Psychiatry Flashcards
(147 cards)
1
Q
A 79-year-old woman with a diagnosis of Alzheimer’s disease is causing concern as she is constantly getting lost on the way back from the local shop to her home, which is only a short walk and one that she has done nearly every day for 20 years. What sort of memory disturbance does this represent?
a) Autobiographical memory
b) Episodic memory
c) Procedural memory
d) Semantic memory
e) Topographical memory
A
E
Topographical memory loss is failure to orientate oneself.
Autobiographical memory describes specific, personal events such as birthday parties, anniversaries, and holidays. This is also known as explicit memory, or episodic memory.
Procedural memory is also known as implicit memory, such as knowing how to drive, or how to play the piano.
Semantic memory is general knowledge, such as knowing geographical capitals or historical events.
2
Q
A 72-year-old woman who suffers from Alzheimer’s disease is asked who the Prime Minister was during the Second World War, to which she replies ‘Winston Churchill’. She is then asked where she lived during the war, to which she answers ‘Winston Churchill’. What phenomenon is being described here?
a) Confabulation
b) Déjà vu
c) Ganser’s syndrome
d) Jamais vu
e) Perseveration
A
E
Perseveration is almost solely seen in organic brain diseases, such as dementia. It isn’t limited to verbal responses, and can be a response to a motor skill.
Confabulation is the phenomenon of false memories leading to incorrect answers, which can be difficult to differentiate from delusions.
Deja but is a sense of familiarity of having encountered something before, even though it is a new event. It can be a feature of temporal love epilepsy, but is also frequently non-pathological.
Ganser’s syndrome is an unusual phenomenon in which people give approximate answers, such as “How many legs does a cow have?” “Five.” It’s also associated with other dissociative symptoms such as fugue, amnesia, and conversion disorder.
Jamais vu is the sense of never having encountered a familiar situation.
3
Q
A young woman wakes from a nightmare and sees her dressing gown hanging from the door, which she mistakes as an assailant. What is being described here?
a) Affect illusion
b) Completion illusion
c) Pareidolic illusion
d) Tactile hallucination
e) Visual hallucination
A
A
An illusion is a misinterpretation of a perception, and are not usually pathological. An affect illusion is dependent on current emotional state, as in this scenario.
A completion illusion is when there is a lack of attention and perception is incorrectly interpreted, for example skipping over a misprint in a book.
A pareidolic illusion is a shape being seen in other objects, such as animals in the clouds, or Jesus in toast.
A hallucination is a new perception in the absence of a stimulus. The can be tactile, visual, olfactory, auditory, or taste.
4
Q
A young man with schizophrenia describes how he can hear the secret service in their base in Finland discussing their plans to assassinate him. What is this phenomenon known as?
a) Extracampine hallucination
b) Functional hallucination
c) Hypnagogic hallucination
d) Hypnopompic hallucination
e) Reflex hallucination
A
A
Hallucinations are new perceptions in the absence of stimuli. An extracampine hallucination is one that occurs outside the usual range of sensation, in this case, beyond the limits of audibility.
A functional hallucination is experienced only when an external stimulus of the same modality occurs, for example only hearing voices when classical music is playing.
Hypnagogic and hypnopompic hallucinations are those experienced upon falling asleep and waking up respectively, such as the feeling of falling off a cliff when sleeping.
Reflex hallucinations are similar to functional hallucinations but with two different modalities, such as listening to classical music and then having a visual hallucination.
5
Q
A 28-year-old man is diagnosed with schizophrenia, with the belief that he has been targeted for extermination by a religious cult who have implanted tiny electrical ‘ants’ into his fingernails. When asked when he knew this, he said he had seen a magazine story 3 months ago on ‘retiring to the country’ and immediately felt this was a covert message from the cult that he should be ‘retired’. There was no evidence of delusions prior to this. What is being described here?
a) Autochthonous (primary) delusion
b) Autoscopy
c) Delusional atmosphere
d) Delusional memory
e) Delusional perception
A
E
Delusional perceptions occur when a normal perception is invested with delusional meaning.
Autochthonous or primary delusions arise spontaneously with no stimulus. Secondary delusions are similar, but are understandable based on the sufferer’s mood or history.
Autoscopy is the sensation of seeing oneself (for example, out-of-body experiences).
Delusional atmosphere or delusional mood is the sensation that something is ‘going on’ without being able to state what.
Delusional memory is when a patient recalls an event and interprets it with delusional meaning.
6
Q
A 48-year-old man with poorly controlled schizophrenia is admitted to the ward. He appears confused and he is difficult to interview. On asking him why he is in hospital, he replies, ‘Jealousy, the Collaborative, collaborate and dissipate. What’s in my fridge? It isn’t my time.’ How would you describe this type of thinking?
a) Circumstantial
b) Derailment
c) Flight of ideas
d) Pressure of speech
e) Thought blocking
A
B
Derailment is a type of formal thought disorder in which disjointed thoughts occur with no meaningful connections.
Circumstantial thinking occurs when the person talks about a subject exhaustively with only loosely relevant associations.
Flight of ideas is accelerated thinking with logical associations, but with poor attention and rapidly changing goals of thinking. Pressure of speech is the verbal description of flight of ideas.
Thought blocking is when the patient stops mid-sentence without being able to explain why. It is different to thought withdrawal, in which the patient believes an external agency is removing thoughts from their head.
7
Q
Which of the following is not a first-rank symptom of schizophrenia as described by Schneider?
a) Delusional perception
b) Persecutory delusions
c) Running commentary
d) Somatic passivity
e) Thought alienation
A
B
Schneider’s first rank symptoms include auditory hallucinations (often repeating the subject’s thoughts out loud, referring to him/her in 3rd person, or giving a running commentary of thoughts and behaviour); thought insertion, broadcasting, and withdrawal (all by an external agency or body); passivity experiences (the idea that actions, sensations, bodily movements, emotions, or thought processes are generated by an outside agency); primary delusions; and delusional perception.
Persecutory delusions are not a first rank symptom.
The first-rank symptoms are not pathognomic of schizophrenia, and not everyone with schizophrenia experiences first-rank symptoms.
8
Q
A 72-year-old man with Parkinson’s dementia is seen in clinic. He is asked how he is feeling, to which he replies, ‘I feel fantastic…tic…tic…tic…tic…’. What is the name for this type of speech abnormality?
a) Alogia
b) Dysarthria
c) Echolalia
d) Logoclonia
e) Neologism
A
D
Logoclonia is often seen in Parkinson’s and describes the last syllable of a word being repeated.
Alogia is extreme poverty of speech.
Dysarthria is a difficulty in manufacturing speech, usually from structural lesions in the vocal cords or brainstem.
Echolalia is repetition of words or sentences, sometimes continuously or incessantly.
Neologisms are new words created by the patient that have specific meanings, usually to do with their delusional beliefs. This is different to metonymy, which is using known words in a different way.
9
Q
A 26-year-old man is seen by his GP. For the last few months, he has become increasingly concerned about a mole on his cheek, which he feels has got bigger, and people are noticing it more. Over the last week he has become convinced people are laughing at it when he passes them. He has a thought in his head of ‘you’re so ugly, look at the size of that mole’. The patient does not feel he knows where the thought comes from, but it does not seem to be his. He wonders if someone has planted the thought there. The GP does not feel the mole is in any way abnormally sized or has other unusual features. What is the most likely aetiology of these symptoms?
a) Compulsion
b) Delusion
c) Hallucination
d) Rumination
e) Somatisation
A
B
The intrusive thought that the thought is not his own suggests this is a delusion. A rumination would be recognised as being the patient’s own thought.
A hallucination is a perception with no stimulus.
A compulsion is a repetitive act driven by obsessive anxiety.
Somatisation is a physical symptom as a result of intrapsychic anxiety with no adequate physical explanation.
10
Q
Which of the following is not a core symptom of depression as defined by ICD-10?
a) Anergia
b) Anhedonia
c) Anorexia
d) Hyperphagia
e) Insomnia
A
D
The three core symptoms of depression are anergia, anhedonia, and low mood.
Other symptoms according to the ICD10 include low concentration, insomnia, tiredness, low self-esteem, early morning wakening, psychomotor retardation, agitation, loss of appetite, weight loss, and loss of libido.
In atypical depression, symptoms may manifest as hypersomnia, hyperphagia, and weight gain.
11
Q
A 42-year-old man sees his GP after witnessing a horrific motorway pile-up. For the last 6 weeks he has been experiencing recurrent and intrusive images of the even where he relives what happened, both at night and during the day. At night he is also having vivid nightmares about the crash which is now stopping him from going to sleep. He has not driven his car since, although he himself was not involved in the crash. Every time a car starts he jumps and becomes extremely upset. His mood is low and he feels disconnected from his wife and children and he has been thinking about killing himself. What symptom is not being described here?
A) Avoidance B) Detachment C) Insomnia D) Increased arousal E) Night terrors
A
E
Night terrors are not nightmares. The subject does not usually remember bad dreams, but awakes confused and terrified, sometimes lashing out, shouting, and screaming.
Avoidance symptoms, detachment, insomnia, and increased arousal (in jumping at the sounds of car engines) are present here.
12
Q
A 42-year-old man sees his GP after witnessing a horrific motorway pile-up. For the last 6 weeks he has been experiencing recurrent and intrusive images of the even where he relives what happened, both at night and during the day. At night he is also having vivid nightmares about the crash which is now stopping him from going to sleep. He has not driven his car since, although he himself was not involved in the crash. Every time a car starts he jumps and becomes extremely upset. His mood is low and he feels disconnected from his wife and children and he has been thinking about killing himself. What is the most likely diagnosis?
A) Acute stress reaction B) Adjustment disorder C) Depressive episode D) Dissociative fugue E) Post-traumatic stress disorder (PTSD)
A
E
PTSD diagnosis includes exposure to a potentially life-threatening incident, re-experiencing the event in multiple ways (such as nightmares, flashbacks), avoidance of stimuli that recall the event, and increased arousal (including hyper vigilance, increased startle reaction, insomnia, irritability, anger). PTSD sufferers may also have depressive symptoms.
Acute stress reactions subside within hours or days of a stressful event, and cause panic, disorientation, confusion, and other symptoms of anxiety.
Adjustment disorders are a result of a significant life change (such as bereavement or emigration). They cause depression or anxiety with inability to cope with daily tasks.
Dissociative fugue is a period of amnesia during which the sufferer will travel, often for long distances before coming to, resolving usually within weeks or months. They often appear normal to passers-by.
13
Q
A 49-year-old woman with schizophrenia is admitted to the psychiatric unit in a mute state. She is staring blankly ahead and not responding to any commands. She is not eating or drinking and looks dehydrated. Which of the following is least likely to be observed in catatonia?
A) Catalepsy B) Clanging C) Echolalia D) Negativism E) Stupor
A
B
Clanging is a thought disorder whereby words are used based on similar sounds or rhyming, with meaning becoming unimportant. For example ‘ A cat pat on my hat sack, ate the bait and skated.’ Catalonia is a state of either stupor, or excitement. It’s associated with various conditions and various symptoms.
Catalepsy is rigidity of the limbs, with movement into uncomfortable positions being retained. It is not cataplexy, in which there is a sudden transient loss of muscle tone causing collapse.
Echolalia is repetition by sufferers of words spoken to them.
Negativism is a symptom in which catatonic patients do the opposite of what is asked.
14
Q
Which of the following statements regarding the two classification systems in psychiatry (ICD-10 and DSM-IV) is false? Note this refers specifically to the section in ICD-10 related to psychiatry and mental health.
A) Dementia cannot be classified in either of the two systems
B) DSM-IV uses a multiaxial system
C) Homosexuality is no longer a diagnostic category in the two systems
D) ICD-10 was developed by the World Health Organisation (WHO)
E) The first categories in ICD-10 are those related to organic disorders
A
A
Dementia is classified in both systems, though not all subtypes are accurately definable.
DSM-IV uses 5 axes: 1 (clinical disorders), 2 (personality disorders and learning disabilities), 3 (acute medical conditions and physical disorders), 4 (psychosocial and environmental factors contributing to the disorder), and 5 (global assessment of functioning). ICD-10 only has a single category per diagnosis.
15
Q
Which of the following would be the best definition of the term ‘loosening of associations’?
A) A decrease in the amount of words produced by a patient
B) An incompleteness of the development of ideas or thoughts, leading to a lack of logical relationship between them
C) Difficulty in verbalising names of objects, despite being able to describe their function
D) Talking in a roundabout manner before finally answering a question
E) The creation of a new word with particular meaning to the patient
A
B
Loosening of associations is an incompleteness of the development of ideas or thoughts, leading to a lack of logical relationship between them.
Alogia is a decrease in the amount of words produced by a patient.
Nominal dysphasia is difficulty in verbalising names of objects, despite being able to describe their function, and is seen in organic disorders.
Circumstantiality is talking in a roundabout manner before finally answering a question, seen in hypomanic states.
Neologism is the creation of a new word with particular meaning to the patient, seen in schizophrenia.
16
Q
A man is admitted to accident and emergency after being found semi-conscious in the street. He is unkempt and does not have any information on his person; he appears to be homeless. In accident and emergency he has a tonic clonic seizure which is self-limiting after 3 minutes. The man is post-ictal for a short time but soon becomes restless, tremulous and sweaty. His speech is rambling, and he complains about the bed sheets being filthy and ‘filled with mites’. He is tachycardic with a BP or 186/114mmHg. What is the most likely diagnosis?
A) Alcoholic hallucinosis B) Delirium tremens C) Cocaine withdrawal D) Diabetic ketoacidosis E) Opiate overdose
A
B
Delirium tremens is a syndrome caused by alcohol withdrawal in chronic alcohol use or dependency. It’s a medical emergency characterised by autonomic instability, nausea and vomiting, altered mental state, tremor, seizures, and hallucinations. The symptoms appear 6-12h after the last drink and peak at 24-48h.
Alcoholic hallucinosis is another symptom of alcohol withdrawal. It’s quite rare, and involves auditory hallucinations.
Cocaine withdrawal can cause formication, the physical sensation of ants crawling over one’s skin, but does no cause autonomic instability or seizures.
Diabetic ketoacidosis causes severe thirst, abdominal pain, confusion, and decreased level of consciousness.
Opiate overdose causes pinpoint pupils, and respiratory and central nervous system depression.
17
Q
A man is admitted to accident and emergency after being found semi-conscious in the street. He is unkempt and does not have any information on his person; he appears to be homeless. In accident and emergency he has a tonic clonic seizure which is self-limiting after 3 minutes. The man is post-ictal for a short time but soon becomes restless, tremulous and sweaty. His speech is rambling, and he complains about the bed sheets being filthy and ‘filled with mites’. He is tachycardic with a BP or 186/114mmHg. You order a full set of bloods on this man. Which of the following results would be most indicative of the underlying cause of his delirium?
A) Elevated serum glucose B) Elevated serum potassium C) Low mean corpuscular volume (MCV) D) Low serum vitamin B12 E) Raised platelets
A
D
Chronic alcohol use causes B12 deficiency due to poor nutritional intake and the toxic effect of alcohol on bone marrow. B12 is used in DNA synthesis, and deficiency leads to impaired erythrocytes metabolism. This causes a raised MCV. Alcohol can also cause thrombocytopenia, hypoglycaemia, and hypocalcaemia.
18
Q
A 73-year-old woman is admitted to hospital with an infective exacerbation of chronic obstructive pulmonary disease (COPD). Apart from COPD and hypertension, she has no other medical problems. On the third day of her admission, she becomes acutely confused. During the night she is awake, shouting constantly for her husband, claiming that the nurses are prison guards and that they are keeping her against her will. She is slightly calmer the day after. You are the FY1 on call and are asked to come and see her over the weekend as the nurses are worried. It will happen again at night. What should your initial management be?
A) Prescribe clozapine 25mg bd regularly
B) Prescribe haloperidol 2mg intravenously immediately
C) Prescribe lorazepam 0.5mg orally just before bedtime
D) Prescrive lorazepam 0.5mg orally twice daily regularly
E) Prescribe nothing at this stage
A
E
This is delirium, an acute confusional state characterised by a recognised causative factor, older age, and fluctuating confusion.
