Y4 Psychiatry

Question 1

According to DSM-5,

What is the diagnostic criteria for Major Depressive Disorder (MDD)?

Answer 1

≥ 5 of the following symptoms for ≥ 2 weeks

MUST include ≥ 1 of diminished interest/pleasure or depressed mood

Depressed or irritable mood

Decreased interest in pleasure/Anhedonia

Significant Weight +/-

Insomnia / Hypersomnia

Psychomotor agitation / retardation

Fatigue / - energy

Feeling of worthlessness

Diminished ability to think/concentrate

Recurrent thoughts of death / SI +/- plan/suicide attempt

Question 2

Which of the following is not a characteristic of affect that should be observed and reported in the mental state examination?

[] Reactivity

[] Range

[] Quality

[] Intensity

[] Amount

Answer 2

Amount

Amount is generally used in relation to speech and thought, rather than affect.

Question 3

The predominant neurobiological hypothesis regarding depression posits key abnormalities in which neurotransmitter group?

[] Amino acids

[] Peptides

[] Purines

[] Acetylcholine

[] Monoamines

Answer 3

Monoamines

The predominant hypothesis regarding the genesis and maintenance of depression is known as the “Monoamine hypothesis” and focusses particularly on serotonin, dopamine and noradrenaline are considered to be important in the genesis and maintenance of depression.

Question 4

ECT is an important treatment in psychiatry.

Which of the following conditions represents a possible indication for ECT?

[] Borderline personality disorder

[] Conversion syndrome

[] Dysthymic disorder

[] Mania

[] Acute dystonic reaction

Answer 4

Mania

It may seem paradoxical but There is a limited but consistent evidence base supporting the use of ECT for the treatment of acute mania (Malhi et al, 2015, RANZCP clinical practice guidelines for mood disorders). It is not indicated in any of the other disorders. Weiss et al (2019; RANZCP professional practice guidelines for the administration of electroconvulsive therapy) has a good discussion of other

possible indications for ECT, including Parkinson’s disease and schizophrenia.

Question 5

ECT is an important treatment in psychiatry.

Which of the following conditions represents a relative contraindication for ECT?

[] Raised intracranial pressure

[] Pregnancy

[] Pseudocholinesterase deficiency

[] Age greater than 80 years

[] Seizure disorder

Answer 5

Raised intracranial pressure

Most recent sources say that there are no absolute contraindications to ECT.

It is routinely administered to the elderly.

Patients who are pregnant or who have significant medical comorbidities need careful anaesthetic assessment.

Concerns have been expressed about the risk of status epilepticus occurring with ECT when there is an underlying seizure disorder, however, ECT has numerous anticonvulsant effects, including elevated seizure threshold and decreased seizure duration, which make it a useful adjunctive therapy in epilepsy that is refractory or not amenable to treatment with medication.

Patients with pseudocholinesterase deficiency can be given an alternative to suxamethonium – in fact, alternative muscle relaxants are more commonly used in practice.

Raised intracranial pressure is a relative contraindication, and some sources say that if this is due to a space-occupying lesion with a mass effect, it is an absolute contraindication.

Question 6

A 30-year-old woman has a history of bipolar disorder with recurrent episodes.

She discontinued all medication 18 months ago when she was pregnant with her first child, and now presents with symptoms consistent with a depressive episode.

It is of moderate severity, and the consultant psychiatrist is of the view that she can safely be treated as an outpatient. Which of the following medications would represent the best choice as monotherapy for this patient?

[] Lithium

[] Olanzapine

[] Venlafaxine

[] Sodium valproate

[] Sertraline

Answer 6

Lithium

Lithium is the best choice here as it has mood stabilising, antidepressant and antimanic actions. It may not work as quickly as an antidepressant, but the depressive illness is not severe enough to mandate admission or treatment that would be more rapidly effective (such as ECT). Also, treatment can (and should) be supplemented with non-pharmacological strategies. The patient should be closely monitored for deterioration and risk.

Antidepressants (sertraline, venlafaxine) should not be used as monotherapy for depression in Bipolar Disorder because of the risk of triggering a manic or mixed episode; Sodium valproate should not be used in women of childbearing age, and it is quite likely that the patient may wish to have further children; olanzapine has minimal antidepressant activity as monotherapy.

Question 7

Which of the following is true of bipolar disorder type 1?

[] Most patients are diagnosed at the time of their first mood episode

[] Depressive episodes are more common than manic episodes

[] If psychotic symptoms occur, the diagnosis should be changed to schizoaffective disorder

[] The index episode is most commonly a manic episode

[] Manic episodes require hospitalisation

Answer 7

Depressive episodes are more common than manic episodes

Psychotic symptoms may occur in either depressive or manic episodes and do not change the diagnosis; at least one manic episode must have been severe enough to require hospitalisation in order to make the diagnosis of Bipolar 1, but it doesn’t mean they will all be that severe; most patients have many mood episodes (often depressive episodes) before the diagnosis is made, often because a manic episode occurs, or thanks to careful questioning about historical mood symptoms suggestive of manic or hypomania; the index (first) mood episode is most commonly a depressive episode.

