Psych Flashcards
1
Q
A 22-year-old woman recently commenced on an antipsychotic who is pacing her bedroom and says she feels very restless.
Best Management of antipsychotic-induced extrapryamidal side-effects A. Intramuscular procyclidine B. Oral procyclidine C. Propranolol D. Stop anticholinergics E. Oral olanzapine F. Intramuscular haloperidol G. Rescuscitation H. Baclofen I. Dantrolene J. Quinine
A
C – Propranolol. This woman is probably experiencing akathisia. This is hard to treat but propranolol or benzodiazepines can help. See Fig. 2.10. Ideally the dose of antipsychotic is reduced. Quinine can be used for restless leg syndrome when in bed. The differential includes agitation secondary to psychosis.
2
Q
A 22-year-old woman recently commenced on an antipsychotic who is staring at the ceiling and has her jaw clenched tight.
Best Management of antipsychotic-induced extrapryamidal side-effects A. Intramuscular procyclidine B. Oral procyclidine C. Propranolol D. Stop anticholinergics E. Oral olanzapine F. Intramuscular haloperidol G. Rescuscitation H. Baclofen I. Dantrolene J. Quinine
A
F – Intramuscular procyclidine. This woman is experiencing a dystonia with an oculogyric crisis and trismus. Her clenched jaw means oral procyclidine is not possible. Baclofen and dantrolene are for chronic spasticity.
3
Q
A 22-year-old woman recently commenced on an antipsychotic who is collapsed in her bedroom with a fast pulse, low blood pressure, reduced consciousness level and stiff limbs.
Best Management of antipsychotic-induced extrapryamidal side-effects A. Intramuscular procyclidine B. Oral procyclidine C. Propranolol D. Stop anticholinergics E. Oral olanzapine F. Intramuscular haloperidol G. Rescuscitation H. Baclofen I. Dantrolene J. Quinine
A
G – Rescuscitation. This woman is acutely unwell. She needs ABC and probably a peri-arrest call/999 ambulance. She may have neuroleptic malignant syndrome, or a range of other differentials (e.g. meningitis, substance intoxication). Dantrolene is not an emergency treatment and is not indicated until the diagnosis is clearer.
4
Q
A 26-year-old man who commenced antipsychotics a month ago. His face shows little expression and he does not swing his arms when he walks. He does not have a tremor and his gait is not shuffling.
Best Management of antipsychotic-induced extrapryamidal side-effects A. Intramuscular procyclidine B. Oral procyclidine C. Propranolol D. Stop anticholinergics E. Oral olanzapine F. Intramuscular haloperidol G. Rescuscitation H. Baclofen I. Dantrolene J. Quinine
A
B – Oral procyclidine. This man has drug-induced parkinsonism. In the early stages the features are different to idiopathic parkinsonism. Anticholinergics can help but ideally the dose of antipsychotic would be reduced or an alternative antipsychotic trialled.
5
Q
A 34-year-old man who has been on antipsychotics and regular procyclidine for over a decade. He makes frequent darting movements with his tongue but seems unaware of this.
Best Management of antipsychotic-induced extrapryamidal side-effects A. Intramuscular procyclidine B. Oral procyclidine C. Propranolol D. Stop anticholinergics E. Oral olanzapine F. Intramuscular haloperidol G. Rescuscitation H. Baclofen I. Dantrolene J. Quinine
A
D – Stop anticholinergics. This man has tardive dyskinesia. This is hard to treat but stopping anticholinergics (in this case procyclidine) and reducing or withdrawing antipsychotics if possible can help.
6
Q
A 32-year-old woman, who has previously been very punctual, has arrived late and slightly inebriated for the past six sessions since the therapist was on leave.
Select the most appropriate descriptor: A. Acting out B. Projective identification C. Hypnosis D. Catharsis E. Parapraxis F. Transference G. Rationalization H. Countertransference I. Dream interpretation J. Working through
A
A – This is an example of acting out: behaving in a certain way in order to express thoughts or feelings that the person feels otherwise incapable of expressing.
7
Q
The therapist of a 59-year-old man realizes that he has been talking to him as if he were a father figure.
Select the most appropriate descriptor: A. Acting out B. Projective identification C. Hypnosis D. Catharsis E. Parapraxis F. Transference G. Rationalization H. Countertransference I. Dream interpretation J. Working through
A
H – Countertransference is the process whereby the therapist unconsciously interacts with the patient as if they were a significant figure from the patient’s past.
8
Q
A 43-year-old man feels better after his first psychotherapy session, because he has ‘got it off his chest’.
Select the most appropriate descriptor: A. Acting out B. Projective identification C. Hypnosis D. Catharsis E. Parapraxis F. Transference G. Rationalization H. Countertransference I. Dream interpretation J. Working through
A
D – Catharsis is a Greek word meaning ‘cleansing’ or ‘purging’. It is often used to describe a feeling of relief after an outpouring of emotive material.
9
Q
A 21-year-old says ‘I’m glad we’re almost finished’. She intended to say ‘I’m sad we’re almost finished’.
Select the most appropriate descriptor: A. Acting out B. Projective identification C. Hypnosis D. Catharsis E. Parapraxis F. Transference G. Rationalization H. Countertransference I. Dream interpretation J. Working through
A
E – Parapraxis is a term used to describe an error of memory, speech, writing, reading or action that may be due to the interference of repressed thoughts and unconscious features of the individual’s personality. It is referred to in common culture as a ‘slip of the tongue’ or a ‘Freudian slip’.
10
Q
A 29-year-old man has been avoiding his psychotherapist for the past few weeks following what he considered to be a ‘clash of personalities’. He decided to return and is keen to uncover his unconscious reasons behind this.
Select the most appropriate descriptor: A. Acting out B. Projective identification C. Hypnosis D. Catharsis E. Parapraxis F. Transference G. Rationalization H. Countertransference I. Dream interpretation J. Working through
A
J – Working through describes the concept of working over one’s emotional difficulties from the past. In psychotherapy, it usually follows an ‘impasse’, which can be thought of as a therapeutic stalemate.
11
Q
A 23-year-old man has recovered from his second episode of schizophrenia. Six months after discharge from inpatient care, he is symptom-free, and insists on stopping all his antipsychotic medication. He lives with his parents in what the clinical team have judged to be a high expressed emotion household. If he goes ahead and stops his medication, what is the probability that he will experience a relapse within nine months?
1% 5% 20% 50% 80%
A
80%
12
Q
While giving his past psychiatric history, a 45-year-old man says that he was treated for depression in the past with medication. He cannot remember the name of the medication, but said that he recalls that when he started taking it, he experienced gastrointestinal discomfort. Also, he started taking it at night but had to switch to taking it in the morning because taking it at night disturbed his sleep even more than the depression itself had done. Which of the following medications is most likely to be the one he was taking?
Amitriptyline Mirtazapine Citalopram Zolpidem Olanzapine
A
Citalopram
13
Q
A 24-year-old man presents with what appears to be an acute psychotic episode. Which of the clinical features below is most likely to discriminate between this being a schizophreniform psychosis or a manic episode?
The presence of auditory hallucinations
The presence of persecutory delusions
The presence of delusions that are incongruent with the patient’s mood
The presence of cognitive impairment
The presence of a disorder of the form of thought
A
The presence of delusions that are incongruent with the patient’s mood
14
Q
A general practitioner refers a 20-year old woman for specialist assessment, stating that she has a phobia. Which of the following features is most likely to indicate a diagnosis of social phobia as opposed to agoraphobia
History of fear of the dark in childhood Fear of standing in supermarket queues Fear of travelling on the underground Correct Fear of blushing in public Palpitations and sweating accompanying episodes of fear
A
Fear of blushing in public
15
Q
A 15-year old girl is brought to her general practitioner by her mother, who suspects that her daughter has an eating disorder. Which of the following features makes it more likely that the daughters diagnosis is bulimia, as opposed to anorexia?
A body-mass index of 18
Visiting the gym daily for a vigorous workout
Making herself vomit after meals
Having very detailed knowledge of the calorific values of different foods
Being very self-conscious about her weight and appearance
A
A body-mass index of 18
16
Q
A 22-year old man presents to his general practitioner with a history of gradually increasing concern about contamination. He worries for much of the day that he has become infected by bacteria, and reports that he has to wash his hands thoroughly whenever he touches objects that he thinks are dusty. He has a particular routine that he must follow when washing his hands and if this routine is interrupted, he must begin the routine again. What term best describes his hand-washing specifically?
Obsession Compulsion Delusion Overvalued idea Stereotypy
A
Correct Compulsion
17
Q
An 18-year old girl presents in the Accident and Emergency Department following an overdose of aspirin tablets. It appears that this was an impulsive gesture, in front of her boyfriend, during the course of an argument. She and her boyfriend had been drinking, but on examination, she did not appear intoxicated. Examination revealed no specific mental state abnormalities, and she denied wanting to kill herself. Statistically, what is the probability that she will present again with another episode of self-harm within the next 12 months?
50% 20% 5% 1% 0.1%
A
20%
18
Q
A 22-year old man comes to the local general practice, asking to be signed on as a temporary patient. The circumstances of his presentation make the doctor suspect that the patient is abusing drugs. As he comes into the consulting room, the doctor notices that he seems to be sweating, has a runny nose and dilated pupils. Such symptoms are associated with withdrawal from one of the following drugs. Which one?
A history of adult-onset diabetes
A history of step-wise decline in her cognitive state
A history of a gradual decline in her cognitive state
The fact that her daughter-in-law first noticed her cognitive impairment a few months previously, when she was already 82 years old
The absence of any family history of cerebrovascular disease
A
A history of a gradual decline in her cognitive state
19
Q
You are a medical house officer, asked to assess a 76-year old man, recently admitted to the medical ward because he had become cachectic, presumably because he was neglecting himself. His mental state fluctuates markedly. At times, he appears lucid, while at other times he is very distressed and appears to be responding to auditory and visual hallucinations. During his lucid times, he can find his way without difficulty to the toilet and back to his bed. When he is distressed, he easily gets lost on his way to or from the toilet. What should be the main focus of his management?
Start treatment with olanzepine, titrating dose against the effect on his mental state
Start treatment with diazepam, titrating dose against the effect on his mental state
Transfer him immediately to an old age psychiatry unit, where staff are trained to make specialist mental state assessments
Move him to a bed which is closer to the toilet
Conduct a thorough physical examination and investigations to identify an underlying organic cause for the presentation
A
Conduct a thorough physical examination and investigations to identify an underlying organic cause for the presentation
20
Q
A 32-year old man presents to his general practitioner with a 5-week history of worsening low mood, which he attributes to tensions within his marriage. On direct questioning, he admits that he finds it very difficult to concentrate on his work, and finds no interest in it. He routinely wakes 3 hours before he was accustomed to previously, and feels unrefreshed when he wakes. He now feels hopeless about the future, and says that life isnt worth living, although on questioning, he has made no plans to end his life. Direct questioning reveals no relevant past or family history. Physical examination reveals no abnormalities. What would be the most appropriate management plan?
Ask him to return to the surgery in a week’s time to review
Refer him to the practice counsellor
Prescribe temazepam to help with his sleep, and ask him to return for review in a week’s time
Prescribe fluoxetine 20 mg once a day and ask him to return for review in a week’s time
Refer him to the local community mental health team for an urgent assessment, in view of his thoughts about ending it all
A
Prescribe fluoxetine 20 mg once a day and ask him to return for review in a week’s time
21
Q
A 45-year old man is brought to Accident and Emergency, having collapsed in a local pub. The ambulance crew state that others in the pub said the man had been drinking heavily, on his own, for some hours, and then had what appears to have been a fit. When you assess him once he has sobered up, he reports that his wife and children left him two weeks earlier, and that he lost his job six months ago because of his drinking. He admits that he has to have a large tot of whisky each morning before he gets out of bed. He has undergone a detoxification regime twice before, once with his general practitioner and once with a specialist alcoholism service. On both occasions, he started drinking again within three weeks of ending the regime. Initial investigations include a raised mean corpuscular volume. What is the most appropriate immediate management plan?
Counsel him about his excessive drinking and discharge him to be followed up by his general practitioner
Admit him for medical observation and then treat him symptomatically
Admit him for medical observation, starting him on a descending regime of chlordiazepoxide, plus vitamin B1
Refer him to the local substance misuse service, asking for an urgent assessment
Refer him to the local inpatient psychiatric unit for admission
A
Admit him for medical observation, starting him on a descending regime of chlordiazepoxide, plus vitamin B1
22
Q
A 20-year old man has just been discharged from inpatient psychiatric care. He has a definitive diagnosis of schizophrenia. There were no conspicuous precipitating factors apart from stress from his work at university. In particular, he has never taken illicit drugs, and there is no family history of psychosis. He has a non-identical twin brother. What is the lifetime risk of his twin developing schizophrenia?
80% 50% 10% 5% 1%
A
10%
23
Q
Among patients on an acute medical inpatient ward, what is the likely prevalence of clinical depression?
1% 5% 10% 25% 60%
A
25%
24
Q
A 16-year old boy is referred to Child and Adolescent Mental Health Services. His parents describe a 4-month history of increasingly bizarre behaviour, disorganised speech, and incongruent affect. On direct questioning, the boy himself admits to hearing voices, and also expresses delusional beliefs. He is diagnosed as having a psychotic episode. What is the overall probability that he will recover fully from this episode and experience no further relapses of psychosis?
80% 50% 20% 10% 1%
A
20%
25
A 20-year old man has been referred by his general practitioner for specialist mental health assessment. He says that people are talking about him all the time, especially when he turns on the television. He believes that the flight path of aircraft have been specially changed so that they fly over his home, and interfere with his brain waves. He complains that he cannot sleep at night because people come into his flat and talk incessantly. He admits that everything that is happening to him is making him feel depressed. The psychiatrist makes a working diagnosis, and prescribes some medication. Which medication would be most appropriate in these circumstances?
```
Diazepam
Temazepam
Fluoxetine
Chlorpromazine
Olanzepine
```
Olanzepine
26
Published research evidence supports the effectiveness of a number of interventions in bulimia nervosa. Which of the following interventions has to date not been supported by robust research evidence?
```
Fluoxetine (high dose)
Cognitive-behaviour therapy
Interpersonal therapy
Psychoanalytic psychotherapy
Self-help materials based on the cognitive model
```
Psychoanalytic psychotherapy
27
An 18-year old woman presents in Accident and Emergency having taken an overdose of aspirin tablets. Which of the factors below indicate a particularly increased risk of a further overdose in the future?
That the patient is female rather than male
That the patient binge-drinks alcohol, and the overdose was taken while intoxicated
That she was seen in A&E following another overdose a few months previously
That she lives in a chaotic and dysfunctional household
That the patient is 18 years old
That she was seen in A&E following another overdose a few months previously
28
Under the Mental Health Act (1983), who can make an application to have a patient admitted to an inpatient psychiatric unit under Section 2 or 3?
The patient's own general practitioner
The patient's psychiatrist
The managers of the unit to which the patient is to be admitted
Any doctor who is fully registered with the GMC
An Approved Social Worker
An Approved Social Worker
29
You are a general practitioner, asked to see an 8-year old boy by his mother, because he has been bed-wetting. Examining the child, you notice several bruises, at different stages of resolution, on the boys arms, and a burn mark on his back, the size of which is consistent with being burned by a lighted cigarette. The mothers explanation for these injuries appears implausible, and you suspect that the boy is being abused. What do you do?
Report your concerns to the police
Report your concerns to the local Primary Care Trust
Report your concerns to Social Services
Organise an urgent child protection case conference
Contact your local Child and Adolescent Mental Health Service (CAMHS) to discuss what best to do
Report your concerns to Social Services
30
A 23-year old woman presents in the Accident and Emergency Department with what appears to acute appendicitis, and a decision is taken to recommend appendectomy. She is accompanied by her mother, who says that her daughter has a learning disability. Although the daughter now lives independently, she attended a special school because of her learning difficulties. The mother does not think that her daughter will understand the need for surgery. What would be the most appropriate course of action?
