Specialties - Psych Flashcards

This deck contains a combination of some cards made by me, and some from Dr. Hugh Hall's psych revision lecture. Those questions have an acknowledgement in the answer

1
Q

List the 7 criteria for alcohol dependence in the ICD10

A

Compulsion
Lack of control
Physical withdrawal
Tolerance
Neglect of other interests or pleasures, with increased time invested in obtaining, taking, or recovering from alcohol
Persistent abuse despite understanding the harmful consequences manifesting

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2
Q

What are the 3 core symptoms of depression?

A
Anhedonia
Anergia
Low mood (diurnal variation - classically feels worse in morning)
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3
Q

A 17 year old girl presents to her GP surgery with low mood. The GP takes a thorough history and finds that this has been ongoing for 18 days, and the girl also describes a lack of energy. She says things have been going well at school recently and her friends are supportive, though this leaves her a little frustrated as she cannot identify what it is she has to be depressed about. She describes a recent lack of confidence, and says she feels her appetite is a little diminished. The GP thoroughly assess her risk, and finds her not to be a danger to herself.

What is the most appropriate next step?

A. Reassure the girl for the time being, and ask her to return for assessment in 2 weeks
B. Explain the concept of CBT to the patient, and explore whether she thinks it may be useful
C. Explain the concept of CBT to the patient, explore whether she thinks it may be useful, and ascertain whether she would be open to taking anti-depressants
D. Prescribe Sertraline on a 4 week trial, and have a conversation about therapies to try in the meantime
E. Prescribe Sertraline and advise her to take it until she is no longer depressed, and then for at least 6 months after

A

A. Reassure the girl for the time being, and ask her to return for assessment in 2 weeks

This is a history of mild depression: it features 2 core symptoms with 2 non-core which are not particularly severe but have persisted for >2 weeks. The initial approach in these patients is frequently ‘watchful waiting’, where they are asked to return in 2 weeks for reevaluation. Though this seems like an inadequate and frustrating response, many of these episodes will self-resolve, and so to over-medicalise a self-resolving issue would not be helpful for the patient.

‘B’ and ‘C’ would be valid options if the girl returned 2 weeks later with persistent symptoms. ‘D’ is the most wrong option, because anti-depressants take 4-6 weeks to begin having an effect, therefore a consultation to assess their affect at 4 weeks is pointless. ‘E’ correctly describes how an SSRI would be used if warranted, but that would be jumping the gun in this case.

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4
Q

Define the following terms:

Hallucination
Illusion
Delusion
Blunted affect

A

Hallucination: A perception in the absence of a stimulus
Illusion: A distorted perception of a stimulus
Delusion: A fixed, false, unshakeable belief that is outside of cultural norms
Blunted affect: Reduced reactivity of mood

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5
Q

Which of the following is not a risk factor for schizophrenia?

A. Obstetric complications
B. Urban living
C. Birth in the winter months
D. Depression
E. Immigration
A

D. Depression

Depression may be a co-morbidity or complication of schizophrenia, and depression may become psychotic in the most severe cases, but it is not a risk factor for developing schizophrenia.

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6
Q

A 22 year old man is brought to a GP appointment by his parents who are concerned for his wellbeing. He is studying Politics at university but recently had been withdrawing from his previously active social life, and has stopped attending lectures and tutorials. His girlfriend of 8 months has recently broken up with him, citing his lack of effort in the relationship. When asked why he has isolated himself, he just shrugs. The GP speaks to him and performs a mental state exam, their findings are as follows:

The young man appears dishevelled and has not showered in a few days, his clothes are stained
He seems distant and is difficult to engage in conversation
He says his mood has been normal, and he does not seem to be of low mood, though his affect does not change much during the consultation
He denies any unusual thoughts or hallucinations and does not express any odd beliefs, nor does he act as if he sees or hears anything that isn’t there
He is orientated in time and space, but apathetic about his situation and not interested in its resolution

What is the most likely cause of these symptoms?

A. Emerging personality disorder
B. Substance misuse
C. At-risk mental state
D. Depression
E. BPAD
A

C. At-risk mental state

An at-risk mental state (ARM) is the more modern term for a prodrome to psychosis/ schizophrenia; the term ‘prodome’ is being phased out because it implies inevitable progression to disease which is inaccurate in this case. The classic picture of ARM is of someone in their late teens or early twenties who begins to withdraw from work and social activity. They stop doing things they previously enjoyed and will allow relationships to deteriorate. This stage does not feature obvious psychotic symptoms, though there may be some mild ones that the patient denies out of fear for their significance.

All of the conditions listed are possible differentials in this case.

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7
Q

A 68 year-old man is referred to memory services after his daughter took him to see the GP with concerns about his memory over the previous 4 weeks. You note that prior to this decline, he was admitted to ITU for a week with a severe pneumonia which progressed to sepsis. Your assessment of him reveals some cognitive impairment and disorientation in time but not place.

What is the most appropriate next step?

A. Refer him for an urgent MRI head
B. Ask the GP to reassess him in a few weeks
C. Take blood cultures and a urine dipstick
D. Refer to a dementia specialist and contact OT to assess the home
E. Perform a chest x-ray

A

B. Ask the GP to reassess him in a few weeks

The cognitive impairment described here is a result of delirium. Delirium refers to a fluctuating state of confusion which comes on quickly and can be the result of drugs, trauma, infection, electrolyte imbalance, or a number of other causes. Though the onset is rapid, delirium can take a long time to fully resolve, with some patients still displaying symptoms at 6 months post-discharge.

Accordingly, memory services will not assess a patient if they have had an episode of delirium within the last 6 weeks as the residual effects will obfuscate the results of the assessment.

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8
Q

A 35 year old, known schizophrenic man presents to A&E with fever. His obs show he is tachycardic and hypertensive, and he seems confused. A brief neuro exam shows increased tone in all limbs. He was taking Olanzapine for a time but was recently switched to Clozapine.

What is the most likely diagnosis?

A. Neutropaenic sepsis
B. Serotonin storm
C. Neuroleptic malignant syndrome
D. Thyroid storm
E. Stroke
A

C. Neuroleptic malignant syndrome

Neuroleptic malignant syndrome is a rare but lethal side-effect of anti-psychotics. It is usually triggered by a change in drugs or dosages and causes muscle stiffness, altered consciousness, fever, tachycardia, and labile BP. Creatine kinase and white cell count will both be elevated in this condition.

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9
Q

For which of the following anti-psychotic drug side effects would procyclidine be a useful treatment?

A. Palpitations
B. Painful involuntary twisting of the neck to one side
C. Reduced libido and amenorrhea
D. An unpleasant feeling of restlessness
E. Rhythmic involuntary sucking and chewing movements

A

B. Painful involuntary twisting of the neck to one side

Procyclidine is used to treat acute dystonias - involuntary, painful, and sustained muscle contractions that start soon after starting medication.

Procyclidine may also be helpful for Parkinsonian features, though those aren’t described here.

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10
Q

How should you respond to a delusional patient asking if you believe them?

A

There are a few great examples from Psych PRN of how to respond to this question. I’ve included them more for the PACES exam and real life practice - they seem like a very useful thing to know:

• I haven’t been through what you’ve been through, but
I can see it’s really frightening you.
• I know you’re not lying. What do your family think
about it?
• I come from a medical background—I think stress has
a lot to do with what you’re experiencing. What do you
think about that?

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11
Q

Which of the following statements is true?

A. A section 136 can be used to enter a person’s home against their wishes
B. Once a patient is taken to a place of safety, they can’t be moved from that place of safety
C. A section 5(2) cannot be used in A&E
D. A nurse has the power to hold a patient for 24 hours under section 5(4)
E. A section 2’s primary function is to allow treatment of a detained patient

A

C. A section 5(2) cannot be used in A&E

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12
Q

Who must be present for a Section 135 to be enacted?