Question 8

You are interviewing a patient in the emergency department. You ask them what has brought them to the hospital today. The patient gives you a very long story, with many details, some of which seem somewhat digressive and not critical. However, eventually, they get to the point. You are able to follow the story and generate a differential diagnosis.

How would you describe this in your mental state examination?

[] Tangentiality

[] Loosening of associations

[] Formal thought disorder

[] Overvalued ideas

[] Circumstantiality

Answer 8

Circumstantiality

This is best described as circumstantiality. Tangentiality is used in two ways: to mean drifting off-topic and losing the point but also as answering not quite to the point – neither is evident here; since you could follow the story this implies logical associations, therefore not really loose and not consistent with formal thought disorder. There is no evidence in the vignette of overvalued ideas.

Question 9

A 27-year-old woman presents with features of a major depressive episode.

She has never sought psychiatric help before and has no Hx of psych admission. You know it is important to screen for the possibility of bipolar disorder.

Which question, if answered positively, would raise the greatest suspicion of an underlying bipolar disorder?

You ask, “Have you ever had a period of at least a week where you …

[] felt really energetic?”

[] felt really confident?”

[] didn’t seem to need sleep?”

[] were very irritable?”

[] had some really unusual thoughts?”

Answer 9

didn’t seem to need sleep?”

Not needing sleep is the most sensitive question here. Although a period of mania may be accompanied by greatly increased confidence and energy, just asking if someone had a time where they felt energetic or confident is not very sensitive – it could occur quite normally. Irritability can occur with either depression or mania, so would not clearly point to a previous manic episode. Unusual thoughts could indicate psychosis, but not specifically bipolar disorder.

Question 10

You are interviewing a young man. When you ask how he is feeling, he replies:

“I can’t tell you that, I went to my brother’s place, he was glowing orange in the sky. It’s like a promise, in largeness.”

How would you best characterise this observation when reporting a mental state examination for the patient?

[] Informal thought disorder

[] Formal thought disorder

[] Tangentiality

[] Thought insertion

[] Circumstantiality

Answer 10

Formal thought disorder

There is a disorder of thought form, meaning that there is no logical, goal-directed flow of ideas. It would also be correct to say that there is a loosening of associations (i.e. the connection between ideas is not clear or logical) – it is quite marked and borders on verbigeration – look this up!

Question 11

A 42-year-old man attends his GP for a review a week post-discharge from hospital where he had a two-week admission after a relapse of his bipolar disorder (manic episode). He is taking lithium carbonate 500mg bd and olanzapine 5mg nocte. He asks whether there are additional treatments available that would help keep his mood stable. What additional strategy has the strongest evidence base for benefit in bipolar disorder?

[] Neuro-Linguistic Programming (NLP)

[] S-Adenosyl Methionine (SAMe)

[] Thought-Field Therapy (TFT)

[] Interpersonal and Social Rhythm Therapy (IPSRT)

[] St John’s Wort

Answer 11

Interpersonal and Social Rhythm Therapy (IPSRT)

Only IPSRT has evidence for efficacy in bipolar disorder

Question 12

The following information pertains to a particular antidepressant:

Elimination half-life of around a week, Has been reported to cause the greatest ejaculatory delay, Only antidepressant recommended for use in depressed children/adolescents, Effective in OCD, Does not inhibit monoamine oxidase.

Which antidepressant best matches the characteristics in the vignette?

[] Sertraline

[] Fluoxetine

[] Imipramine

[] Mirtazapine

[] Desvenlafaxine

Answer 12

Fluoxetine

Question 13

The National Survey of Mental Health and Wellbeing was a general household survey of the adult population aged 16-85 years, conducted by the Australian Bureau of Statistics in 2007. Which of the following is true regarding the prevalence of depression in the community?

[] The difference in prevalence rates between men and women was most marked in middle age

[] People aged 16-24 years had the highest prevalence of depression

[] People aged 65-85 years had the lowest prevalence of depression

[] More males than females met criteria for depression in the two youngest age groups

Answer 13

People aged 65-85 years had the lowest prevalence of depression

Question 14

Which of the following neurotransmitter effects can cause hyperthermia?

[] Antimuscarinic activity

[] Decreased serotonergic activity

[] Antihistaminergic activity

[] Cholinergic activity

[] Increased adrenergic activity

Answer 14

Antimuscarinic activity

Antimuscarinic side effects caused by atropine or scopolamine:

“Blind as a bat (mydriasis), mad as a hatter (delirium), red as a beet (flushing), hot as a hare (hyperthermia), dry as a bone (decreased secretions and dry skin), the bowel and bladder lose their tone (urinary retention and paralytic ileus), and the heart runs alone (tachycardia).”

Please note that SSRIs and MDMA (“ecstasy”) can cause hyperthermia as well as antipsychotics (i.e. neuroleptic malignant syndrome). This needs to be treated as a medical emergency!

Question 15

Which of the following would be the most appropriate psychological management for agoraphobia?