Do not proceed with surgery, but manage the patient conservatively until the diagnosis and required treatment are more certain
Ask the patient's mother to sign the consent form on behalf of the patient
Explain to the patient what is considered to be the problem, and the need for surgery, to ascertain whether she can give informed consent
Go ahead with the appendectomy without the patient's informed consent, under Common Law, on the grounds that it is urgently necessary
Contact the Trust solicitors immediately, giving details of the case, and asking them to arrange an urgent hearing before a judge to get permission to carry out the appendectomy
Explain to the patient what is considered to be the problem, and the need for surgery, to ascertain whether she can give informed consent
31
A care home for the elderly contacts you as the local general practitioner to see an 86-year old widow who was previously frail but otherwise quite well, but now presents with a 3-day history of confusion. Talking with staff, you learn that she sometimes cannot find her way to the dining room, or back to her own room, and sometimes appears to mis-recognise people she has known for a long time. However, at other times, she appears to be her normal self. The home is finding her behaviour increasingly difficult to cope with. What would be your most appropriate initial response to this situation?
Carry out a physical examination, blood tests and urine screen to try to identify a physical cause for the patient's presentation
Arrange for the practice nurse to visit regularly, to build up a more detailed picture of the presenting problems
Ask for a domiciliary visit by the local psychiatry for the elderly team
Arrange for her to be transferred to a nursing home, where staff are better able to manage her current behaviour
Send her to the local Accident and Emergency Department, so that she can be thoroughly examined and investigated, and admitted if necessary
Carry out a physical examination, blood tests and urine screen to try to identify a physical cause for the patient's presentation
32
A 38-year old man comes to see you, his general practitioner, because of persistent gastrointestinal pains. You think his symptoms are likely to be due to a gastric ulcer. You elicit a history of binge-drinking with friends in the local pub at weekends, but the patient insists that he drinks only two cans of lager each evening during the week. He denies having to drink first thing in the mornings, or experiencing craving to drink during weekdays. What would be your most appropriate response to the psychiatric component of this history?
Refer him to the local specialist substance misuse service for further assessment and counselling
Recommend that he starts attending the local branch of Alcoholics Anonymous
Tell him that because he is probably showing the first indications of physical damage due to alcohol, he must now abstain from alcohol
Counsel him about the harmful effects of drinking alcohol, and about safe limits of alcohol intake
Tell him that because he is probably showing the first indications of physical damage due to alcohol, he must now abstain from alcohol, and prescribe a descending-dose regime of chlordiazepoxide
Counsel him about the harmful effects of drinking alcohol, and about safe limits of alcohol intake
33
You are asked, as a house officer, to assess a man in his 50s who has recently been admitted to an acute medical ward from the Accident and Emergency Department. Nursing staff are concerned that he appears to be disoriented. On examination, you note that, amongst other signs, he has a horizontal nystagmus, and some difficulties in heel-toe walking. What is the most likely diagnosis?
```
Wernicke's encephalopathy
Korsakoff's syndrome
Post-ictal state following a temporal lobe epileptic seizure
Cerebellar degeneration
Vitamin B12 deficiency
```
Wernicke's encephalopathy
34
A 26-year old woman on antidepressant prophylaxis following successful treatment of a first episode of depression six months previously, presents at a follow-up appointment at the local community mental health team with a two-week history of expansive mood and great confidence, feeling on top of the world, having boundless energy, and requiring hardly any sleep. What would be the most appropriate immediate intervention?
Leave her antidepressant medication unchanged and ask her to return again for review in two days' time
Leave her antidepressant medication unchanged, and prescribe temazepam to help her sleep
Leave her antidepressant medication unchanged, and start her on a moderate dose of olanzepine daily
Leave her antidepressant medication unchanged, and start her on lithium carbonate
Discontinue her antidepressant medication, and start her on lithium carbonate
Discontinue her antidepressant medication, and start her on lithium carbonate
35
A 28-year old woman lives in supported accommodation. She is able to manage most tasks of self-care, but needs help with taking her medications (in the form of a dosette box, filled by a carer). She has a flat occiput, and short, broad hands. On the basis of this information, what is the likelihood that she has an IQ under 50 and has multiple associated physical abnormalities?
```
0.1%
1%
10%
50%
80%
```
10%
36
A 42-year old man with a 25-year history of schizophrenia has been on regular monthly injections for approximately 18 years. This medication regime has been kept unchanged, because his mental state has been stable, and he has not had any positive symptoms of schizophrenia. The community mental health team consider that he would probably take oral medication as directed, but he has preferred to remain in the injections. However, he now presents with repetitive involuntary movements of his mouth and tongue, which have become progressively worse over the past two months or so. What would be the most appropriate intervention?
Discontinue the depot antipsychotic medication and start him on oral olanzepine
Discontinue the depot antipsychotic medication and start him on oral olanzepine plus procyclidine
Keep him on the same depot injection regime, but in addition ask him to take procyclidine regularly
Keep him on the same depot injection regime, but in addition ask him to take propranolol regularly
Increase the frequency of his depot antipsychotic medication injections
Discontinue the depot antipsychotic medication and start him on oral olanzepine
37
A 18-year old girl presents to a general psychiatry outpatient clinic. She has had what her mother describes as an eating problem for some years, but it has become considerably worse over the past year. She has lost considerable weight, and at the clinic, her weight is 40 kg and her Body Mass Index is 15 kg/m2. She admits that she is very fastidious about her food, carefully choosing what to eat, and disregarding her mothers advice. She goes to the gym daily for a work-out lasting at least 90 minutes. Her periods had been regular, but she has had none for the last 3 months. At the appointment, she is accompanied by her mother, who is clearly exasperated by her daughters behaviour, and expresses considerable criticism of her. What would be the most appropriate initial intervention?
Refer her to a dietician for specialist dietetic counselling, and arrange to see her again in the clinic after she has seen the dietician
Explain to her the potential hazards of her current behaviour, give her appropriate self-help materials, and tell her that appropriate advice on further interventions will depend on how much progress she makes
Refer her, along with her mother, for family therapy, and arrange further follow-up in the clinic
Refer her to a specialist eating disorders clinic, so that she can receive a combination of nutritional advice, individual and family therapy
Arrange to have her admitted to a specialist eating disorders unit
Refer her to a specialist eating disorders clinic, so that she can receive a combination of nutritional advice, individual and family therapy
38
A 19-year old woman is on the post-natal unit, having given birth to her first baby (at term) three days earlier. There were no complications during pregnancy or labour, but the baby is not feeding well (breast-feeding proved very difficult, and the baby is now being fed by bottle). During antenatal care, she told the midwives that her father told her that her own mother was never quite the same after giving birth to her (she is an only child). Three days after delivery, the woman tells the midwife that she is very worried that there is something seriously wrong with the baby, and over the next 24 hours, she is constantly seeking reassurance that the baby is alive and well. She is very tearful, and her mood appears to fluctuate considerably. When her partner visits, she snaps at him. Which of the statements below most accurately describes this presentation?
Such a presentation is common among women who have just had their first baby, and does not warrant further specific intervention
The patient is likely to have 'the baby blues', should be reassured and the clinical picture monitored over time
The patient is likely to have 'the baby blues', but given that she is bottle-feeding, she should be started on prophylactic fluoxetine because of the strong likelihood that this will otherwise develop into post-natal depression
The patient is likely to have post-natal depression and should be commenced immediately on fluoxetine
Because of the time of onset after labour, this is likely to be a prodromal presentation of a post-natal psychosis, and the patient should be started on a small dose of olanzepine
The patient is likely to have 'the baby blues', should be reassured and the clinical picture monitored over time
39
A 45 year old man seeks help from his general practitioner. He has never had paid employment but, having left school, devoted himself to looking after his widowed mother who had severe arthritis and was virtually housebound. She died 6 months ago, and he now feels that his life is empty. He thinks about his mother a great deal, and feels guilty that he could not do more to help her in the months before her death. On further questioning, he admits that he has felt this emptiness since childhood, and has never made friends, but has always been a loner. Which of the details below suggest that he has a personality disorder?
The fact that the patient is male
His comment that his feelings of emptiness have been with him since childhood
The fact that he devoted himself to looking after his mother
His comment that he feels guilty about how he cared for his mother
The fact that he has never had paid employment
His comment that his feelings of emptiness have been with him since childhood
40
A 67 year old man is visited at home by his GP who finds him in squalor, grossly self neglected and expressing ideas that his heart is 'rotten' and he believes he is guilty of genocide by causing crops to fail in Africa.
Diagnosis:
A. Grief reaction
B. Hebephrenic schizophrenia
C. Depression with psychotic features
D. Paranoid schizophrenia
E. Depression without psychotic features
F. None of the above
G. Schizophrenia with mainly negative symptoms
H. Mania/hypomania
I. Acute organic brain syndrome (delirium)
J. Mental state shows no specific abnormality
Depression with psychotic features
41
A 25 year old man says his thoughts are being controlled and that people are reading his thoughts. For the past 2 weeks he has been convinced of a conspiracy against him by his previous employer and he feels certain there are messaged from this person in the newspaper headlines.
Diagnosis:
A. Grief reaction
B. Hebephrenic schizophrenia
C. Depression with psychotic features
D. Paranoid schizophrenia
E. Depression without psychotic features
F. None of the above
G. Schizophrenia with mainly negative symptoms
H. Mania/hypomania
I. Acute organic brain syndrome (delirium)
J. Mental state shows no specific abnormality
Paranoid schizophrenia
42
A 32 year old man talking quickly with lots of ideas that are difficult to follow. He expresses ideas that he has special powers and can control the weather.
Diagnosis:
A. Grief reaction
B. Hebephrenic schizophrenia
C. Depression with psychotic features
D. Paranoid schizophrenia
E. Depression without psychotic features
F. None of the above
G. Schizophrenia with mainly negative symptoms
H. Mania/hypomania
I. Acute organic brain syndrome (delirium)
J. Mental state shows no specific abnormality
Mania/hypomania
43
An 80 year old woman is brought to the Accident and Emergency Department with acute shortness of breath. From her history, it appears that she is in heart failure. She knows her name, but thinks she's in her local church, and that the doctor is a visiting priest
Diagnosis:
A. Grief reaction
B. Hebephrenic schizophrenia
C. Depression with psychotic features
D. Paranoid schizophrenia
E. Depression without psychotic features
F. None of the above
G. Schizophrenia with mainly negative symptoms
H. Mania/hypomania
I. Acute organic brain syndrome (delirium)
J. Mental state shows no specific abnormality
Acute organic brain syndrome (delirium)
44
A 25 year old man is brought for an assessment by his parents. They give a history of deterioration in social functioning over the past 4-5 months. On examination, the patient displays affect that does not seem to fit with the conversation, and seems to move from one topic to another in an illogical manner.
Diagnosis:
A. Grief reaction
B. Hebephrenic schizophrenia
C. Depression with psychotic features
D. Paranoid schizophrenia
E. Depression without psychotic features
F. None of the above
G. Schizophrenia with mainly negative symptoms
H. Mania/hypomania
I. Acute organic brain syndrome (delirium)
J. Mental state shows no specific abnormality
Hebephrenic schizophrenia
45
A man holds a strange pose that looks uncomfortable, bending half way over, and when you examine him you notice you can move his limbs to other positions, which he doesn't resist and he then hold the pose you put him in until you move him again.
```
Phenomena?
A. Thought broadcast
B. Catatonic symptom
C. Hallucinatory voices
D. Thought echo
E. Passivity phenomena
F. Negative symptom
G. Delusional perception
H. Neologism
I. Overvalued idea
J. Paranoid delusion
```
Catatonic symptom
46
A man wearing metal helmet to stop his thoughts being projected out of his head, because he believes other people can hear his thoughts unless he wears the helmet.
```
Phenomena?
A. Thought broadcast
B. Catatonic symptom
C. Hallucinatory voices
D. Thought echo
E. Passivity phenomena
F. Negative symptom
G. Delusional perception
H. Neologism
I. Overvalued idea
J. Paranoid delusion
```
Thought broadcast
47
A woman keeps repeatedly saluting, and says someone is making her do this using a remote control beaming device.
```
Phenomena?
A. Thought broadcast
B. Catatonic symptom
C. Hallucinatory voices
D. Thought echo
E. Passivity phenomena
F. Negative symptom
G. Delusional perception
H. Neologism
I. Overvalued idea
J. Paranoid delusion
```
Passivity phenomena
48
A woman has stopped going out as she has the feeling that she is being followed. She says she can't be sure about this, but she has read in the newspapers about high crime rates, and she has heard from her neighbours that a few people have been followed home and mugged in the local area recently.
```
Phenomena?
A. Thought broadcast
B. Catatonic symptom
C. Hallucinatory voices
D. Thought echo
E. Passivity phenomena
F. Negative symptom
G. Delusional perception
H. Neologism
I. Overvalued idea
J. Paranoid delusion
```
Overvalued idea
49
A woman has been seeing a CPN for many years and when you review her you notice she does very little daytime activities, seems unmotivated and apathetic but not depressed, and she has a limited range of emotional expression.
```
Phenomena?
A. Thought broadcast
B. Catatonic symptom
C. Hallucinatory voices
D. Thought echo
E. Passivity phenomena
F. Negative symptom
G. Delusional perception
H. Neologism
I. Overvalued idea
J. Paranoid delusion
```
Negative symptom
50
A 28 year old man feels uneasy and is unable to relax during the day, worried something dreadful might happen. This feeling of unease is with him throughout her waking hours, but sometimes becomes worse. He tends to feel exhausted by the end of the day.
```
A. Social phobia
B. Agoraphobia
C. Generalised anxiety disorder
D. None of the above
E. Specific phobia
F. Obsessive-compulsive disorder
G. Hypochondriasis
H. Mental state shows no specific abnormality
I. Panic disorder
```
Generalised anxiety disorder
51
A 33 year old woman is convinced that the salmonella germ may be in her kitchen, so she is making her family follow a ritual whereby plates must be dipped in bleach and placed on the drainer to dry for 2 minutes before the plate can be used to eat off. She is really upset by having to perform this ritual but cannot stop herself because she is so worried about contaminating the children.
```
A. Social phobia
B. Agoraphobia
C. Generalised anxiety disorder
D. None of the above
E. Specific phobia
F. Obsessive-compulsive disorder
G. Hypochondriasis
H. Mental state shows no specific abnormality
I. Panic disorder
```
Obsessive-compulsive disorder
52
A 45 year old woman is repeatedly presenting to her GP convinced that she has a brain tumour. She says she has headaches and sometimes a tightness across her forehead. Investigations have been negative but she keeps coming back to ask for further brain scans to find the cancer.
```
A. Social phobia
B. Agoraphobia
C. Generalised anxiety disorder
D. None of the above
E. Specific phobia
F. Obsessive-compulsive disorder
G. Hypochondriasis
H. Mental state shows no specific abnormality
I. Panic disorder
```
Hypochondriasis
53
A 20 year old student is unable to go to the pub with friends, or to travel on the Underground, because he is very worried that if someone looks at him, he'll blush and embarrass himself.
```
A. Social phobia
B. Agoraphobia
C. Generalised anxiety disorder
D. None of the above
E. Specific phobia
F. Obsessive-compulsive disorder
G. Hypochondriasis
H. Mental state shows no specific abnormality
I. Panic disorder
```
Social phobia
54
A 30 year old woman describes episodes when she cannot catch her breath and her fingers tingle.
```
A. Social phobia
B. Agoraphobia
C. Generalised anxiety disorder
D. None of the above
E. Specific phobia
F. Obsessive-compulsive disorder
G. Hypochondriasis
H. Mental state shows no specific abnormality
I. Panic disorder
```
Panic disorder
55
An 80 year old woman who lives alone, and presents with increasing forgetfulness, which she finds very distressing. Her score on the Mini Mental State Exam is 22/30
```
A. Sertraline
B. Procyclidine
C. Temazepam
D. Diazepam
E. Haloperidol
F. Doneprazil
G. Olanzepine
H. Acamprosate
I. Methadone
J. None of the above
```
Doneprazil
56
A 35 year old heavy goods vehicle driver with a past history of alcohol dependence who has been strongly advised to remain abstinent from alcohol
```
A. Sertraline
B. Procyclidine
C. Temazepam
D. Diazepam
E. Haloperidol
F. Doneprazil
G. Olanzepine
H. Acamprosate
I. Methadone
J. None of the above
```
Acamprosate
57
A 22 year old man with a history of schizophrenia who has been admitted as an inpatient on Section 3, acutely psychotic.