A

An AMP
A registered medical practitioner
A police constable

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13
Q

Match each of the following sections of the Mental Health Act (1983) to the correct description:

  1. Gives a doctor the power to detain an inpatient in hospital for 72 hours
  2. Allows a person to be taken from a public place to a place of safety
  3. Allows admission and detention for 6 months for treatment
  4. Allows admission and detention for 28 days for assessment
  5. Gives a nurse the power to detain an inpatient in hospital for 6 hours
  6. Allows a person to be taken from their home to a place of safety but requires a warrant
A. Section 2
B. Section 3
C. Section 5(2)
D. Section 5(4)
E. Section 135
F. Section 136
A
  1. Gives a doctor the power to detain an inpatient in hospital for 72 hours - C. Section 5(2)
  2. Allows a person to be taken from a public place to a place of safety - F. Section 136
  3. Allows admission and detention for 6 months for treatment - B. Section 3
  4. Allows admission and detention for 28 days for assessment - A. Section 2
  5. Gives a nurse the power to detain an inpatient in hospital for 6 hours - D. Section 5(4)
  6. Allows a person to be taken from their home to a place of safety but requires a warrant - E. Section 135
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14
Q

List the ICD10 non-core symptoms of depression

A

Reduced concentration and attention
Reduced self-esteem and self-confidence
Ideas of guilt and unworthiness (even in a mild type of episode)
Bleak and pessimistic views of the future
Ideas or acts of self-harm or suicide
Disturbed sleep
Diminished appetite

Mild: At least 2 core plus at least 2 other symptoms, should not be intense
Moderate: At least 2 core plus at least 3 other symptoms, preferably 4 for moderate
Severe: All 3 core plus at least 4 other symptoms, somatic syndrome (physical manifestations) almost definitely present
Severe with psychosis: as for severe depression with the added presence of delusions, hallucinations, or depressive stupor

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15
Q

You visit the home of a 45 year-old man being treated in the community for his schizophrenia. He was diagnosed 25 years ago and has been mostly well managed, but is now beginning to disengage from psychiatric services. When talking to him you notice his pattern of thought seems disordered, and he occasionally seems to react to sounds or sights that you do not perceive. He also grimaces, and makes rhythmic sucking movements with his mouth in a way that seems unrelated to the conversation.

What is the most likely explanation for the grimacing and sucking movements?

A. Tetany
B. Parkinsonism
C. A reaction to hallucinations
D. Acute dystonia
E. Tardive dyskinesia
A

E. Tardive dyskinesia

Tardive dyskinesias develop after years of anti-psychotic use, and are characterised by rhythmic involuntary movements of the face, limbs, mouth, and trunk. These movements may includes grimaces or chewing movements, and can be very distressing and alienating for the patient. They can be treated with Tetrabenazine, but not an anti-cholinergic like Procyclidine, as this will probably make then worse.

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16
Q

You are called to see a 72 year-old patient who was noted to be distressed and disorientated on the ward yesterday. She seemed mentally well when she was admitted, but over the next several hours became confused and agitated with fluctuating consciousness, and spoke fearfully of the creatures she saw scurrying about on the floor, which the nursing staff could not see. The nurses reported her speech and thought patterns seemed disordered. When you see her she seems calm and reasonable, without much memory of her episode last night. Her drug chart reveals she was prescribed laxatives and steroids after admission.

What is the most likely cause of her symptoms?

A. Vascular dementia
B. Alzheimer's disease
C. Delirium
D. Lewy body dementia
E. Parkinson's disease
A

C. Delirium

The key features indicating delirium here are: the acute onset, the fluctuating consciousness, and the rapid return to normal. The steroids have most likely caused delirium in this case.

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17
Q

A 56 year old woman has been hospitalised for myocardial infarction. 2 nights after admission, she screams that there is a man sitting by her bed. When the light is turned on, she is relieved that ’the man’ is actually a chair with clothes draped over it.

What misperception best describes this?

A. Delusion
B. Hallucination
C. Illusion
D. Projection
E. Formication
A

C. Illusion

An illusion is the misperception of a stimulus (as has happened here) and though it may appear as part of a pathology, is is not inherently pathological.

A hallucination is a perception in the absence of a stimulus.

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18
Q

You are asked to assess a 63 year-old man with Parkinson’s. He seems to be low in mood. When you speak with him, he seems to understand all your questions and answers appropriately, but he appears to have difficulty getting his words out.

Which of the following speech disorders does this describe?

A. Dysphasia
B. Bradykinesia
C. Poverty of speech
D. Dysarthria
E. Loosening of association
A

D. Dysarthria

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19
Q

A 78 year old man attends GP with his daughter who is concerned about his memory. She says his memory and concentration have been significantly reduced from his normal baseline, and that she is especially worried as her mother died a few months ago, and she thinks he cannot cope on his own. On questioning, the man admits to poor memory, sleep, and concentration. He speaks slowly throughout the concentration, and seems rapidly fatigued. His notes show no significant PMHx.

What is the most likely cause of his cognitive impairment?

A. Delirium
B. Vascular dementia
C. Parkinson's disease
D. Alzheimer's disease
E. Depression
A

E. Depression

This history could potentially describe either Parkinson’s disease or depression, and is intended to illustrate how closely the two may resemble each other. It is helpful to break the history down into concise symptoms, which may then be compared with disease-specific criteria, in cases where the overall picture for different diseases is similar.

This history features: cognitive impairment, sleep disturbance, slow speech, and easy fatigue/ anergia. The core features of depression are anergia, low mood, and anhedonia, with at least two of these necessary for a diagnosis of depression. Whilst only anergia is explicitly present in this question, the recent loss of his wife does suggest low mood and a potential trigger for depression.

Conversely, Parkinson’s disease is defined by a triad of rigidity, a resting tremor, and bradykinesia. None of these features are present in this history. Though Parkinson’s does also feature cognitive impairment (the poor memory and concentration) and slow speech, it is unlikely these symptoms would manifest with none of the classic motor symptoms.

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20
Q

Which of the following is true of anti-psychotic drugs?

A. Involuntary painful muscle spasms may occur within hours of starting anti-psychotics
B. Haloperidol is a safe alternative for use in patients at risk of arrhythmia
C. There are no atypical anti-psychotics available as depot injections
D. Neuroleptic malignant syndrome is usually triggered by suddenly decreasing anti-psychotic dose/ sudden non-compliance
E. Typical anti-psychotics usually cause less severe extra-pyramidal side effects

A

A. Involuntary painful muscle spasms may occur within hours of starting anti-psychotics

Acute dystonia is an extra-pyramidal side-effect (i.e. affecting dopaminergic pathways) of anti-psychotic drugs. It describes an involuntary, sustained, painful muscle contraction (e.g. torticollis - twisting of the neck, oculogyric crisis - eye twists up and can’t look down). Acute dystonias can be attenuated using anticholinergic drugs e.g. procyclidine.

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21
Q

In bipolar disorder, which of the following is correct?

A. It typically presents with delusions of control
B. Hypermania is a severe form of mania
C. Depressive episodes are usually accompanied by psychotic symptoms
D. Manic episodes are often associated with irritability rather than elevated mood
E. At least 3 episodes of mania are required for the diagnosis

A

D. Manic episodes are often associated with irritability rather than elevated mood

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

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22
Q

A 78 year old man with severe depressive illness is referred to your clinic and started on an antidepressant. A few weeks later he is admitted to hospital with symptomatic hyponatraemia.

Which medication is most likely to have caused this?

