difficult to cope
with daily chores. Such personalities may excessively give priority to the
needs and wishes of others, over their own, in an attempt to maintain their
close relationships

Question 38

A 20-year-old woman says that her mind is racing; so much so that she can
barely speak fast enough to express all her thoughts. She speaks rapidly, frequently
changing the subject without explaining her meaning.
Which of the following terms best describes this thought disorder?

A. Delusion

B. Flight of ideas

C. Obsession

D. Overvalued idea

E. Monomania

Answer 38

B – Flight of ideas

Flight of ideas is accelerated thoughts with abrupt incidental changes of subject
and no central direction. The connections between topics are based on chance
relationships, such as rhyming words or alliteration.
Schneider’s three features of normal thought are constancy, organization and
consistency. There are five features of Schneider’s formal thought disorder.
These are:
† Derailment ! a thought derails on to a subsidiary thought
† Drivelling ! a disordered intermixture of constituent parts of a thought
† Fusion ! heterogeneous thoughts are interwoven with each other
† Omission ! part of a thought is omitted
† Substitution ! a major thought is substituted with a subsidiary thought
A delusion is a belief held with absolute conviction, such that it is not changeable,
even by compelling counterargument or proof to the contrary. A
primary delusion has no obvious cause considering the patient’s circumstances.
Secondary delusions are more closely linked with the rest of the clinical picture,
for example grandiose delusions (which is the belief of inflated self worth) are
common in mania, and a persecutory delusion may be seen in paranoid schizophrenia.
A bizarre delusion is one which would be seen as totally implausible
within the patient’s culture.
An overvalued idea is an unreasonable, sustained, intense preoccupation that is
maintained with less than delusional intensity, i.e. the patient may accept that it
might not be true. An obsession is a repetitive senseless thought which is recognized
as irrational but is unsuccessfully resisted by the person. The motor equivalent
of an obsessional thought is a compulsion – a repetitive, stereotyped,
seemingly purposeful behaviour which is not actually useful and is recognized
as such by the patient. Ideas of reference are thoughts that the events or
objects in one’s immediate environment have a particular or unusual significance.
Monomania is the pathological preoccupation with a single subject,
and egomania is the pathological preoccupation with oneself.

Question 39

A 32-year-old woman is in her first pregnancy. She has been spotted in
public talking to her unborn baby while doing the shopping. Her behaviour
has been concerning some passers-by. She has no previous psychiatric
history.
What is the most likely diagnosis?

A. Couvade syndrome

B. Cyclic psychosis

C. Normal behaviour

D. Pseudocyesis

E. Puerperal psychosis

Answer 39

C – Normal behaviour

Although this behaviour may be seen as eccentric, there is nothing in the history
that suggests an underlying psychiatric disorder

Question 40

Which of the following is not a key symptom of depression?

A. Anhedonia

B. Delusions of poverty

C. Disturbed sleep

D. Low energy

E. Reduced appetite

Answer 40

B – Delusions of poverty

The three core symptoms of depression are low mood, anhedonia (loss of pleasure)
and anergia (low energy). The diagnostic criteria require there to be a history of two out of three core symptoms for at least 2 weeks. In addition, there
should be at least two of the following seven symptoms:
† Decreased concentration
† Reduced self-esteem
† Guilt
† Pessimism about the future
† Self-harm ideation
† Disturbed sleep
† Reduced appetite
The severity of depression is classified as mild (4 symptoms in total), moderate
(5–6 symptoms in total), and severe (7 symptoms in total, including all 3 core
symptoms).
Beck’s cognitive triad describes types of negative thought that occur in
depression. They are a negative view of oneself, a negative view of the world
and a negative view of the future

Question 41

A 27-year-old woman describes a preference for sexual activity that involves
bondage or inflicting pain on her partner.
Which of the following words best describes this definition?

A. Exhibitionism

B. Fetishism

C. Masochism

D. Sadism

E. Voyeurism

Answer 41

D – Sadism

Sadism and masochism are forms of paraphilia.
Sadism involves pleasure from inflicting pain or humiliating someone. Masochism
involves gaining sexual excitement from having pain or humiliation
inflicted on oneself. Sadomasochism is a term comprising both sadism and
masochism
Sadism, from the French novelist Marquis de Sade, whose writings describe it.
Masochism, from the Austrian writer Leopold von Sacher-Masoch, whose stories
describe it.

Question 42

A 42-year-old woman presents to the emergency department with sweating,
fever, agitation and confusion. On examination, she is shocked and has
overactive reflexes. Routine observations reveal a heart rate of 118/min
and a blood pressure of 186/106 mmHg. She denies illicit drug use, but
has recently been prescribed tramadol for chronic back pain. Her repeat prescription
includes paracetamol, fluoxetine, a salbutamol inhaler and
aspirin.
From which of the following conditions is she suffering?