```
A. Sertraline
B. Procyclidine
C. Temazepam
D. Diazepam
E. Haloperidol
F. Doneprazil
G. Olanzepine
H. Acamprosate
I. Methadone
J. None of the above
```
Olanzepine
58
A 24 year old woman who is considerably handicapped by having to wash her hands repeatedly, in a particular way
```
A. Sertraline
B. Procyclidine
C. Temazepam
D. Diazepam
E. Haloperidol
F. Doneprazil
G. Olanzepine
H. Acamprosate
I. Methadone
J. None of the above
```
Sertraline
59
A 19 year old man who regularly uses amphetamines and other stimulants but wishes to discontinue these
```
A. Sertraline
B. Procyclidine
C. Temazepam
D. Diazepam
E. Haloperidol
F. Doneprazil
G. Olanzepine
H. Acamprosate
I. Methadone
J. None of the above
```
None of the above
60
A 23 year old man has been an inpatient under Section 3. Who is responsible for arranging the Care Programme Approach meeting?
```
A. Approved social worker
B. Consultant psychiatrist
C. General practitioner
D. Nurse (based at mental health unit)
E. Key worker
F. Occupational therapist
G. Patient advocate
H. Community psychiatric nurse
I. Music therapist
J. Clinical psychologist
```
Key worker
61
A 17 year old man with severe learning disability shows repeated self-injurious behaviour, that has not responded to any pharmacological intervention
```
A. Approved social worker
B. Consultant psychiatrist
C. General practitioner
D. Nurse (based at mental health unit)
E. Key worker
F. Occupational therapist
G. Patient advocate
H. Community psychiatric nurse
I. Music therapist
J. Clinical psychologist
```
Clinical psychologist
62
A 20 year old woman is presents in the Accident and Emergency Department after an impulsive overdose of 10 aspirin tablets, taken during an argument with her mother. Assessment reveals no mental state abnormality, and no suicidal intent is elicited.
```
A. Approved social worker
B. Consultant psychiatrist
C. General practitioner
D. Nurse (based at mental health unit)
E. Key worker
F. Occupational therapist
G. Patient advocate
H. Community psychiatric nurse
I. Music therapist
J. Clinical psychologist
```
General practitioner
63
A 28 year old man is assessed under the Mental Health Act. Whose responsibility is it to consider interventions other than inpatient admission?
```
A. Approved social worker
B. Consultant psychiatrist
C. General practitioner
D. Nurse (based at mental health unit)
E. Key worker
F. Occupational therapist
G. Patient advocate
H. Community psychiatric nurse
I. Music therapist
J. Clinical psychologist
```
Approved social worker
64
A 45 year old woman with a history of bipolar affective disorder has been well and stable in the community for the past 18 months. She is due a Care Programme Approach Meeting.
Who is responsible for organising this?
```
A. Approved social worker
B. Consultant psychiatrist
C. General practitioner
D. Nurse (based at mental health unit)
E. Key worker
F. Occupational therapist
G. Patient advocate
H. Community psychiatric nurse
I. Music therapist
J. Clinical psychologist
```
Key worker
65
Carries a small but important risk of neutropenia and possibly agranulocytosis
```
A. Diazepam
B Temazepam
C. Olanzepine
D. Lithium
E. Procyclidine
F. Clozapine
G. Sertraline
H. Amitryptyline
I. Zolpidem
J. Haloperidol
```
Clozapine
66
Carries a small but important risk of hypothyroidism
```
A. Diazepam
B Temazepam
C. Olanzepine
D. Lithium
E. Procyclidine
F. Clozapine
G. Sertraline
H. Amitryptyline
I. Zolpidem
J. Haloperidol
```
Lithium
67
Has, amongst its most common adverse effects, headache, gastrointestinal disturbance and insomnia
```
A. Diazepam
B Temazepam
C. Olanzepine
D. Lithium
E. Procyclidine
F. Clozapine
G. Sertraline
H. Amitryptyline
I. Zolpidem
J. Haloperidol
```
Sertraline
68
Needs clinical monitoring, particularly when treatment is first started, for extra-pyramidal effects
```
A. Diazepam
B Temazepam
C. Olanzepine
D. Lithium
E. Procyclidine
F. Clozapine
G. Sertraline
H. Amitryptyline
I. Zolpidem
J. Haloperidol
```
Haloperidol
69
Carries a small but important risk of renal failure
```
A. Diazepam
B Temazepam
C. Olanzepine
D. Lithium
E. Procyclidine
F. Clozapine
G. Sertraline
H. Amitryptyline
I. Zolpidem
J. Haloperidol
```
Lithium
70
A 38 year old man, well know to the police as well as mental health services for his long history of schizophrenia with recurrent relapses, is brought to the attention of the police because he is causing a disturbance in a local shopping mall
```
A. Section 2
B. Involve an independent mental capacity advocate
C. Section 3
D. Further treatment cannot be given without the patient's consent
E. Section 136
F. Treat under Common Law
G. Section 12
H. Section 5(2)
```
Section 136
71
A 25 year old woman has recently been admitted as an inpatient. She appears willing to remain in hospital and to accept medication, but is very deluded and the psychiatrist judges that she cannot make decisions about his treatment. She has no known relatives or friends.
```
A. Section 2
B. Involve an independent mental capacity advocate
C. Section 3
D. Further treatment cannot be given without the patient's consent
E. Section 136
F. Treat under Common Law
G. Section 12
H. Section 5(2)
```
Involve an independent mental capacity advocat
72
A 23 year old man is brought to the Accident and Emergency Department in a highly excitable state. He is overfamiliar, expansive, and shows pressure of speech. He says that he is invincible, and to demonstrate this, has been wandering in the traffic. He is not known to mental health services, and denies any past psychiatric history. There is a suspicion that he might be using illicit drugs.
```
A. Section 2
B. Involve an independent mental capacity advocate
C. Section 3
D. Further treatment cannot be given without the patient's consent
E. Section 136
F. Treat under Common Law
G. Section 12
H. Section 5(2)
```
Section 2
73
A 32 year old man who has had several previous Mental Health Act admissions, usually when he relapses after stopping his medications, tells his community psychiatric nurse that he stopped his medications last week. He is unwilling to resume treatment, or to consider any other intervention. Currently, there is no evidence of any mental state abnormalities.
```
A. Section 2
B. Involve an independent mental capacity advocate
C. Section 3
D. Further treatment cannot be given without the patient's consent
E. Section 136
F. Treat under Common Law
G. Section 12
H. Section 5(2)
```
Further treatment cannot be given without the patient's consent
74
A 47 year old woman with a clear history of bipolar disorder appears to be relapsing. She has numerous features of hypomania, including being sexually disinhibited and reckless.
```
A. Section 2
B. Involve an independent mental capacity advocate
C. Section 3
D. Further treatment cannot be given without the patient's consent
E. Section 136
F. Treat under Common Law
G. Section 12
H. Section 5(2)
```
Section 3
75
A 63 year old man presents with a 6-month history of progressive memory loss, with prominent dysphasia. Prior to the onset of the cognitive impairment, he developed bradykinesia and rigidity. His wife noted that his memory and intellect seemed to fluctuate markedly and he sometimes appeared to be hallucinating.
```
A. Huntingdon's chorea
B. Depressive pseudodementia
C. Lewy body dementia
D. Mild cognitive impairment
E. Creutzfeld-Jacob disease
F. Vascular dementia
G. Alzheimers disease
H. Delirium
I. Pick's disease
J. Korsakoff's syndrome
```
Lewy body dementia
76
A 78 year old woman presents in a memory clinic with a long history of hypertension and, according to her general practitioner's letter, a history of several transient ischaemic attacks. She has a Mini Mental State Exam (MMSE) score of 21/30.
```
A. Huntingdon's chorea
B. Depressive pseudodementia
C. Lewy body dementia
D. Mild cognitive impairment
E. Creutzfeld-Jacob disease
F. Vascular dementia
G. Alzheimers disease
H. Delirium
I. Pick's disease
J. Korsakoff's syndrome
```
Vascular dementia
77
A 49 year old woman is brought to the doctor by her husband, who notes that she has become more careless in her daily activities, and seems to have great difficulty in changing from one activity to another. On examination, she shows some brief but repetitive facial grimacing, and slight dysarthria.
```
A. Huntingdon's chorea
B. Depressive pseudodementia
C. Lewy body dementia
D. Mild cognitive impairment
E. Creutzfeld-Jacob disease
F. Vascular dementia
G. Alzheimers disease
H. Delirium
I. Pick's disease
J. Korsakoff's syndrome
```
Huntingdon's chorea
78
A 58 year old man is brought to the clinic by his daughter. He appears to recall his early life in detail, and gives a consistent account of this. However, when asked what he did the previous day, his answer, though elaborate, is inconsistent. On examination, he has horizontal nystagmus.
```
A. Huntingdon's chorea
B. Depressive pseudodementia
C. Lewy body dementia
D. Mild cognitive impairment
E. Creutzfeld-Jacob disease
F. Vascular dementia
G. Alzheimers disease
H. Delirium
I. Pick's disease
J. Korsakoff's syndrome
```
Korsakoff's syndrome
79
An 82 year old woman, who has previously enjoyed reasonably good health and was not on any long-term medication, presents with a history of gradually worsening memory. She cannot remember three objects after five minutes, but is able to describe the journey from her home (where she has lived some years) to the local shopping mall. She clearly pays less attention to her appearance than she did in the past. She appears to have some awareness of her memory problems, and become distressed on formal testing. Her MMSE score is 23/30.
```
A. Huntingdon's chorea
B. Depressive pseudodementia
C. Lewy body dementia
D. Mild cognitive impairment
E. Creutzfeld-Jacob disease
F. Vascular dementia
G. Alzheimers disease
H. Delirium
I. Pick's disease
J. Korsakoff's syndrome
```
Alzheimers disease
80
A 12 year old girl has become increasingly faddish about her diet. By a combination of refusing a variety of foods and vigorous exercise, her Body Mass Index (BMI) has come down to 13.5. Her mother has become increasing angry and frustrated by her behaviour, but her father has withdrawn from the problem, spending more time than before at work.
```
A. Counselling
B. Family therapy
C. Behaviour therapy
D. No specific treatment indicated
E. Psychodynamic psychotherapy
F. Treatment with medication
G. Cognitive-behaviour therapy
H. Motivational interviewing
```
Family therapy
81
A 65 year old woman is encouraged by her daughter to see her general practitioner. She was widowed six weeks earlier, and cannot stop herself from becoming tearful when she thinks about her husband.
```
A. Counselling
B. Family therapy
C. Behaviour therapy
D. No specific treatment indicated
E. Psychodynamic psychotherapy
F. Treatment with medication
G. Cognitive-behaviour therapy
H. Motivational interviewing
```
No specific treatment indicated
82
A 25 year old man seeks help from his general practitioner because he feels that his life is unhappy and unfulfilled, to the extent that he gets thoughts of killing himself. On questioning, he denies experiencing any biological features of depression, and says that, apart from the thoughts of suicide which started relatively recently, he has felt as he now does as long as he can remember.
```
A. Counselling
B. Family therapy
C. Behaviour therapy
D. No specific treatment indicated
E. Psychodynamic psychotherapy
F. Treatment with medication
G. Cognitive-behaviour therapy
H. Motivational interviewing
```
Psychodynamic psychotherapy
83
A 30 year old man diagnosed with diabetes is being followed up by his general practitioner. Despite the patient clearly have a good knowledge about diabetes, his diabetes is poorly controlled. Neither the general practitioner not the diabetes clinic can identify any physiological reason why the diabetes might be so difficult to control.
```
A. Counselling
B. Family therapy
C. Behaviour therapy
D. No specific treatment indicated
E. Psychodynamic psychotherapy
F. Treatment with medication
G. Cognitive-behaviour therapy
H. Motivational interviewing
```
Motivational interviewing
84
A 42 year old lecturer develops an irrational fear of speaking in public, worrying that she will make a mistake in a lecture that will show her in a bad light and cause her great embarrassment. She has started to seek ways to avoid giving lectures.
```
A. Counselling
B. Family therapy
C. Behaviour therapy
D. No specific treatment indicated
E. Psychodynamic psychotherapy
F. Treatment with medication
G. Cognitive-behaviour therapy
H. Motivational interviewing
```
Cognitive-behaviour therapy
85
A 43 year old man, with a long history of alcohol abuse, who presents in the Accident and Emergency Department with a 2-day history of confusion and increasing difficulty walking.
```
A. Prescribe naloxone
B. Prescribe acamprosate
C. Recommend gradual reduction in amount of drug consumed
D. Give intravenous vitamin B1
E. Outpatient detoxification
F. Prescribe methadone
G. Give intravenous flumazanil
H. Inpatient detoxification
```
Give intravenous vitamin B1
86
A 50 year old woman with a longstanding dependence on diazepam whose friends bring her to the Accident and Emergency Department saying that she couldn't sleep and has taken an overdose of diazepam. She is unrousable, and her breathing is very shallow.
```
A. Prescribe naloxone
B. Prescribe acamprosate
C. Recommend gradual reduction in amount of drug consumed
D. Give intravenous vitamin B1
E. Outpatient detoxification
F. Prescribe methadone
G. Give intravenous flumazanil
H. Inpatient detoxification
```
Give intravenous flumazanil
87
A 27 year old sales executive who has to hide alcohol at work so that he can drink there, and always has alcohol by his bedside to consume before he gets up in the morning. He recognises that his drinking is a problem and seeks the help of his general practitioner for this.
```
A. Prescribe naloxone
B. Prescribe acamprosate
C. Recommend gradual reduction in amount of drug consumed
D. Give intravenous vitamin B1
E. Outpatient detoxification
F. Prescribe methadone
G. Give intravenous flumazanil
H. Inpatient detoxification
```
Outpatient detoxification
88
A 22 year old woman who has been taking heroin for five years orally and also intravenously seeks help because she developed severe cellulitis and a deep vein thrombosis from injecting herself. Twice previously, she has tried on her own to withdraw from heroin, and is very reluctant to consider supervised withdrawal.
```
A. Prescribe naloxone
B. Prescribe acamprosate
C. Recommend gradual reduction in amount of drug consumed
D. Give intravenous vitamin B1
E. Outpatient detoxification
F. Prescribe methadone
G. Give intravenous flumazanil
H. Inpatient detoxification
```
Prescribe methadone
89
A 36 year old unemployed single man who has been dependent on alcohol for some years presents in the Accident and Emergency Department having been hit by a car when he wandered into the road while drunk. He has undergone two previous detoxifications, but resumed drinking soon after each had ended. He is now asking for further treatment
```
A. Prescribe naloxone
B. Prescribe acamprosate
C. Recommend gradual reduction in amount of drug consumed
D. Give intravenous vitamin B1
E. Outpatient detoxification
F. Prescribe methadone
G. Give intravenous flumazanil
H. Inpatient detoxification
```
Inpatient detoxification
90
A 12 year old boy has a history of repeated purposeless shrugging of the shoulders, eye-blinking, and repetition of socially unacceptable and obscene words, which he appears unable to stop despite sanctions.
```
A. Separation anxiety
B. Childhood autism
C. Depressive disorder
D. Secondary enuresis
E. Encopresis
F. Attachment disorder
G. Oppositional defiant disorder
H. Conduct disorder
I. Primary enuresis
J. Tourette's syndrome
```
Tourette's syndrome
91
A 10 year old girl has been wetting the bed at night about twice a week for the past 6 months. She had been continent from the age of 3 until 6 months ago. Her step-father has been charged with sexual offences against his daughter from a previous marriage.
```
A. Separation anxiety
B. Childhood autism
C. Depressive disorder
D. Secondary enuresis
E. Encopresis
F. Attachment disorder
G. Oppositional defiant disorder
H. Conduct disorder
I. Primary enuresis
J. Tourette's syndrome
```
Secondary enuresis
92
A 9 year old boy with normal intelligence repeatedly passes faeces on the floor of his bedroom and sometimes hides them in his mother's shoes. He is one of 6 children all of whom have behaviour problems. His parents are separated and he lives with his mother who is a heroin addict.
```
A. Separation anxiety
B. Childhood autism
C. Depressive disorder
D. Secondary enuresis
E. Encopresis
F. Attachment disorder
G. Oppositional defiant disorder
H. Conduct disorder
I. Primary enuresis
J. Tourette's syndrome
```
Encopresis
93
A 6 year old boy throws severe tantrums when he does not get his wishes. Both his parents and teachers complain that he does not do as told. He often argues and is easily provoked. Other children avoid him because of his temper.
```
A. Separation anxiety
B. Childhood autism
C. Depressive disorder
D. Secondary enuresis
E. Encopresis
F. Attachment disorder
G. Oppositional defiant disorder
H. Conduct disorder
I. Primary enuresis
J. Tourette's syndrome
```
Oppositional defiant disorder
94
A 7 year old is having difficulty attending school because she fears that her mother may die while she is at school. She is an only child and lives with her mother. She refuses to stay with grandparents unless her mother comes along. She often has nightmares of getting lost while out with her mother.