A. Amitriptyline
B. Citalopram
C. Mirtazapine
D. Duloxetine
E. Trazadone
A

B. Citalopram

Citalopram is an SSRI, and although many anti-depressants can cause hyponatraemia, SSRIs are particularly associated with it.

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

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23
Q

Which of the following is most important to monitor in patients taking clozapine?

A. BMI & waist circumference
B. ECG
C. FBC
D. Lipid profile and fasting blood glucose
E. Mental state
A

C. FBC

Anyone taking anti-psychotics will need a wide range of routine blood tests, especially if they are taking clozapine. Though effective at treating resistant schizophrenia, clozapine is a very ‘dirty’ drug with a huge range of side effects. Surveillance is greatest at initiation of treatment, and is slightly relaxed after several months.

The most important complication of clozapine is agranulocytosis which occurs in ~0.7% of patients. Accordingly, patients taking clozapine have their WCC and neutrophils very closely monitored, and are told to come to A&E if they develop any signs of illness.

Other side effects of clozapine include: prolonged QT interval, dyslipidaemia, hypotension, anaemia, myocarditis, and impaired glucose tolerance. As a result, fasting blood glucose, lipid profile, BMI, waist circumference, basic observations, and an ECG all form part of the monitoring for patients taking clozapine.

NB: All schizophrenic patients should receive regular assessment of cardiovascular health and risk factors regardless of their treatment due to their increased susceptibility.

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24
Q

Which of the following is least likely to be a direct physical cause of depression?

A. Hypoactive delirium
B. Hypercalcaemia
C. Beta blocker use
D. Cocaine use
E. Stroke
A

A. Hypoactive delirium

Hypoactive delirium is an important yet easily missed diagnosis, as patients who make the most noise and cause the most problems will also attract the most attention. Though it mimics depression, hypoactive delirium is a separate disorder. All the rest of the options can be direct physical causes of depression.

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25
Q

Which of the following statements about mood disorders is incorrect?

A. The presence of the ‘amine’ suffix means the drug is a TCA
B. Dexamethasone cortisol suppression tests are often abnormal in patients with depression
C. TCAs are effective, but cardiotoxic in overdose
D. Many anti-depressants can cause hyponatraemia and sexual dysfunction
E. St. John’s Wort has some efficacy as an anti-depressant, but is an enzyme inducer

A

A. The presence of the ‘amine’ suffix means the drug is a TCA

This is an important point to remember when learning drug names: they are named for their chemical structure, not their function so the ‘amine’ suffix does not line up with one particular class of drugs, though many TCAs have it.

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26
Q

Which of the following interventions would be classified as CBT?

A. Exploring the patient’s current and future life for a deeper meaning in order to shift their focus from themselves
B. Allowing transference to guide therapy, thereby illuminating a patient’s hidden problematic feelings to them
C. Discussing a patient’s own distorted beliefs with them, and challenging their rationale
D. Discussing the underlying issues that patient and doctor believe caused or precipitated mental illness
E. Exploration of previous social, family, and romantic relationships to find trends and explanations for current symptoms

A

C. Discussing a patient’s own distorted beliefs with them, and challenging their rationale

In many conditions, states of mental illness are perpetuated by negative thoughts resulting from the illness, which themselves either worsen the illness or impair the individual’s ability to cope. CBT challenges these thoughts and allows the person to control them to avoid this harmful spiral.

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27
Q

What is most important to tell a patient taking carbamazepine?

A

Attend hospital urgently if they develop a sore throat or fever, or if they feel ill because of the risk of agraulocytosis and subsequent sepsis.

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28
Q

A woman with known BPAD visits her psychiatrist for counselling regarding getting pregnant. She wants to know how pregnancy will affect her mental health, and whether her medication would need to be changed. She is currently taking lithium and this has been working very well for her.

What should you tell her?

A. Lithium use in pregnancy is associated with fetal neural tube defects
B. Lamotrigine is a safe drug to take during pregnancy and does not require extra monitoring
C. If she becomes pregnant, she should immediately stop taking lithium and book an appointment to discuss medication options
D. Though carbamazepine, lithium, and valproate are risky during pregnancy, they are safe to take whilst breast-feeding
E. She will be at most risk of relapse of her condition in the 6 weeks post-partum

A

E. She will be at most risk of relapse of her condition in the 6 weeks post-partum

The puerperium (6 weeks post-partum) is a very important time and, amongst other things, it carries the greatest risk of VTE and psychosis of any time in pregnancy.

‘A’ is incorrect because Lithium use is associated with Ebstein’s anomaly (malformation of the tricuspid valve, essentially leading to a single right-sided heart compartment - atrialisation) but not neural tube defects.

‘B’ is incorrect because although Lamotrigine is a relatively safe drug for the fetus, pregnancy alters metabolism and so Lamotrigine levels have to be frequently monitored.

‘C’ is incorrect because it is almost never good practice to advise a patient to immediately stop taking medication for a mental health condition. Not only is this dangerous for the mother, it is not guaranteed to protect the fetus because the woman may have been taking lithium for some time before she discovers she is pregnant.

‘D’ is incorrect because these drugs may all be excreted in breast milk and cause toxicity in the baby.

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29
Q

A 16 year old boy is brought to his GP by his guardian. She is becoming increasingly worried at the lability of his moods: he has periods of elation closely followed by low mood. These periods occur multiple times per day, and have been steadily developing over the past months. The boy lives in foster care and has done since he was 9.

What is the most likely cause of his symptoms?

A. Type I BPAD
B. Personality disorder
C. Rapid-cycling BPAD
D. Cyclothymia
E. Type II BPAD
A

B. Personality disorder

None of the variants of BPAD will cause fluctuation of mood so rapid that they change within a day. Though ‘rapid-cycling BPAD’ sounds like it matches this clinical picture, rapid-cycling is defined as 4 or more affective episodes per year and certainly does not feature swapping from mania to depression in the same day.

Cyclothymia refers to a rapid-cycling BPAD-like disorder where the depression and mania are not severe enough to be diagnosed as BPAD. These patients do have a risk of developing BPAD, but even cyclothymia will not switch so quickly as to cause different moods within a day.

This history is particularly suggestive of EUPD with the labile mood and disrupted childhood.

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30
Q

A 25 year old man visits his GP on the orders of the Prime Minister in order to share his recently discovered cure for death. He exhibits rapid, pressured speech, and speaks at length about the instructions and praise he receives from the Prime Minister directly every day, though he states he has not seen the Prime Minister, only heard him. His GP notes reveal that he was previously seen several months ago for a prolonged period of low mood, diagnosed with depression, and started on an SSRI.

What is the most likely diagnosis?

A. Schizoaffective disorder
B. Acute phase of schizophrenia
C. Substance misuse
D. Cyclothymia
E. BPAD
A

E. BPAD

This question is intended to illustrate similarities in presentations of different psychiatric conditions

The SSRI has probably helped precipitate the episode.

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31
Q

In clinic, a 69 year old man states he was on the way to meet some friends but has become lost. He tries to shoo away the “dogs” he says have been following him around. He has a mild tremor at rest and his gait is slightly stiff. He denies having had any medical problems recently and says he feels “right as rain”.

Which would be the best treatment?

A. Thyroxine
B. Sertraline
C. Donepezil
D. Olanzapine
E. L-Dopa
A

C. Donepezil

This is a history of Lewy body dementia, as indicated by the tremor and gait disturbance in combination with the hallucinations. Lewy body dementia is treated with Donepezil.

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

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32
Q

The son of an 80 year old woman asks you to conduct a home visit as he is concerned that his mother’s memory “isn’t what it was”. She has not been dressing herself in the morning and no longer reads or does the crossword. She has put on weight, become increasingly withdrawn, lethargic; her movements are slowed. Her only significant past medical history is T2 N0 M0 carcinoma of the larynx, successfully treated with radiotherapy 4 years ago.