A. Acute dystonia

B. Hyperthyroidism

C. Neuroleptic malignant syndrome

D. Opioid toxicity

E. Serotonin syndrome

Answer 42

E – Serotonin syndrome

This lady has recently started taking opioids (tramadol). The combination of
opioids with selective serotonin reuptake inhibitors (fluoxetine in this case) is
associated with the development of serotonin syndrome. Signs include severe
hypertension, tachycardia, high pyrexia, myoclonus, sweating and hyperreflexia.
Managementis initially symptomatic followed by removal of the offending drugs.
Other drugs that may contribute to the serotonin syndrome include other antidepressants
(monoamine oxidase inhibitors, triptans, herbs (St John’s wort,
ginseng), stimulants (cocaine, amphetamines), lithium and metoclopramide

Question 43

A 5-year-old girl wakes suddenly during the night, screaming. She seems
very distressed. She is unable to explain why she is upset and returns to
sleep after 10 minutes. The next morning the girl cannot remember the previous
night’s events.
Which of the following terms best describes this scenario?

A. Night terrors

B. Nightmares

C. Non-organic disorder of the sleep–wake cycle

D. Psychiatric disorder causing sleep disturbance

E. Somnambulism

Answer 43

A – Night terrors

Night terrors are seen in children, affecting 6% of 4 to 12-year-olds, and resolve
by adolescence. The child usually awakes suddenly during the first third of the
night in a state of panic and fearfulness. There are associated autonomic
responses, e.g. tachycardia and dilated pupils. Affected children are not easily
comforted but, when they fully awake (usually the next morning), they have
no recollection of the event.
Nightmares are frightening dreams in which the individual awakes suddenly and
is then fully alert and can remember the dream very well. They usually occur
during the second half of the night. Nightmares affect up to 50% of adults
occasionally while 3 to 5-year-olds are more likely to experience repeated nightmares.
Non-organic disorder of the sleep–wake cycle is caused by a lack of synchrony
with the desired sleep–wake pattern. The problem is often perceived as either
insomnia or hypersomnia. Management is by attention to sleep hygiene.

Question 44

A 32-year-old man being investigated for confusion asks, ‘Please may I use
the Internet . . . net . . . net . . . net?’
Which of the following terms best describes this speech?

A. Dysarthria

B. Expressive aphasia

C. Logorrhoea

D. Neologism

E. Perseveration

Answer 44

E – Perseveration

In perseveration, mental operations are continued beyond when they are relevant.
It is highly suggestive of organic brain disease. Examples are palilalia,
which is repeating a whole word e.g. ‘knife . . . knife . . . knife . . . ’ and logoclonia,
which is repeating the last syllable of a word e.g. ‘pass the yorkshire pudding . . .
ding . . . ding . . . ding’. Word salad or schizophasia is an incomprehensible mishmash
of words and phrases. Dysprosody is loss of the normal melody of speech.
Logorrhoea describes fluent, rambling speech – an extreme version of verbal
diarrhoea! A neologism is a new word, or an old word, used in a new way.
Expressive aphasia is a difficulty verbalizing thoughts, although comprehension
is intact. It is seen in patients after a stroke. In receptive aphasia, there is difficulty
understanding, and although the patient feels they are speaking fluently, it is not
usually possible to make out any words in their voice. In global aphasia, both
expressive and receptive aphasias are present. Dysarthria is the physical difficulty
in controlling movements of the mouth in order to articulate the words.
Mutism is the complete loss of speech. Poverty of speech is reduced/restricted
speech, e.g. monosyllabic answers. Pressure of speech is increased quality and
rate of speech. Stammering is when the flow of speech is broken by pauses
and repetition. Echolalia is the imitation of another person (even if it is in a
foreign language). Coprolalia is the explosive exclamation of obscenities, seen
in Tourette’s syndrome.
The following forms of speech give the examiner insight into the form of the
patient’s thoughts. Knight’s move thinking is demonstrated when speech
jumps from one subject to another with no link. Flight of ideas is accelerated
thoughts with abrupt incidental changes of subject and no central direction

Question 45

A 91-year-old man is an inpatient on an orthopaedic ward following an
elective knee replacement. The nursing staff said he vomited earlier and
has been poorly responsive since his operation 12 hours ago. On examination,
you noticed his pupils are 2 mmand reactive and he has a respiratory
rate of 8 breaths per minute.
Which of the following is the most likely cause?

A. Alcohol withdrawal

B. Opiate use

C. Opiate withdrawal

D. Sedative use

E. Sedative withdrawal

Answer 45

B – Opiate use

This man is likely to be suffering the effects of opiate use. Examples of opiates
include morphine, heroin, methadone and codeine. Effects of opiates (in
addition to analgesia) include euphoria, nausea and vomiting, constipation,
anorexia, hypotension, respiratory depression, tremor, pinpoint pupils and erectile
dysfunction. The treatment of overdose (after A-B-C) is with the antidote
naloxone. This is ideally given intravenously (but can be given intramuscularly
or by inhalation). An infusion of naloxone may be necessary as the half-life is
short. The effects of opiate withdrawal can be very extreme. They include
dilated pupils, lacrimation, sweating, diarrhoea, insomnia, tachycardia, abdominal
cramp-like pains, nausea and vomiting.