```
A. Separation anxiety
B. Childhood autism
C. Depressive disorder
D. Secondary enuresis
E. Encopresis
F. Attachment disorder
G. Oppositional defiant disorder
H. Conduct disorder
I. Primary enuresis
J. Tourette's syndrome
```
Separation anxiety
95
The diagnosis is more common in men than in women
```
A. Alzheimer-type dementia
B. Social phobia
C. Bipolar affective disorder
D. Schizophrenia
E. Alcohol dependence
F. Obsessive-compulsive disorder
G. Agoraphobia
H. Depressive disorder
```
Alcohol dependence
96
The peak age of onset is in the late 30's
```
A. Alzheimer-type dementia
B. Social phobia
C. Bipolar affective disorder
D. Schizophrenia
E. Alcohol dependence
F. Obsessive-compulsive disorder
G. Agoraphobia
H. Depressive disorder
```
Depressive disorder
97
The condition is recognised to have a better prognosis in developing countries than in Westernised cultures
```
A. Alzheimer-type dementia
B. Social phobia
C. Bipolar affective disorder
D. Schizophrenia
E. Alcohol dependence
F. Obsessive-compulsive disorder
G. Agoraphobia
H. Depressive disorder
```
Schizophrenia
98
The prevalence of the disorder is the same in first degree relatives of those affected as in the general population
```
A. Alzheimer-type dementia
B. Social phobia
C. Bipolar affective disorder
D. Schizophrenia
E. Alcohol dependence
F. Obsessive-compulsive disorder
G. Agoraphobia
H. Depressive disorder
```
Agoraphobia
99
Among monozygous twins, the concordance for the condition is approximately 60-70%
```
A. Alzheimer-type dementia
B. Social phobia
C. Bipolar affective disorder
D. Schizophrenia
E. Alcohol dependence
F. Obsessive-compulsive disorder
G. Agoraphobia
H. Depressive disorder
```
Schizophrenia
100
'I don't know what to do Dr. i know they are monitoring my actions using special radio waves and there's no way I can get away from it.'
Mental State Examination:
```
A. Appearance
B. Behaviour
C. Thought form and Speech
D Mood
E Affect
F. Thought Content
G. Abnormal perception
H. Cognition
I. Insight
J. Not part of MSE
```
F - Thought content
Any notable content of thought should be recorded here, including the presence of delusions, obsessive thoughts and phobias. A risk assessment should also be conducted to assess for any ideations of harming self or others. This is particularly important for those presenting with self harm to ascertain the presence of any active suicidal ideation.
101
'Can't you hear them? They're constantly criticising me.'
Mental State Examination:
```
A. Appearance
B. Behaviour
C. Thought form and Speech
D Mood
E Affect
F. Thought Content
G. Abnormal perception
H. Cognition
I. Insight
J. Not part of MSE
```
G - Abnormal Perception
Any visual, auditory, olfactory, gustatory, tactile and somatic illusions and hallucinations should be recorded under abnormal perceptions
102
'I'm not eating anymore, and I constantly feel guilty for everything. I feel like I'm in a deep trench and I'm suffering down below'
Mental State Examination:
```
A. Appearance
B. Behaviour
C. Thought form and Speech
D Mood
E Affect
F. Thought Content
G. Abnormal perception
H. Cognition
I. Insight
J. Not part of MSE
```
D - Mood
Features of subjective (patients own words) and objective (as observed by interview) mood should be recorded under mood, including any biological features such as the effect of mood on appetite and sleep
103
'After that I decided to go home....Home and away....Swaying my way.'
Mental State Examination:
```
A. Appearance
B. Behaviour
C. Thought form and Speech
D Mood
E Affect
F. Thought Content
G. Abnormal perception
H. Cognition
I. Insight
J. Not part of MSE
```
C - Thought form and speech
This is an example of flight of ideas, which is a rapid succession of thoughts vaguely associated with the sounds of other words. There may be punning and rhyming. This commonly occurs in patients with mania and is a disorder of the form of speech.
Loosening of associations occurs in schizophrenia, and this includes 'knight's thinking,' where there is no logical association between successive thoughts, 'word salad' where speech is an incomprehensible mixture of words and phrases, and 'neologisms' where a new word is invented by the patient
104
'I don't need these tablets.... Everything that is happening to me is real! I'm not mad and I'm definitely not staying in hospital.'
Mental State Examination:
```
A. Appearance
B. Behaviour
C. Thought form and Speech
D Mood
E Affect
F. Thought Content
G. Abnormal perception
H. Cognition
I. Insight
J. Not part of MSE
```
I - Insight
Assessment of insight involves identifying whether the patient believes that he or she has an illness, whether the illness is attributed to a mental disorder, whether the patient believes that psychiatric treatment will be helpful, and whether they are willing to accept advice.
105
'My uncle got killed in a car accident 2 days ago. Ha ha ha. He was speeding and the car just went out of control. Ha ha ha. I just can't stop laughing'
```
A. Alexithymia
B. Anhedonia
C. Blunting of affect
D. Circumstantiality
E. Delusional Mood
F. Incongruitity of Mood
G. Knight's move thinking
H. Labile Mood
I. Perseveration
J. Tangentiality
```
F - Incongruity of Mood is the dissociation of one's emotions and the content of one's thoughts or actions. The observed affect is inappropriate to the situation, such as laughing when talking about something that's normally perceived as being sad.
106
'I don't really do the things that I used to. I used to be an active person and enjoyed running. i even played tennis competitively and really liked it, but they don't seem to be pleasurable at all'
```
A. Alexithymia
B. Anhedonia
C. Blunting of affect
D. Circumstantiality
E. Delusional Mood
F. Incongruitity of Mood
G. Knight's move thinking
H. Labile Mood
I. Perseveration
J. Tangentiality
```
B - Anhedonia is loss of enjoyment in previously pleasurable activites and interests. It is a core feature of depression along with low mood and lack of energy.
107
'You want to know where I'm from, that's a hard question because I'm technically from the UK but I do know that my ancestors came from Northern Europe. I think several generations ago they were living as Vikings. But yes, I'm from England.'
```
A. Alexithymia
B. Anhedonia
C. Blunting of affect
D. Circumstantiality
E. Delusional Mood
F. Incongruitity of Mood
G. Knight's move thinking
H. Labile Mood
I. Perseveration
J. Tangentiality
```
D -Circumstantiality is a type of disorder of thought form (formal thought disorder) in which the patient goes at verbose length to include every detail in order to answer a simple question. In the course of the response, the eventual answer to the question is reached (unlike tangentiality where the answer is not reached).
108
'It just feels so strange. i know something weird is going on and that something will definitely happen soon. I can't exactly explain it, but I know it's going to be horrible'
```
A. Alexithymia
B. Anhedonia
C. Blunting of affect
D. Circumstantiality
E. Delusional Mood
F. Incongruitity of Mood
G. Knight's move thinking
H. Labile Mood
I. Perseveration
J. Tangentiality
```
E - Delusional mood (also known as delusional atmosphere) is a type of primary delusion where the patient feels that something odd is going on or is about to happen.
109
'Yes I do take my medications as directed, Dr. I take one tablet every morning after having my breakfast, and then it was his turn to be punished. It's a fight involving everyone, but the unaffected third party just pretended nothing happened.'
```
A. Alexithymia
B. Anhedonia
C. Blunting of affect
D. Circumstantiality
E. Delusional Mood
F. Incongruitity of Mood
G. Knight's move thinking
H. Labile Mood
I. Perseveration
J. Tangentiality
```
G - knight's move thinking is a type of formal thought disorder in which the patient starts answering a question appropriately, but the line of thought is suddenly shifted to an unrelated topic. It is also known as derailment of thought.
Tangentiality is a related formal thought disorder in which the patient starts answering the question, but then talks off the topic in an area that is only indirectly related to the intended answer, as a result the answer to the original question is not reached.
Alexithymia is the inability to describe one's subjective emotional state. For example, an alexithymic individual would not be able to verbalise his sad and low feelings, despite feeling so. It is also seen in somatisiation disorder.
Emotional blunting refers to a lack of emotional sensitivity and loss of appropriate responses to events that would usually invoke a response. it is a negative symptom of schizophrenia. Similarly flattening of affect refers to a marked decrease in the usual range of emotions. it may also be seen with severely depressed patients who no longer feel the will to live and find nothing interesting, or in a patient with schizophrenia.
A labile mood indicates a marked variability in the affect, with rapid changes in mood observed over a short period of time, for example crying then suddenly laughing within a minute
Perseveration is the inability to switch from one line of thinking to another. An example is when a patient who is asked about his FH continues to talk about this even when the Dr moves on to SH.
110
An 18 year old male is brought to hospital by his parents because they have noticed that he has been acting strangely recently. His parents say that he has 'lost it' since failing his final examinations. The patient was noted to be giggling to himself, spending almost all his time in his room, and making unusual gestures with his hands. In addition his speech has been incomprehensible and his parents cannot make any sense of it.
```
A. Acute and transient psychotic disorder
B. Bipolar Affective Disorder
C. Catatonic Schizophrenia
D. Hebephrenic schizophrenia
E. Paranoid Schizophrenia
F. Residual Schizophrenia
G. Schizoaffective disorder
H. Schizotypal disorder
I. Simple schizophrenia
J. Undifferentiated schizophrenia
```
D - Hebephrenic Schizophrenia is a subtype of schizophrenia that is characterised by changes in affect (flattening or incongruity of affect), thought disorder, and behaviour that is aimless or disjointed.
Mannerisms are also quite common.
Hallucinations and delusions are usually fragmentary and do not dominate the clinical picture. Individuals tend to become socially isolated and tend to develop prominent negative symptoms.
This type of schizophrenia is usually diagnosed in adolescents or young people.
111
A 30 year old female is brought to hospital as she has been violent and hostile to her neighbours. According to the patient, her grandfather was a successful writer and she acquired his fortunes recently. However she belives her neighbours have found out about it and claims she heard them talking about stealing her money.
```
A. Acute and transient psychotic disorder
B. Bipolar Affective Disorder
C. Catatonic Schizophrenia
D. Hebephrenic schizophrenia
E. Paranoid Schizophrenia
F. Residual Schizophrenia
G. Schizoaffective disorder
H. Schizotypal disorder
I. Simple schizophrenia
J. Undifferentiated schizophrenia
```
E - Paranoid Schizophrenia is a common subtype where delusions and hallucinations are prominent. the delusions are not necessarily persecutory in nature, but they all must pertain to the individual, whether it be grandiose, love etc. other symptoms such as abnormalities of affect, catatonic symptoms or thought disorder may be present but not to a significant degree.
112
A 37 year old female who previously held a managerial position in a large financial firm is brought to hospital by her parents. According to the parents, the patient has not been coping with her work for the last few years and has gradually become withdrawn. She was fired from her work 3 years ago and since then has been doing nothing but smoking in her bed all day. On MSE her affected is blunted and she appears to have no motivation.
```
A. Acute and transient psychotic disorder
B. Bipolar Affective Disorder
C. Catatonic Schizophrenia
D. Hebephrenic schizophrenia
E. Paranoid Schizophrenia
F. Residual Schizophrenia
G. Schizoaffective disorder
H. Schizotypal disorder
I. Simple schizophrenia
J. Undifferentiated schizophrenia
```
I - Simple schizophrenia is an uncommon and controversial subtype of schizophrenia, which is characterised by at least 1 year history of progressive development of negative symptoms (apathy, blunting of affect, lack of initiative and drive), gradual changes in social behaviour and social withdrawal. There is no evidence of preceding acute psychotic symptoms.
113
A 25 year old male is brought to hospital as he was found to be trashing his apartment and throwing things from his window. he claims that everything in his flat is 'contaminated' and that voices are telling him to get rid of his possessions. He admits that this has been going on for a week. He agrees to a urine drug test, and the results are negative for all drugs. A week after admission, however, he makes a dramatic recovery and is now completely back to normal.
```
A. Acute and transient psychotic disorder
B. Bipolar Affective Disorder
C. Catatonic Schizophrenia
D. Hebephrenic schizophrenia
E. Paranoid Schizophrenia
F. Residual Schizophrenia
G. Schizoaffective disorder
H. Schizotypal disorder
I. Simple schizophrenia
J. Undifferentiated schizophrenia
```
A - Acute and trsnsient psychotic disorder is characterised by the acute onset of psychotic symptoms, usually within 2 weeks. The symptoms resolve within a few weeks and in some cases after a few days. It is best thought of as a 'one off' psychotic episode.
114
A 27 year old male with no previous psychiatric history is brought to hospital by his family. His parents noticed that he has been 'high' for the last few months, and that his behaviour has become increasingly erratic. he was also noted to have strange beliefs, such as the world being flat and the government trying to prevent this fact from being disclosed. He even stated that he has a radiotransmitting device implanted in his head which allowed him to pick up the signals sent from space. His elated mood and strange beliefs continued for a year.
```
A. Acute and transient psychotic disorder
B. Bipolar Affective Disorder
C. Catatonic Schizophrenia
D. Hebephrenic schizophrenia
E. Paranoid Schizophrenia
F. Residual Schizophrenia
G. Schizoaffective disorder
H. Schizotypal disorder
I. Simple schizophrenia
J. Undifferentiated schizophrenia
```
G - Schizoaffective disorder comprises symptoms that meet some of the diagnostic criteria for both affective disorder (depression, mania, mixed-type) and schizophrenia. The symptoms must occurs simultaneously and in approximately equal proportions.
It does not include patients with schizophrenia who go on to develop affective symptoms or patients with an affective disorder who go on to develop psychotic symptoms.
Notes:
For an ICD-10 diagnosis of schizophrenia, one of the following must be fulfilled for at least 1 month:
- At least one of the following must be present: thought insertion, withdrawal, broadcast, echo; voices giving a running commentary or discussing the patient's behaviour; delusional perception; passivity phenomena, delusion of control; persistent delusions - these are mostly Schneider's first rank symptoms.
- At least two fo the following must be present: persistent hallucinations in any modality, formal thought disorder (incoherent speech and neologisms); catatonic symptoms, negative symptoms, decrease in social functioning.
For a DSM-IV diagnosis, at least 2 symptoms (delusions, hallucinations, disorganised speech, negative symptoms, catatonic symptoms) must be present for at least 1 month, including signs of disturbance for at least 6 months.
115
A 38 year old male was previously in a general psychiatric ward for 2 years because he thought the government was sending beams into his brain and trying to control his actions. He is now discharged into the community and seems less bothered by those thoughts. However he prefers to stay indoors and does nothing all day, hardly socialising with anyone. On approaching him, he shows marked poverty of speech and restricted affect.
```
A. Acute and transient psychotic disorder
B. Bipolar Affective Disorder
C. Catatonic Schizophrenia
D. Hebephrenic schizophrenia
E. Paranoid Schizophrenia
F. Residual Schizophrenia
G. Schizoaffective disorder
H. Schizotypal disorder
I. Simple schizophrenia
J. Undifferentiated schizophrenia
```
F - Residual schizophrenia is a chronic stage in schizophrenic illnesses where there is a clear progression from an active psychotic phase to a chronic negative phase. The negative phase comprises of psychomotor retardation, affective blunting, reduced motivation, reduced speech output, and a decline in social functioning. Both simple and residual schizophrenia are similar in that they are makred by a negative phase, but residual is always preceded by an active psychotic phase, while simple schizophrenia does not
116
A 46 year old female is brought to hospital as she believes that she is a divine being in the process of transforming into God. She belives that she is able to control other people's feelings and behaviours. In the last few days, she has become increasingly aggressive to her neighbours as she thinks that they are stopping her from acquiring her further powers. On examination, her speech is normal, and no signs of elation or agitation are seen. Her psychiatric history is unremarkable.
```
A. Acute and transient psychotic disorder
B. Bipolar Affective Disorder
C. Catatonic Schizophrenia
D. Hebephrenic schizophrenia
E. Paranoid Schizophrenia
F. Residual Schizophrenia
G. Schizoaffective disorder
H. Schizotypal disorder
I. Simple schizophrenia
J. Undifferentiated schizophrenia
```
E - paranoid schizophrenia is marked by hallucinations and delusions. the delusions are usually paranoid in that they relate to the patient, but it does not always have to be persecutory in nature. In this example the patient is experiencing delusions of grandiosity with some persecution. Grandiose delusions are commonly seen in bipolar affective disorder, but this has been ruled out in this patient due to the lack of manic symptoms.