[] Dialectical behaviour therapy (DBT)

[] Graded exposure

[] Eye movement desensitisation and reprocessing therapy (EMDR)

[] Supportive counselling

[] “Flooding”

Answer 15

Graded exposure

Graded exposure is the most appropriate intervention which can be combined with supportive counselling (not effective alone) or as part of cognitive behaviour therapy. Flooding where the patient learns to associate to associate feelings of relaxation when directly exposed to the fear-inducing stimuli which is usually an object like a spider. EMDR has its place in trauma therapy. However, the evidence suggests that it is not as effective or long-lasting as exposure therapy. DBT is a form of cognitive behaviour therapy targeting emotional regulation, self-harm tendencies, better coping with stressors, and improve relationships with others.

Question 16

Please select a common adverse effect caused by antipsychotics and related to D2-receptor-like blockade:

[] Postural hypotension

[] Urinary retention

[] Blurred vision

[] Delayed ejaculation

[] Hyperprolactinaemia

Answer 16

Hyperprolactinaemia

In this list, hyperprolactinaemia is an adverse side effect mediated by D2-receptor-like blockade. The other side effects are mediated by acetylcholine (Blurred vision) e.g. when taking tricyclic antidepressants; serotonergic (Delayed ejaculation) e.g when taking SSRIs; alpha-1 adrenergic (Postural hypotension) e.g. when taking mirtazapine; anticholinergics but also opioids, benzodiazepines, and calcium channel antagonists (Urinary retention).

Question 17

A 7-year-old boy presented with intense restlessness, jumping and running into things at home. His behaviour was considered intolerable in school where he has been disruptive and inattentive in his class.

[] Reactive attachment disorder

[] Oppositional defiant disorder

[] Pervasive developmental disorder

[] Tourette’s syndrome

[] Attention-deficit Hyperactivity Disorder

Answer 17

Attention-deficit Hyperactivity Disorder

All listed disorders are conditions which are usually emerging in childhood and can present with poor affect regulation and impulsivity. However, being inattentive and hyperactive consistently in at least two settings (in this case in school and at home) is one of the DSM5 criteria for attention-deficit hyperactivity disorder. Impulsivity is another one.

Question 18

The psychiatrist informed a 55-year-old man with Alzheimer’s disease in an early stage about his diagnosis, treatment and prognosis to enable him to make decisions about his future. Select the ethical principle most likely to guide the doctor’s approach:

[] Paternalism

[] Directing

[] Autonomy

[] Therapeutic privilege

[] Utilitarianism

Answer 18

Autonomy

The psychiatrist offers the patient choices about his treatment. Since the condition is in an early stage, it is very likely that that patient can still provide informed consent, thus giving him autonomy over his decisions.

Question 19

2.7 A 20-year-old man was admitted after a relapse in his schizophrenia. He was restless, agitated and aggressive on admission. He received 10 mg haloperidol IM. On day 2, he developed involuntary painful protrusion of his tongue.

[] Catalepsy

[] Myoclonus

[] Athetosis

[] Dystonia

[] Akathisia

Answer 19

Dystonia

Haloperidol is a highly potent dopamine D2-receptor blocker and likely to cause adverse motor system side effects including akathisia, as myoclonus dystonia, and catalepsy as extrapyramidal side effect (EPS). Athetosis occurs with basal ganglia degeneration as in Huntington disease as chorea but can also emerge after stroke and brain trauma. The patient here developed an acute onset of dystonia on the second day after receiving haloperidol. Acute dystonia is mediated by nigrostriatal dopamine D2-receptor blockade leading to excess striatal cholinergic output which causes often painful involuntary movements.

Question 20

A patient visits their GP and describes a series of recent problems and disappointments, which have made them feel somewhat low in mood. The GP responds by saying: “It is not uncommon for people in your situation to feel so low when things go bad.”

[] Reflection

[] Closed statement

[] Open statement

[] Introductory statement

[] Normalising statement

Answer 20

Normalising statement

The GP aims to put the patient’s feelings into perspective by normalising them.

Question 21

A 63-year-old man was asked where he lived as a child, he replied: “Newcastle Knights is my favourite football team. I loved watching them. I lived there”.

[] Tangentiality

[] Circumstantiality

[] Flight of ideas

[] Derailment

[] Confabulation

Answer 21

Tangentiality

The five options are standing for forms of thought disorder. Derailment or loosening of associations is a form of thought disorder often see in schizophrenia when the patient jumps from one idea to another unrelated idea or only remotely related idea. Flight of ideas is a thought disorder which is more common in mania. It has an element of illogicality and is often impossible to follow the train of thoughts. Circumstantial thinking is when the patient gets lost in too much detail but without losing track of the question contrary to tangentiality.

Question 22

A 48-year-old married man was involved in a road traffic accident 3 weeks ago. He complains of depressed mood, panic attacks, insomnia, and feeling unable to cope with his work and home situation.

[] Panic Disorder

[] Adjustment disorder

[] Major depressive disorder with anxiety symptoms

[] Generalised anxiety disorder

[] Post-traumatic Stress Disorder

Answer 22

Adjustment disorder

The patient presents with a history and symptoms consistent with all provided options. However, the recency of the event is more consistent with the DSM5 criteria for adjustment disorder = experiencing psychological and/or behavioural symptoms within three months of an identifiable stressor/stressors in life.