Question 46

An 18-year-old boy feels that he is a woman trapped in a man’s body. He has
changed his name to Sarah (from Sean), often goes out wearing women’s
clothes and is trying to get a sex change.
Which of the following words best describes his behaviour?

A. Homosexuality

B. Sadism

C. Transvestic fetishism

D. Transsexualism

E. Voyeurism

Answer 46

D – Transsexualism

Transsexualism, a gender identity disorder, is the persistent desire to live and be
accepted as a member of the opposite sex. There is a feeling that the physical
body is inconsistent with the sense of self. There may be a desire to have
surgery or hormonal treatment in order to change it. Dual role transvestism is
the intermittent desire to dress as the opposite sex that is not for the purpose
of arousal, or for any permanent change. The male to female ratio is approximately
3:1. Management is usually by specialists, and surgery/hormone treatments
can be done although the long-term outcome is uncertain. There is
usually a requirement to live as the opposite sex for a year before starting
treatment.

Question 47

A 34-year-old man is being assessed by a psychiatrist for severe depression.
The patient tells the psychiatrist that he is dead, that his arms and legs are
rotting away. Further questioning elicits that he firmly believes this.
From which of the following conditions is he suffering?

A. Cotard’s syndrome

B. Ekbom’s syndrome

C. Ganser syndrome

D. Othello syndrome

E. Rett syndrome

Answer 47

A – Cotard’s syndrome

Cotard’s syndrome is a nihilistic delusion that one is dead, has lost all their possessions,
does not exist or is decaying, etc. It can be a feature of severe
depression. Ekbom’s syndrome is a delusional psychosis that one is infected
with parasites. It may be accompanied by a physical sensation of parasites crawling
around or burrowing into the skin (formication).

Question 48

A 30-year-old woman is admitted to hospital after taking an overdose of
paracetamol. This is her first such episode.
What is her risk of completed suicide over the next year?

A. 0.1%

B. 1%

C. 5%

D. 10%

E. 40%

Answer 48

B – 1%

Suicide is important to consider because it is one of the most extreme negative
outcomes in psychiatry. It is important to know the risk factors in order to identify
and manage those at risk. Discussing suicidal ideation with a patient does not
increase their risk of suicide (as is sometimes feared).
Risk factors for suicide include:
† Male sex
† Age .45 years
† Being divorced, single or widowed
† Unemployed
† Social classes I and V
† Psychiatric illness
† Previous episodes of self-harm
† Chronic physical illness
† Recent adverse life events
Protective factors include having children and being religious. In populations,
the rate of suicide increases in summer months and decreases during times
of war.
The annual incidence of suicide is 1 in 10,000. After an act of self-harm the
risk of completed suicide within the next year is 1%, i.e. 100 times more that the risk in the general population. The following features of self-harm are indicators
of strong suicidal intent: a more violent/dangerous action, careful planning
and preparation, making precautions to avoid being discovered, failing
to seek help afterwards and final acts (such as making a suicide note or a
will). It should be ascertained whether or not they intended to die at the time
and, if so, what their reaction is to still being alive (do they regret being alive
and still wish to die?). There is a high rate of recurrence in people who self-harm.

Question 49

A 22-year-old man is brought to the emergency department by his
Approved Social Worker on a Saturday night, behaving strangely. His
only speech is an impersonation of a rap artist, which he does while
break-dancing. He has a history of bipolar affective disorder. His social
worker says that he has stopped sleeping and thinks this is a manic
episode. No one is available to admit the patient under Section 2.
For how long can the emergency department doctor admit the patient?

A. 6 hours

B. 24 hours

C. 48 hours

D. 72 hours

E. 7 days

Answer 49

D – 72 hours

Section 4 allows an emergency admission to hospital when there is not enough
time to organize a Section 2. Its duration is 72 hours and there is no right of
appeal against it. It can be arranged by one doctor and the Approved Social
Worker. This allows time for a Section 2 or 3 to be sought. Section 4 orders
are not commonly used.

Question 50

A 28-year-old woman living in the Arctic Circle has a sudden-onset episode
of bizarre behaviour. Her friends say that she began crying and shouting
hysterically, took off her clothes and started throwing large objects. She
had to be physically restrained. Later, she had no recollection of the
episode.
Which of the following terms describes this behaviour?

A. Generalized anxiety disorder

B. Latah

C. Piblokto

D. Susto

E. Windigo
Practice

Answer 50

C – Piblokto

Piblokto is described in Inuit women living within the Arctic Circle. There is
sudden-onset hysteria (screaming, crying, etc.) and bizarre behaviour. This
may include removal of clothes, coprophagia (ingestion of faeces) and violence.
Attacks last a couple of hours and there is often amnesia after the event. It is
thought that piblokto may be related to vitamin A toxicity, as the native
Eskimo provides large quantities of it.
Windigo is recognized in native North American tribes. Affected people believe
that their body is possessed with a spirit that craves human flesh. This results in
obsessive thoughts and compulsions regarding violence and cannibalism