117
A 38 year old male is described as a loner by his family as he does not seem to have any close friends. He usually spends his time alone at home because he becomes extremely anxious around other people. When talking to others, he feels that they are being nice to his face but that there's an alternative agenda. He likes to dress in silver clothing because he feels it brings him 'closer to cosmis forces.'
```
A. Acute and transient psychotic disorder
B. Bipolar Affective Disorder
C. Catatonic Schizophrenia
D. Hebephrenic schizophrenia
E. Paranoid Schizophrenia
F. Residual Schizophrenia
G. Schizoaffective disorder
H. Schizotypal disorder
I. Simple schizophrenia
J. Undifferentiated schizophrenia
```
H - Schizotypal is classified as a schizophrenic illness in ICD-10, but belongs to personality disorder in DSM-IV. It is thought to be related to schizophrenia in that the incidence is higher in relatives of patients with schizophrenia. It is similar to schizophrenia, but lacks the hallucinations and delusions (although transient psychotic episodes can occur). Characteristics seen any ideas of reference, odd beliefs, eccentric appearance and speech, inappropriate affect, suspiciousness and social anxiety.
118
A 25 year old male is taken to hospital by the police as he was found screaming on the streets. He had been trying to light himself with a lighter, claiming he was invincible and had the power to fix all evil in the world. His speech was highly pressured and he complains that his thoughts are going out of control. According to hospital records, he had been admitted to hospital 3 times in the last year for similar episodes.
```
A. Acute and transient psychotic disorder
B. Bipolar Affective Disorder
C. Catatonic Schizophrenia
D. Hebephrenic schizophrenia
E. Paranoid Schizophrenia
F. Residual Schizophrenia
G. Schizoaffective disorder
H. Schizotypal disorder
I. Simple schizophrenia
J. Undifferentiated schizophrenia
```
B - Bipolar affective disorder is a mood disorder characterised by the presence of several depressive and manic/hypomanic episodes during the lifetime of a patient. In this example the patient is exhibiting grandiose delusions with manic symptoms such as pressure of speech and flight of ideas.
119
A 30 year old male is brought to hospital by his family because of increasing concerns about his behaviour. In the last few months, the patient has been going through periods when his mind appears to be preoccupied, staring in space and maintaining funny posture like a statue. on examination, he is mute and does not respond to any stimuli. his urine drug screen is negative.
```
A. Acute and transient psychotic disorder
B. Bipolar Affective Disorder
C. Catatonic Schizophrenia
D. Hebephrenic schizophrenia
E. Paranoid Schizophrenia
F. Residual Schizophrenia
G. Schizoaffective disorder
H. Schizotypal disorder
I. Simple schizophrenia
J. Undifferentiated schizophrenia
```
C - Catatonic schizophrenia is dominated by psychomotor distrubances, which may fluctuate between extremes of excitement and hyperkinesis to stupor and mutism. Catatonic behaviours such as automatic obedience and posturing are also seen.
Undifferentiated schizophrenia is a condition that meets the geenral diagnostic criteria for schizophrenia, but does not fit with one particular subtype. For example a patient may exhibit thought withdrawal but have no other behavioural symptoms to specify the type of schizophrenia.
120
A 20 year old male becomes anxious in the company of unfamiliar people and fears possible scrutiny by others. he worries that he will act in a way that will be humiliating or embarassing and he attempts to avoid soical situations. He realises that this has resulted in him failing to get promoted at work.
```
A. Adjustment disorder
B. Agoraphobia
C. Conversion disorder
D. Generalised Anxiety disorder
E Hypochondriasis
F. OCD
G. Panic Disorder
H. PTSD
I. Social Phobia
J. Somatisation
```
I - Social phobia is characterised by a marked fear of being the focus of attention and the fear that one will behave in an embarassing or humiliating way. This leads to avoidance of social situations such as speaking or eating in public. The individual may present with blushing, shaking, nausea, vomiting or urgency of micturation during these situations.
121
A 30 year old female avoids travelling alone, using public transport, or being in crowded places as this makes her feel anxious. She feels that such situations make her feel unsafe. She eventually becomes housebound as she identifies her home as being the only safe place for her
```
A. Adjustment disorder
B. Agoraphobia
C. Conversion disorder
D. Generalised Anxiety disorder
E Hypochondriasis
F. OCD
G. Panic Disorder
H. PTSD
I. Social Phobia
J. Somatisation
```
B- Agoraphobia is the fear and avoidance of crowded places, public places (such as shops), travelling alone (e.g. on trains or buses), and being away from home. There are symptoms of anxiety, which are restricted to those 'unsafe' situations only.
Agoraphobia may be associated with panic attacks.
122
A 32 year old male has recurrent and persistent thoughts of contamination, which he recognises as irrational. he washes his hands repeatedly throughout the day, which relieves his anxiety. He also performs a ritual which must be performed in the correct order to prevent something dreadful happening to his wife.
```
A. Adjustment disorder
B. Agoraphobia
C. Conversion disorder
D. Generalised Anxiety disorder
E Hypochondriasis
F. OCD
G. Panic Disorder
H. PTSD
I. Social Phobia
J. Somatisation
```
F - OCD is characterised by recurrent obsessional thoughts and compulsions. Obsessions are recurrent and unpleasant thoughts, images or impulses that intrude into the patients mind and are recognised by the patient as being his own thoughts. Compulsions are acts that are repeated constantly amd carried out to relieve anxiety or to prevent an event from happening, such as a loved one getting hurt. The patient attempts to resist these obsessions and compulsions, often with limited success, and recognises that they are irrational and absurd. the obsessions and compulsions causes significant social and occupational distress.
123
A 37 year old female who previously held a managerial position in a large financial firm presents to the clinic saying that she is no longer able to continue with her job. About a month ago she started having episodes of dizziness and palpitations, coupled with the thought that she was going to die. These episodes only last for a few minutes, and seem to occur randomly at home, work or outside. Although she is able to function normally between these episodes, she is now worried as to when these attacks will next come on.
```
A. Adjustment disorder
B. Agoraphobia
C. Conversion disorder
D. Generalised Anxiety disorder
E Hypochondriasis
F. OCD
G. Panic Disorder
H. PTSD
I. Social Phobia
J. Somatisation
```
G - Panic disorder is characterised by recurrent panic attacks. An episode of panic attack develops rapidly and peaks at around 10 minutes, and usually does not last for more than 20-30 minutes. Typical symptoms include palpitations, sweating, trembling, chest pain, SOB, numbness, tingling, fear of losing control and a fear of dying. it is important to exclude substance misuse or a medical disorder such as hyperthyroidism, Cushing's syndrome, hypoglycaemia, phaecromocytoma, anaemia and cardiac arrhythmias. Comorbidity with other psychiatric conditions is common (agoraphobia, depression and other anxiety disorders).
124
A 22 year old male is preoccupied with the fear that he has cancer. he has had a number of investigations which have not revealed any abnormalities, but is not reassured. he has visited 3 hospitals in the last year.
```
A. Adjustment disorder
B. Agoraphobia
C. Conversion disorder
D. Generalised Anxiety disorder
E Hypochondriasis
F. OCD
G. Panic Disorder
H. PTSD
I. Social Phobia
J. Somatisation
```
E - Hypochondriasis is the persistent preoccupation of having a serious physical disorder or the preoccupation with a presumed deformity or disfigurement (body dysmorphic disorder). The symptoms cause distress and lead the patient to seek medical treatment or investigations, but there is a refusal to accept reassurance.
Notes:
- GAD is characterised by generalised. persistent anxiety or excessive worry about daily events and problems, associated with muscle tension, sleep disturbance and autonomic hyperactivity. This is a chronic disorder lasting longer than 6 months.
Anxiety disorders can be simplified as follows:
- Is anxiety generalised or episodic? If general: GAD
- If episodic, is the trigger known or random? If random: panic disorder. if known specify the trigger:
- Simple phobia (objects or situations)
- Agoraphobia (unsafe places)
- Social phobia (social situations).
125
A 65 year old male was admitted to a medical ward with a history of chest pain, low mood and weight loss. No medical cause was found. He said that about 12 days ago, his house was burgled and he lost his belongings. he progessed well in the ward and appeared cheerful, but as his discharge date approached, he complained of feeling 'not right' and refused to go back home.
```
A. Abnormal grief reaction
B. Acute stress reaction
C. Adjustment disorder
D. Agoraphobia
E. Conversion disorder
F. Depressive disorder
G. GAD
H. Normal grief reaction
I. PTSD
J. Simple (specific) phobia
```
C - An adjustment disorder must occur within 1 month of a psychosocial stressor and should not occur for longer than 6 months, except in the case of a prolonged depressive reaction, which may last up to 2 years (ICD-10). Symptoms cause significant distress but are not severe enough to meet the criteria of a major psychiatric illness such as depression. A bereavement or grief reaction also fits into this category.
126
A 47 year old female and her son were involved in a car accident while she was driving. Her son unfortunately died in the accident, and she spent 2 weeks in hospital for a head injury. Although she made an uneventful recovery, 4 months after the accident, she started experiencing intrusive thoughts about the accident. She has been unable to get into a car and has avoided visiting the accident site. She complains of poor concentration, anxiety and low mood.
```
A. Abnormal grief reaction
B. Acute stress reaction
C. Adjustment disorder
D. Agoraphobia
E. Conversion disorder
F. Depressive disorder
G. GAD
H. Normal grief reaction
I. PTSD
J. Simple (specific) phobia
```
I - PTSD is a severe psychological distrubance that occurs following a traumatic event. Symptoms include persistent reliving of the incident in the form of flashbacks or nightmares, avoidance of situations resembling or associated with the incident, inability to recall completely or partially some aspects of the event, and persistent symptoms of arousal (difficulty concentrating, irritability, difficulty falling asleep, hypervigilance and exaggerated startle response).
127
A 22 year old college student found out that her previously well after was killed in a car accident unexpectedly. She returns home and prepares for her father's funeral, but finds it very difficult. She is tearful, agitated and unable to concentrate. Two years later, she is still mourning her father's death and has dropped out of college. She has avoided visiting the site of the accident, and also seems to deny the incident. Her father's room is left untouched since the day of the accident, and she pretends he is still alive.
```
A. Abnormal grief reaction
B. Acute stress reaction
C. Adjustment disorder
D. Agoraphobia
E. Conversion disorder
F. Depressive disorder
G. GAD
H. Normal grief reaction
I. PTSD
J. Simple (specific) phobia
```
A - Abnormal grief reaction is a grief that is delayed (by more than 2 weeks), prolonged (greater than 6 months), or abnormal in grief content. Symptoms include feelings of worthlessness, excessive guilt, suicidal ideation, hallucinatory experiences (other than the voice or image of the deceased), and denial. On the other hand, normal grief is characterised by disbelief, numbness, anger, sadness, tearfulness and pseudo-hallucinations of the deceased, which eventually resolves by 6 months
128
A 24 year old medical student travels abroad for his elective. While going back to his residence late at night, he is held to a gunpoint by 2 masked figures asking for his money. He promptly hands in his wallet and the assailants run away. He returns home, but upon arrival, he feels numb and becomes tearful. The following day he has recollections of the events but is no longer troubled by it.
```
A. Abnormal grief reaction
B. Acute stress reaction
C. Adjustment disorder
D. Agoraphobia
E. Conversion disorder
F. Depressive disorder
G. GAD
H. Normal grief reaction
I. PTSD
J. Simple (specific) phobia
```
B - An acute stress reaction is a transient disorder that usually develops within an hour and resolves within a few hours or days. Symptoms may include disorientation, feeling 'dazed', aggression, social withdrawal, anger and despair
129
A 32 year old female is unable to walk following her sudden separation from her husband. She is now unable to walk unaided and requires a wheelchair, and her husband has agreed to visit once a week to help her out. Neurological examination is inconsistent with her symptoms and investigations are normal.
```
A. Abnormal grief reaction
B. Acute stress reaction
C. Adjustment disorder
D. Agoraphobia
E. Conversion disorder
F. Depressive disorder
G. GAD
H. Normal grief reaction
I. PTSD
J. Simple (specific) phobia
```
C - Conversion or dissociative disorders are associated with a loss or disturbance of normal functioning. The symptoms develop in close relationship to a psychological stressor. Symptoms include paralysis, sensory loss, seizures, amnesia, and loss of speech.
The disturbance conforms to the patient's understanding of the disorder and physical examination in often inconsistent with the patient's symptoms. Investigations are normal. Most symptoms resolve after a few weeks or months, but some disorders may become chronic if associated with insoluble or unbearable personal problems. In this vignette, the patient displays dissociative motor disorder.
Notes:
- Simple (specific) phobia refers to an intense fear induced by the presence of a specific object or situation, such as heights and spiders.
130
A 56 year old male suffering from schizophrenia is discharged home as his mental state is now stable after a 4 week admission. On returning home with the social worker, however, he initially says that his house seems unfamiliar, as if it were like a stranger's house, but he quickly recognises it as his own.
```
A. Anterograde amnesia
B. Confabulation
C. Deja vu
D. Delusional memory
E. Delusional misidentification
F. Dissociative amnesia
G. Dissociative fugue
H. Jamais vu
I. Malingering
J. No mental illness
```
H - Jamais vu is the experience of a situation being unfamiliar even though it has been experience before. It can be a normal experience but may also occur in some disorders such as temporal lobe epilepsy and schizophrenia.
The opposite of jamais vu is deja vu, where an experience is perceived as being familiar although objectively it has never been experienced before.
131
A 45 year old male with a history of alcohol abuse is admitted to a ward. He was oriented to the ward but is unable to remember the name of the ward or hospital. He is also unable to remember the name of his primary nurse, despite seeing her everyday. His psychiatrist comes and interviews him, but he repeatedly asks her name.
```
A. Anterograde amnesia
B. Confabulation
C. Deja vu
D. Delusional memory
E. Delusional misidentification
F. Dissociative amnesia
G. Dissociative fugue
H. Jamais vu
I. Malingering
J. No mental illness
```
A - The patient in the scenario is suffering from Korsakoff's syndrome, a recognised complication of chronic alcohol abuse. The prominent feature here is that of anterograde amnesia, which is the inability to form new memories. The converse of this is retrograde amnesia, which is the inability to recall memory before an amnesic episode.
132
A 24 year old female recently lost her fiancé in a car crash. Following this she is reported missing by her family as they are unable to get hold of her, but police reports indicate that she was working in a bar abroad. Four weeks later, she returns home in a completely fit state but unable to recall where she has been
```
A. Anterograde amnesia
B. Confabulation
C. Deja vu
D. Delusional memory
E. Delusional misidentification
F. Dissociative amnesia
G. Dissociative fugue
H. Jamais vu
I. Malingering
J. No mental illness
```
G - Dissociative fugue is associated with a stressful event and involves the individual undertaking an unexpected but organised journey from home, during which self care is maintained. The patients behaviour may appear completely normal to passers-by. There is partial or complete amnesia for the event.
- Dissociative amnesia refers to memory loss that may be selective and is a possible choice. However, the vignette describes the patient taking a trip with evidence of adequate self care, and thus a dissociative fugue would be the better answer.
133
A 40 year old female suffering from schizophrenia breaks down in tears during the ward round, saying that she was raped by her brothers during childhood. Collateral history from her mother indicates that she is the only child, but she remains adamant that her brothers raped her. She points to stretch marks on her abdomen and says that they are proofs of the sexual assault
```
A. Anterograde amnesia
B. Confabulation
C. Deja vu
D. Delusional memory
E. Delusional misidentification
F. Dissociative amnesia
G. Dissociative fugue
H. Jamais vu
I. Malingering
J. No mental illness
```
D - Delusional memory is used to describe either a situation where a patient 'remembers' past experiences that clearly did not occur, or when a normal memory is given a delusional meaning. The vignette described here refers to the first definition, as the patient claims she remembers an event that did not happen
134
A 41 year old male had an argument with his wife, as he was not forth coming about where he has been spending his time during the day. When the wife confronts him whether he was out gambling, he replies 'Yes, yes, I have been gambling ... in fact I won quite a bit!' However his explanations are unreliable and appear to change significantly during the conversation depending on what the wife says. He has a history of alcohol abuse
```
A. Anterograde amnesia
B. Confabulation
C. Deja vu
D. Delusional memory
E. Delusional misidentification
F. Dissociative amnesia
G. Dissociative fugue
H. Jamais vu
I. Malingering
J. No mental illness
```
B - Confabulation is a falsification of memory occurring in a clear consciousness in association with organic amnesia. In these cases, patients fill the conversation with anything that comes to mind in an effort to mask their memory loss and thus the content is heavily influenced by the conversation taking place. Confabulation is often seen in patients with Korsakoff's syndrome.