Managing delirium is conservative unless the patient is putting themself or others at risk of harm. Management may involve using a side room, reassurance, having prominent clocks and appropriate lighting for the time of day, and treating the underlying cause.
If medication is needed, low dose haloperidol is the most useful, but oral prescription would be adequate, unless refusal occurs. As medications can be a cause of delirium, and worsen it, they should only be used if absolutely necessary. BZDs are second-line agents, but again should only be uesd sparingly. Clozapine is used for treatment-resistant schizophrenia, so is not appropriate here.
19
Q
Which of the following medications is most likely to be associated with an organic depressive disorder?
A) Prednisolone B) Sertraline C) Thyroxine D) Tramadol E) Tryptophan
A
A
Prednisolone is a corticosteroid, and may cause mania, psychosis, or depression.
Sertraline may cause a rise in suicidal ideation, however it is debated, and could be a result of side effects such as restlessness (akathisia) rather than an actual organic depressive disorder.
Thyroxine is not associated with depressive disorders.
Tramadol and other opiates are not depressive, and may in fact cause central serotonin release, with antidepressant effects. Augmentation of treatment-resistant depression treatments has been reported with opioid use.
Tryptophan is a precursor of serotonin, and may be used as an augmentation strategy in treatment-resistant depression.
20
Q
A 27-year-old man is involved in a road traffic accident. During rehabilitation, his family have become very upset as they feel that he has ‘changed’. They report that his concentration is poor and at times he is saying very hurtful things to his wife, which they say is extremely out of character. He has also begun eating large quantities of junk food, whereas before he was extremely fit and careful with his diet. Which part of the brain is most likely to have suffered an injury?
A) Basal ganglia B) Frontal lobe C) Limbic structures D) Parietal lobe E) Occipital lobe
A
B
Frontal lobe syndromes tend to cause personality changes including an inappropriate or fatuous affect, lability of mood, hypersexuality, hyperphagia, and childishness. There is no insight into the change, and poor concentration may also occur. Forced utilisation is another phenomonen observed, in which patients must use objects in front of them. Primitive reflexes may also be present.
Basal ganglia injuries cause slowing of movement and lack of spontaneity, and increase in obsessional symptoms. Contusions are uncommon, but cerebral hypoxia can injure them.
Limbic injury would result in some kind of amnesic syndrome.
Partietal lobe lesions are associated with visuo-spatial deficits such as agnosias or dyspraxias. Dysphasias may also occur.
Occipital lobe lesions can cause complex visual disturbances, including Anton’s syndrome, in which the patient is cortically blind with no insight, continuing to affirm adamantly that they can see.
21
Q
A 28-year-old woman is admitted to hospital systemically very unwell, with a reduced level of consciousness, headache, fever, nausea and vomiting, and dysphasia. This is followed by several seizures. initial cerebrospinal fluid analysis shows the CSF is clear, with raised protein, raised mononuclear cell count, no polymorphs, and normal glucose. Her partner says that for the preceding few days she had been acting strangely, seeing things that were not there, accusing him of leaving the gas on and getting very agitated. She then became drowsy and he called the ambulance. Your initial management should be based on which being the most likely diagnosis?
A) Bacterial meningitis B) Herpes simplex encephalitis C) Neurosyphilis D) Sporadic Creutzfeld-Jakob disease (CJD) E) Temporal lobe epilepsy
A
B
HSV encephalitis tends to target the temporal and orbitofrontal structures, causing unusual behaviour or psychotic symptoms, including olfactory hallucinations (as with the gas in this case). HSV encephalitis has a 70% mortality rate, and IV aciclovir is needed as soon as possible. The CSF is in keeping with viral encephalitis.
Bacterial meningitis would give a turbid or purulent CSF, with high polymorphs, high protein, and low glucose.
Neurosyphilis would be uncommon in a woman of this age, though not impossible.
Sporadic CJD presents with rapid onset dementia with associated mood symptoms, spasticity, and blindness.
Temporal lobe epilepsy seizures are gradual in onset characterised by motionless stares and automatisms. Auras are common and may mimic typical psychotic hallucinations of any modality.
22
Q
A 76-year-old man with squamous cell lung carcinoma attends accident and emergency with his wife who is his full-time carer. She has become concerned as he has become extremely depressed over the last couple of weeks, along with being extremely thirsty and having little energy. Up until then he was coping very well with his diagnosis. What is the most likely cause of these symptoms?
A) Hypercalcaemia B) Hypocalcaemia C) Hyperkalaemia D) Hypokalaemia E) Hypophosphataemia
A
A
Hypercalcaemia is a common side effect of cancers. In squamous cell lung carcinoma, it is likely a result of parathyroid-related peptide release causing increased bone turnover, or direct bone invasion. Hypercalcaemia causes kidney stones, bone pain, constipation, depression and confusion. Thirst, nausea, vomiting, and anorexia are also common.
Hypocalcaemia causes peripheral neurological signs, such as hyperreflexia, tetany, paraesthesia, and bruising. Psychiatric symptoms may occur, but with no particular pattern.
Hyperkalaemia causes muscle weakness and fatigue.
Hypokalaemia may cause muscle weakness, fatigue, depression, and anxiety.
Hypophosphataemia usually causes a delirium, with motor problems.
23
Q
A 14-year-old boy, with no prior psychiatric or medical history, is noted to be seriously slipping in his GCSE coursework, after previously being a Grade A student. He has also started behaving recklessly, going out late whereas previously he had been shy with few friends. He is getting into frequent fights at school. Other changes include the onset of tremor and strange writhing movements in his arms. His mother has also noticed that his skin appears to have taken on a yellow tinge. What is the most likely diagnosis?
A) Huntington's disease B) Multiple sclerosis C) Multiple system atrophy D) Wilson's disease E) Young-onset Parkinson's disease
A
D
Wilson’s disease is an autosomal recessive disorder of copper metabolism. This causes copper accumulation in numerous tissues, including the liver and CNS. Kayser-Fleischer rings are also observed. Symptoms include liver failure, aggression, reckless behaviour, disinhibition, and sometimes self-harm.
Huntington’s disease is an autosomal dominant movement disorder. It causes accumulation of inclusion bodies leading to cell death in the basal ganglia, substantia nigra, and cerebellum. This results in choreoid and athetoid movements, dementia, and perosnality changes. It usually presents in the 4th and 5th decades of life.
MS is an inflammatory demyelinating disease. It can be episodic or progressive, and is characterised by a wide range of neurological, psychiatric, and cognitive symptoms.
Multiple system atrophy is a are disease of unknown cause, clinicaly similar to Parkinson’s disease, but with more involvement of the putament and caudate nuclei, and no Lewy bodies in the substantia nigra. Dementia does no occur, but sleep disorders and depression is common.
Juvenile PD is rare and similar to PD, but with more dystonia. Depression may occur, and dementia is almost unheard of in younger patients.
24
Q
Which of the following is the most common psychiatric manifestation following stroke?
A) Anxiety symptoms B) Delusions C) Depressive symptoms D) Hallucinations E) Obsessive-compulsive (OCD) symptoms
A
C
Prevalence of depression in stroke is around 1 in 3, higher than expected from chronic disease alone, suggesting some organic cause.
Psychotic symptoms may occur in 1-2% of stroke patients. Antipsychotics in patients with co-morbid dementia can increase risk of death, so care should be taken.
Anxiety symptoms are seen in up to 1 in 4 stroke patients.
OCD is rare in stroke.
25
```
A 38-year-old man is admitted with a several week history or rapidly deteriorating memory, which he covered to some extent with extensive confabulation. He was also found to be sleeping, drinking, and eating excessively. On examination he was pyrexial. His blood work showed a markedly raised serum osmolality. An MRI shows an intracranial mass. Where is the most likely anatomical location for this lesion?
A) Around the third ventricle
B) Cerebellum
C) Corpus callosum
D) Frontal lobe
E) Pons
```
A
The thalamus and hypothalamus are at the base of the third ventricle, leading to the symptoms described. The raised serum osmolality is a result of cranial diabetes insipidus.
Cerebellar tumours would be less psychiatric, but raised ICP may cause dementia-like symptoms. Symptoms would include signs such as ataxia, and nystagmus.
Corpus callosum tumours produce profound psychiatric problems, and rapid deterioration of higher functions, including catatonia and severe memory problems.
Frontal lobe tumours cause personality change and may be mistaken for dementia.
Pons tumours tend to be aggressive gliomas, presenting with nausea, headache, vomiting, diplopia, drowsiness, and dysarthria.
26
A 34-year-old woman presents to accident and emergency claiming that the devil has returned to earth and is hunting her through her neighbours, who are recording her every movement. The psychiatric assessment shows florid delusions and auditory hallucinations. She has no past psychiatric history. Her husband tells you that she was fine up until 2 weeks ago. Her hands have also been shaking and she has complained that the devil has been torturing her muscles. She has widespread lymphadenopathy and an enlarged spleen. An unusual rash is present across her cheeks and nose, which she says is the brand of the devil. What is the most likely diagnosis?
```
A) Behcet's disease
B) CREST syndrome
C) Graves' disease
D) Systemic lupus erythematosus (SLE)
E) Wegener's granulomatosis
```
D
SLE is an autoimmune connective tissue disorder that can affect any organ in the body. It presents most commonly in women of the 3rd or 4th decade. Neuropsychiatric symptoms such as psychosis, dementia-like illnesses, or affective disorders may present at the beginning of the disease course. Parkinsonism, myalgia, lymphadenopathy, splenomegaly, and the malar rash suggest a functional psychiatric disorder is unlikely, and SLE would explain all of her symptoms.
Behcet's disease is an autoimmune disorder causing recurrent mouth ulcers, genital ulcers, and uveitis.
The CREST syndrome is a type of scleroderma. It is characterised by Calcinosis, Raynaud's phenomonen, oEsophageal atresia, Sclerodactyly, and Telangiectasia.
Graves' disease is an autoimmune thyroiditis, which can occur with SLE, or, more commonly, rheumatoid arthritis. Hyperthyroid signs are seen.
Wegener's granulomatosis is an autoimmune vasculitis that affects the lungs, kidneys, and nervous system. It presents with dyspnoea, cough, haemoptysis, nasal ulceration, sinusitis, systemic symptoms, haematuria, and peripheral neuropathy.
27
Which of the following vitamin deficiencies is most likely to lead to a triad of gastrointestinal disturbance, dermatological symptoms, and a heterogeneous constellation of psychiatric symptoms?
```
A) Niacin
B) Vitamin A
C) Vitamin B1
D) Vitamin C
E) Vitamin D
```
A
Niacin is also known as nicotinic acid. The deficiency is known as pellagra. It causes diarrhoea, anorexia, gastritis, symmetrical bilateral bullous lesions in sun-exposed areas, apathy, depression, and irritability. Later stages can develop to delirum, psychosis, or a Korsakoff-like presentation. Treatment with nicotinic acid leads to prompt and dramatic improvements.
Vitamin A deficiency is associated with night blindness, dry skin, and anaemia.
Vitamin B1 (thiamine) is known as beriberi. It causes neuropathy and heart failure. Acute depletion, as in Wernicke's, leads to encephalopathy.
Vitamin C deficiency causes scurvy, which involves anorexia, diarrhoea, irritability, anaemia, gingival haemorrhage, poor wound healing, leg pain, and swelling over the long bones.
Vitamin D deficiency causes rickets in children and osteomalacia in adults. It may have a role in seasonal affective disorder.
28
Which of the following statements regarding neuropsychiatric manifestations of epilepsy is correct?
A) Automatisms in epilepsy are usually pre-ictal
B) Epilepsy is usually associated with enduring personality difficulties
C) Psychosis is negatively correlated with epilepsy
D) Rates of suicide are higher in people with epilepsy than people not suffering with epilepsy
E) Temporal lobe epilepsy is uaully associated with tonic clonic seizures
D
Epilepsy has many neuropsychiatric and psychological interactions. As well as rates of suicide, co-morbid psychiatric illnesses are higher than in the general population.
Auomatisms are repetitive motor activities observed in most forms of epilepsy, but most often in complex partial seizures (such as temporal lobe epilepsy). They are ictal or post-ictal.
Psychotic symptoms are positively correlated with epilepsy, particularly temporal lobe epilepsy.
Temporal lobe epilepsy is associated with psychological and psychiatric symptoms such as aura, sensory disturbances, depersonalisation, derealisation, deja vu, and jamais vu.
29
Which of the following regarding early-onset dementia (or young-onset dementia (YOD)) is correct?
A) Alzheimer's disease in younger patients is not associated with a family history
B) Alzheimer's disease is an uncommon cause of YOD
C) Dementia is under-represented in Down's syndrome
D) Pick's disease is classically associated with personality change
E) YOD is usually caused by prion diseases
D
Pick's disease is a frontotemporal dementia, presenting in the 6th decade of life. It causes changes in behaviour and personality before amnesia is obvious.
Alzheimer's disease in younger people is associated with inherited genetic mutations, and is the major cause of YOD.
Trisomy 21 confers a much greater risk of dementia, estimated at around 50% of those aged 60 or above.
Prion diseases are very rare, and do cause YOD, but only account for about 1.5%
30
A 19-year-old white woman presents to accident and emergency with abdominal pain, arm weakness and diminished reflexes. She is also extremely agitated and is responding to auditory hallucinations. You are unable to get a history from her, and you call her GP - there is little of note in her history, although she has only been in the practice for a few months as she is a first year student. The only recent entry is a new prescription for the oral contraceptive pill. What is the most likely diagnosis?
```
A) Acromegaly
B) Acute intermittent porphyria
C) Diabetic ketoacidosos
D) Heroin intoxication
E) Sickle cell anaemia
```
B
Acute intermittent porphyria is is a rare autosomal dominant inherited disorder, presenting from the 2nd to 4th decade. It is a haem metabolism disorder causing porpyrins to build up. Attacks are precipitated by menstruation, alcohol, poor nutrition, and certain drugs, including the OCP. It causes abdominal pain and neuropsychiatric symptoms.
Acromegaly is increased growth hormone secretion. It has no psychiatric associations.
DKA could present with abdominal pain, but peripheral neuropathy would be unlikely at this age. Psychosis would also be uncommon, although confusion and low consciousness is common.
Heroin intoxication wouldn't present this way. Withdrawal would cause abdominal cramps and muscle aches, but without frank weakness and changes in reflexes.
Sickle cell anaemia could cause an abdominal crisis, but is unlikely to present this late in age, in a white individual.
31
A 24-year-old student presents with a 3-month history of social withdrawal and low mood. She is difficult to interview because she talks about random themes and has difficulty answering questions. She has vague paranoid ideation. She is childish and pulls faces at you during the interview. The most likely diagnosis is:
```
A) Hebephrenic schizophrenia
B) Catatonic schizophrenia
C) Paranoid schizophrenia
D) Residual schizophrenia
E) Simple schizophrenia
```
A
Schizophrenia is a term that describes multiple disorders. Current classification divides schizophrenia into five subtypes.
Hebephrenic (or disorganised) schizophrenia is predominated by thought disorder and affective symptoms (often childlike and fatuous). Social withdrawal and negative symptoms are common. Psychosis is present, but fragmented and not the most striking feature.
Catatonic schizophrenia is characterised by catatonia, including psychomotor retardation and stupor, or florid over-activity. Unusual symptoms such as automatic obedience or negativism may occur. Waxy flexibility will be seen in the most severe cases. Psychosis, again, is present but is not dominating.
Paranoid schizophrenia is dominated by psychosis, and is thought of the 'classical' subtype.
Residual schizophrenia is late-stage schizophrenia in which positive symptoms are replaced by negative symptoms.
Simple schizophrenia is 'the insidious development of oddities of conduct, inability to meet the demands of society, and decline in total performance' (ICD-10). There are no overt psychotic symptoms.
32
What is the lifetime prevalence of schizophrenia in the UK?