Which is the most appropriate treatment?

A. Fluoxetine
B. Donepezil
C. Levothyroxine 
D. Lithium
E. Memantine
A

C. Levothyroxine

It is always important to rule out organic causes before making psychiatric diagnoses, and in this case there are biological symptoms that admittedly could be due to depression, but the medical history should raise suspicion of hypothyroidism.

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

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33
Q

A 72 year old man he has been losing weight and no longer leaves the house. He appears dishevelled. His wife died last year. He is orientated to time but not place, and scores 72/ 95 on the ACE III , saying he “doesn’t know” and becomes frustrated with further questioning. He has been feeling very lethargic and sleeps poorly.

Which is the best treatment?

A. Cognitive behavioural therapy
B. Clonazepam
C. Psychodynamic therapy
D. Grief counselling
E. Sertraline
A

E. Sertraline

This is a case of depression. The reaction is too intense and has persisted for over 6 months, which indicates it is not a normal grief reaction. Nor is this an abnormal grief reaction because of the severe symptoms of depression present.

Differentiating between an abnormal grief reaction and depression is very difficult. Sometimes the best way to differentiate them is by the overall feel of the history: does this history feel like someone with depression, or someone who is suffering because of a loss?

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

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34
Q

An elderly patient recovering in a surgical ward experiences fluctuating episodes of consciousness and visual hallucinations with an altered sleep-wake cycle.

Which is the most likely diagnosis?

A. Alzheimer’s dementia
B. Lewy Body disease
C. Paraphrenia 
D. Delirium
E. Acute psychotic episode
A

D. Delirium

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

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35
Q

A 24 year old has been taking Risperidone for 3 weeks. Nursing staff note she “keeps pacing by the door“ and are concerned that she is trying to abscond from the ward. During the consultation she seems on edge and unable to settle. On several occasions she rises from her seat to pace up and down.

Which is the mostly likely phenomenon causing her symptoms?

A. Stereotypies
B. Partially treated psychosis
C. Tics
D. Compulsions
E. Akathisia
A

E. Akathisia

Akasthisia is an extra-pyramidal side-effect and is characterised by a feeling of restlessness.

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

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36
Q

An 18 year old man seen in A and E is asked to describe his mood. He states, ‘My mood is flextitating; I am up and down.’

The patient is exhibiting which of the following thought disorders?

A. Clang association
B. No thought disorder
C. Thought block
D. Tangentiality
E. Neologism
A

E. Neologism

A neologism is a made up word, and is a sign of mania.

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

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37
Q

A 23 year old man has been diagnosed with a first episode of paranoid schizophrenia.

Which of the following is the most appropriate treatment option?

A. Flupentixol Decanoate
B. Olanzapine
C. Fluoxetine
D. Diazepam
E. Clozapine
A

B. Olanzapine

Olanzapine is an atypical anti-psychotic and the most suitable option for a first-line treatment. Diazepam and Fluoxetine are not treatments for schizophrenia, and Flupentixol Decanoate is a depot injection which can be used but is not the ideal first option. Clozapine is not used unless two other anti-psychotics have been trialled unsuccessfully.

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

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38
Q

A 35 year old man with schizophrenia attends your clinic seeking advice on lifestyle changes.

Which of the following is true of psychotic disorders?

A. Life expectancy is reduced by 20 years in comparison with the general population
B. Life expectancy is the same as for the general population
C. Any reduction in life expectancy is largely explained by an increased suicide rate
D. Cardiovascular disease does not excessively contribute to mortality
E. Death rates from cancer are lower than in the general population

A

A. Life expectancy is reduced by 20 years in comparison with the general population

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

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39
Q

A 32 year old mother attends clinic 2 months after having her first child. She presents with a 6 week history of low mood, marked anxiety, guilt, anhedonia and low energy. She is worried that she is an incapable mother. She denies any thoughts about harming herself or her child.

What is the most likely diagnosis?

A. Mild depressive episode
B. Postnatal depression
C. Baby blues
D. Normal adjustment reaction
E. Postpartum psychosis
A

B. Postnatal depression

This history of symptoms is too prolonged to be baby blues, which usually occur within a week after birth and last only a few days. Moreover, all the core symptoms of depression are present, and have been for a prolonged amount of time (6 weeks). Her symptoms are ‘marked’ which implies this is not mild depression, in which the symptoms should not feel intense. There is nothing in the history to suggest psychosis.

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

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40
Q

A 66 year old man presents to his GP with low mood following the death of his wife 2 months previously.

Which of the following features is suggestive of a normal bereavement reaction?

A. Psychomotor retardation
B. Suicidal ideation
C. Insomnia
D. Delusions of poverty
E. Impaired occupational functioning
A

C. Insomnia

Sleep disturbance is a common feature of a normal grief reaction. It is difficult to distinguish grief from depression, as the symptoms produced by grief may well be called depression in another patient. The key is that there is no underlying abnormality, and that is does not disable the person’s normal functioning as depression does.

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

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41
Q

A 35 year old woman is admitted to hospital for complaints of abdominal pain. Her history states mother was a nurse and she is a trained phlebotomist. On examination, she has multiple abdominal scars and marked abdominal tenderness. She is evasive when asked where she had the surgeries, but can described in detail what was done in each.

What is the most likely diagnosis?

A. Somatisation disorder
B. Hypochondriasis
C. Malingering
D. Schizophreniform disorder
E. Conversion disorder
A

A. Somatisation disorder

Somatisation disorder is one of the confusing conditions in psych regarding patients who have symptoms without a physical pathology. Patients with somatisation disorder truly feel the symptoms they report e.g. headache, paraesthesia, abdominal pain, dizziness, fatigue. This will result in them having an extensive medical history in the absence of any underlying disorder. The symptoms will usually change from admission to admission, but these patients are not lying and are truly experiencing these symptoms. There is a high rate of comorbid anxiety, depression, and personality disorders, and this disorder is thought to be a result of attitudes to illness during childhood.

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

42
Q

A 28 year old taxi driver is chronically consumed by fears of having run over a pedestrian. Although he tries to convince himself his worries are silly, his anxiety continues to mount until he drives back to the scene of the ‘accident’ and proves to himself that nobody lies hurt in the street.

This behaviour is consistent with:

A. An obsession secondary to a compulsion
B. A compulsion triggered by an obsession
C. A delusional ideation
D. A typical manifestation of anankastic personality disorder
E. A phobia

A

B. A compulsion triggered by an obsession

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

43
Q

Steve is a 28 year-old man who was involved in a road traffic collision yesterday. His cousin who was driving was killed. Since admission to hospital Steve has been aggressive and irritable.

Which of the following is TRUE in an acute stress reaction?

A. It may arise up to 6 months after the event
B. It rarely resolves without treatment
C. Both depersonalisation and derealisation are recognised features
D. Psychological debriefing during an acute stress reaction decreases the risk of developing later PTSD
E. Pharmacological treatment is contraindicated

A

C. Both depersonalisation and derealisation are recognised features

PTSD often has a latent period between the event and the development of symptoms, which may be as much as 6 months. First line treatment is CBT, but SSRI drugs or EMDR therapy may be used based on patient preference. Derealisation is a feeling of being in a dream state, and depersonalisation refers to the sensation of watching yourself from outside your body.

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

44
Q

A 68 year-old man whose wife recently had an ischaemic stroke presents with sudden onset of bilateral leg paralysis. On examination he denies sensation to the groin, though twitches slightly as you test pinprick sensation. Reflexes and tone are normal. Motor function is 0/5 throughout, though staff report they have noticed him moving his legs while he is sleeping. CT and nerve conduction studies are normal.

What is the most appropriate management?