Notes:
- Delusional misidentification refers to patients being unable to correctly identify another person or place correctly, for example claiming that an individual has been replaced by an imposter
- Malingering refers to the conscious production of false symptoms for clear secondary gain, and memory loss may be faked for clear gain, such as an individual trying to avoid a court hearing by claiming to have lost all memory
135
A 28 year old female presents to the clinic complaining of low mood. She explains that she has always felt low, as if something was missing from her heart. Other than that, she has no complaints, and her sleep and appetite are both healthy. She is able to keep her job and appears to be enjoying a reasonable social life
```
A. Bipolar affective disorder
B. Cyclothymia
C. Depressive episode, mild
D. Depressive episode, moderate
E. Depressive episode, severe
F. Dysthymia
G. Hypermania
H. Hypomania
I. Mania
J. Recurrent depressive disorder
```
F - Dysthymia is characterised by the presence of chronic low mood, which must be present for more than 2 years but not severe enough for a diagnosis of depressive disorder. There may be intervening periods of normal mood, but these do not last longer than a few weeks.
136
A 28 year old female presents to the clinic complaining of low mood. She has been feeling like this for the past 3 months and is unable to identify any triggers. She feels tearful and does not seem to enjoy things she once did. She is still able to go to work, although at times it has been difficult for her to concentrate. Her appetite has decreased but she manages to sleep around 7 hours per night. Her past psychiatric history is unremarkable.
```
A. Bipolar affective disorder
B. Cyclothymia
C. Depressive episode, mild
D. Depressive episode, moderate
E. Depressive episode, severe
F. Dysthymia
G. Hypermania
H. Hypomania
I. Mania
J. Recurrent depressive disorder
```
C - Depressive disorders are classified into mild, moderate, severe without psychotic symptoms and severe with psychotic features according to ICD-10.
The severity of the episode is dependent on the number and intensity of the depressive symptoms and must be present for 2 weeks:
- Core depressive symptoms are low mood, decreased energy and anhedonia.
- Associated symptoms are disturbed sleep, diminished appetite, self harm impulses, disturbed attention/concentration, feeling of guilt/worthlessness, hopelessness, low self esteem.
The following are diagnostic criteria guidelines for ICD-10:
- Mild: Total of 4 core and associated (at least 2 core symptoms)
- Moderate: 6 core and associated symptoms (at least 2 core symptoms)
- Severe: 8 core and associated symptoms (all core symptoms needed)
A diagnosis of recurrent depressive disorder is made when a patient has at least 2 depressive disorders without any history of hypomania or mania
137
A 28 year old female presents to the clinic complaining of low mood. She describes her mood as 'depressing' and is unable to do anything. Because of her low mood, she has not eaten for 3 days. She mentions that a year ago she was feeling on top of the world and went through periods when she did not have to sleep. On that occasion she was admitted to hospital because her parents thought she was going 'out of control.'
```
A. Bipolar affective disorder
B. Cyclothymia
C. Depressive episode, mild
D. Depressive episode, moderate
E. Depressive episode, severe
F. Dysthymia
G. Hypermania
H. Hypomania
I. Mania
J. Recurrent depressive disorder
```
A - the vignette described sound like a mild or moderate depressive episode, but given the patients history of a manic episode, the best diagnosis is bipolar affective disorder, which by definition is characterised by 2 or more episodes of significant mood disturbance, of which one episode must be mania or hypomania.
Bipolar affective disorder is further subdivided into 2:
- Type I: depressive episodes with at least one manic episode
- Type II: depressive episodes with at least one hypomanic episode (but NOT MANIA)
138
A 28 year old female presents to the clinic, but she is over active and unable to sit still. When she finally starts talking, she is clearly overexcited and her thoughts are hard to follow. She vaguely mentions about having a connection with God, and that she is the 'chosen' one. She believes that she has the power to heal all humans suffering from the world, and even claims that she is hearing God's voice at present. Her past psychiatric history is unremarkable.
```
A. Bipolar affective disorder
B. Cyclothymia
C. Depressive episode, mild
D. Depressive episode, moderate
E. Depressive episode, severe
F. Dysthymia
G. Hypermania
H. Hypomania
I. Mania
J. Recurrent depressive disorder
```
I - Mania is an episode characterised by symptoms of elevated mood (for at least 1 week) increased activity, pressure of speech, flight of ideas, decreased need for sleep, loss of social inhibitions and reckless behaviour (overspending, reckless driving). There may be mood-congruent psychotic symptoms, which are frequently grandiose delusions and second person auditory hallucinations.
- Hypomania is a milder form of mania, in which the patient has an elevated mood but the symptoms are not severe enough to cause disruption to social life
- The vignette described here cannot be BAD as this was the first episode for the patient
139
A 28 year old female presents to the clinic, but the doctor is unable to fully carry out an assessment as the patient is mute and does not make eye contact. According to the mother, the patient has been like this for the past few weeks and has hardly eaten anything. She has told her mother that she is dead and thus does not need to be fed. Earlier today, she was found stacking a pile of wood in the garden as she wanted to cremate her dead body. Her past psychiatric history is unremarkable
```
A. Bipolar affective disorder
B. Cyclothymia
C. Depressive episode, mild
D. Depressive episode, moderate
E. Depressive episode, severe
F. Dysthymia
G. Hypermania
H. Hypomania
I. Mania
J. Recurrent depressive disorder
```
E - Depressive episode, severe, characterised with psychotic features. Psychotic symptoms are mood congruent and include delusions of guilt, worthlessness, poverty, nihilistic delusions and 2nd person auditory hallucinations of voice that are derogatory in nature.
Notes:
- Hypermania does not exist
- Cyclothymia is a persistent instability of mood, characterised by a mild to moderate depression and mild elation, none of which are severe enough to qualify for a formal diagnosis of BAD or recurrent depressive disorder
140
Depressive episode whereby the patient complains of depressed mood less often and instead complains of physical symptoms such as disturbed sleep and somatic problems. These patients remain at substantially higher risk of completed suicide
```
A. Atypical depression
B. Bonding failure
C. Childhood depression
D. Depression in the elderly
E. Dysthymia
F. Post partum blues
G. Post partum depression
H. Post partum psychosis
I. Premenstrual syndrome
J. Seasonal affective disorder
```
D - Depression in the elderly is more likely to present as somatic, anxiety or hypochondria symptoms, nihilistic delusions of poverty or physical illness, cognitive impairment (pseudo dementia), and severe psychomotor agitation or retardation. Pseudo dementia is poor concentration and memory associated with depression that can mimic dementia. It usually improves when the symptoms of depression resolve.
141
Affective episode temporarily related to child birth with an abrupt onset at about 2-4 weeks. The episodes may be marked with psychotic features such as hallucinations and delusions relating to the baby. Risk is increased in first time mothers and instrumental deliveries
```
A. Atypical depression
B. Bonding failure
C. Childhood depression
D. Depression in the elderly
E. Dysthymia
F. Post partum blues
G. Post partum depression
H. Post partum psychosis
I. Premenstrual syndrome
J. Seasonal affective disorder
```
H - Post partum (puerperal) psychosis occurs in 0.2% of births. Features include labile mood, perplexity, disorientation, insomnia, psychotic symptoms and thoughts of suicide and harming the baby. Other risk factors include the lack of social support and a personal or family history of postpartum psychosis, BAD or schizophrenia.
142
Depressive episodes in which the patient does complain of low mood, but appears to lack the biological and other associated features of depression. The patient can present with features such as hypersomnia, hyperphagia and heaviness of limbs
```
A. Atypical depression
B. Bonding failure
C. Childhood depression
D. Depression in the elderly
E. Dysthymia
F. Post partum blues
G. Post partum depression
H. Post partum psychosis
I. Premenstrual syndrome
J. Seasonal affective disorder
```
A - features of atypical depression include a reactive mood, reversal of diurnal variation in mood (mood better in the morning), increased appetite, weight gain, and increased sleep. Atypical depression is thought to respond better to mono-amine oxidase inhibitors.
143
Clinical symptoms involve low mood, hypersomnia, fatigue, increased appetite and weight gain. Social functioning can be decreased during the episode. The episodes follow a recurring pattern, and light therapy is suggested in the form of treatment.
```
A. Atypical depression
B. Bonding failure
C. Childhood depression
D. Depression in the elderly
E. Dysthymia
F. Post partum blues
G. Post partum depression
H. Post partum psychosis
I. Premenstrual syndrome
J. Seasonal affective disorder
```
J - Seasonal affective disorder is associated with recurrent episodes of depression, which has a seasonal pattern of episodes in winter. Mild hypomania may occur in the summer. UV light therapy is associated with a good response.
144
Depressive episode characterised by low mood, anhedonia, an altered sleep and appetite. In addition, it may manifest with somatisation, behavioural disruptions, and substance abuse. Male to female rate is roughly equal, and completed suicide is rare.
```
A. Atypical depression
B. Bonding failure
C. Childhood depression
D. Depression in the elderly
E. Dysthymia
F. Post partum blues
G. Post partum depression
H. Post partum psychosis
I. Premenstrual syndrome
J. Seasonal affective disorder
```
C - Childhood depression may present as irritability, hyperactivity, tantrums, apathy, poor feeding, somatisation, and regression (enuresis, soiling). In older children features include school refusal, poor performance at school, somatisation, and poor sleep. The prevalence of depression before puberty is roughly equal between the sexes but increases in females after puberty.
Notes:
- Post partum blues (baby blues) is experienced by up to 75% of mothers and occurs about 2-3 days after birth and lasts for 1-2 days. The mother is typically tearful and emotionally labile, but this is self limiting and only reassurance is usually required.
- Post partum depression is a significant depressive episode that occurs in 10-15% of pregnant women, peaking around 3-4 weeks after childbirth. The symptoms are similar to that of any other depressive episode, but usually are related to the baby's health or ability to cope. Risk factors are a history of depression, single motherhood, ambivalence towards the pregnancy, and poor social support.
- Bonding failure occurs when the mother fails to develop a normal loving, emotional relationship with her baby, usually in the context of unwanted, ambivalent pregnancies or depressive illness
- Premenstrual syndrome is a collection of psychological (mood disturbance, insomnia, poor concentration) and physical (head ache, bloating) symptoms occurring 24 hours after ovulation, and quickly reversed by menstrual flow
145
A 45 year old male works in data processing from home. He has never had a relationship, and was often described as a loner at school. He hardly has any friends, but is not bothered by it as he prefers working and living at home
```
A. Anakastic
B. Anxious (avoidant)
C. Dependent
D. Dissocial
E. Emotionally unstable (bordeline)
F. Emotionally unstable (impulsive)
G. Histrionic
H. Paranoid
I. Passive aggressive
J. Schizoid
```
J - Schizoid personality disorder is characterised by emotional coldness and detachment, preference for solitary activities, excessive introspection, no desire for relationships, indifference to praise or criticism, and a marked insensitivity to social norms and conventions (but this is unintentional). These patients are loners who prefer their own company
Personality disorders are deeply ingrained and enduring patterns of behaviour, which manifest as inflexible responses to a broad range of personal and social situations, and are a significant deviation from how the average person in a given culture thinks, feels and relates to others. They are frequently associated with subjective distress and problems in social functioning.
146
A 30 year old female works as a medical secretary. She always arrives to work 2 hours before everyone else as she likes to ensure that her desk and office is in order. She usually leaves work 2 hours late as she had difficulty completing her work on time due to her thorough checking and rechecking. The other secretaries think she is stubborn and become annoyed with her when she insists that they do things in a similar way
```
A. Anakastic
B. Anxious (avoidant)
C. Dependent
D. Dissocial
E. Emotionally unstable (bordeline)
F. Emotionally unstable (impulsive)
G. Histrionic
H. Paranoid
I. Passive aggressive
J. Schizoid
```
A - Anakastic (obsessive) personality is characterised by an excessive concern with details and order, excessive conscientiousness, perfectionism that interferes with task completion, feelings of excessive doubt and caution, rigidity and stubbornness, and insistence that others submit to his or her way of doing things
147
A 50 year old female describes herself as 'always having mood swings.' She goes out on a blind date with a man she has met over the internet, but while having a conversation about politics in a restaurant, she gets upset about a comment her date makes. She starts screaming at him and throw dishes on the floor screaming: 'Look what you made me do!'
```
A. Anakastic
B. Anxious (avoidant)
C. Dependent
D. Dissocial
E. Emotionally unstable (bordeline)
F. Emotionally unstable (impulsive)
G. Histrionic
H. Paranoid
I. Passive aggressive
J. Schizoid
```
F - Emotionally unstable PD has 2 subtypes.
The impulsive subtype is associated with a tendency to act without consideration of the consequences quarrelsome behaviour, outbursts of anger or violence, and an inability to control such behavioural explosions.
Unstable mood and difficulty in maintaining a course of action that offers no reward are also seen.
148
A 22 year old bubbly female college student has a lot of friends, but they often complain that she has verbal diarrhoea and find her to be too dominating in conversation. She often wears very short skirts and likes being the centre on attention. While out clubbing, she trips over and scratches her leg, but the following day she tells friends she was attacked in the club and had to go to hospital to have her leg treated
```
A. Anakastic
B. Anxious (avoidant)
C. Dependent
D. Dissocial
E. Emotionally unstable (bordeline)
F. Emotionally unstable (impulsive)
G. Histrionic
H. Paranoid
I. Passive aggressive
J. Schizoid
```
G - Histrionic PD is characterised by a shallow and labile affect, over dramatisation or exaggerated expression of emotions. suggestibility (easily influenced by others), over concern with physical appearance, inappropriate seductiveness in appearance and behaviour, and the need to be the centre of attention
149
An 18 year old student who recently started university finds it hard to talk to others. He would like to make new friends, but finds everything too intimidating. He rationalises that he would not fit in as he comes from another part of the country and thus would have nothing in common. Because he is scared of being rejected by his classmates, rather than attending classes, he spends the majority of the time in the library and at home
```
A. Anakastic
B. Anxious (avoidant)
C. Dependent
D. Dissocial
E. Emotionally unstable (bordeline)
F. Emotionally unstable (impulsive)
G. Histrionic
H. Paranoid
I. Passive aggressive
J. Schizoid
```
B - Anxious PD is characterised by persistent feelings of tension and apprehension, the belief that one is socially inferior, and excessive preoccupation with being criticised of rejected. This leads to avoidance of social and occupational activities and unwillingness to engaged with people unless certain of being liked. Unlike those with schizoid PD, these patients want social interaction but are unable to do so.
Notes:
- The types of PD differ slightly between ICD-10 and DSM-IV - Dissocial PD is known as anti-social in DSM-IV, and emotionally unstable impulsive type does not exist in DSM-IV
- Passive aggressive is also known as negativistic PD and characterised by a passive resistance to authoritarian circumstances, manifesting as procrastination, stubbornness, resentment, and forgetfulness. For example, a person who is opposed to a specific project may frequently miss meetings or make errors as a means of protest
150
A 22 year old male gets angry after finding out that he failed his college examinations, saying that the paper was badly set. He has very few friends as he is very picky and feels some of his peers are not up to his level. His parents aren't too worried, saying that he has always been like that.
```
A. Anti-social
B. Avoidant
C. Borderline
D. Dependent
E. Histrionic
F. Narcissistic
G. Obsessive Compulsive
H. Paranoid
I. Schizoid
J. Schizotypal
```
F - Narcissistic PD includes a grandiose sense of self importance, preoccupation with fantasies of unlimited success, the belief that he/she is special and should only associate with other special or high status people, a sense of entitlement, the need for excessive admiration, a lack of empathy, and envy towards others or believes that others are envious of him/her.
151
A 20 year old female with a history of childhood sexual abuse had chronic suicidal ideation. She is currently in an abusive relationship marked by arguments, but still prefers to be with her boyfriend. She presents to the hospital today for deliberate self harm and tells the duty doctor 'you are the best doctor that I have ever come across.'