```
A) 0.01 per cent
B) 0.1 per cent
C) 0.4 per cent
D) 4 per cent
E) 10 per cent
```
C
33
A 19-year-old twin is diagnosed with schizophrenia. His mother makes an appointment to see you at the GP practice and asks what the likelihood is of his twin developing schizophrenia. What should you tell her?
A) It is inevitable that schizophrenia will develop in the brother
B) There is no increased risk of developing schizophrenia
C) The risk is about one in 100
D) The risk is about one in 10
E) The risk is about one in two
E
The risk of 1 in 100 is vaguely that of the general population (0.4%), and 1 in 10 is the risk of developing schizophrenia if you have one first degree relative with the disease.
34
A 19-year-old man with schizophrenia is brought to accident and emergency by his sister as he has become unwell over the last few days. He has recently been started on risperidone. He is confused, sweaty, and tremulous. On examination, the signs include tachycardia, low BP, pyrexia, and lead-pipe rigidity. His GCS is decreased, at 12/15. What is the most likely diagnosis?
```
A) Acute dystopia
B) Malignant hyperthermia
C) Neuroleptic malignant syndrome
D) Serotonin syndrome
E) Tyramine reaction
```
C
NMS is a medical and psychiatric emergency. Without treatment, mortality is up to 30%. It's a complication of antipsychotic use. It's thought to be a result of dopamine blockade in the hypothalamus and nigrostriatal pathway, causing pyrexia and extrapyramidal symptoms. Peripheral blockade can exacerbate stiffness and lead to muscle breakdown, rhabdomyolysis and renal failure. Treatment is removal of the offending antipsychotic, and supportive treatment.
Acute dystonias are acute muscular spasms, side effects of antipsychotic use.
35
A 23-year-old man is diagnosed with schizophrenia. He has had florid persecutory beliefs and auditory hallucinations for the past 3 months. In terms of medical history he has poorly controlled insulin-dependent diabetes and is obese. On admission to hospital, he was so distressed that he required intramuscular rapid tranquilization. On administration of 5mg of haloperidol, he developed acute dystonia in his neck muscles which was excruciatingly painful. What would be the most appropriate drug to commence to control his schizophrenia?
```
A) Aripiprazole
B) Clozapine
C) Olanzapine
D) Oral haloperidol
E) Sertraline
```
A
Aripiprazole is a newer antipsychotic and has fewer side effects (less propensity to weight gain, and lower incidence of extrapyramidal side effects). It can cause nausea and insomnia, however.
Clozapine is reserved for treatment-resistant schizophrenia, usually after at least one, or usually two, other antipsychotics have been trialled.
Olanzapine is effective for positive symptoms, but usually causes weight gain and can worsen diabetic control.
Extrapyramidal side effects are caused by oral and IM formulations, so oral haloperidol would not avoid the acute dystonia.
Sertraline is an SSRI, used in depression, and not as an antipsychotic.
36
A 24-year-old man with a diagnosis of schizophrenia, last admitted 6 months ago under Section, is brought in by police to the Mental Health Unit under Section 136. He has been harassing his ex-girlfriend with constant threatening phone calls and turning up at her house. He says he believes she is twisting his bones at night, preventing him sleeping and causing him massive pain, through witchcraft. He states that he is going to kill her if it goes on one more night, and he has purchased a special knife from a ‘witchcraft’ shop on the internet. He is experiencing auditory hallucinations directing him in the best way to use the knife against her. Against the advice of his consultant, he has recently stopped his medication, which usually keeps him well. His symptoms typically follow these themes of violence and the supernatural when unwell. He claims that being in hospital will just allow her to target him more easily, and will not stay voluntarily. What Section of the Mental Health Act is most likely to be appropriate in this case?
```
A) Section 135
B) Section 2
C) Section 3
D) Section 4
E) Section 5(2)
```
C
Section 3 is used to detain people for up to 6 months for treatment (not diagnosis).
Section 2 is used to detain for a maximum of 28 days for assessment and treatment, used when the nature or degree of a patient's condition is unclear.
Section 135 is a warrant allowing police to search premises and remove patients from those premises. It's made by the AMHP to a magistrate. The police in question must be accompanied by an AMHP and a doctor.
Section 4 is an emergency Section used in exceptional circumstances for emergency admission. It requires one AMHP and only one doctor, so is used when two doctors cannot be found for a section 2 or 3.
Section 5(2) is a 72-hour section for inpatients by any fully registered medical practitioner to allow a full MHA assessment to be carried out. Section 5(4) is the equivalent for nurses, but only allows detention for 6 hours.
Section 136 is used if police believe a person has a mental illness and requires care or control. They can take the patient to a place of safety.
37
A 24-year-old man with a diagnosis of schizophrenia, last admitted 6 months ago under Section, is brought in by police to the Mental Health Unit under Section 136. Against the advice of his consultant, he has recently stopped his medication, which usually keeps him well. His symptoms typically follow these themes of violence and the supernatural when unwell. He is admitted under Section 3. On admission to the ward, he is acutely disturbed and becomes violent towards others and himself. He has slapped a member of staff. Staff try to calm him down but it is felt that the risks are escalating. He was prescribed 2mg lorazepam orally which he has spat into the nurse’s face. He has no prior recorded adverse drug reactions. What is the most appropriate pharmacological management of the patient?
A) Haloperidol decanoate (depot) 50mg intramuscular
B) Haloperidol 10mg orally
C) Lorazepam 2mg intramuscular
D) Lorazepam 2mg slow intravenous injection
E) Propofol 120mg intravenous injection
C
Rapid tranquilisation is used when senior advice says that non-pharmacological methods have failed and risks to the patient or others are sufficiently high.
IM lorazepam is commonly used for rapid tranquilisation. It's often combined with IM haloperidol (non-depot). These patients should be monitored by nursing and medical staff to ensure no respiratory depression or other side effects occur. It should not be given without ensuring a supply of flumazenil (a BZD antagonist).
Haloperidol decanoate is a depot medication and would not have an immediate effect.
Lorazepam can be given as a slow IV injection but is more likely to cause respiratory depression when given this way.
Propofol is used to induce anaesthesia, not to tranquilise.
38
A 22-year-old man with paranoid schizophrenia has been treated with three different antipsychotics and remains unwell. His team decide to prescribe clozapine which he has now been on for 3 weeks. He comes in for his regular blood test and the nurse in the clozapine clinic asks the junior doctor to see him as he appears unwell. On examination, he is sweaty and tachycardic with a temperature of 38.5 degrees Celsius. He has no chest pain but is coughing purulent sputum. What would the most likely isolated abnormality be on blood testing?
```
A) High eosinophil count
B) High platelet count
C) Low haemoglobin
D) Low lymphocyte count
E) Low neutrophil count
```
E
Clozapine can cause neutropenia, and even agranulocytosis.
These symptoms could also be neuroleptic malignant syndrome, but that usually causes raised leukocytes, which is not an option here.
Eosinophilia is a described side effect of clozapine, but is likely to be related to side effects of myocarditis and colitis, not those mentioned here.
Similarly, thrombocytopenia and anaemia have been described with clozapine, but neither would cause this clinical picture.
Low lymphocyte count may be part of an overall decrease in all white blood cells, but wouldn't be found as an isolated abnormality.
39
A 54-year-old man with schizophrenia has been on depot antipsychotics for the last 27 years as he hates taking tablets and has stopped them in the past. He has not been unwell in terms of his schizophrenia for the last decade. His community psychiatric nurse notices that he has developed odd movements around his mouth over the last few months, where he purses and smacks his lips. It is causing him difficulty speaking and is distressing for him and his family. Which is the most appropriate course of action for managing this symptom?
A) Gradual decrease in depot medication
B) Offer emotional support
C) Start anticholinergic such as procyclidine
D) Start ‘second-generation’ antipsychotic such as olanzapine
E) Stop depot immediately to prevent further deterioration
A
This symptom is tardive dyskinesia (TD), which is a side effect of long term antipsychotics. As the patient has been well for so long, a gradual decrease in medication could be tried with extreme caution and regular medical supervision. 50% of cases improve after this course of action. There may be a paradoxical increase in TD initially.
Anticholinergics can exacerbate TD.
Olanzapine and other second-generation antipsychotics tends to cause TD less than others, but as this patient is against oral medication, this wouldn't work.
Antipsychotics should not be discontinued abruptly, unless an emergency such as neuroleptic malignant syndrome occurs.
40
A 22-year-old single man is diagnosed with schizophrenia. This is followed by a very rapid psychotic breakdown characterised by well-defined persecutory delusions. There is no mood component to his symptoms. He has shown a poor response to treatment. Which of the following indicates a positive prognostic feature of this man’s illness?
```
A) Absence of mood symptoms
B) Being male
C) Being young
D) Poor initial response to treatment
E) Rapid onset of symptoms
```
E
Rapid onset confers a positive prognosis in schizophrenia. All other options are associated with poorer prognosis. As well as those mentioned, poor prognostic markers include lack of social networks, being single, poor pre-morbid educational attainment, having predominantly negative symptoms, and having a long duration of illness before treatment.
41
A 38-year-old single woman is arrested outside the house of a celebrity TV chef after shouting outside all night. On interview, she claims that the man has declared his love for her several times, but is being prevented from seeing her by his wife, who is keeping him handcuffed inside. She states it is he that has made several advances to her by sending her special messages when he is cooking on television. What syndrome or symptom is being described here?
```
A) Capgras syndrome
B) de Clerambault’s syndrome
C) Folie a deux
D) Othello syndrome
E) Querulant delusions
```
B
de Clerambault's syndrome is also known as erotomania. It involves the sufferer becoming delusionally convinced that someone famous has become infatuated with them. It is more common in women.
Capgras syndrome is when the sufferer believes a person close to them has been replace by a double.
Folie a deux is a rare phenomenon where two people in a close relationship develop the same delusional beliefs.
Othello syndrome is a disease of delusional jealousy, more common in men. There is potential for violence.
Querulant delusions lead to sufferers having sustained and excessive complaints and litigations against authorities, ending up in lengthy and tangled legal battles.
42
A 27-year-old man has been started on haloperidol, a ‘first-generation’ antipsychotic, for control of his symptoms of schizophrenia. A few weeks later, he comes to his GP in a highly embarrassed state, claiming that the CIA are experimenting on him, turning him into a woman. When the GP asks how he knows this, the man states that he has noticed his chest growing into ‘breasts’ and he can no longer get an erection with his girlfriend. What is the most likely cause of these symptoms?
```
A) Alpha-blockade
B) Drug-induced hepatitis
C) Hyperprolactinaemia
D) New-onset diabetes
E) Prostatic hypertrophy
```
C
Hyperprolactinaemia is a common side effect of antipsychotics, including second-generation. Dopamine blockade of the tuberoinfundibulnar pathway causes prolactin secretion, leading to gynaecomastia, and sexual dysfunction.
Alpha-blockade would cause sexual dysfunction but not gynaecomastia.
Drug-induced hepatitis is rare with haloperidol, and would rarely present with these symptoms.
Diabetes is unlikely to cause these symptoms in the early stages, however chronic poor control could lead to kidney failure and therefore gynaecomastia.
Prostatic hypertrophy is rare in such young men, although it can be worsened by some antipsychotics.
43
Which of the following is not recognised as a diagnostic feature of schizophrenia according to ICD-10?
```
A) Formal thought disorder
B) Grandiose delusions
C) Running commentary
D) Symptoms lasting at least 1 month
E) Thought broadcasting
```
B
Grandiose delusions are more commonly associated with mania.
The ICD-10 requires over one month of symptoms including 'thought echo; thought insertion or withdrawal; thought broadcasting; delusional perception and delusions of control; influence or passivity; hallucinatory voices commenting or discussing the patient in the third person; thought disorders and negative symptoms.'
44
A 28-year-old woman presents in the GP surgery. She is over-talkative and over-familiar with you. It is difficult to get a full history, but it seems for the last 4 weeks she has been elated and experiencing voices telling her that her mother was a descendent of the Virgin Mary and that she is a female ‘second-coming’. This was the result of an experiment by the Nazi party who genetically engineered her grandparents. She believes that the remnants of the Nazi party are now controlling her arms and legs, which results in her alternately trying to hug you and then kicking out at the desk. What is the most likely diagnosis?
```
A) Hebephrenic schizophrenia
B) Induced delusional disorder
C) Paranoid schizophrenia
D) Schizoaffective disorder
E) Schizotypal disorder
```
D
This appears to be schizoaffective disorder of the manic type. Here, schizophrenic symptoms (delusions of passivity, auditory hallucinations) with affective disorder (manic symptoms) presenting within the same episode lead to this diagnosis.
Hebephrenic schizophrenia is a childish affect with fleeting delusions or hallucinations.
Induced delusional disorder is another term for folie a deux.
Paranoid schizophrenia would be a possible diagnosis, but delusions would be expected to be more paranoid in nature, without such florid affective symptoms.
Schizotypal disorder is a personality disorder characterised by eccentric behaviours and beliefs mimicking schizophrenia without any definite psychotic symptoms.
45
Which of the following is the least likely to be a side effect of antipsychotic treatment?
```
A) Akathisia
B) Convulsions
C) Hypotension
D) Renal failure
E) Tachycardia
```
D
Antipsychotics cannot cause renal failure except for in cases of neuroleptic malignant syndrome leading to rhabdomyolysis.
Akathisia or restlessness is common as an extrapyramidal side effect.
Antipsychotics can lower the seizure threshold, especially clozapine.
Hypotension is possible in adrenergic blockade, so medications are titrated to prevent sudden hypotension and collapse.
Tachycardia is a side effect of antipsychotics.
46
A 35-year-old woman complains of low mood after the death of her husband in a car-accident. She does not speak and remains immobile for long periods. What is the most likely diagnosis?
```
A) Seasonal affective disorder
B) Dysthymia
C) Atypical depression
D) Depressive stupor
E) Post-partum depression
```
D
Depressive stupor is characterised by mutism and akinesia. Severe psychomotor retardation can lead to dehydration and pressure sores.
SAD is depressive symptoms that recur in winter months.
Dysthymia is chronic low grade mood symptoms not amounting to a depressive illness.
Atypical depression is a depressive episode with weight gain, increased appetite, and hypersomnia.
47
A 45-year-old female has had persistent mild depressive features since her late teens. She sometimes experience loss of energy and tearfulness. She believes her low mood began after she was abused by her step-father as a teenager. She has no other symptoms. What is the most likely diagnosis?
```
A) Depressive episode
B) Recurrent depressive disorder
C) Dysthymia
D) Cyclothymia
E) Bipolar affective disorder
```
C
Dysthmia is chronic low grade mood symptoms not amounting to a depressive illness.
Depressive episodes are classified as one core symptom (low mood, anhedonia, and anergia) for a minimum of two weeks.
Recurrent depressive disorder is associated with repeated episodes of depression with euthymic intervals.
Cyclothymia is a persistent instability of mood with a cycle of low grade elevated and depressed mood.
Bipolar disorder is characterised by discrete episodes of mania or hypomania which may or may not be accompanied by episodes of depression.
48
What is the most likely condition causing a depressive episode in a 76-year-old man with a history of smoking and hypertension?
```
A) Multiple sclerosis
B) Parkinson's disease
C) Huntington's disease
D) Stroke
E) Spinal cord injury
```
D
30% of stroke patients develop depression, and this patient has a history of risk factors.
MS is sometimes associated with depression or elevation of mood.
PD is associated with depression, as is Huntington's disease, and spinal cord injury.
49
A 35-year-old female visits her GP complaining of low mood and weight loss. On questioning she also experiences fatigue which is exacerbated by pain in her legs. Blood tests reveal high potassium. Which of the following is most likely to cause her depression?
```
A) Cushing's disease
B) Addison's disease
C) Hypothyroidism
D) Primary hyperparathyroidism
E) Premenstrual tension syndrome
```
B
Adrenocortical insufficiency causes fatigue, myalgia, joint pain, skin tanning, hyponatraemia, hyperkalaemia, and depression.
Cushing's disease is high cortisol leading to irritability, aggression, and depression.
Hypothyroidism can cause depressive symptoms.