A. Rest for 4-6 weeks followed by gradual increase in activity levels
B. Reassure him that symptoms resolve completely in 75% of cases
C. Provide a temporary wheelchair to improve mobility and independence
D. Reassure him that normal function should return quickly
E. Avoid providing further care for his wife, since this will reinforce his symptoms

A

B. Reassure him that symptoms resolve completely in 75% of cases

This is a case of conversion disorder: the manifestation of psychiatric disturbance as physical symptoms e.g. stroke. ‘Conversion’ refers to the conversion of repressed psychic conflict into physical ailments.

NB: There is some confusion between conversion and dissociative disorder, as ICD10 uses them interchangeably, whereas the DSM IV uses dissociative to refer to mental symptoms, and conversion to refer to physical.

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

45
Q

Match each of the vignettes with the most likely diagnosis:

A. Conversion disorder
B. Hypochondriasis
C. Munchausen’s syndrome
D. Somatisation disorder

  1. A 50 year old man presents to A&E for the fifth time in as many weeks insisting that he has been feeling sweaty at night and is sure he has cancer
  2. A 65 year old man with right sided hemiparesis in the absence of any apparent organic cause. His wife had a stroke a week ago which has been very stressful for them both
  3. A 35 year old woman presents to A&E with severe acute RIF pain. Her notes show past presentations with headache, abdominal pain, and dizziness, though no cause was found
  4. A 26 year old man presents with abdominal pain. Examination is normal, and his notes reveal several past visits to A&E with a variety of symptoms, and that he has given a different address each time. When confronted, he becomes angry and leaves
A
  1. A 50 year old man presents to A&E for the fifth time in as many weeks insisting that he has been feeling sweaty at night and is sure he has cancer - B. Hypochondriasis
  2. A 65 year old man with right sided hemiparesis in the absence of any apparent organic cause. His wife had a stroke a week ago which has been very stressful for them both - A. Conversion disorder
  3. A 35 year old woman presents to A&E with severe acute RIF pain. Her notes show past presentations with headache, abdominal pain, and dizziness, though no cause was found - D. Somatisation disorder
  4. A 26 year old man presents with abdominal pain. Examination is normal, and his notes reveal several past visits to A&E with a variety of symptoms, and that he has given a different address each time. When confronted, he becomes angry and leaves - C. Munchausen’s syndrome
46
Q

A 24 year old woman is hospitalised after superficially slashing both her wrists. At the ward round 3 days later, the male CT doctor argues she has been doing well, but the nursing staff become angry, saying he is showing favouritism towards the patient, despite her being non-compliant with the ward rules.

The defence mechanism used by the patient here is a feature of which personality disorder?

A. Dissocial 
B. Histrionic
C. Borderline / emotionally unstable
D. Anankastic
E. Dependent
A

C. Borderline / emotionally unstable

It’s worth remembering that EUPD patients are notorious for being able to rile up the people who try to work with them.

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

47
Q

A 52 year old woman is sent to see you after being disciplined at work for consistently turning in her assignments late. She insists tasks must be done ‘perfectly, unlike my colleagues’ work.’ She has few friends because she annoys them with her ‘precision’ and lack of emotional warmth. These features have been lifelong.

What is the most likely diagnosis?

A. Obsessive compulsive disorder
B. Anankastic personality disorder
C. Borderline personality disorder
D. Anxiety disorder, not otherwise specified
E. Schizoid personality disorder
A

B. Anankastic personality disorder

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

48
Q

For each of the descriptions, choose the modality of therapy which best fits it:

A. CBT
B. Cognitive analytic therapy
C. Dialectical behavioural therapy
D. Family (systemic) therapy
E. Psychodynamic therapy
F. Art therapy
  1. A mode of therapy where unhelpful feelings, thoughts and actions are examined and challenged
  2. A technique used for people with a personality disorder, which looks at ways of dealing with distress and using ‘mindful awareness’
  3. A technique used in people that find it difficult to express themselves verbally
A
  1. A mode of therapy where unhelpful feelings, thoughts and actions are examined and challenged - A. CBT
  2. A technique used for people with a personality disorder, which looks at ways of dealing with distress and using ‘mindful awareness’ - C. Dialectical behavioural therapy
  3. A technique used in people that find it difficult to express themselves verbally - F. Art therapy

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

49
Q

A 7 year old boy with a diagnosis of ADHD has been treated with methylphenidate for the past 3 years. His parents are concerned that he might be developing adverse effects.

Which of these is a common side effect of methylphenidate?

A. Early morning awakening
B. Sedation
C. Weight gain
D. Bradycardia
E. Weight loss
A

E. Weight loss

Stunted growth is the main concern in methylphenidate (Ritalin) use, and so children taking it must be monitored regularly.

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

50
Q

An emaciated and lethargic 16 year old girl arrives in clinic. Her blood pressure is 75/50, HR 52 bpm, potassium 2.8mmol/L, bicarb 40mmol/L. The girl’s parents report she has lost 35 lbs in 3 months but is still convinced she is overweight. She eats only small amounts of low calorie food and runs 2 – 3 hours per day.

What other activities is this patient also likely to be engaged in?

A. Sexual promiscuity
B. Alcohol misuse
C. Purging
D. Wearing tight clothes
E. Shoplifting
A

C. Purging

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

51
Q

A 19 year old woman presents to an outpatient clinic with a history of excessive exercise, dietary restrictions and a morbid fear of fatness. Her BMI is 16.

Which of the following psychological treatments is not recommended in the NICE guidelines for this condition?

A. Psychoanalysis
B. CBT
C. Interpersonal therapy
D. Cognitive analytic therapy
E. Family interventions focused specifically on eating disorders
A

A. Psychoanalysis

Psychoanalysis is an in depth exploration of a person’s unconscious self in order to explain symptoms of mental disorders. It is the most ambitious type of therapy in its aim, and takes years to yield results, making it unsuitable for anorexia. It can also be very distressing for the patient, and is perhaps not the best choice in anorexia given the classic personality traits associated (e.g. perfectionism).

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

52
Q

For each of the side-effects listed, choose which drug is most likely to be responsible:

A. Amisulpride
B. Moclobamide
C. Lithium
D. Lorazepam
E.  Citalopram
F. Haloperidol
G. Donepezil
  1. Loss of outer third of eyebrows
  2. Cogwheel rigidity
  3. Hypertensive crisis
  4. Anxiety
A
  1. Loss of outer third of eyebrows - C. Lithium
  2. Cogwheel rigidity - F. Haloperidol
  3. Hypertensive crisis - B. Moclobamide
  4. Anxiety - E. Citalopram

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

B: MAOIs – act on DA, tyramine, phenylethylamine, benzylamine, leading to accumulation of monoamines in the synaptic cleft. Hypertensive crises with tyramine-rich foods such as cheese, port, Marmite, some medications
E: Citalopram can make anxiety worse in the initial weeks of treatment, though this then usually improves

53
Q

A 65 year old man is on the orthopaedic ward after surgical management of a fractured neck of femur. He has a history of alcohol misuse. The day after admission he becomes anxious and nauseous. On examination he is sweaty, with a sinus tachycardia and bilateral tremor.

Which is the most appropriate first step in managing this patient?

A. Chlordiazepoxide
B. Sodium valproate
C. Olanzapine
D. Disulfiram
E. Propranolol
A

A. Chlordiazepoxide

This man is undergoing delirium tremens, which occurs 48-72 hours after drinking cessation. It typically features agitation, sweating, tachycardia, confusion, hallucinations, and delusions. The patient may even have seizures. Chlorodiazepoxide is a benzodiazepine given to attenuate these symptoms as the patient withdraws.