```
A. Anti-social
B. Avoidant
C. Borderline
D. Dependent
E. Histrionic
F. Narcissistic
G. Obsessive Compulsive
H. Paranoid
I. Schizoid
J. Schizotypal
```
C - Borderline PD is characterised by disturbances in self image and/or personal preferences (such as sexuality), intense and unstable relationships, self harming, excessive efforts to avoid abandonment, and chronic feelings of emptiness. A fairly significant proportion of self harmers presenting to hospital fall into this category.
152
A 29 year old female, who has always been described as odd and strange by her friends, has a very strong interest in the occult and mystics, and believes that she is able to see spirits. Despite coming from a middle class English family, she prefers to wear traditional native American clothing as she believes this will help her contact nature better. She once saw a cat being run over by a car, and deiced to become a vegetarian then as she took the incident as being a divine message from God.
```
A. Anti-social
B. Avoidant
C. Borderline
D. Dependent
E. Histrionic
F. Narcissistic
G. Obsessive Compulsive
H. Paranoid
I. Schizoid
J. Schizotypal
```
J - Schizotypal disorder is classified as a PD in DSM-IV, but not in ICD-10 (schizophrenic spectrum disorder). Features include eccentric appearance or behaviour, cold and aloof affect, odd beliefs and magical thinking that is inconsistent with social norms, paranoid ideas, unusual perceptual experiences and transient quasi-psychotic episodes.
153
A 19 year old male dropped out of school aged 13 for violent behaviour. He has been spending his days doing nothing but pacing around the streets and pick-pocketing from strangers. He has been convicted several times in the past for armed robbery, and claims that this was done for self defence. He appears to have no remorse for the victims, and has never been able to maintain relationships.
```
A. Anti-social
B. Avoidant
C. Borderline
D. Dependent
E. Histrionic
F. Narcissistic
G. Obsessive Compulsive
H. Paranoid
I. Schizoid
J. Schizotypal
```
A - Antisocial PD is characterised by irresponsibility and disregard for social norms and rules, callous disregard for the feelings of others, tendency to become aggressive, inability to experience guilt, inability to learn from punishment, tendency to blame others, and an inability to maintain relationships.
154
A 29 year old waitress has never been able to live alone. Ever since finishing university she always lived in an apartment with her friends as she finds the prospect of living alone too daunting. She constantly needs reassurances and support from her friends, and does not appear to be able to make up her own mind about anything. When her friends ask her for a favour she always complies and finds it difficult to refuse them.
```
A. Anti-social
B. Avoidant
C. Borderline
D. Dependent
E. Histrionic
F. Narcissistic
G. Obsessive Compulsive
H. Paranoid
I. Schizoid
J. Schizotypal
```
D - Dependent PD is characterised by the need of encouragement from others to make important decisions, inability to make everyday decisions without excessive reassurance and advice from others, feelings of helplessness when left alone, undue compliance with the wishes of others, and an unwillingness to make even reasonable demands on the people one depends on.
Notes:
- The choices in this question derive from the DSM-IV classification of PDs, which differ slightly from ICD-10. Passive aggressive disorder was recognised as a PD in the old DSM-III, but was omitted in DSM-IV and put in the appendix as there were controversies regarding its use.
- Paranoid PD is marked by a strong sense of suspiciousness, sensitivity to set backs, tendency to bear grudges, and an unwillingness to forgive. Other features include a high sense of entitlement to personal rights, persistent self referential attitudes, and a tendency to distort experiences as being hostile or threatening.
155
A 21 year old female has not been eating adequately for the last 6 months and has lost approximately 15 kgs in weight. She claims that all food and tap water are contaminated with cyanide and thus has been taking food supplements and bottled water only. On examination her BMI is 15 and she has not had her menstrual periods for almost 3 months
```
A. Anorexia nervosa
B. Binge Eating disorder
C. Bipolar affective disorder
D. Bulimia Nervosa
E. Depression
F. Diabetes Mellitus
G. OCD
H. Paranoid schizophrenia
I. Specific phobia
J. No mental illness
```
H - Paranoid Schizophrenia
The patient in this vignette has decreased food intake associated with decreased weight and physical abnormalities, which all stems from her delusional beliefs regarding poisoned food or water. The presence of this delusion therefore suggests a diagnosis of schizophrenia.
156
A 20 year old male spends the majority of his time at home eating greasy fast food, playing on the computer and sleeping all day. He does not seem to engage in any physical activities despite constant encouragement from his family, citing that he is 'too lazy.' On examination his BMI is 34 and abdominal stretch marks are noted
```
A. Anorexia nervosa
B. Binge Eating disorder
C. Bipolar affective disorder
D. Bulimia Nervosa
E. Depression
F. Diabetes Mellitus
G. OCD
H. Paranoid schizophrenia
I. Specific phobia
J. No mental illness
```
J - No mental illness
The patient in this vignette is obese due to his BMI 34 (obese > 30), but the underlying causes of this obesity is unhealthy eating habits and physical inactivity. There is thus no evidence of a mental illness, but treatments should be mainly behavioural and psychological to re-establish sensible eating and physical activity.
157
A 28 year old female is brought to hospital by her family as she has lost a considerable amount of weight in 4 weeks. She describes having no appetite or energy, and has lost interest in looking after herself. This seems to have started following her divorce, and she feels guilty about the break up of her marriage all the time. Her BMI is 19
```
A. Anorexia nervosa
B. Binge Eating disorder
C. Bipolar affective disorder
D. Bulimia Nervosa
E. Depression
F. Diabetes Mellitus
G. OCD
H. Paranoid schizophrenia
I. Specific phobia
J. No mental illness
```
E - Depression is the underlying cause of this patients decreased appetite, as evidence by her anergia, anhedonia and constant sense of guilt
158
A 19 year old female is brought to hospital as she collapsed at work. She reports that she is in the midst of a 'strict dieting regimen' as she feels too fat. For the last 8 months she has been eating a small portion of salad a day, working out 5 days a week and taking appetite suppressants. She has not had a menstrual cycle in 3 months. On examination she is weak and anaemia and her BMI is 16
```
A. Anorexia nervosa
B. Binge Eating disorder
C. Bipolar affective disorder
D. Bulimia Nervosa
E. Depression
F. Diabetes Mellitus
G. OCD
H. Paranoid schizophrenia
I. Specific phobia
J. No mental illness
```
A - Anorexia nervosa
| The ICD-10 criteria are BMI
159
A 21 year old female is complaining of feeling bad about herself because everyone around her is looking down on her. As a means of releasing her stress, she goes through periods of frantically eating 3 boxes of cereal and 8 bars of chocolates in one go. Following this, she feels even worse and ends up making herself sick. Her BMI is 25 and her history is significant for polysubstance and alcohol abuse
```
A. Anorexia nervosa
B. Binge Eating disorder
C. Bipolar affective disorder
D. Bulimia Nervosa
E. Depression
F. Diabetes Mellitus
G. OCD
H. Paranoid schizophrenia
I. Specific phobia
J. No mental illness
```
D - Bulimia nervosa
The ICD-10 criteria for bulimia nervosa are recurrent episodes of bingeing, persistent preoccupation with eating (craving). attempts to counteract the fattening effects of food through use of complimentary mechanisms (self-induced vomiting, purging, use of laxatives, use of appetite suppressants, excessive exercise), and the perception of being too fat with an intrusive dread of fatness. The usual age range of onset is later than anorexia, usually late teens to 30 years old.
Notes:
- Binge eating disorder is similar to bulimia nervosa, but is not associated with the compensatory vomiting or purging effects
- When assessing patients with a low weight, it is always important to rule out an organic cause such as DM, malabsorption syndromes and endocrine disease (Addison's, thyroid disorders)
- Poor prognostic factors for anorexia nervosa include longer illness duration, older age of onset, being male, poor parental relationship and excessive weight loss. Onset is usually around 13-20 years, and has a male to female ration of 1:10-20. It is more commonly seen in social classes I and II in industrialised countries, and is more frequent in specific occupations, such as models and dancers.
Efforts to lose weight are seen in both anorexia and bulimia, and vomiting is seen in both conditions.
Treatment for both eating disorders are education, pharmacological (SSRIs e.g. fluoxetine) and psychological (CBT and family therapy). The UK NICE guidelines recommend hospital treatment if one of the following criteria are met:
- BMI
160
Included in the ICD-10 diagnostic criteria for anorexia
A. Arrhythmia and cardiomyopathy
B. Cerebral atrophy (pseudoatrophy)
C. Tachycardia and malignant hypertension
D. Hypernatraemia and hyperkalaemia
E. Hypoglycaemia with raised cholesterol and amylase
F. Hypophosphataemia
G. Hypothalamic dysfunction with decreased gonadotrophins
H. Lanugo hair
I. Metabolic acidosis
J. Russell's sign
G - Endocrine complications resulting from disruption of the hypothalamic-pituitary-adrenal (HPA) axis is one of the diagnostic criteria of AN, and this commonly manifests as amenorrhoea. Other endocrine disturbances seen in anorexia are raised GH and cortisol levels
161
Consequence of excessive laxative use
A. Arrhythmia and cardiomyopathy
B. Cerebral atrophy (pseudoatrophy)
C. Tachycardia and malignant hypertension
D. Hypernatraemia and hyperkalaemia
E. Hypoglycaemia with raised cholesterol and amylase
F. Hypophosphataemia
G. Hypothalamic dysfunction with decreased gonadotrophins
H. Lanugo hair
I. Metabolic acidosis
J. Russell's sign
I - Metabolic acidosis with hypokalaemia is seen with excessive use of laxatives, as bicarbonate and fluids are lost from the gut. There is also evidence that excessive laxative use can lead to renal tubular acidosis.
On the other hand, metabolic ALKALOSIS is seen with frequent vomiting, as hydrochloric acid is lost from the stomach
162
Leading cause of mortality in patients with anorexia
A. Arrhythmia and cardiomyopathy
B. Cerebral atrophy (pseudoatrophy)
C. Tachycardia and malignant hypertension
D. Hypernatraemia and hyperkalaemia
E. Hypoglycaemia with raised cholesterol and amylase
F. Hypophosphataemia
G. Hypothalamic dysfunction with decreased gonadotrophins
H. Lanugo hair
I. Metabolic acidosis
J. Russell's sign
A - Cardiovascular complications of AN account for 10% mortality, and since these include significant bradycardia, hypotension (systolic BP
163
Indicative of repeated self induced vomiting
A. Arrhythmia and cardiomyopathy
B. Cerebral atrophy (pseudoatrophy)
C. Tachycardia and malignant hypertension
D. Hypernatraemia and hyperkalaemia
E. Hypoglycaemia with raised cholesterol and amylase
F. Hypophosphataemia
G. Hypothalamic dysfunction with decreased gonadotrophins
H. Lanugo hair
I. Metabolic acidosis
J. Russell's sign
J - Russell's sign refers to callused skin on the backs of the hands (over the knuckles) due to repeated manual induction of vomiting. Other signs of repeated self-induced vomiting include parotid enlargement, eroded tooth enamel and oesophageal tears.
164
Core feature of re-feeding syndrome
A. Arrhythmia and cardiomyopathy
B. Cerebral atrophy (pseudoatrophy)
C. Tachycardia and malignant hypertension
D. Hypernatraemia and hyperkalaemia
E. Hypoglycaemia with raised cholesterol and amylase
F. Hypophosphataemia
G. Hypothalamic dysfunction with decreased gonadotrophins
H. Lanugo hair
I. Metabolic acidosis
J. Russell's sign
F - Hypophosphataemia
Refeeding syndrome occurs when a previously starved severely malnourished patient is recommenced on a normal diet. Upon being re-fed carbohydrate metabolism and insulin secretion occur, leading to cellular uptake of phosphate. The resulting hypophosphataemia usually triggers non-specific symptoms, but these can lead to rhabdomyolysis, leucocyte dysfunction, respiratory failure, arrhythmias, coma, seizures and sometime death. The phenomenon usually occurs within 4 days of re-feeding and thus regular monitoring of kidney function and electrolytes is necessary. Treatment involves dietician input and supplementation with phosphate
Notes:
Other physical consequences of AN are:
- GI: delayed gastic emptying, gastric atrophy, constipation
- Metabolic: hypokalaemia, hyponatraemia, hypoglycaemia, hypocalcaemia, hypomagnesaemia, hypercholesterolaemia, deranged thyroid function
- Haematological: anaemia, leucopenia, thrombocytopenia
- Neurological: peripheral neuropathy, cerebral pseudoatrophy, ventricular enlargement
- Physical signs: lanugo (thin, fine) body hair, brittle nails, hypothermia
- Musculoskeletal: osteoporosis, proximal myopathy
165
A 73 year old female presents with increasing confusion, lethargy and disorientation. On examination she is obese and has a distinctive deep voice. Her pulse is 40 and BP 110/72. She complains of constipation
```
A. Alzheimer's dementia
B. Creutzfeldt-Jakob Disease (CJD)
C. HIV-associated dementia
D. Hypothyroidism
E. Lewy Body Dementia
F. Neurosyphilis
G. Pick's Disease
H. Subdural Haematoma
I. Vascular dementia
J. Vitamin B12 deficiency
```
D. Hypothyroidism is a reversible cause of dementia and should be excluded in everyone presenting with cognitive impairment in those over the age of 65. Clinical signs and symptoms are hypotension, bradycardia, cold intolerance, confusion and constipation.
166
An 80 year old female presents with longstanding dizziness, weakness and increasing confusion. On examination she has an ataxic gait with loss of vibration sense and proprioception. Fundoscopy reveals optic atrophy.
```
A. Alzheimer's dementia
B. Creutzfeldt-Jakob Disease (CJD)
C. HIV-associated dementia
D. Hypothyroidism
E. Lewy Body Dementia
F. Neurosyphilis
G. Pick's Disease
H. Subdural Haematoma
I. Vascular dementia
J. Vitamin B12 deficiency
```
J - Vitamin B12 deficiency can cause sub-acute combined degeneration of the spinal cord, which is characterised by peripheral neuropathy and loss of joint position and vibration sense. It can also cause dementia. Causes include pernicious anaemia, gastrectomy, Crohn's disease and dietary deficiency
167
A 50 year old male is brought to hospital with a severe chest infection. He has word finding difficulties, apathy, and social withdrawal. On examination he has ataxia, marked tremor, myoclonus and incoordination. Blood tests reveal decreased lymphocytes.
```
A. Alzheimer's dementia
B. Creutzfeldt-Jakob Disease (CJD)
C. HIV-associated dementia
D. Hypothyroidism
E. Lewy Body Dementia
F. Neurosyphilis
G. Pick's Disease
H. Subdural Haematoma
I. Vascular dementia
J. Vitamin B12 deficiency
```
C. HIV-associated dementia is an AIDS-defining illness, and it's clinical features include dementia (subcortical), motor abnormalities (tremor, ataxia, and myoclonus), and mood disturbance (depression, agitation, mania). CT or MRI scans show atrophy. Other HIV associated illnesses such as pneumocystic carinii pneumonia may also be present at the time of presentation
168
A 60 year old male presents with grandiose delusions and hypomania, associated with increasing memory problems. On examination he has brisk reflexes, extensor plantar reflexes and small pupils that are unresponsive to light
```
A. Alzheimer's dementia
B. Creutzfeldt-Jakob Disease (CJD)
C. HIV-associated dementia
D. Hypothyroidism
E. Lewy Body Dementia
F. Neurosyphilis
G. Pick's Disease
H. Subdural Haematoma
I. Vascular dementia
J. Vitamin B12 deficiency
```
F - Neurosyphilis can present with meningovascular syphilis (cranial nerve palsies), focal deficits from gum expansion, raised ICP, delirium and dementia) after 5-25 years, or tabes dorsalis (demyelination of the dorsal roots leading to lightening pains, loss of proprioception, paraesthesia and Charcot's joints) after 8-12 years. A characteristic sign in neurosyphilis is the Argyll Robertson pupils - small bilateral pupils which constrict on accommodation but not reactive to light.
169
A 55 year old male is brought to hospital by his family. They have noticed that over the last 2 years, the patient's personality has changed and he no longer seems to care about anything. He is disinhibited and easily gets into arguments with others. He constantly repeats the same thing and his memory is poor
```
A. Alzheimer's dementia
B. Creutzfeldt-Jakob Disease (CJD)
C. HIV-associated dementia
D. Hypothyroidism
E. Lewy Body Dementia
F. Neurosyphilis
G. Pick's Disease
H. Subdural Haematoma
I. Vascular dementia
J. Vitamin B12 deficiency
```
G - Pick's disease is associated with frontal lobe syndrome - personality changes, social disinhibition, and speech and language abnormalities such as echolalia and perseveration. Cognitive impairment occurs later. There is atrophy of the frontal and temporal lobes. Pick bodies (irregular neurofilament inclusions) and balloon cells are seen histopathologically.