Primary hyperparathyroidism causes decreased PTH and increased calcium (moans, bones, groans, and stones).
Premenstrual tension syndrome is characterised by low mood, irritability, and stress, associated with the menstrual cycle.
50
A 43-year-old female visits her GP complaining of a 4-week history of fever, fatigue, low mood, and lower back pain. She had visited China in the previous month and mentioned she was drinking plenty of goat's milk as this was the only type of milk available. What is the most likely infective cause?
```
A) Hepatitis C
B) Infectious mononucleosis
C) Herpes simplex
D) Brucellosis
E) Syphilis
```
D
Brucellosis is a contagious zoonosis transmitted via unpasteurised goat's milk or contact with infected animals. It causes fever, headaches, fatigue, pain, and depression.
Hepatitis C is a blood borne virus, causing fever, appetite loss, and nausea. It can cause depression.
Infectious mononucleosis is caused by EBV with fever, sore throat, fatigue, and depression.
HSV can sometimes cause depressive symptoms.
Syphilis is a STD that may lead to neurological involvement, associated with psychosis, dementia, mania, and depression.
51
A 35-year-old woman has had a low mood for 2 months associated with fever, fatigue, and joint pain. She has a rash on her face which gets worse with exposure to the sun. What is the most likely cause of her low mood?
```
A) Pancreatic cancer
B) Systemic lupus erythematosus (SLE)
C) Rheumatoid arthritis
D) Porphyria
E) Pellagra
```
B
SLE is a multiorgan autoimmune disease associated with anti-nuclear antibodies. It can cause headaches, depression, and seizures.
Pancreatic cancer and RA are associated with depression.
Porphyrias are associated with anxiety, hallucinations, and depression.
Pellagra is caused by vitamin B3 deficiency with sensitivity to sunlight, dementia, and diarrhoea.
52
Which of the following is most likely to cause depression?
```
A) Methyldopa
B) Atenolol
C) Ibuprofen
D) Prednisolone
E) Amlodipine
```
D
Corticosteroids are associated with mania and depression.
Methyldopa's side effects include depression, suicidal ideation, and nightmares.
Propranolol may cause depression as it can cross the blood-brain barrier, but atenolol cannot.
Ibuprofen is rarely associated with depression.
Amlodipine has an occasional side effect of depression, as with all calcium channel blockers.
53
A 25-year-old woman visits her GP complaining of low mood, fatigue, and weight gain. She is observed to be wearing several layers despite its being a warm day. On examination, she is found to have a pulse rate of 55. What is the most likely underlying diagnosis?
```
A) Cushing's disease
B) Hypocalcaemia
C) Addison's disease
D) Hypothyroidism
E) Diabetes mellitus
```
D
Hypothyroidism is associated with fatigue, weight gain, cold intolerance, and depression. Bradycardia and slow-relaxing reflexes may occur.
Cushing's disease, Addison's disease, and diabetes mellitus are associated with depression, but not the rest of the clinical picture.
Hypocalcaemia is rarely associated with depression.
54
A 45-year-old woman is taken to see a GP by her husband. He mentions that his wife has been irritable for the last two weeks. She is not sleeping well and on examination she has pressure of speech and mild elation. She is not hallucinating and there is no evidence of delusional thinking. What is the most likely diagnosis?
```
A) Hypomania
B) Mania
C) Cyclothymia
D) Agitated depression
E) Bipolar affective disorder
```
A
Hypomania is elevated mood or irritability, interfering with activities of daily living without being severely disruptive or associated with psychological symptoms.
Mania is significantly elevated mood affecting work and social activities, lasting over a week, often with mood-congruent psychotic features.
Cyclothymia is persistent instability of mood.
Agitated depression presents with irritability and anxiety, but not elation.
Bipolar affective disorder is diagnosed if two or more affective episodes have occurred, one of which must be mania or hypomania.
55
A 25-year-old man with bipolar disorder is seen on the psychiatric ward by a medical student. Taking a history is not easy, as the patient continually wants to speak. The patient is difficult to interrupt. What feature of mania is demonstrated by this patient?
```
A) Elevated mood
B) Poor concentration
C) Flight of ideas
D) Pressure of speech
E) Impaired judgement
```
D
Pressure of speech is a result of pressure of thought.
Elevated mood may be overly cheerful or irritable.
Flight of ideas is a patient's thoughts moving from topic to topic, although there is usually a connection between the ideas.
56
A 25-year-old man is seen in accident and emergency with an elevated mood and mild signs of meningism. He has a low grade fever and a bullseye rash is seen on his left lower arm. What is the most likely diagnosis?
```
A) HIV
B) Lyme disease
C) Encephalitis
D) Neurosyphilis
E) Meningococcal septicaemia
```
B
Lyme disease is a bacterial disease transmitted by ticks causing fever, headache, fatigue, and mood changes. An expanding bullseye rash known as erythema chronic migraines occurs.
HIV can cause manic symptoms.
Encephalitis can cause confusion, headaches, cognitive decline, and mania.
Syphilis is a STD that may lead to neurological involvement, associated with psychosis, dementia, mania, and depression.
Meningococcal septicaemia presents as acutely unwell, not with psychological symptoms.
57
According to the ICD-10, which of the following is a core feature of depression?
```
A) Anergia
B) Diurnal variation of mood
C) Loss of appetite
D) Suicidal ideation
E) Waking early
```
A
The core symptoms are anergia, anhedonia, and low mood. At least one feature must be present for at least 2 weeks.
Biological features include change of appetite and weight, change in sleep pattern, loss of libido, and diurnal variation of mood (worsening in the morning).
Psychological features include feelings of guilt and hopelessness, poor concentration, low self-esteem, and suicidal ideation.
58
Which of the following antidepressants is not a serotonin specific reuptake inhibitor (SSRI)?
```
A) Citalopram
B) Fluoxetine
C) Mirtazapine
D) Paroxetine
E) Sertraline
```
C
Mirtazapine is a noradrenergic and specific serotinergic antidepressant with a tetracyclic structure. It is often used second-line, and does not usually cause nausea or weight loss. It can induce sleep.
59
Which of the following is a significant risk factor for depression?
```
A) Education to degree level
B) Male gender
C) Obesity
D) Older age
E) Social isolation
```
E
Risk factors include family history, female gender, childhood abuse, poverty, and social isolation.
Education may be protective.
Obesity and older age do not affect risk.
60
Which of the following statements is most consistent with a diagnosis of psychotic depression?
A) The bank has said I'm bankrupt and are going to sell all my clothes
B) I have developed a special computer program which will cure people of depression
C) The Queen is hiding in the police station and controls my movements through the radio
D) I'm worried I have got cancer and will die soon
E) The prime minister was on the radio last and told the country how much he was in love with me
A
Psychotic depression involves mood-congruent delusions and hallucinations, including those of poverty or self-worth.
Manic delusions are often grandiose.
Schizophrenic delusions tend to be bizarre, with passivity or thought alienation.
Option E is suggestive of de Clerembault's syndrome, occurring in mania or schizophrenia, but rarely depression.
Option D is non-delusional ideation, not held with subjective certainty.
61
Which of the following is the most significant risk factor for completed suicide?
```
A) Female sex
B) Older age
C) Previous suicide attempt
D) Obsessive-compulsive symptoms
E) Unemployment
```
C
1% of people who attempt suicide will kill themselves in the following year.
Suicide is more common in men and the unemployed. Older age used to be a risk, but recent data has shown that is no longer the case.
Obsessive-compulsive disorder may be protective.
62
Which of the following symptoms is a recognised psychological symptom of depression?
```
A) Diurnal variation of mood
B) Nihilism
C) Loss of libido
D) Decreased appetite
E) Early morning waking
```
B
Symptoms of depression include the core symptoms (anergia, low mood, anhedonia), psychological symptoms (feelings of guilt and hopelessness, poor concentration, low self-esteem, suicidal ideation), and biological features (change of appetite and weight, change in sleep pattern, loss of libido, diurnal variation of mood).
63
Which of the following is not a typical feature of anxiety?
```
A) Constipation
B) Dyspnoea
C) Fear
D) Palpitations
E) Tremor
```
A
Anxiety includes psychological symptoms (intense worries, fear, irritability, hypersensitivity to noise, poor concentration, avoidance), and somatic symptoms (dry mouth, abdominal discomfort, diarrhoea, dyspnoea, hyperventilation, palpitations, tachycardia, urgency, impotence, tremor, headache, sleep disturbance).
64
A 46-year-old woman is referred to secondary psychiatric services by her GP. Over the last 6 months she has suffered multiple losses, including the death of her sister, and a close friend. She lives alone with few social contacts. She has become extremely withdrawn, and is leaving the house less, stating that she gets 'terrified that I won't be able to get back to my house'. She reports that when she does go out, she feels breathless, sweaty, and like 'she might faint and make a fool of myself'. What is the most likely diagnosis?
```
A) Agoraphobia
B) Generalised anxiety disorder (GAD)
C) Obsessive-compulsive disorder (OCD)
D) Panic disorder
E) Social phobia
```
A
Agoraphobia is a fear of being out of the house, on public transport, in crowds, or other situations difficult to escape from. Avoidance and anticipatory anxiety are common.
GAD is persistent anxiety not restricted to a particular stimulus. It often coexists with depression, but are separate entities.
OCD is characterised by obsessive, intrusive thoughts, and irresistible compulsions.
Panic disorder is characterised by panic attacks (intense fear of imminent doom, going mad, or losing control; choking feeling; hyperventilation) but with no stimulus. Panic attacks can occur in agoraphobia, but in reponse to stimulus.
Social phobia is excessive worry about social situations such as public speaking. Alcohol misuse is often co-morbid as a relaxant in these situations.
65
A woman is diagnosed with agoraphobia. She is willing to try any form of treatment as her condition is very disabling. Which of the following management options would not be considered appropriate in the overall management of agoraphobia first line?
```
A) Cognitive behavioural therapy
B) Exposure therapy
C) Lorazepam
D) Paroxetine
E) Psychoeducation
```
C
BZDs should be avoided where possible, but prescribed in short bursts for severe anxiety. Lorazepam, however, is very short acting, so in this case diazepam would be more appropriate.
CBT identifies automatic negative thoughts and identifies behavioural patterns to help break vicious cycles.
Exposure therapy is a form of CBT involving gradual exposure to the anxiety-provoking stimulus.
Paroxetine is an SSRI. SSRIs have use for anxiety disorders, but may cause a paradoxical worsening of symptoms for the first few days.
Psychoeducation is very important to explain the nature of the patient's disease to them, as mental health disorders tend to be misunderstood.
66
Which of the following statements concerning social phobia is correct?
A) Beta-blockers are of no therapeutic value in social phobia
B) Genetic factors do not have a role in the aetiology of social phobia
C) It only arises as the result of a particularly stressful social episode
D) Men are less likely to report symptoms of social phobia than women
E) Social phobia most commonly manifests before puberty
D
Social phobia is equally prevalent in men and women, but men tend to report symptoms less.
Beta blockers can be used alongside psychological interventions as symptom relievers.
Population and twin studies confirm that social phobia has genetic components.
Most cases develop as a result of a critical event, but can develop without.
It tends to develop in the late teens or third decade.
67
Which of the following statements regarding generalised anxiety disorder (GAD) is incorrect?
A) GAD is more common in women than men
B) GAD may be mistaken for a physical disorder
C) GAD may be triggered by stressful events
D) Physical disorders may be mistaken for GAD
E) The presence of major depression excludes a diagnosis of GAD
E
Anxiety and depression tend to overlap, and both are risk factors for the other. The diseases are separate entities, though, so neither trumps the other.
GAD has a prevalence rate of 3% in adults, and affects women more than men.
GAD is often misdiagnosed as a physical disorder (especially in the elderly) and vice versa.
68
Which of the following statements regarding theories of anxiety is correct?
A) Cognitive theories propose that anxiety is the result of distorted thinking, such as catastrophising and labelling
B) Freud believed that anxiety was the result of conscious conflict
C) Neurobiological theories implicate dopamine as the most commonly involved neurotransmitter
D) The psychoanalytic theory argues that secure attachment is a primary cause of anxiety
E) The adaptive theory of anxiety is a maladaptive process
A
Freud believed anxiety was a result of intrapsychic, unconscious conflict.
Neurobiological theories implicated non-dopaminergic pathways, including the noradrenergic, GABAergic and sertoninergic pathways.
Secure attainment is protective of anxiety, but attachment problems may cause separation anxiety.
The adaptive theory suggests anxiety exists as an evolutionary advantage due to the fight or flight response. Anxiety below a certain point can improve performance.
69
Which of the following statements regarding OCD is correct?
A) OCD affects women and men equally
B) OCD is the most common anxiety disorder
C) The fear of contamination is a common compulsion
D) The compulsions in OCD cannot be resisted
E) The obsessive thoughts in OCD do not usually feel unpleasant
A
OCD affects men and women equally, often with onset in the third decade of life. Lifetime prevalence is around 2-3%, but OCD is one of the less common anxiety disorders.
Contamination fear is common, but is an obsession, not a compulsion. Obsessions are recurrent and intrusive words, images, ideas, and beliefs, that are always unpleasant for the sufferer, interfering with their everyday life.
Compulsions are repetitive behaviours or mental acts in response to obsessional thoughts. The compulsions are recognised to be maladaptive, but resistance leads to increased anxiety and sufferers will succumb.
70
Which one of the following statements regarding OCD is incorrect?
A) Antidepressants do not have a role in the management of OCD
B) Preventing patients from performing compulsions in a mainstay of behavioural therapy
C) Streptococcal infections may precipitate OCD in children
D) People with OCD know the intrusive thoughts are their own
E) Tourette's syndrome and OCD are interrelated disorders
A
SSRIs have significant anti-obsessional properties.
Prevention in the mainstay of psychological therapy.
Beta-haemolytic streptococcal infections in children can occasionally lead to an autoimmune reaction known as PANDAS (Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections). It can cause OCD and tic disorders.
Tic disorders and OCD appear to be related, thought to be due to basal ganglia changes.
71
Which of the following statements regarding somatoform and dissociative disorders is correct?
A) Amnesia may be a form of dissociation
B) Body dysmorphic disorder (BDD) involves a psychotic belief about one's body
C) Cultural differences are not important in the diagnosis of somatoform disorders
D) Hypochondriasis implies there is nothing wrong with the patient
E) Multiple personality disorder has a prevalence roughly equal to that of schizophrenia
A
Dissociation refers to a loss of integration between consciousness, memory, perception, identity, and bodily movements. This includes amnesia.
BDD is a hypochondriacal disorder involving persistent preoccupation that one's body is disfigured or abnormal. This is an overvalued idea, not a delusion.
Cultural differences have a huge impact on diagnosis of somatoform disorders. For example, trance states are seen as abnormal in the West, but can be normal in some societies.
MPD is more correctly termed as dissociative identity disorder (DID). It is very rare and poorly understood.
72
A 42-year-old man is involved in a serious road traffic accident caused by a drunk driver. He is hospitalised for several weeks. Following discharge, friends and family notice that he is not going out, has become withdrawn and appears frightened and anxious all the time. He reluctantly agrees to see his GP. Which of the following would not be consistent with a diagnosis of post-traumatic stress disorder (PTSD)?
```
A) Diminished startle response
B) Flashbacks of the accident
C) Hypervigilance
D) Poor concentration
E) Reluctance to drive
```
A
PTSD involves exaggerated sensitivity and psychological arousal, poor sleep, poor concentration, irritability, anger, hypervigilance, flashbacks, vivid nightmares, and avoidance.
73
Which of the following findings on a MRI scan would be most consistent with a diagnosis of early Alzheimer's disease?
```
A) Caudate atrophy
B) Cerebellar atrophy
C) Frontal atrophy
D) Hippocampal atrophy
E) Periventricular white matter lesions
```
D
Hippocampal volume loss, generalised cerebral atrophy, and enlarged ventricles are the common findings in early Alzheimer's disease.
Caudate, cerebellar, and frontal atrophy occur later in disease.