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

54
Q

A 76 year old woman was admitted to hospital after being found lying on the floor of her bedroom by her daughter. In hospital, the patient was found to be incoherent, hypervigilant and had disorganised thoughts. The woman’s medication before hospitalisation included digoxin and a benzodiazepine which had been recently started for insomnia.

What is the most likely diagnosis?

A. Delirium due to a medical condition
B. Delirium secondary to substance intoxication
C. Alzheimer’s dementia
D. Vascular dementia
E. Pseudodementia secondary to major depression

A

B. Delirium secondary to substance intoxication

Both digoxin and benzodiazepines are causes of delirium in the elderly.

NB: This question is reproduced from Dr Hugh Hall’s Psychiatry Revision lecture

55
Q

A 75 year old man is brought to his GP by his daughter who is very concerned. He has “seemed slow” for the past few months and hasn’t been eating or sleeping as much. She also observed him talking to thin air as if it were his wife, who passed away recently. When asked, the father says he knows his wife isn’t there, but still hears her sometimes and has occasionally seen her lying in bed with him.

What is the most likely diagnosis?

A. Lewy body dementia
B. Psychotic depression
C. Normal grief reaction
D. Alzheimer's disease
E. Malignancy
A

C. Normal grief reaction

Though there are elements of this history that suggest psychosis, this is a red herring. The patient is aware these phenomena aren’t real and is clearly grounded in reality; these perceptions are referred to as pseudo-hallucinations and may be part of a normal grief reaction.

56
Q

ECT indications

A

Prolonged or severe mania
Catatonia
Persistent or life threatening depression

57
Q

A 25 year old woman is brought to A&E by her friend who is concerned at her erratic behaviour. For the past week she has been extremely energetic and has barely slept or eaten. She has been spending a lot of time at a casino and the friend is very worried she has lost a lot of money. She has never had symptoms like this before and has been fairly well previously.

What would be the best immediate intervention for this patient (assuming compliance)?

A. No intervention is necessary
B. Lithium
C. Olanzapine
D. Fluoxetine
E. CBT
A

C. Olanzapine

This is a case of mania, which is managed in secondary care with an antipsychotic (haloperidol, olanzapine, quetiapine, or risperidone). This is because these drugs can quickly stabilise mood and will sedate the patient somewhat, which makes them very useful for terminating a manic episode. Lithium is the main mood stabiliser used to control bipolar affective disorder (BPAD), but is less useful in managing acute mania because it takes several days to work and requires intensive monitoring, which can be tricky in a manic patient who may well not consent which adds complexity to the situation.

58
Q

How frequently should serum levels be monitored in a patient taking lithium?

A

1 week after starting lithium or changing the dose, then weekly until the levels are stable
Then every 3 months in the first year, or in higher risk patients
Then every 6 months after the first year in low risk patients

59
Q

At what point after alcohol cessation would you see a peak in:

Start of withdrawal symptoms
Peak incidence in seizures
Peak incidence in Delirium Tremens

A

Start of withdrawal symptoms: 6-12 hours
Peak incidence in seizures: 36 hours
Peak incidence in Delirium Tremens: 48-72 hours

NB: This is reproduced from PassMed

60
Q

Which of the following is a known fetal complication if a pregnant woman takes an SSRI in the 3rd trimester?

A. Neural tube defects
B. Congenital cardiac abnormalities
C. IUGR
D. Pulmonary hypoplasia
E. Persistent pulmonary hypertension of the newborn
A

E. Persistent pulmonary hypertension of the newborn

There is also a small risk of congenital cardiac defects with SSRI use, but only in the first trimester.

61
Q

Match each of the following characteristics to the appropriate personality disorders:

A. Anankastic
B. Histrionic
C. Schizoid
D. Schizotypal
E. Emotionally unstable
F. Antisocial
  1. Labile mood, impulsive, forms intense unstable relationships
  2. Eccentric, paranoid, aloof, increased risk of schizophrenia
  3. Irresponsible, guiltless, heartless, volatile
  4. Excessively detailed, inflexible, excludes pleasure
  5. No sexual interest, indifferent to praise or criticism, limited emotional range
  6. Theatrical, seductive, shallow affect
A
  1. Labile mood, impulsive, forms intense unstable relationships - E. Emotionally unstable
  2. Eccentric, paranoid, aloof, increased risk of schizophrenia - D. Schizotypal
  3. Irresponsible, guiltless, heartless, volatile - F. Antisocial
  4. Excessively detailed, inflexible, excludes pleasure - A. Anankastic
  5. No sexual interest, indifferent to praise or criticism, limited emotional range - C. Schizoid
  6. Theatrical, seductive, shallow affect - B. Histrionic
62
Q

Which of the following would be a safe and sensible use of Sertraline?

A. In a patient with poorly controlled epilepsy
B. In a patient with a recent MI
C. In a patient on NSAIDs
D. In a patient taking Phenelzine
E. In a patient taking Sumitriptan for migraines

A

B. In a patient with a recent MI

63
Q

What are Schneider’s first rank symptoms of schizophrenia?

A

Delusional perception
Passivity
Delusions of thought interference (insertion, withdrawal, broadcasting)
Auditory hallucinations (thought echo, third person conversations, narration)

64
Q

What is a major concern with Zopiclone use in the frail and elderly?

A

It increases the risk of falls

Zopiclone is a drug separate to benzodiazepines, but with a similar mechanism of action - it potentiates the action of GABA receptors. It should be avoided if possible in the elderly because it causes ataxia and postural hypotension, which increases the risk of falls.

65
Q

How may ‘knight’s move thinking’ be distinguished from ‘flight of ideas’?

A

Flight of ideas (FoI) will feature a rapidly changing train of thought, but the links between topics in the person’s speech will be perceivable.

However in knight’s move thinking (KMT), someone listening will not be able to discern how the person talking is progressing from one idea to the next.

E.g.
KMT - “I arrived here in my car, red always was my favourite colour, my childhood was fairly complex really, did you know Cornwall has its own language?”
FoI - “I travelled on the bus, I love buses, I love horses too, my favourite ever racehorse was Epitaph, Spike Milligan has a great epitaph”

66
Q

An 80 year old man visits his GP for a routine checkup. Whilst he is there he mentions he has lost weight recently. Upon probing he reveals he hasn’t been eating or sleeping well for the past month, and admits to low mood and lethargy. He mentions feelings of loneliness since his wife died. The GP suspects depression and prescribes an anti-depressant.

Which would be the most appropriate anti-depressant in this case?

A. Sertraline
B. Mirtazapine
C. Citalopram
D. Imipramine
E.  Lithium
A

B. Mirtazapine

Mirtazapine is a very useful drug for depression in the elderly because depression often causes poor sleep and appetite in that demographic, Mirtazapine is a Noradrenergic and specific serotonin
antidepressant (NASSA) which is well known for increasing appetite and sleep

67
Q

Decide whether each of the following side-effects is most likely to be caused by a typical or atypical anti-psychotic:

A. Neuroleptic malignant syndrome
B. Acute dystonia
C. Weight gain
D. Dyslipidaemia
E. Sexual dysfunction
F. Tardive dyskinesia
A
A. Neuroleptic malignant syndrome - Typical
B. Acute dystonia - Typical
C. Weight gain - Atypical
D. Dyslipidaemia - Atypical
E. Sexual dysfunction - Typical
F. Tardive dyskinesia - Typical
68
Q

What is the SSRI of choice in children and adolescents?

A

Fluoxetine

69
Q

Which SSRI does not necessarily need gradually titrating down before stopping because of its long half-life?

A

Fluoxetine
It has a half life of ~ 1 week and so can often be stopped abruptly. A period of time is needed for its concentration in the body to decrease (washout period), then a new anti-depressant can be started.

70
Q

Which of the following is a risk of SSRI use in the first trimester of pregnancy?