Notes:
A subdural haematoma may present with changes in consciousness, headache and dementia, often weeks or months after the injury causing the bleed.
Dementias are often referred to as cortical or subcortical:
- Subcortical dementia: e.g. Huntington's disease, progressive supra nuclear palsy, HIV associated dementia, usually affect the basal ganglia and are associated with slowing of thought process (bradyphrenia), abnormal movements, and changes in personality. Dysarthria, incoordination and psychomotor retardation may be present.
- Cortical dementia: e.g. Alzheimer's dementia, Pick's disease, are more likely to present with problems in memory, visiospatial problems, agnosia, apraxia, aphasia, and frontal lobe abnormalities. Mood is likely to be euthymic, with an absence of dysarthria and abnormal movements. Coordination is usually normal.
170
A 72 year old male has been experiencing attacks of confusion, memory problems and visual hallucinations over the last year. Each episode lasts for a few weeks and he is fine between these episodes; however, with subsequent episodes his condition seems to be getting worse. His medical history shows BP of 150/101 and he has had TIA's in the past. On examination there is an upping plantar
```
A. Alcoholic dementia
B. Alzheimer's dementia
C. HIV associated dementia
D. Huntington's disease
E. Lewy Body Dementia
F. Normal pressure hydrocephalus
G. Pick's Disease
H. Pseudodementia
I. Vascular Dementia
J. Wilson's Disease
```
I - Vascular dementia is the second most common dementia and accounts for 20% of cases. Features include a sudden onset on symptoms, a stepwise deterioration with periods of intervening stability, and cardiovascular risk factors. Deficits are unevenly distributed with some functions being affected whilst others are spared.
Insight and personality are usually preserved until later on. Depression, a labile affect and confusion are common. Physical signs include a unilateral spastic weakness of all limbs, increased tendon reflexes, an extended plantar response and pseudo bulbar palsy
171
A 78 year old female presents with episodes of wandering at night. She is unable to look after herself and is no longer able to recognise her family. Her MMSE score is 19/30
```
A. Alcoholic dementia
B. Alzheimer's dementia
C. HIV associated dementia
D. Huntington's disease
E. Lewy Body Dementia
F. Normal pressure hydrocephalus
G. Pick's Disease
H. Pseudodementia
I. Vascular Dementia
J. Wilson's Disease
```
B - Alzheimers dementia is the most common cause of dementia, accounting for 70% of cases. Symptoms develop gradually and early symptoms include poor short term memory, wandering, irritability, and deterioration of self care. Receptive and expressive aphasia, apraxia & agnosia may occur. Depression, psychotic symptoms, behavioural disturbances and personality change may occur.
CT scan of the brain may show cortical atrophy, which is marked over the parietal and temporal lobes with ventricular dilatation
172
A 60 year old male is referred to a specialist with cognitive problems. On his arrival it is noted that he has an unsteady gait and he wife also reveals that he has been incontinent
```
A. Alcoholic dementia
B. Alzheimer's dementia
C. HIV associated dementia
D. Huntington's disease
E. Lewy Body Dementia
F. Normal pressure hydrocephalus
G. Pick's Disease
H. Pseudodementia
I. Vascular Dementia
J. Wilson's Disease
```
F - Normal pressure hydrocephalus presents with a triad of cognitive impairment, ataxia and urinary incontinence. Lumbar puncture reveals normal CSF pressure, and CT scan of the brain reveals dilated ventricles. Half of the cases are due to mechanical obstruction to the flow of CSF across the meninges. Treatment is with a ventricle-peritoneal shunt
173
An 82 year old female is convinced that she sees children playing inside her house. Her daughter noticed that her memory tends to fluctuate and that she has recently developed a mild tremor of her right hand. Physical examination reveals cog wheel rigidity and a shuffling gait. When the doctor looking after her administers a small dose of haloperidol, she is found to be very sensitive to this
```
A. Alcoholic dementia
B. Alzheimer's dementia
C. HIV associated dementia
D. Huntington's disease
E. Lewy Body Dementia
F. Normal pressure hydrocephalus
G. Pick's Disease
H. Pseudodementia
I. Vascular Dementia
J. Wilson's Disease
```
E - Lewy Body dementia accounts for 15-20% of cases and is characterised by dementia, parkinsonian features, visual hallucinations (often of people or animals), fluctuating cognitive function, and episodes of confusion. There is a marked sensitivity to anti-psychotics. Patients may present with recurrent falls due to unsteadiness of gait.
174
A 40 year old male is referred to a specialist because of difficulties with his memory. He admits to feeling increasingly depressed over the last 6 months. There is evidence of psychomotor retardation, and the psychiatric assessment is difficult because he answers many of the questions with 'I don't know.'
```
A. Alcoholic dementia
B. Alzheimer's dementia
C. HIV associated dementia
D. Huntington's disease
E. Lewy Body Dementia
F. Normal pressure hydrocephalus
G. Pick's Disease
H. Pseudodementia
I. Vascular Dementia
J. Wilson's Disease
```
H. Pseudodementia - some patients with depression may present with cognitive impairment resulting in a lower than expected score on the MMSE, known as pseudo dementia.
It is difficult to differentiate from dementia and should be suspected if there are biological symptoms of depression and deficits such as apraxia or agnosia are absent. Concentration is partially affected. Individuals often respond to answers on the MMSE just with 'I don't know.' Such difficulties usually resolve with anti-depressant treatment.
Notes:
- Dementia occurs in 20-30% of patients with Parkinson's disease. It may be difficult to differentiate PD from Lewy Body Dementia, but generally if motor symptoms precede the onset of dementia by 12 months a diagnosis of PD is given. Lewy Body's are present in both disorders.
175
A 44 year old African female refugee from a famine stricken area presents with loose stools, cognitive impairment, impairment, and itchy, flaky skin. Her diet in Africa consisted mostly of maize. Her mood is noticeably low with marked apathy. Her family is worried about her as she seems to have lost her interests and is unable to work
```
A. Acute intermittent porphyria
B. Huntington's chorea
C. Multiple Sclerosis
D. Neurosyphilis
E. Pellegra
F. Sporadic CJD
G. Thiamine deficiency
H. Variant CJD
I. Vitamin B12 deficiency
J. Wilson's disease
```
E. Pellagra is a rare condition caused by nicotinic acid deficiency and is characterised by the classic triad of diarrhoea, dementia and dermatitis, although not all symptoms are usually present together. Other features include neuropathy, depression, ataxia and seizures. Nicotinic acid deficiency is seen in this with a poor diet, consisting solely of maize, usually among rural South American's, those from famine stricken areas, prisoners, and sometimes in chronic alcoholics
176
A 35 year old male presents with jaundice and ascites. He has been complaining of tremor in his arms and legs, and has becoming increasingly irritable. His speech is slurred and he has an ataxic gait. His blood tests show elevated liver enzymes and decreased caeruloplasmin levels
```
A. Acute intermittent porphyria
B. Huntington's chorea
C. Multiple Sclerosis
D. Neurosyphilis
E. Pellegra
F. Sporadic CJD
G. Thiamine deficiency
H. Variant CJD
I. Vitamin B12 deficiency
J. Wilson's disease
```
J. Wilson's disease results in the accumulation of copper in the brain and the liver. Urinary copper is increased and serum caeruloplasmin is decreased. Features include tremor, dyskinesia, dysarthria, ataxia, and Kaiser-Fleischer rings on the cornea. Psychiatric features include mood disturbances, dementia, and rarely psychosis
177
A 35 year old female presents with painless loss of vision in one eye, weakness of her right arm and leg, uncontrollable spasms of her muscles, constipation, and urinary retention. Her symptoms worsen after she takes a hot bath. Her family have noticed that her memory has deteriorated and she admits to feeling depressed
```
A. Acute intermittent porphyria
B. Huntington's chorea
C. Multiple Sclerosis
D. Neurosyphilis
E. Pellegra
F. Sporadic CJD
G. Thiamine deficiency
H. Variant CJD
I. Vitamin B12 deficiency
J. Wilson's disease
```
C. Multiple Sclerosis is characterised by plaques of demyelination throughout the CNS. It may present with motor and sensory symptoms, bladder and bowel symptoms, visual problems, depression, dementia and psychosis. Symptoms may worsen due to increased temperature, and this is known as Uhthoff's sign. Lhermitte's sign may also be present (paraesthesia of the limbs on flexing the neck).
178
A 30 year old female presents with peripheral neuropathy, colicky abdominal pain, bulbar palsies and psychosis after being prescribed the oral contraceptive pill. Her urine is noted to be deep red after a period of standing
```
A. Acute intermittent porphyria
B. Huntington's chorea
C. Multiple Sclerosis
D. Neurosyphilis
E. Pellegra
F. Sporadic CJD
G. Thiamine deficiency
H. Variant CJD
I. Vitamin B12 deficiency
J. Wilson's disease
```
A. Acute intermittent porphyria is an AD condition and attacks may be precipitated by many drugs, including anaesthetic drugs, certain Abx, oral hypoglycaemics and the OCP. It is characterised by raised urinary porphobilinogens (red urine). Other psychiatric symptoms include depression and delirium.
179
A 25 year old male is referred to a psychiatrist for anxiety and depressive symptoms. He performs poorly on the MMSE, and on physical examination he has an ataxic gait with evidence of myoclonus. A CT scan of his head reveals atrophy of the cortex and cerebellum, and he has an abnormal EEG.
```
A. Acute intermittent porphyria
B. Huntington's chorea
C. Multiple Sclerosis
D. Neurosyphilis
E. Pellegra
F. Sporadic CJD
G. Thiamine deficiency
H. Variant CJD
I. Vitamin B12 deficiency
J. Wilson's disease
```
H. Variant CJD
CJD is a rare prion disease characterised by parietal lobe symptoms, cortical blindness, myoclonic jerks, speech disturbance and epileptic fits. The variant form mainly affects young males in their 20s, sensory symptoms (pain, numbness, and burning sensation) and psychiatric symptoms (anxiety and depressive symptoms) are usually the reasons for presenting to a doctor. The course of illness is 1-2 years, and patients usually develop personality changes and dementia.
Notes:
Sporadic CJD has an age of onset of 50-70 years, with equal sex distribution. There are cerebellar and extrapyramidal signs, myoclons, and rapidly progressing dementia. Prions are seen primarily in the cortex, and the EEG is characterised by triphasic complexes. Positive FH is seen in 15%. Death occurs within 1 year.
Huntington's disease is a rare autosomal disorder caused by a gene defect that results in the expansion of the trinucleotide sequence CAG. It presents with chorea, personality changes, psychosis and progressive dementia.
Neurosyphilis may present with the 'general paralysis of the insane', in which the patient displays grandiose delusions, mania, dementia and personality change. A significant finding on neurological examination is the Argyll Robertsons pupil, which accommodates but is slow to react to light (prostitute pupils - accommodates but does not react)
180
A 32 year old male presents to hospital with severely depressed mood. On examination, he has central obesity with purple stretch marks on his abdomen. He informs that he has recently gained 15kg in weight and that he tends to bruise easily. His past medical history is significant of a rib fracture he sustained a month ago
```
A. Addison's Disease
B. Cushing's syndrome
C. Diabetes insipidus
D. Diabetes mellitus
E. Hyperparathyroidism
F. Hyperprolactinaemia
G. Hyperthyroidism
H. Hypopituitarism
I. Hypothyroidism
J. Phaecromocytoma
```
B. Cushing's syndrome - excess production of cortisol. Causes of cushion's syndrome include a pituitary tumour (cushing's disease), adrenal adenoma or carcinoma, and iatrogenic (treatment with steroids).
Symptoms include weight gain, amenorrhoea and other menstrual abnormalities, muscle weakness and impotence in men and hirsuitism in women, fractures, depression, euphoria and psychotic symptoms. Signs include purple striae, bruising, myopathy, osteoporosis, HTN and hyperglycaemia.
181
A 55 year old female presents to hospital complaining of feeling depressed and lethargic. She feels that her concentration is decreased and she has trouble sleeping a night. On physical examination she has a left sided colicky abdominal pain radiating to the groin. She scores 20/30 on MMSE, losing points for concentration and memory. Her PMH is significant for a fracture of her humerus
```
A. Addison's Disease
B. Cushing's syndrome
C. Diabetes insipidus
D. Diabetes mellitus
E. Hyperparathyroidism
F. Hyperprolactinaemia
G. Hyperthyroidism
H. Hypopituitarism
I. Hypothyroidism
J. Phaecromocytoma
```
E. Hyperparathyroidism manifests with increased serum calcium, due to the increased levels of PTH. Signs and symptoms are thus secondary to raised calcium, and are commonly known as 'stones (kidney), groans (abdominal pain and myalgia), and moans (psychiatric).' Psychiatric symptoms include depression, delirium and cognitive impairment
182
A 25 year old female presents to her doctor after losing 11 kg in weight. She finds tolerating warm weather difficult, and a complains of loose stools and irregular periods. She also feels embarrassed about her hands shaking. Her partner believes that she has become extremely irritable and agitated recently
```
A. Addison's Disease
B. Cushing's syndrome
C. Diabetes insipidus
D. Diabetes mellitus
E. Hyperparathyroidism
F. Hyperprolactinaemia
G. Hyperthyroidism
H. Hypopituitarism
I. Hypothyroidism
J. Phaecromocytoma
```
G. Hyperthyroidism - causes include Grave's disease, toxic adenoma, multi-nodular goitre, and subacute thyroiditis. Symptoms include weight loss, heat intolerance, sweating, tremor, irritability, anxiety and rarely delirium and psychosis. Signs include tremor, AF, tachycardia, palmar erythema, and lid lag. In Grave's disease exophthalmus, pretibial myxoedema, thyroid acropatchy, and thyroid bruit may occur
183
A 69 year old female is admitted to hospital because of her low mood. Although she is not losing weight, she feels TATT and lacks motivation. Her family are worried about her as she has become increasingly forgetful and has trouble looking after herself. Her physical examination is remarkable for slow reflexes, bradycardia, constipation and a slow hoarse voice
```
A. Addison's Disease
B. Cushing's syndrome
C. Diabetes insipidus
D. Diabetes mellitus
E. Hyperparathyroidism
F. Hyperprolactinaemia
G. Hyperthyroidism
H. Hypopituitarism
I. Hypothyroidism
J. Phaecromocytoma
```
I. Hypothyroidism may occur due to under activity of the thyroid or less commonly due to disease of the hypothalamus or pituitary. The commonest cause is AI disease. it can present with a large number of symptoms, including lethargy, weight gain, cold intolerance, constipation and menorrhagia. Signs include dry skin, loss of eyebrows and slow relaxing reflexes. it may present with psychiatric symptoms such as depression, dementia or psychosis.
184
A 42 year old male complains of 'panic attacks' which have become worse recently. He describes these episodes as anxiety, associated with palpitations, recurrent headaches, and sweating. On examination he was hypertensive and tachycardic, and his urine revealed raised catecholamine levels
```
A. Addison's Disease
B. Cushing's syndrome
C. Diabetes insipidus
D. Diabetes mellitus
E. Hyperparathyroidism
F. Hyperprolactinaemia
G. Hyperthyroidism
H. Hypopituitarism
I. Hypothyroidism
J. Phaecromocytoma
```
J. Phaecromocytoma is a rare tumour that produces catecholamines. The majority of tumours are in the adrenal medulla. Characteristic features include episodes of HTN, palpitations, chest tightness, restlessness, anxiety, sweating, headache, pallor, and weakness. It can be detected by using urinary catecholamine levels.
Notes:
Addison's disease is a rare condition caused by destruction of the adrenal cortex, leading to reduced cortisol, aldosterone and androgen production. The majority of cases in the western world (80%) are due to autoantibodies against the adrenal cortex. It as an insidious onset and may present with lethargy, depression and anorexia, weight loss, hypotension and hyper pigmentation
Hyperprolactinaemia can result from iatrogenic causes (anti-psychotics), prolactinoma, PCOS, chronic renal failure, and hypothyroidism. It manifests with menstrual disruption, galactorrhoea, loss of libido, and impotence.
Causes of hypopituitarism include hypophysectomy, pituitary adenoma (non functioning) and irradiation. Signs and symptoms occur due to deficiency of APH hormones (FSH, LH, TSH). Psychiatric symptoms include depression, cognitive impairment and rarely delirium