Periventricular white matter lesions are associated with vascular dementia.
74
Which of the following modes of action of currently available pharmacological agents are thought to target some of the symptoms of dementia?
A) Drugs which decrease the levels of serotonin in the brain
B) Drugs which increase the levels of dopamine in the brain
C) Drugs which increase the levels of acetylcholine in the brain
D) Drugs which decrease the levels of histamine in the brain
E) Drugs which increase the levels of GABA in the brain
C
Current medications block acetylcholinesterase to increase levels of ACh.
Serotonin levels are not decreased by any licensed drugs, but can be decreased after ecstasy causes massive release leading to subsequent depletion of available serotonin, and thus depressive symptoms.
Dopamine is increased by Parkinson's disease drugs.
Antihistamines can cause confusion in old age.
GABA is the target of BZDs.
75
A 79-year-old married woman comes to see her GP with her husband. The husband reports his wife has a history of several months of deteriorating memory and is now forgetting names and faces. He also explains that at times she seems much more lucid, but there are occasions where she becomes very forgetful and confused, sometimes saying there are people sat in the living room with them, which they both find distressing. More recently she has developed a tremor in her left hand. What is the most likely diagnosis?
```
A) Alzheimer's disease
B) Lewy body dementia
C) Parkinson's dementia
D) Pick's disease
E) Vascular dementia
```
B
Lewy bodies are cytoplasmic inclusions associated with disorders such as Parkinson's disease. In dementia with Lewy bodies (DLB), a triad of symptoms is seen: visual hallucinations, fluctuating cognitive impairment, and parkinsonism.
Psychotic symptoms are less common in AD.
Parkinson's dementia occurs in 30% of people with Parkinson's disease. In this case, parkinsonism precedes the cognitive symptoms, whereas in DLB the parkinsonism's onset is about 1 year after the other symptoms begin.
Pick's disease is also known as frontotemporal dementia (FTD). There is a significant familial component, and it presents in the 5th and 6th decades of life. It's characterised by disinhibition, aggression, and antisociality.
Vascular dementia can present in many ways depending on the part of the brain affected, but shows a step-wise deterioration.
76
Which of the following features would suggest a diagnosis of depression rather than dementia in a patient presenting with memory loss?
```
A) Delusions
B) Fluctuating conscious level
C) Low mood
D) Poor verbal fluency
E) Excessive worry over memory loss
```
E
Depression in older age typically presents with cognitive difficulties. Subjective and excessive worrying over memory is not characteristic of dementia, however, as insight is typically lost.
77
Which of the following statements most accurately reflects depression in older age?
A) Anxiety states are uncommon in depressive disorders in older age
B) Depression in older age is not associated with deliberate self-harm
C) Depression is less common in residential homes than in the general community
D) Old age is a risk factor for depression
E) Somatization is a common presentation of depression in old age
E
Somatisation is a common psychological symptoms of the very young and very old. It is important however to not assume a somatic symptom is a result of depression.
Anxiety is a common presentation of depression in the elderly.
Self-harm in the elderly does occur, and often with a high level of suicidal intent.
Nursing homes have a rate of depression up to 3 times higher than in the community.
Age alone is not a risk factor for depression, but chronic diseases and age-related co-morbidities are.
78
A 90-year-old woman is admitted to the psychiatric inpatient unit with severe depression. She has the following medical history: end-stage chronic renal failure, hypertension, type 2 diabetes controlled with oral hypoglycaemic, and has had a stroke 3 years ago leaving her with some slight speech slurring. Which of the following statements is false?
A) An SSRI would be a safe choice
B) BZDs should not be prescribed routinely for this patient
C) ECT would be contraindicated because of the stroke
D) Lithium would not be the first line option
E) The patient's diabetes will impact on the course and prognosis of her depression
C
There are very few, if any, absolute contraindications to ECT. Relative contraindications include heart disease, raised ICP, and poor anaesthetic risk.
SSRIs are safe in renal disease, but renal function should be monitored for SIADH.
BZDs are not recommended for older age or for depression.
Lithium is not first line in depression, and is not to be used in someone with renal-disease as it is directly nephrotoxic.
The relationship between chronic disease and depression is well-established.
79
An 84-year-old man is brought in to the psychiatric unit with a diagnosis of severe depression with psychotic symptoms. He has had three previous admissions with very similar symptoms. During his admission he begins voicing his desire to leave the ward, claiming that the devil is possessing all of the staff and patients, and that he is next. He claims that if he isn't allowed to leave he will do whatever he can to escape the devil, even if this means ending his life. He has had to be moved away from the door after trying to follow visitors out of the ward. What would be the most appropriate course of action?
A) Detain him under common law for his own safety
B) Do nothing as staff have been able to coax him back on to the ward
C) Place him on Section 3 of the MHA
D) Request an immediate Deprivation of Liberty Safeguard (DOLS) assessment under the Mental Capacity Act
E) Use IM rapid tranquilisation to alleviate his distress and keep the ward safe
C
Section 3 allows detention for up to 6 months for treatment.
Common law is not a reason to detain.
DOLS assessment is part of the Mental Capacity Act, which applies when someone's liberty is deprived, not restricted. It doesn't apply here.
IM medication should only be used if the patient is at risk to themselves or others, and other management efforts have failed.
80
Which of the following statements most accurately reflects manic syndromes in older age?
A) All manic elderly patients should be detained under the MHA
B) Bipolar disorder resolves in later life
C) In bipolar disorder beginning in old age, most would have had episodes of depression before a manic episode
D) Unipolar mania is more common than bipolar disorder in older age
E) Unlike depression, physical co-morbidity does not have an impact on manic syndromes in the elderly
C
Late-onset bipolar disorder is taken to be over the age of 50, and the manic phase tends to present latently, following many depressive episodes.
81
An 80-year-old woman with a past medical history including hypertension, diabetes, and macular degeneration is admitted to accident and emergency complaining of frightening images of birds swooping around her flat day and night. At first she thought they were real but now realises they could not be. She has no past psychiatric history and apart from bing very tearful about the images, there is nothing else of note in the mental state. What is the most likely diagnosis?
```
A) Charles Bonnet syndrome
B) Cotard's syndrome
C) Ekbom's syndrome
D) Fregoli's syndrome
E) Rett's syndrome
```
A
Charles Bonnet syndrome is a syndrome of complex, vivid, visual hallucinations occurring in people with severe visual impairment such as macular degeneration. Insight is retained and no other symptoms occur. It is self-limiting, with no specific treatment other than reassurance and education.
Cotard's syndrome occurs in psychotic depression in which the sufferer believes a part of their body has ceased to exist.
Ekbom's syndrome is also known as delusional parasitosis. It's the delusional (not hallucinatory) belief that animals or insects are crawling below the sufferer's skin. Sufferers may resort to extreme, violent methods to rid themselves of the parasites.
Fregoli's syndrome is a form of delusional misidentification, in which sufferers believe complete strangers are actually people they know in disguise.
Rett's syndrome is a dominantly inherited X-linked developmental disorder seen almost exclusively in girls associated with severe physical and learning disabilities.
82
A 74-year-old widowed woman, previously fit and well with no past psychiatric history, presents to her GP to 'have it out once and for all about these bloody neighbours'. She says for the last month her neighbours have been spying on her and are leaking radiation through her ceiling which is making her cough incessantly. On examination she does indeed have a severe cough and has lost weight since her last appointment 3 months ago. Otherwise she looks fairly healthy and well kept, with an MMSE of 29/30. Which of the following statements is the most accurate?
A) Antipsychotics are likely to have a rapid and successful effect
B) Rehousing is likely to be the most effective treatment
C) The cough is a delusional elaboration of her other symptoms
D) The most likely diagnosis is an early dementia
E) The most likely diagnosis is very late-onset schizophrenia-like psychosis (VLOSLP)
E
VLOSLP typically affects women more than men and causes delusions with few personality or cognitive problems. The delusions can be any form, but typically are partition delusions, in which solid structures become permeable to people or substances. Response to antipsychotics is relatively poor, but psychological intervention can help. The cough may be coincidental, but is unlikely to be delusional elaboration. It may represent a more sinister co-morbidity.
83
Which of the following statements concerning alcohol misuse in older age is the most accurate?
A) Alcohol dependence almost always begins in earlier life
B) Alcohol dependence is easier to spot in elderly people
C) Genetic factors do not have an influence on alcohol misuse in older age
D) Heavy alcohol use may lead to dementia
E) The male:female ratio is much lower in older people with alcohol misuse than in the young
D
Alcohol dementia is a complex result of different pathologies. Alcohol can predispose to cerebrovascular disease, head injury, and is directly toxic. Korsakoff's syndrome is also a result of prolonged use.
84
Which of the following statements concerning anxiety in older age is the most accurate?
A) CBT is less effective in older age than in younger patients
B) Inpatient management of anxiety is the most successful setting for treatment
C) Men are more likely to develop anxiety disorders than women in older age
D) Poor physical health is not associated with the onset of anxiety disorders
E) Worries over physical health are more common in older adults with anxiety
E
Anxiety in the elderly is often similar to anxiety in younger patients. However, similarly to depression, anxiety in the elderly may focus around issues related to physical health.
CBT and medication are equally effective, but antidepressants may have to be chosen with more care. SSRIs can cause GI bleeding, and TCAs could exacerbate falls because of their anticholinergic effects.
85
A 71-year-old man, previously fit and well, presents to his GP with his wife who states he has 'lost his marbles' over the last 2 months, with worsening memory loss. He scores 21/30 on the MMSE, losing points mainly on recall as well as dysphasia. His wife has also noticed that he has lost weight. Routine blood tests show the following:
Na: 129 mol/L
K: 4.4 mol/L
Adjusted Ca: 3.1 mol/L
What is the most likely diagnosis?
```
A) Addison's disease
B) Cerebral malignancy
C) Cushing's disease
D) Hyperthyroidism
E) Primary hyperparathyroidism
```
B
Hyponatraemia, hypercalcaemia, and normal potassium are shown, and this, along with the clinical picture, suggest cerebral malignancy. Hypercalcaemia is the most common paraneoplastic syndrome. SIADH is responsible for the hyponatraemia, another paraneoplastic syndrome.
Addison's disease would show hyperkalaemia, hyponatraemia, and hypercalcaemia. Memory loss is not often described, but depression and fatigue are common.
Cushing's disease is an endogenous increased glucocorticoid production, usually from an adenoma.
Hyperthyroidism doesn't cause amnesia, but could cause anxiety.
Primary hyperparathyroidism would cause hypercalcaemia, but not a low sodium.
86
A 90-year-old woman is in hospital with late-stage colon cancer which has metastasised. She has been remarkably well all her life before being diagnosed with cancer. She lost her husband 3 years ago but has a supportive family. On the ward, she develops a chest infection. The consultant wants to start her on antibiotics, but she says she does not want them. The consultant asks for a psychiatric opinion, worried that she is depressed. However, the psychiatrist reports she is not depressed, is fully competent to make this decision, and is choosing how to die as she wishes. What ethical concept is best described here?
```
A) Autonomy
B) Beneficence
C) Capacity
D) Justice
E) Non-maleficence
```
A
Autonomy is the ethical concept of the right to make one's own decisions.
Beneficence refers to acting in the best interest of the patient, or making decisions to benefit the patient.
Capacity is demonstrated in this question, but capacity is a legal concept rather than an ethical one.
Justice refers to fairness, such as balancing the needs of the individual against wider society.
Non-maleficence is the obligation of practitioners to not do anything to bring about harm, pain or suffering.
87
Which of the following statements is true about medicines use in older age?
A) Antipsychotics are the drugs of choice for behavioural disturbance in dementia
B) Fat-soluble drugs, such as diazepam, will have a longer duration of action because of increased body fat in older people
C) Lithium doses in older people should generally be lower because the liver cannot excrete it as efficiently
D) Older people are less sensitive to the effects of BZDs
E) TCAs will not cause constipation in older people because of a general increase in gut motility
B
There is a general increase in body fat with age, and a decrease in body water. Fat-soluble drugs are therefore increased in duration of action.
Anti-psychotics increase all-cause mortality in dementia patients and should be avoided.
Lithium should be given at lower doses because it is renally excreted.
Older people are more sensitive to BZDs.
TCAs decrease gut motility, and there is a general decrease in the elderly.
88
In the general diagnosis of personality disorder according to ICD-10, which of the following is not necessary for a diagnosis?
A) The behaviour must affect the ability to control impulses
B) The behaviour or way of interacting must be pervasive across different situations
C) The patterns of behaviour are associated with considerable distress
D) The patterns of behaviour arise in late childhood or adolescence
E) There must be no evidence of organic brain disease or injury as a cause of the disorder
A
A personality disorder must be pervasive, inflexible, maladaptive, and dysfunctional. There must be distress to the individual, or their social environment. It must be present from childhood or adolescence, and should be stable with long duration. It would manifest in one or more of cognition, affectivity, control over impulses, or manner of relating to others.
89
Regarding personality and its development, which of the following statements is false?
A) Body build is not a reliable way to assess personality type
B) Freudian theory states that normal personality development involves successfully passing through various stages of development
C) Idiographic personality theories state that every individual is unique
D) It is now generally accepted that personality can be described by three factors
E) The environment plays a large part in personality development
D
Five factors describe personality, described by the mnemonic OCEAN: Openness to experience, Conscientiousness, Extraversion/intraversion, Agreeableness, and Neuroticism.
90
Which of the following is least likely to predict dangerous behaviour?
```
A) Co-morbid mental disorder
B) Co-morbid substance abuse disorder
C) Juvenile delinquency
D) Pathological lying
E) Superficial charm
```
A
While there are specific examples when co-morbid mental disorder (which excludes personality disorder) would increase dangerousness (e.g. the presence of violent command hallucinations, high levels of perceived threat in paranoid states), overall, very little violence is directly attributable to mental illness.
91
A 22-year-old woman with a diagnosis of borderline personality disorder attends accident and emergency after saying she has taken an overdose of paracetamol following an argument with her mother. She is an outpatient at the local personality disorder service where she has a key worker. This is her fourth attendance in accident and emergency for similar reasons in the past 6 weeks. A full assessment reveals no evidence of depression. Her blood results reveal low levels of paracetamol. She does not want to die but cannot say she will not try and harm herself again. What would the most appropriate management be?
A) Admit to inpatient unit
B) Call for urgent Mental Health Act (MHA) assessment
C) Detain under Section 5(2) of the MHA in the accident and emergency department
D) Discharge from accident and emergency with follow-up from her key worker
E) Remove patient and ban from further accident and emergency attendances
D
Borderline personality disorder sufferers feel chronically abandoned, so often use admissions to justify their behaviours. Therefore, inpatient admission would not be helpful here. Even if it were, then the MHA would only be used if the patient then refused to voluntarily admit themselves and there were grounds for detainment. Banning the patient from accident and emergency will escalate the behaviour, confirming the abandonment issues.
92
A 29-year-old man is arrested for aggravated assault on a former girlfriend. It is his ninth offence of a similar nature. The court asks for a psychiatric opinion. He is noted to be emotionally cold with an extremely reduced tolerance to frustration. He feels no remorse for his actions, blaming his girlfriend for 'putting it about'. What is the most likely diagnosis?
```
A) Anankastic personality disorder
B) Antisocial personality disorder
C) Emotionally unstable personality disorder
D) Histrionic personality disorder
E) Schizoid personality disorder
```
B
Antisocial personality disorder is also known as dissocial, psychopathic, or sociopathic personality disorder. It affects men more than women, and individuals show disregard for social norms, cannot maintain meaningful relationships, and have disordered development in childhood.
Anankastic personality disorder is also known as obsessive-compulsive personality disorder in DSM-IV. Sufferers tend to be preoccupied with rules and schedules, and are overly pedantic perfectionists.
Emotionally unstable personality disorder, also known as borderline personality disorder, leads to self-harming behaviour, intense but unstable relationships, and sufferers go to great lengths to avoid abandonment.
Histrionic personality disorder sufferers are prone to overly dramatic displays and occasional self-harm. They are faddish and attention-seeking, often sexually. They have a shallow affect, tend to be obsessed with their physical appearance, and struggle to maintain relationships.