A. Intra-uterine growth restriction
B. Persistent pulmonary hypertension of the newborn
C. Neural tube defects
D. Cleft palate
E. Congenital heart defects
A

E. Congenital heart defects

There is a small risk of congenital heart defects if SSRIs are used in the first trimester of pregnancy, and this risk must be weighed up against the risk to the mother’s mental health of discontinuing the medication. SSRIs will also increase the risk of persistent pulmonary hypertension, but that risk is not associated with first trimester use.

71
Q

What are the 2 main features that separate hypomania from mania?

A

The presence of psychotic symptoms e.g. delusions

Functionality

72
Q

A patient on antidepressants develops dry mouth, blurred vision, urinary retention, and postural hypotension.

Which class of drugs is most likely to have caused these symptoms?

A. A selective serotonin reuptake inhibitor
B. A tricyclic anti-depressant
C. A serotonin and noradrenaline reuptake inhibitor
D. A monoamine oxidase inhibitor
E. A noradrenergic and specific serotonin anti-depressant

A

B. A tricyclic anti-depressant

Tricyclic anti-depressants have a wide range of side effects because they affect a range of receptors. Accordingly they have anti-muscarinic side effects (dry mouth, blurred vision, urinary retention, postural hypotension) that are not usually seen with other anti-depressants.

73
Q

Which of these anti-depressants could exacerbate hypertension?

A. Mirtazapine
B. Venlafaxine
C. Sertraline
D. CItalopram
E. Fluoxetine
A

Venlaflaxine

74
Q

A patient taking medication for an affect disorder presents to their GP with lethargy and constipation. On examination they have gained some weight, have muscle weakness in the shoulders, and are bradycardic.

Which medication are they most likely to be taking?

A. Citalopram
B. Sertraline
C. Lithium
D. Imipramine
E. Phenelzine
A

C. Lithium

This is a history of hypothyroidism, a complication of lithium use.

75
Q

A 35 year old man presents to A&E with vomiting. He appears confused, has a tremor in his hands, and is ataxic. The doctors consult his notes and see he is taking medication for a psychiatric condition, which they suspect he may have overdosed on.

Which medication is this most likely to be an overdose of?

A. Clozapine
B. Sertaline
C. Imipramine
D. Lithium
E. Quetiapine
A

D. Lithium

76
Q

Which atypical anti-psychotic has the fewest side-effects?

A

Aripiprazole

77
Q

A 36 year old man with treatment-resistant schizophrenia is brought into hospital under section. The psychiatrist manages to elicit from him that he is on Clozapine and last took it 3 days ago. The psychiatrist wishes to start him on Clozapine again and he agrees.

How should this patient’s Clozapine be managed?

A. Calculate the appropriate starting dose for his ideal bodyweight
B. Calculate the appropriate starting dose for his actual bodyweight
C. Restart therapy at the previous dose
D. Titrate up from a small dose to a therapeutic dose over a few weeks
E. Restart therapy at a higher dose, then reduce once symptoms are controlled

A

D. Titrate up from a small dose to a therapeutic dose over a few weeks

If a patient misses their Clozapine dose for more than 48 hours, they must be restarted on 12.5mg and have the dose titrated back up over several weeks.

78
Q

A 26 year old man attends a checkup with his GP regarding his ongoing depression. He started taking Sertraline 6 weeks ago but is still experiencing low mood, anergia, and anhedonia. He is also struggling to sleep and describes reduced appetite. The GP proposes trying another anti-depressant and the patient agrees.

What would be the safest way to swap to the new drug?

A. Stop the Sertraline at the appointment, allow a 1 week ‘washout’ period, then start another SSRI
B. Stop the Sertraline at the appointment, and start a new SSRI to be taken the next day
C. Taper the Sertraline off over at least 2 weeks, and switch to a TCA as Sertraline is being tapered off
D. Taper the Sertraline off over at least 4 weeks, then start another SSRI
E. Introduce the other drug, then taper off the Sertaline

A

D. Taper the Sertraline off over at least 4 weeks, then start another SSRI

79
Q

Which therapy is first-line for treatment of PTSD?

A. Eye movement desensitisation and reprocessing (EMDR)
B. Sertraline
C. Cognitive behavioural therapy (CBT)
D. Dialectical behavioural therapy (DBT)
E. Logotherapy
A

C. Cognitive behavioural therapy (CBT)

Generally speaking, CBT (as with many conditions in psych) is the preferred first-line treatment of PTSD. In adults treatment is largely guided by preference, so although CBT is ostensibly first-line, different patients may start with CBT, EMDR, or drug treatment (Venlafaxine or an SSRI).

EMDR is a form of therapy where the patient describes their ordeal in as vivid detail as possible, whilst keeping their eyes trained on the therapist’s finger which is moved from side to side in front of them.

80
Q

What is the most suitable mode of therapy for personality disorders (particularly EUPD/ Bordeline)?

A

Dialectical behavioural therapy

81
Q

A 26 year old woman is brought to see the GP by her housemate who is worried about her because she has noticed her disappearing after meals, and has heard her vomit on several occasions. The patient admits to purging after meals by inducing vomiting and sometimes with laxative use. She is obese, though the GP does not measure her BMI to avoid upsetting her.

What is the most likely diagnosis

A. Binge eating disorder
B. Depression
C. Anorexia nervosa
D. Organic cause
E. Bulimia nervosa
A

E. Bulimia nervosa

This question is designed to illustrate the point that bulimia is diagnosed based on behaviour, not body habitus. The presence of purging behaviours is enough for a diagnosis, the patient does not have to have a low BMI. In fact obesity is common in patients with bulimia, though 50% will also have had a history of anorexia nervosa.

82
Q

Which of the following is not a key feature of anorexia?

A. Purging behaviours
B. BMI <17.5
C. Deliberate weight loss
D. Distorted body image
E. Endocrine abnormalities
A

A. Purging behaviours

Though purging may absolutely be a feature in patients with anorexia nervosa, it is not always present and is not a key feature for diagnosis.

83
Q

Which of the following is not associated with anorexia nervosa?

A. Myopathy
B. Tachycardia
C. Cytopenias
D. Lanugo hair
E. Russell's sign
A

B. Tachycardia

Anorexia nervosa is a debilitating systemic disease that can cause severe symptoms if sufficiently advance. However it tends to cause bradycardia rather than tachycardia. Below are some of the symptoms by system of anorexia nervosa:

General: lanugo (fine) hair, cold extremities, cytopenias (inc. anaemia)
Neurological: Peripheral neuropathy, delusions, seizures
Cardiovascular: bradycardia, arrhythmia, postural hypotension
Musculoskeletal: muscle wasting, weakness (myopathy), fractures
Metabolic: hypercholesterolaemia

84
Q

Which of the following is the most suitable initial intervention for a 15 year old with anorexia nervosa?

A. An SSRI
B. Cognitive behavioural therapy
C. Desensitisation therapy
D. Dietary advice
E. Family therapy
A

E. Family therapy

For under 18s, family based therapy is the first line intervention. If this is unsuitable, CBT or psychotherapy can be tried. SSRIs are not routinely used for anorexia itself, though they can be used to treat its comorbidities e.g. depression.

85
Q

Which of the following is not true of PTSD?

A. Patients suffer from nightmares and flashbacks
B. It may cause cognitive impairment
C. Avoidance is a key feature
D. SSRIs and CBT can be used to treat it
E. The symptoms should present within a month of the event

A

E. The symptoms should present within a month of the event

Though symptoms may present within a month of the event, there is often a latent period between the event and symptoms, which may be up to 6 months.

86
Q

What is the first line management for mild depression (after 2 weeks of active monitoring)?