Schizoid personality disorder tend to be isolative, aloof, and emotionally detached. They gain little pleasure from things, and usually have few friends or relationships.
93
A 52-year-old woman comes in to her GP with a swollen knee which appears to be osteoarthritic. During the assessment, however, she quizzes the GP on every little detail of what he is doing. She began the interview by saying how disappointed she was that the GP was running twelve and a half minutes late and that her schedule had been ruined as a result. She asked several times about minute details concerning the referral process. What is the most likely diagnosis?
```
A) Anankastic personality disorder
B) Anxious-avoidant personality disorder
C) Emotionally unstable personality disorder
D) Histrionic personality disorder
E) Paranoid personality disorder
```
A
Anankastic personality disorder is also known as obsessive-compulsive personality disorder in DSM-IV. Sufferers tend to be preoccupied with rules and schedules, and are overly pedantic perfectionists.
Anxious-avoidant personality disorder is characterized by feelings of tension and apprehension, insecurity and inferiority. There is a continuous yearning to be liked and accepted, a hypersensitivity to rejection and criticism with restricted personal attachments, and a tendency to avoid certain activities by habitual exaggeration of the potential dangers or risks in everyday situations.
Emotionally unstable personality disorder, also known as borderline personality disorder, leads to self-harming behaviour, intense but unstable relationships, and sufferers go to great lengths to avoid abandonment.
Histrionic personality disorder sufferers are prone to overly dramatic displays and occasional self-harm. They are faddish and attention-seeking, often sexually. They have a shallow affect, tend to be obsessed with their physical appearance, and struggle to maintain relationships.
Paranoid personality disorder leads to excessive sensitivity to setbacks, unforgiveness of insults, suspiciousness, and misconstruing neutral or friendly actions as hostile. Jealousy and a tenacious sense of personal rights are also common.
94
A 23-year-old woman is referred to the pastoral services at her college because of concerns over her behaviour. She is reported to have episodic outbursts of rage towards her classmates, although she acts in a flirtatious and fawning way towards her male tutors. She has been admitted twice with impulsive self-harming attempts. She has become obsessed with one of the more popular girls in the class, adopting a similar dress sense and texting her often. When she was told by the girl to leave her alone, she became enraged. What is the most likely diagnosis?
```
A) Anxious-avoidant personality disorder
B) Emotionally unstable personality disorder
C) Histrionic personality disorder
D) Narcissistic personality disorder
E) Paranoid personality disorder
```
C
Histrionic personality disorder sufferers are prone to overly dramatic displays and occasional self-harm. They are faddish and attention-seeking, often sexually. They have a shallow affect, tend to be obsessed with their physical appearance, and struggle to maintain relationships.
Anxious-avoidant personality disorder is characterized by feelings of tension and apprehension, insecurity and inferiority. There is a continuous yearning to be liked and accepted, a hypersensitivity to rejection and criticism with restricted personal attachments, and a tendency to avoid certain activities by habitual exaggeration of the potential dangers or risks in everyday situations.
Emotionally unstable personality disorder, also known as borderline personality disorder, leads to self-harming behaviour, intense but unstable relationships, and sufferers go to great lengths to avoid abandonment.
Narcissistic personality disorder leads to an inflated sense of self-worth. Individuals tend to be pretentious and boastful. They crave attention, and can be callous with little regard for the feeling of others.
Paranoid personality disorder leads to excessive sensitivity to setbacks, unforgiveness of insults, suspiciousness, and misconstruing neutral or friendly actions as hostile. Jealousy and a tenacious sense of personal rights are also common.
95
Which of the following statements regarding management of personality disorder is correct?
A) Antidepressant medications have no role in the management of personality disorder
B) Antipsychotic medications have shown evidence of effectiveness in management of personality disorder
C) Dynamic psychotherapy is contraindicated in emotionally unstable personality disorder
D) Benzodiazepines are the drug of choice in borderline personality disorder
E) Group psychotherapy is ineffective in managing personality disorder
B
Antipsychotics and antidepressants have both been shown to have some efficacy in personality disorders, but require consistent and long-term psychological interventions alongside.
Dynamic psychotherapy is used for many types of personality disorder, including emotionally unstable personality disorder (also known as borderline personality disorder). Group psychotherapy and CBT are also used.
BZDs should be used with extreme caution in borderline personality disorder as they have a tendency to become dependent.
96
A 68-year-old woman attends her GP following the death of her husband. She is tearful but 'doesn't want to bother the doctor'. The GP notices that she says yes to every suggestion and she says she does not know how to cope as her husband did everything for her except the cooking. The GP feels very helpless and somewhat irritated by the end of the conversation. What is the most likely diagnosis?
```
A) Anankastic personality disorder
B) Dependent personality disorder
C) Emotionally unstable personality disorder
D) Histrionic personality disorder
E) Schizoid personality disorder
```
B
Dependent personality disorders often only present after spouses leave or die. They allow others to take responsibility for them, and find it hard to make decisions. They require large amounts of help and advice, despite tending not to ask things of others.
Anankastic personality disorder is also known as obsessive-compulsive personality disorder in DSM-IV. Sufferers tend to be preoccupied with rules and schedules, and are overly pedantic perfectionists.
Emotionally unstable personality disorder, also known as borderline personality disorder, leads to self-harming behaviour, intense but unstable relationships, and sufferers go to great lengths to avoid abandonment.
Histrionic personality disorder sufferers are prone to overly dramatic displays and occasional self-harm. They are faddish and attention-seeking, often sexually. They have a shallow affect, tend to be obsessed with their physical appearance, and struggle to maintain relationships.
Schizoid personality disorder tend to be isolative, aloof, and emotionally detached. They gain little pleasure from things, and usually have few friends or relationships.
97
A 19-year-old man is referred to the local psychiatric community team as his new GP is worried he is schizophrenic. The letter states that he is 'extremely odd, and does not seem to have an emotional response to anything'. On assessment, he states he has only come to understand the 'psychiatric care pathway' a little more but does not feel he has any problems. He seems aloof and disdainful of the psychiatrist. He appears to have few hobbies except for inventing his own mathematical equations. What is the most likely diagnosis?
```
A) Anankastic personality disorder
B) Emotionally unstable personality disorder
C) Histrionic personality disorder
D) Schizoid personality disorder
E) Schizotypal personality disorder
```
D
Schizoid personality disorder tend to be isolative, aloof, and emotionally detached. They gain little pleasure from things, and usually have few friends or relationships.
Anankastic personality disorder is also known as obsessive-compulsive personality disorder in DSM-IV. Sufferers tend to be preoccupied with rules and schedules, and are overly pedantic perfectionists.
Emotionally unstable personality disorder, also known as borderline personality disorder, leads to self-harming behaviour, intense but unstable relationships, and sufferers go to great lengths to avoid abandonment.
Histrionic personality disorder sufferers are prone to overly dramatic displays and occasional self-harm. They are faddish and attention-seeking, often sexually. They have a shallow affect, tend to be obsessed with their physical appearance, and struggle to maintain relationships.
Schizotypal personality disorder presents as social anxiety, odd cognitive and perceptual experiences, and beliefs that do not amount to delusions or hallucinations. They may have unusual speech patterns, and is related to schizophrenia, unlike schizoid personality disorder.
98
In the structural model proposed by Freud, what is the term used to define the mainly conscious part of the mind that negotiates between the inner wishes and needs and the external world?
```
A) Genital stage
B) Ego
C) Id
D) Oedipus complex
E) Superego
```
B
Freud's structural model divided the mind into three parts: the id, the ego, and the superego.
The ego refers to the conscious part of the mind that composes rational thinking and balances the needs of the individual against the demands of the outside world.
The id is the unconscious part of the mind that contains innate instincts such as sexuality and aggression.
The superego is analogous to conscience, and contains moral rules.
The genital stage is one of Freud's stages of early development, along with the genital and anal stages. It's generally disregarded.
The Oedipus complex took place between the ages of 3 and 5 and is concerned with the child’s realization of their gender, their resentment of never possessing what the opposite parent has and their jealousy of the parental relationship.
99
A 42-year-old woman suffers a painful breakup with her long-term partner after finding him in bed with another man. She finds the situation, including telling her friends and family, extremely difficult. One year later, she is asked how she is feeling. She denies any knowledge of seeing her partner being unfaithful, and says, 'oh, we just had our differences, you know, there's no hard feelings'. What is this form of defence mechanism called?
```
A) Denial
B) Idealisation
C) Regression
D) Repression
E) Splitting
```
D
Repression is the unconscious exclusion of painful desires, thoughts, or fears.
Denial is a refusal to accept reality despite logical evidence, usually in response to current events.
Idealisation involves perceiving another individual as having more positive traits or qualities than they actually may possess. It's a part of the complex defence of splitting, in which the individual perceives everything as good (idealisation) or bad (devaluation).
Regression involves the individual reverting to an earlier developmental stage to avoid stressful events.
100
Which of the following represents a 'mature' (i.e. healthy) defence mechanism?
```
A) Acting out
B) Dissociation
C) Projection
D) Projective identification
E) Sublimation
```
E
Sublimation involves transforming negative emotions or situations into positive feelings or behaviours.
Acting out involves using strong feelings from therapy sessions destructively out of the therapy session. It is not cathartic, and is usually unhelpful.
Dissociation is modification of one personality or identity in order to avoid distress. It involves derealisation, depersonalisation, dissociative amnesia, dissociative fugue, and dissociative identity disorder.
Projection is a defence mechanism used to ascribe one's own thoughts, fears, attributes, or emotions to the external world.
Projective identification can be thought of as 'self-fulfilling prophecy'.
101
The following statement refers to which type of psychotherapy? A type of talking therapy, usually short-term and practical, that aims to change the way individuals think or behave with regards to themselves and others, by exploring erroneous patterns of thoughts, feelings, and behaviours.
```
A) Cognitive behavioural therapy
B) Counselling
C) Mindfulness therapy
D) Music therapy
E) Psychodynamic therapy
```
A
Counselling is a supportive therapy used to give individuals a space to discuss their problems, without offering advice.
Mindfulness therapy shares similarities with CBT, but combines cognitive theories with mindfulness stress reduction. It's recommended by NICE for those with three or more past depressive episodes.
Music therapy uses music to establish and explore a therapeutic relationship to improve psychological health.
Psychodynamic psychotherapy is a long-term therapy looking at deep-rooted problems as a result of past trauma or stresses. It can involve free association, dream interpretation, and analysis of transference.
102
The following statement refers to which type of psychotherapy? A model of therapy where the interactions and relationships between people are explored as opposed to the inner world of the individual.
```
A) Cognitive analytical therapy
B) Dialectical behavioural therapy
C) Eye movement desensitisation and reprocessing
D) Play therapy
E) Systemic therapy
```
E
Systemic therapy is also known as family therapy. It looks at addressing issues around relationships, and includes narrative therapy, solution-focused therapy, and strategic family therapy.
CAT is designed as a very short-term therapy combining techniques to identify chains of events that maintain problems.
DBT is used for treating borderline personality disorder. It combines CBT, distress tolerance, and mindfulness.
EMDR is primarily used in PTSD to replace distressing memories by more positive memory networks.
Play therapy is a form of psychodynamic therapy employed in children, using creative and imaginary plan to explore intrapsychic distress.
103
John, a 19-year-old male sculpture student comes to his GP complaining of problems with sleeping. Over the last few months he has been increasingly preoccupied with counting, and is now checking the light switches and other electrical items over and over again well into the night. He now feels compelled to turn the light switch on and off seven times before he can go to bed. He has never had problems before and this is causing him and his girlfriend considerable distress. What is the most likely effective treatment?
```
A) Art therapy
B) CBT
C) Family therapy for patient and partner
D) Psychoeducation
E) Watchful waiting
```
B
CBT challenges the idea of 'magical thinking', an illogical connection between certain behaviours and the avoidance of unwanted consequences. CBT also involves exposure and response prevention therapy.
Art therapy uses artistic expression to convey emotions and distress.
Family therapy looks at difficult or unhealthy relationships between individuals, so isn't appropriate here.
Psychoeducation is always useful, but alongside treatment.
Watchful waiting would be inappropriate in this situation, as there is obvious distress, and the situation will probably worsen if delayed.
104
Which of the following statements regarding CBT is false?
A) CBT may be carried out without a full qualification in CBT
B) CBT may make reference to early childhood experiences
C) CBT is more effective than medication for generalised anxiety disorder
D) CBT is not useful in dementia
E) CBT may involve family members
D
CBT is useful in dementia, for both sufferers and their carers.
It's often employed by mental health professionals without full qualifications, under supervision of qualified therapists, or by using techniques in everyday management.
Medication and CBT have an additive effect in treatment of GAD and other disorders.
Family members may be invited to sessions and can even act as co-therapists.
105
A 32-year-old woman is being seen for CBT to treat a depressive episode. During the initial assessment, she tells the therapy that 'to tell the truth, I'm just a bad person'. How might this statement be named in the CBT formulation?
```
A) Arbitrary inference
B) Catastrophising
C) Core negative belief
D) Generalisation
E) Minimisation
```
C
Core negative beliefs are central ideas about one's self and represent 'absolute truths' by the individual.
Arbitrary inference is a cognitive distortion in which the individual jumps to a conclusion without necessary evidence.
Catastrophising is a distortion in which the focus becomes the worst possible scenario.
Generalisation is when the individual takes one example or incident and applies it to wide generalisation.
Minimisation involves minimising positive or successful outcomes.
106
A 25-year-old man recently married, having abstained from sex until marriage. He reports becoming very anxious during sexual interfcouse and is gripped by a 'fear of failure'. Consequently, he finds himself monitoring his performance, and, as a result, he cannot maintain an erection. What is the most likely diagnosis?
```
A) Sexual aversion disorder
B) Hypoactive sexual desire disorder
C) Premature ejaculation
D) Erectile dysfunction
E) Orgasmic disorder
```
D
Erectile dysfunction is the inability to develop or maintain an erection during sexual intercourse. Factors such as previous negative sexual experiences, recreational drugs, alcohol, stress, and fatigue can lead to ED.
Sexual aversion disorder is characterised by a depressed sexual desire.
Hypoactive sexual disorder is a milder form of sexual aversion disorder.
Orgasmic disorder is a persistent or recurrent difficulty in achieving orgasm following a normal excitation phase of sex. This can be delayed, or absent.
107
A 49-year-old man has been successfully treated for anxiety and depression. He is struggling to reach an orgasm during sex, although his sexual desire is normal. What is the most likely cause of his current problem?
```
A) Citalopram
B) Trazodone
C) Lithium
D) Chlorpromazine
E) Clonazepam
```
A
Citalopram is an SSRI, and side effects include delayed ejaculation and anorgasmia.
Trazodone is a 5HT2aR antagonist, associated with priapism, which is a medical emergency that can result in impotence or gangrene of the penis.
Lithium is a mood stabiliser. Side effects include diminished sexual interest and erectile dysfunction.
Chlorpromazine is a typical antipsychotic, associated with priapism.
Clonazepam is a BZD, associated with loss of libido.
108
A 35-year-old man is picked up by the transport police after reports that he had been rubbing his erect penis against several female passengers on a train. The female victims were unknown to the offender. What is the most likely diagnosis?
```
A) Exhibitionism
B) Voyeurism
C) Frotteurism
D) Sexual masochism
E) Transvestic fetishism
```
C
Frotteurism is the paraphilic activity of touching and rubbing against another person's body for sexual pleasure. This is usually committed by males, in crowded public places.
Exhibitionism is indecent exposure of genitals in a public place.
Voyeurism includes watching others have sex or undress, and can include use of hidden cameras or peep-holes.
Sexual masochism is defined as the pleasure of receiving pain through sexual acts.
Transvestic fetishism is associated with attaining sexual arousal from cross-dressing.
109
A 62-year-old female with a history of rheumatoid arthritis complains that when she attempts to sleep, she feels an urge to move her legs due to uncomfortable sensations. Movement does ease the distress. What is the most likely diagnosis?
```
A) Obstructive sleep apnoea
B) Periodic limb movement disorder
C) Restless legs syndrome
D) Nocturnal eating syndrome
E) Nocturnal leg cramps
```
C
Restless leg syndrome is an uncomfortable, painful sensation in the leg, relieved by movement. It is idiopathic, or familial, and associated with RA, uraemia, and iron deficiency anaemia.
Obstructive sleep apnoea is seen in obese patients causing periods of airway obstruction during sleep, associated with loud snoring and daytime fatigue.
Periodic limb movement disorder is common in the elderly and involves repetitive limb movements while sleeping, leading to excessive daytime sleepiness.
Nocturnal eating syndrome is primarily paediatric, associated with late-night consumption of food.
110
A 23-year-old medical student is nearing her final examination. She feels as though she should study as much as possible and consequently has been revising into the early hours of the morning, drinking up to six cups of coffee per day as well as an energy drink. She has little difficulty getting to sleep but wakes intermittently during the night. She does not wake refreshed and feels tired the next day. There are no other symptoms. What is the most likely diagnosis?
```
A) Inadequate sleep hygiene
B) Environmental sleep disorder
C) Depression
D) Adjustment sleep disorder
E) Limit setting sleep disorder
```
A
Sleep hygiene involves drinking low levels of caffeine, going to sleep at a regular time (before midnight), not looking at screens before bed, and having a bed time and morning routine.
Environmental sleep disorder is caused by lights, noise, heat, and cold, reducing the ability to sleep.
Depression can cause insomnia, hypersomnia, and early morning wakening, alongside other symptoms.
Adjustment sleep disorder is associated with stress, conflict, or environmental change. It is usually temporary.
Limit setting sleep disorder is primarily a paediatric condition, occurring when a caregiver imposes strict bedtime rules with subsequent refusal.
111
A 20-year-old male patient is taken to see a GP by his father. The patient has had three distinct periods of binge eating, coupled with long periods (lasting up to 18 hours) of sleep over the past 3 months. Each attack lasts a few days or so and then spontaneously resolves. What is the most likely diagnosis?
```
A) Post-traumatic hypersomnia
B) Narcolepsy
C) Insufficient sleep syndrome
D) Depression
E) Kleine-Levin syndrome
```
E
Kleine-Levin syndrome is characterised by distinct periods of extreme somnolence and excessive hunger. Males are far more affected than females. Other symptoms include sexual disinhibition, confusion, irritability, euphoria, hallucinations, and delusion.
Post-traumatic hypersomnia may occur after trauma to the brainstem or posterior hypothalamus. Insomnia is more common after head trauma.
Narcolepsy features a tetrad of periods of sudden deep sleep, cataplexy, sleep paralysis, and hypnagogic hallucinations.
Insufficient sleep syndrome is the failure to obtain sufficient nocturnal sleep to support daytime activities, associated with unsociable working hours.
Depression can cause insomnia, hypersomnia, and early morning wakening, alongside other symptoms.
112
A 45-year-old businessman, who travels regularly as part of his work, visits the corporate physician complaining of difficulty in getting to sleep as well as daytime fatigue and reduced performance during presentations. he also has periodic headaches that are relieved by paracetamol. What is the most likely diagnosis?
```
A) Shift work disorder
B) Time zone change syndrome
C) Irregular sleep-wake syndrome
D) Delayed sleep phase syndrome
E) Advance sleep phase syndrome
```
B
Time zone change syndrome causes difficulty initiating and maintaining sleep, and daytime fatigue. Apathy and irritability may ensue, as may altered appetite, muscle aches, and headaches.
Shift work disorder causes insomnia or hypersomnia, and may present with physical symptoms.
Irregular sleep-wake cycle is a disruption of the circadian rhythm, leading to insomnia and frequent naps during the daytime. It's associated with Alzheimer's disease, head injury, and hypothalamic tumours.
Delayed sleep phase syndrome occurs when sleep begins late, leading to difficulties waking up. Patients may adapt by taking late night jobs.
Advance sleep phase syndrome is the opposite, and is common in the elderly.
113
A 20-year-old female student visits her GP complaining of suddenly waking with a 'feeling of falling'. What is the likely diagnosis?
```
A) Rhythmic movement disorder
B) Somniloquy
C) Nocturnal leg cramps
D) Hypnic jerks
E) Somnambulism
```
D
Hypnic jerks occur at the onset of sleep and are associated with contractions of the limbs, neck, or body. When wakened by the jerks, there is a characteristic feeling of falling into space.
Somniloquy is sleep talking.
Nocturnal leg cramps are associated with diabetes, pregnancy, and arthritis.
Somnambulism is sleep walking.
114
Which of the following features would indicate a diagnosis of bulimia nervosa rather than anorexia nervosa?
```
A) Fear of fatness
B) Amenorrhoea
C) Being at least 15 per cent below expected weight
D) Recurrent episodes of overeating
E) Self-induced vomiting
```
D
Bulimia's hallmark is episodes of bingeing, followed by episodes of purging, for example by vomiting, using appetite suppressants, and periods of starvation.
Fear of fatness is common to both, as is self-induced vomiting, and low-weight. Anorexia requires at least 15% lower than expected body weight.
Amenorrhoea can occur in bulimia, but is diagnostic of anorexia.
115
Which of the following is not a recognised complication of sustained anorexia nervosa?
```
A) Bradycardia
B) Heart failure
C) Hypercholesterolaemia
D) Parotid gland enlargement
E) Thrombocytosis
```
E
Low platelet count can be found in anorexia nervosa, but not increased. There may be pancytopenia.
Bradycardia and other arrhythmias are common complications, including as a result of hypokalaemia.
Heart failure can occur as a result of the disorder and of refeeding.
Hypercholesterolaemia is not uncommon, though seemingly paradoxical.
Parotid gland enlargement occurs is a result of nutritional deficiencies and purging behaviour.
116
A 26-year-old male sees his GP. He recently fell and broke his wrist while drunk, and is seeing his GP for a follow-up appointment. He has lost his job as he was found drinking vodka from a water bottle. The patient insists his recent problems are down to 'bad luck' and not alcohol. What is the most likely diagnosis?
```
A) Acute intoxication
B) Dependence syndrome
C) Harmful use
D) Withdrawal state
E) Psychotic disorder
```
C
Harmful use is when substance misuse has been continuing for at least 1 month, despite damage to the user's physical or mental health. The patient’s occupation and family are often severely affected, with the damage being played down by the patient.
Acute intoxication is the immediate effect of consumption of a specific substance.
Dependence syndrome is a physical need for a substance to function normally. Withdrawal is a result of abstaining from the dependent drug.
Psychotic disorder is a result of alcohol use, characterised by auditory hallucinations and paranoid thinking.
117
A 40-year-old regular cocaine user was made redundant as an advertising executive 2 weeks ago. He presents with a 6-day history of low mood, anhedonia, irritability, increased appetite, and general fatigue. What is the most likely diagnosis?
```
A) Withdrawal state
B) Complicated withdrawal
C) Amnestic syndrome
D) Residual disorder
E) Depression
```
A
Dependence is a physical need for a substance to function normally. Withdrawal is a result of abstaining from the dependent drug.
Features are specific to that drug, and can involve physical and psychological symptoms.
Complicated withdrawal occurs when the withdrawal state is associated with delirium, seizures or psychotic features.
Amnestic syndrome is associated with chronic loss of memory. There is often difficulty learning new material as well as time perception.
Residual disorder occurs when symptoms of withdrawal persist despite continued abstinence.
Depression would have a history of at least 2 weeks.
118
A 52-year-old confused man is brought to accident and emergency by ambulance after being found on the ground with a head injury. He is known to have alcohol dependence. On examination, the patient is obtunded, ataxic, and has bilateral weakness in his lateral recti ocular muscles. What is the likely diagnosis?
```
A) Wernicke's encephalopathy
B) Alcohol withdrawal
C) Korsakoff's syndrome
D) Intoxication
E) Delirium tremens
```
A
Wernicke's encephalopathy is caused by thiamine deficiency in alcohol dependence. It's characterised by a triad of ataxia, confusion, and ophthalmoplegia.
Alcohol withdrawal is acute and involves physical symptoms (tremor, sweating, insomnia, vomiting, tachycardia), and psychological symptoms (hallucinations, illusions).
Korsakoff's syndrome is an irreversible, late complication of Wernicke's encephalopathy. It causes amnesia with normal consciousness level.
Intoxication involves mood changes and disinhibition.
Delirium tremens is a medical emergency seen 24-72 hours into withdrawal, characterised by confusion, hallucinations, affective changes, tremor, autonomic disturbance, seizures, and delusions.
119
A 21-year-old university student is at a union event on a Friday night. He becomes aggressive and gets into a fight with a stranger over a spilt drink. What is the most likely diagnosis?
```
A) Alcohol-induced amnesia
B) Alcohol intoxication
C) Harmful drinking
D) At-risk drinking
E) Alcohol dependence
```
B
Blood alcohol concentration (BAC) correlates with symptoms. Low BAC causes elevated mood and disinhibition, leading up to high BAC with slurred speech, ataxia, aggressiveness, and unconsciousness.
Alcohol-induced amnesia, also known as alcoholic palimpsest, typically involves short-term anterograde memory loss with the patient unable to recall events during a specific time window.
Harmful use is when substance misuse has been continuing for at least 1 month, despite damage to the user's physical or mental health.
At-risk drinking is drinking with increased risk to health due to circumstances, such as pregnancy or driving.
Dependence is a physical need for a substance to function normally.
120
A 42-year-old man with alcohol dependence has gone to extreme lengths to prove his belief that his wife is having an affair with the gardener. The patient has admitted to placing secret surveillance cameras in the home he shares with his wife. What is the most likely diagnosis?
```
A) Alcohol hallucinosis
B) Alcohol induced psychotic disorder
C) Othello syndrome
D) Alcoholic dementia
E) Korsakoff's syndrome
```
C
Othello syndrome can occur in multiple psychiatric disorders, including alcohol abuse. The patient holds delusional beliefs that his/her partner is being unfaithful and may adopt extreme methods to prove this. The syndrome is associated with an increased risk of homicide towards the partner.
Alcoholic hallucinosis is characterised by auditory hallucinations.
Alcohol-induced psychotic disorder is a result of long-term alcohol misuse, causing grandiose or persecutory delusions.
Alcohol dementia causes widespread cognitive difficulties.
Korsakoff's syndrome causes severe anterograde amnesia.
121
A 34-year-old man with a long history of alcohol dependence is admitted to a hospital ward. Two days later the patient is found to be quadriplegic and can only communicate 'yes' and 'no' using eye signals. What is the most likely diagnosis?
```
A) Wernicke-Korsakoff syndrome
B) Peripheral neuropathy
C) Marchiafava-Bignami disease
D) Central pontine myelinolysis
E) Alcoholic polymyopathy
```
D
Central pontine myelinolysis occurs in alcoholics due to over-rapid correction of hyponatraemia. Symptoms include a pseudobulbar palsy and quadriplegia.
Wernicke's is a triad of confusion, ataxia, and opthalmoplegia. Korsakoff's is a chronic anterograde amnesia. Both are results of thiamine deficiencies.
Peripheral neuropathy includes sensory loss in lower extremities, absent tendon reflexes and muscle weakness.
Marchiafava-Bignami disease is a progressive neurological condition caused by corpus callous demyelination, associated with chronic alcoholism. Presentation is variable and often non-specific, involving sudden stupor, coma or seizures, dementia, incontinence, aphasia, and apraxia.
Alcoholic polymyopathy causes weakness, stiffness, and cramps.
122
A 26-year-old Asian man has been drinking a bottle of whisky a day for 10 years. He has had a cough for 6 weeks, with haemoptysis and night sweats. What is the most likely diagnosis?
```
A) Dilated cardiomyopathy
B) Tuberculosis
C) Atrial fibrillation
D) Pneumonia
E) Stroke
```
B
Long-term alcohol abuse can suppress the immune system, putting users at risk of opportunistic infections, such as TB and pneumonia. These symptoms are more indicative of TB.
Dilated cardiomyopathy can be caused by alcohol dependence and presents with breathlessness, pulmonary oedema, and arrhythmia.
AF can be caused by binge-drinking.
Stroke is very unlikely at this age.
123
A 45-year-old woman who lost her family in a road traffic accident 10 years ago has been dependent on alcohol since. She presents to her GP with difficulty swallowing. She is referred to a gastroenterologist who reports the presence of columnar epithelium in the lower oesophagus. What is the most likely diagnosis?
```
A) Alcoholic liver disease
B) Acute gastritis
C) Barrett's oesophagus
D) Mallory-Weiss tear
E) Chronic pancreatitis
```
C
Barrett's oesophagus arises from long-term distal oesophageal exposure to alcohol or acid. It causes squamous epithelium metaplasia, and can progress to adenocarcinoma.
Alcoholic liver disease begins with fatty change and can progress to alcoholic hepatitis and cirrhosis.
Acute gastritis is inflammation of the stomach mucosa as a result of excessive alcohol consumption. Epigastric pain, nausea, vomiting, and loss of appetite are characteristic.
Mallory-Weiss tears occur after repeated vomiting causes an oesophageal tear, with associated with haematemesis.
Alcohol is the most common cause of chronic pancreatitis, characterised by epigastric pain, radiating to the back (relieved on sitting forward), steatorrhoea, and diabetes.
124
A 30-year-old city executive presents with alcohol dependence. On further questioning it emerges he has always been very anxious about having to give presentations to his colleagues. When he is required to speak in front of them, his heart races, he begins to sweat profusely and feels an urge to leave the stage. He has been drinking vodka in order to suppress these symptoms. What is the most likely diagnosis?
```
A) Social phobia
B) Depression
C) Psychotic disorder
D) Generalised anxiety disorder
E) Morbid jealousy
```
A
Alcohol is anxiolytic, so self-medication in anxiety syndromes is not uncommon. Alcohol can have a poorer long-term affect on co-existing mental health disorders, though, as withdrawal can cause anxiety and panic, and alcohol can result in depression.
Alcohol-induced psychotic disorder is a result of long-term alcohol misuse, causing grandiose or persecutory delusions.
Generalised anxiety disorder tends to have less situationally dependent symptoms.
Morbid jealousy is associated with alcohol dependency and will manifest as a delusion that a partner is unfaithful. There is associated impotence, and a high risk towards the partner.
125
A 48-year-old man is seen by his community psychiatric nurse. On questioning, he shows evidence of persecutory delusions, despite treatment with risperidone. The patient has a history of long-term drug misuse. What is the most likely causative drug?
```
A) Barbiturates
B) Magic mushrooms
C) Glue sniffing
D) Heroin
E) Cannabis
```
E
Long-term cannabis use is linked to schizophrenia. Patients with the Val-Val polymorphism of the gene coding for catechol-O-methyl transferase are highly susceptible to developing schizophrenia after chronic cannabis use.
Chronic barbiturate users have increased irritability, aggressiveness, and fatigue.
Magic mushrooms cause visual disturbances.
Chronic glue sniffing can lead to irreversible brain damage, memory defects, and mood disorders.
Heroin rarely causes psychiatric symptoms.
126
A 45-year-old man presents to his GP because he has recently become worried about his drinking. He says that drinking red wine can be 'beneficial' and drinks four bottles over the course of the week. He is otherwise well but now thinks he should cut down his drinking. What is the next appropriate step in management?
```
A) Education and advice
B) Referral to Alcoholics Anonymous
C) Disulfiram
D) Acamprosate
E) Risperidone
```
A
This patient is drinking 40 units of alcohol per week, which is above the recommended limit of 14 per week, spread over 3 or more days. Early intervention in the GP setting can reduce risk of progression to heavier drinking.
Alcoholics Anonymous offers long-term support for alcohol dependents.
Disulfiram and acamprosate are used in maintenance of abstinence in alcohol dependents.
Antipsychotics are not used in alcohol use.
127
A 40-year-old man is brought into accident and emergency. He is extremely agitated and confused about both time and day and provides a very unfocused history. He is sweating and tachycardic. Later that evening he complains that tiny birds are attacking him. What is the next appropriate step in management?