A

Self-help CBT or group CBT

The 2 weeks of active monitoring may be undertaken depending on patient preference and clinical judgement

87
Q

A 60 year old woman with a chronic mental health condition is seen by a psychiatrist who visits her home. When the psychiatrist walks in she is stood still in the middle of the room with her arms outstretched in an odd posture. The doctor asks her to sit down but she does not respond and does not answer any of his questions, occasionally repeating words back at him. When he moves her arm, it stays in the position he moves it to.

Which disease classically underlies the described condition?

A. Depression
B. Alzheimer's disease
C. Parkinson's disease
D. Schizophrenia
E. BPAD
A

D. Schizophrenia

This is a description of catatonia - a state of stupor found in some cases of schizophrenia. It may feature abnormal posturing, waxy flexibility, mutism and echolalia amongst others. Though catatonia may also arise because of depression, it is classically a consequence of schizophrenia.

88
Q

Define an acute stress reaction

A

A reaction to an event starting within minutes and lasting hours - days
Anxiety, amnesia, depersonalisation, disorientation, and agitation are all features

89
Q

A 22 year old man presents to his GP with recurrent headaches that occur in a band distribution around his forehead and make him feel like his head is being squeezed. The GP probes and finds that he has been feeling increased anxiety for the past 8 months, and that it is not linked to one particular stimulus. The GP suspects a general anxiety disorder, discusses this with the patient, and decides on active monitoring. The patient returns 2 weeks later with no change.

What is the next step in the management of GAD?

A. Psychodynamic therapy
B. An SNRI e.g. Venlafaxine
C. Low-intensity CBT-based interventions
D. An SSRI e.g. Sertraline
E. CBT
A

C. Low-intensity CBT-based interventions

Generalised anxiety disorders are dealt with in a stepwise approach as follows:

Step 1: Identification of condition, education, and active monitoring
Step 2: Low intensity psychological intervention (individual non-facilitated self-help, individual guided self-help and psychoeducational groups)
Step 3: Drug treatment (SSRI or SNRI) or high intensity psychological intervention (CBT or applied relaxation)
Step 4: Complex psychological and/ or drug treatment with MDT input and potential inpatient care

NB: If there is marked functional impairment, skip to step 3. If there is very marked functional impairment or risk of harm, skip to step 4.

90
Q

Which of the following is the only disorder NOT regularly treated with both an SSRI and CBT according to NICE?

A. PTSD
B. Schizophrenia
C. Depression
D. Generalised anxiety disorder
E. Obsessive-compulsive disorder
F. Social phobia
A

B. Schizophrenia

Schizophrenia treatment should include CBT, but not SSRIs (unless there is comorbid depression). All the other options are regularly treated with SSRIs and/or CBT.

91
Q

Match each drug to the side effect it treats

A. Tardive dyskinesia
B. Acute dystonia
C. Akasthisia

  1. Procyclidine
  2. Tetrabenazine
  3. Propranolol
A
  1. Procyclidine - B. Acute dystonia
  2. Tetrabenazine - A. Tardive dyskinesia
  3. Propranolol - C. Akasthisia
92
Q

Which electrolyte abnormalities are classically seen in re-feeding syndrome?

A

Low phosphate, magnesium, and potassium

93
Q

Which of the following drugs is most suitable for rapid tranquilisation of an aggressive patient?

A. Oral Diazepam
B. I.M. Haloperidol
C. Rectal Diazepam
D. I.M. Lorazepam
E. I.V. Haloperidol
A

D. I.M. Lorazepam

94
Q

What is the treatment for mild, moderate, and severe OCD?

A

Mild: Low intensity CBT, or SSRI if this is ineffective/ unsuitable
Moderate: Either more intensive CBT, or an SSRI
Severe: Both an SSRI and high intensity CBT

95
Q

Match each of these drugs for use in alcoholism with their effects:

A. Naltrexone
B. Disulfiram
C. Acamprosate

  1. Reduced cravings for alcohol
  2. Reduces pleasure of drinking
  3. Used for aversion therapy by creating a very unpleasant sensation in response to alcohol
A
  1. Reduced cravings for alcohol - C. Acamprosate
  2. Reduces pleasure of drinking - A. Naltrexone
  3. Used for aversion therapy by creating a very unpleasant sensation in response to alcohol - B. Disulfiram
96
Q

What is the management of ADHD in a child?

A

1st: Parental support and advice sessions, with environmental modifications (e.g. lighting and noise adjustment, school adjustments, regular work breaks)
2nd: Medication e.g. methylphenidate (Ritalin)
3rd: Add CBT is there is still functional impairment

97
Q

Which parameters are regularly monitored in a patient taking lithium?

A

Serum Lithium levels, U&Es (eGFR), BMI, and TFTs every 6 months

98
Q

What are Schneider’s first rank symptoms of schizophrenia?

A

Delusional perception
Passivity
Delusions of thought interference (insertion, withdrawal, broadcasting)
Auditory hallucinations (thought echo, third person conversations, narration)

99
Q

A man with schizophrenia speaks to his doctor and tells her how he saw an advert for Fairy liquid on the TV, and immediately knew that this meant the fairies had returned to Ireland and were sending him a message.

What feature of psychosis is being described here?

A

Delusional perception - the linking of an irrational and often bizarre conclusion to perception of something normal

100
Q

Match each of the example sentences to the feature they exhibit:

A. Clang associations
B. Word salad
C. Knight's move thinking
D. Flight of ideas
E. Tangentiality
  1. “I walked through the cemetery, you know they have just replanted the flower beds, there were so many people there, I wonder if that’s actually a little disrespectful, that cemetery should not be a footpath, but anyway yes I eventually arrived here”
  2. “Heat the paper wax statuesque chair is locked”
  3. “I got here by bus, my favourite bus is the 29, I got 29 ways, ways and means, my landlord is mean”
  4. “I want to buy a motorcycle, the cats are a real problem, streetlights should be dimmer”
  5. “I ate the bait to skate with my mate Nate”
A
  1. “I walked through the cemetery, you know they have just replanted the flower beds, there were so many people there, I wonder if that’s actually a little disrespectful, that cemetery should not be a footpath, but anyway yes I eventually arrived here” - E. Tangentiality
  2. “Heat the paper wax statuesque chair is locked” - B. Word salad
  3. I got here by bus, my favourite bus is the 29, I got 29 ways, ways and means, my landlord is mean - D. Flight of ideas
  4. I want to buy a motorcycle, the cats are a real problem, streetlights should be dimmer - C. Knight’s move thinking
  5. I ate the bait to skate with my mate Nate at the fete - A. Clang associations
101
Q

Which of the following features in a history would support a diagnosis of social phobia INSTEAD of agoraphobia?

A. Being too anxious to leave the house
B. Anxiety around being unable to escape from a crowd
C. Presence of dependent personality disorder
D. Experiencing sweating, shaking, and nausea when in large crowds
E. A fear of public embarrassment

A

E. A fear of public embarrassment

Social phobia and agoraphobia are difficult to differentiate between, as they may cause identical symptoms in identical situations. The key difference is in the object of fear in each: for agoraphobia it is a fear of being unable to escape to a place of safety, e.g. from a crowd, public place, or somewhere far from home; for social phobia it is the fear of embarrassment, criticism, or scrutiny in social situations.

102
Q

A 78 year old woman becomes agitated and frightened on the ward after her admission for pneumonia. Her observations are normal, but she is in considerable distress despite attempts to calm and re-orientate her. She has been previously well and multiple standard tests have been performed in hospital which revealed no underlying health problems.

Which medication would be most suitable to calm this patient?

A. Sertraline
B. Haloperidol
C. Promethazine
D. Lorazepam
E. Olanzapine
A

B. Haloperidol

This patient has developed delirium, for which haloperidol is recommended by NICE.