```
A) Oral chlordiazepoxide
B) Oral haloperidol
C) Oral thiamine
D) IV chlordiazepoxide
E) IV diazepam
```
A
Delirium tremens is a medical emergency caused by alcohol withdrawal. It causes marked confusion, visual and auditory hallucinations, and autonomic instability (sweating, hypertension, tachycardia). Oral chlordiazepoxide is most appropriate, reducing severity of symptoms and risk of seizures.
Haloperidol and other antipsychotics should only be used if psychotic symptoms are persistent.
Oral thiamine is poorly absorbed, so withdrawing alcoholics should be given high dose IV thiamine.
IV chlordiazepoxide and diazepam would only be used if the oral route was not available.
128
A 30-year-old banker presents to accident and emergency. He is agitated and continuously scratches his skin, complaining there are 'insects crawling all over him'. His blood pressure is raised, and an ECG shows a tachyarrhythmia. What is the most likely cause of his symptoms?
```
A) Heroin
B) Cocaine
C) LSD
D) Caffeine
E) Benzodiazepines
```
B
Cocaine causes increased alertness, euphoria, irritability, delusions, and hallucinations. This may include formication, the sensation of insects crawling on the skin. It may also cause tachycardia, hypertension, and arrhythmias.
Heroin induces euphoria followed by sedation, with pinpoint pupils, bradycardia, respiratory depression, and constipation.
LSD can cause depersonalisation, illusions, synaesthesia, and visual hallucinations.
Caffeine intoxication causes headaches, anxiety, confusion, tremors, arrhythmias, nausea, and vomiting.
BZDs cause drowsiness, confusion, and reduced anxiety.
129
Which of the following is an atypical (second-generation) antipsychotic drug?
```
A) Chlorpromazine
B) Isoniazid
C) Lithium
D) Olanzapine
E) Trazodone
```
D
Atypical antipsychotics are first line for treating psychotic illness. They cause fewer anti pyramidal side effects than typical antipsychotics, like chlorpromazine. Most are associated with weight gain, however.
Isoniazid is an anti-TB drug with incidental antidepressant activity.
Lithium is a mood stabiliser.
Trazodone is a serotonin antagonist and reuptake inhibitor (SARI) used as an antidepressant. It's also a sedative, and anxiolytic.
130
A 29-year-old man is seen by a psychiatrist and commenced on venlafaxine. What class of drug is this?
A) Monoamine oxidase inhibitor (MAOI)
B) Noradrenaline reuptake inhibitor (NARI)
C) Selective serotonin reuptake inhibitor (SSRI)
D) Serotonin and noradrenaline reuptake inhibitor (SNRI)
E) Tetracyclic antidepressant (TCA)
D
Venlafaxine, an SNRI, is second line in depression.
MAOIs are a class of antidepressant rarely used in current practise because of side effects, and their interaction with tyramine rich foods (known as the cheese reaction).
NARIs include atomoxetine and reboxetine.
SSRIs are the most commonly used antidepressants, as they are well tolerated and less lethal in overdose compared with other drugs.
TCAs include mirtazapine, mianserin, and amitryptaline.
131
Which of the following drugs is not used as a mood stabiliser?
```
A) Carbamazepine
B) Lamotrigine
C) Lithium carbonate
D) Sodium valproate
E) Trimipramine
```
E
Trimipramine is a tricyclic antidepressant. Antidepressants should be used cautiously in bipolar, as they can induce a manic episode.
Carbamazepine, lamotrigine, and sodium valproate are all anti-epileptics used in the prophylaxis of bipolar disorder and the acute manic phase.
Lithium carbonate is a mood stabiliser, used in the treatment of mania, depression, and the prophylaxis of bipolar disorder.
132
Which of the following would be the most appropriate choice in the first line management of new-onset schizophrenia?
```
A) Clozapine
B) Lithium carbonate
C) Pimozide
D) Quetiapine
E) Sertraline
```
D
Quetiapine is an atypical antipsychotic, the recommended first line for new-onset schizophrenia. They have fewer extra-pyramidal side effects than typical antipsychotics like clozapine, but do cause weight gain and metabolic change. Clozapine is reserved for treatment resistant schizophrenia, as it can cause neutropenia or agranulocytosis, and patients must have regular blood tests.
Lithium is a mood stabiliser used in bipolar disorder.
Pimozide is an older antipsychotic infrequently used in current practice, as it's associated with long QT syndrome.
Sertraline is an SSRI, used in depression.
133
Which of the following would not be an appropriate choice in the prophylaxis of bipolar disorder?
```
A) Carbemazepine
B) Diazepam
C) Lithium
D) Olanzapine
E) Sodium valproate
```
B
Diazepam is a BZD used for short term anxiolysis and sedation.
Carbamazepine and sodium valproate are anti-epileptics used in the prophylaxis of bipolar disorder and the acute manic phase.
Lithium is a mood stabiliser, used in the treatment of mania, depression, and the prophylaxis of bipolar disorder.
Olanzapine is an antipsychotic that is also effective in bipolar prophylaxis.
134
Which of the following would be the most appropriate choice of drug for the management of a 55-year-old with postoperative delirium who has become extremely agitated?
```
A) Amitriptyline
B) Haloperidol
C) Lithium carbonate
D) Temazepam
E) Zuclopenthixol acetate (Acuphase)
```
B
Delirium is treated in various ways, usually not pharmacologically, as medications can be the cause of delirium. However, haloperidol is the treatment of use if absolutely necessary.
Amitriptyline is a tricyclic antidepressant.
Lithium is a mood stabiliser.
Temazepam is a BZD. On some occasions, BZDs could be used for delirium, but temazepam is not the most appropriate choice of all BZDs.
Acuphase is a potent intramuscular antipsychotic medication used for rapid tranquilisation of extremely agitated patients not responding to standard pharmacological treatments.
135
Which of the following is most likely to cause tardive dyskinesia (TD) in a middle-aged man with schizophrenia?
```
A) Aripiprazole
B) Clozapine
C) Flupentixol decanoate
D) Lithium carbonate
E) Trazodone
```
C
TD arises after years of treatment, in particular with depot medications such as flupentixol decanoate. It is very difficult to treat once present.
Airpiprazole has a lower incident of TD than older agents.
Clozapine actually improves symptoms of TD, unlike other agents.
Lithium (a mood stabiliser) and trazodone (an anti-depressant) rarely cause TD.
136
Which of the following primarily acts to increase levels of acetylcholine in the brain?
```
A) Aripiprazole
B) Carbamazepine
C) Diazepam
D) Donepezil
E) Haloperidol
```
D
Donepezil is an acetylcholinesterase inhibitor.
Aripiprazole is an atypical antipsychotic, working as a partial dopamine agonist.
Carbamazepine is an anti-epileptic with mood stabilising qualities.
Diazepam is a BZD, which works as a GABA agonist.
Haloperidol is another antipsychotic, working by antagonising dopamine.
137
Which of the following drugs is contraindicated in myasthenia gravis (MG)?
```
A) Chlorpromazine
B) Citalopram
C) Galantamine
D) Procyclidine
E) Pyridostigmine
```
D
Procyclidine is an antimuscarinic used in Parkinson's disease. As MG is an autoimmune disease against acetylcholine receptors at the postsynaptic neuromuscular junction, antimuscarinics will worsen symptoms.
Chlorpromazine is a first-generation antipsychotic, and should be used with caution if MG is present because it does have anticholinergic properties.
Citalopram is an SSRI, with very low activity at AChRs.
Galantamine is an AChEI used in Alzheimer's disease, which increases the availability of ACh.
Pyridostigmine is another AChEI, and is used in the treatment of MG.
138
A 4-year-old boy is brought into his GP by his parents. They are worried as he is constantly dropping things and trips often, sometimes causing injury. He does not show any affection towards his family and does not play well with others at nursery, although his older sister is a very warm child. He plays with dinosaurs by himself but completely ignores other toys. His speech is relatively normal. What is the most likely diagnosis?
```
A) Asperger's syndrome
B) Attachment disorder
C) Childhood autism
D) Conduct disorder
E) Down's syndrome
```
A
Asperger's syndrome is similar to autism in that there are qualitative abnormalities in social interactions, and unusual interest in a restricted range of behaviours or activities. Unlike autism, however, there is no language or cognitive delay. Asperger's persists, and is associated with psychotic episodes in later life.
Attachment disorders start in the first five years of life and are characterized by persistent abnormalities in the child's pattern of social relationships (e.g. fearfulness and hypervigilance, poor social interaction with peers, aggression towards self and others, misery, and growth failure in some cases). The syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling.
Conduct disorders are characterized by a repetitive and persistent pattern of dissocial, aggressive, or defiant conduct, amounting to major violations of age-appropriate social expectations.
Down's syndrome is a genetic syndrome causing characteristic physical appearance, severe development and language delay, and associated medical problems.
139
A 12-year-old boy is referred to the child psychiatry service. His behaviour has become so aggressive that he has been excluded from school for assaulting fellow pupils and, more recently, teachers. He has smashed up several classrooms, and, the previous week, the fire brigade were called as he set fire to his bedroom. He shows no remorse for the way he behaves. What is the most likely diagnosis?
```
A) Attention deficit hyperactivity disorder (ADHD)
B) Childhood disintegrative disorder
C) Conduct disorder
D) Oppositional defiant disorder (ODD)
E) Tic disorder
```
C
Conduct disorders are characterized by a repetitive and persistent pattern of dissocial, aggressive, or defiant conduct, amounting to major violations of age-appropriate social expectations.
ADHD sufferers show inattention, poor concentration, hyperactivity, and impulsivity. There tends to be less violent, and destructive behaviour.
Childhood disintegrative disorder causes normal development before a period of loss of previously acquired skills and social withdrawal.
ODD manifests in younger children as disobedient and disruptive behaviour, without frank aggression and violence.
Tics are involuntary, rapid, recurrent, non-rhythmic motor movements or vocal acts. They can be suppressed sometimes, but with great difficulty and significant anxiety.
140
Which of the following would be least appropriate for the first line management of conduct disorder?
```
A) Cognitive behavioural therapy (CBT)
B) Family therapy
C) Methylphenidate
D) Parent training
E) Risperidone
```
E
Risperidone is an antipsychotic, and should rarely be used in children, as side effects tend to be more significant in children.
CBT, family therapy, and parent training are effective in conduct disorder.
Methylphenidate is a stimulant that is effective in conduct disorder, especially when there is co-morbid ADHD. It should be combined with psychological therapies.
141
Which of the following is not part of the diagnostic criteria for ADHD?
A) Aggression towards peers
B) Excessive motor activity
C) Inattention
D) Symptoms present in more than one setting
E) Symptoms present for at least 6 months
A
ADHD involves excessive motor activity, inattention, and hyperactivity. Aggression is not a hallmark, and if present, a co-morbid conduct disorder should be considered.
142
A 9-year-old boy is brought to the GP as he has started wetting the bed, despite being continent for the last 4 years. What is this symptom known as?
```
A) Cluttering
B) Encopresis
C) Enuresis
D) Pica
E) Trichotillomania
```
C
Childhood enuresis can be primary (never had a period of dryness) or secondary (as in this case). Secondary enuresis tends to be associated with psychological or emotional problems. Primary enuresis is more likely due to developmental delay, or medical causes.
Cluttering is the symptom of rapid speech with a breakdown in fluency, with no repetitions or hesitations.
Encopresis is voluntary or involuntary voiding in inappropriate settings.
Pica is the persistent eating of non-nutritive substances, like sand, or paint.
Trichotillomania is the disorder that involves pulling out one's hair, considered to be an impulse control disorder related to OCD.
143
A 9-year-old boy is referred to the local child psychiatry service. For the past 18 months, he has begun displaying odd speech, with outbursts of strange and sometimes obscene words. More recently, he has begun grimacing and blinking excessively. He is unable to control this and it is causing him some distress. What is the most likely diagnosis?
```
A) Asperger's syndrome
B) Tourette's syndrome
C) Hyperkinetic disorder
D) Lesch-Nyhan syndrome
E) Transient tic disorder
```
B
Tourette's syndrome is a chronic tic disorder with vocal and motor tics. Tics are involuntary, rapid, recurrent, non-rhythmic motor movements or vocal acts. They can be suppressed sometimes, but with great difficulty and significant anxiety. Onset is at 7-10 years, and tends to worsen through adolescence.
Asperger's syndrome is similar to autism in that there are qualitative abnormalities in social interactions, and unusual interest in a restricted range of behaviours or activities. Unlike autism, however, there is no language or cognitive delay.
Hyperkinetic disorder is the spectrum of disorders include ADHD.
Lesch-Nyhan syndrome is a rare X-linked recessive disorder resulting in hyperuicaemia form lack of uric acid metabolism. It causes learning disability, self-injurious behaviour, and odd movements that could be chorea- or tic-like.
Transient tic disorders occur for less than one year. All tic disorders, unlike Tourette's, involve either vocal or motor tics - not both.
144
An 11-year-old boy is diagnosed with Gilles de la Tourette syndrome. There is no evidence of any co-morbid diagnosis. What would the most appropriate management be?
```
A) Atomoxetine
B) Deep brain stimulation
C) Psychoanalytic therapy
D) Psychoeducation
E) Risperidone
```
D
The purpose of psychoeducation is to explain the nature and course of the disorder to prevent deterioration in personal and family functioning. People with Tourette’s are at high risk of co-morbid disorders such as depression and obsessive–compulsive disorder – screening for these is also critical and targeted therapy should be recommended if they coexist.
Atomoxetine is a stimulant used in ADHD. It can be useful in Tourette's with comorbid ADHD.
Deep brain stimulation is used in Parkinson's, and treatment resistant depression, but is still relatively experimental, so wouldn't be used in a child or a straightforward disorder.
Psychoanalysis has no use in tic disorders.
Risperidone has shown some effectiveness in Tourette's, but in younger patients it should only be used in severe cases.
145
Which of the following statements regarding learning disability is correct?
A) Epilepsy is over-represented in patients with learning disability
B) Mild learning disability is usually defined by an IQ between 35 and 49
C) The point prevalence of schizophrenia in people with learning disability is equal to that of the general population
D) Suicide is more common in people with learning disability than the general population
E) A person with learning disability cannot consent to treatment for medical conditions
A
Epilepsy, and schizophrenia, are both over-represented in learning disability. Suicide is less common in those with moderate and severe learning disabilities, although self-injurious behaviours are common.
Mild learning disability is usually classified as occurring in people with an IQ of between 50 and 70. Moderate learning disability is classified in the IQ range of 35 to 49, with severe learning disability at 34 and below.
146
Which of the following is not usually associated with learning disability?
```
A) Angelman's syndrome
B) Down's syndrome
C) Edwards' syndrome
D) Guillain-Barre syndrome
E) Hunter's syndrome
```
D
Guillain-Barre is an ascending peripheral polyneuropathy, caused by an immune response to antigens.
Angelman's is an inactivation of maternal chromosome 15. It causes severe learning disability, almost no use of language, ataxia, and unusual behaviour.
Down's syndrome is trisomy 21, and causes characteristic physical appearance, severe development and language delay, and associated medical problems.
Edwards' syndrome results from trisomy 18. Only 5-10% of infants will live beyond their first year. If they do live, severe learning disability is ubiquitous.
Hunter's syndrome is a lysosomal storage disease. It has a wide phenotypic presentation, and is progressive and severe. Learning disability is often present.
147
Which of the following statements regarding trisomy 21 is correct?
A) Alzheimer's disease is more common in people with Down's syndrome than the general population
B) Mosaicism is responsible for approximately 20% of cases of Down's syndrome
C) Not all cases of trisomy 21 will result in learning disability
D) People with Down's syndrome cannot live independently
E) People with Down's syndrome have a lower incidence of anxiety than the general population
A
At least 50% of Down's syndrome patients in their 6th decade have dementia.
Mosaicism accounts for 1-2% of cases.
People with Down's syndrome are at a higher risk of most psychiatric disorders.
