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Flashcards in Psychiatry EMQs from PRN online Deck (125)
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1
Q
A. Summarising
B. Active listening techniques
C. Question funnelling
D. Linking
E. Reflection
F. Platitudes
G. Paternalism
H. Empathy
I. Motivational interviewing
J. Bargaining

Student: What happened today to bring you into hospital?

Bob: Well, I got back from visiting my family in Australia, only a few days ago. I was a bit jet-lagged, but pretty good otherwise. Then yesterday, my leg swelled up - really painful! It hurts to walk on it. I kind of thought it would go down, but it didn’t, so I came in here.

Student: What else have you noticed?

Bob: It’s gone really red - and hot. It’s only the right leg, and it makes the left one look tiny by comparison.

Student: I see… Have you had any problems with your breathing?

Bob: No.

A

C. Question funnelling

Question funnelling is a useful technique, whereby the interviewer starts with an open question(s) and moves to closed or clarifying questions. It allows the patient to freely express what has happened to them whilst enabling you to direct the conversation.

2
Q
A. Summarising
B. Active listening techniques
C. Question funnelling
D. Linking
E. Reflection
F. Platitudes
G. Paternalism
H. Empathy
I. Motivational interviewing
J. Bargaining

Student: You’ve given me a lot of information. Can I just see if I’ve got this right?

Ahmed: OK

Student: You lost your job about 3 months ago, which led to money problems. Since then you’ve felt increasingly that your life was out of control, and that planning for the future is pointless. You’ve been having a lot of trouble sleeping, which has left you feeling tired.

Ahmed: That’s right. I’m so tired I can’t get out the house anymore. I feel bad for my wife - I must be making her so miserable.

A

A. Summarising

3
Q
A. Summarising
B. Active listening techniques
C. Question funnelling
D. Linking
E. Reflection
F. Platitudes
G. Paternalism
H. Empathy
I. Motivational interviewing
J. Bargaining

Anneke: Since the attack, I haven’t been able to let my partner near me. It seems stupid, but I’m just so edgy all the time.

Student: I’m sure he understands.

Anneke: Actually, I don’t think he gets what I’m going through… I can’t see how things will improve until I can sort my head out.

Student: Well, things will get better - they always do.

A

F. Platitudes

usually unhelpful, since they can come across as dismissive or patronising - no matter how well intended they were.

4
Q
A. Summarising
B. Active listening techniques
C. Question funnelling
D. Linking
E. Reflection
F. Platitudes
G. Paternalism
H. Empathy
I. Motivational interviewing
J. Bargaining

Dimitrios: I don’t need to be here. I don’t even want to be here. I’m only here because my parents are overreacting. I just don’t want to be spied on by the others anymore.

Student: The others?

Dimitrios: Yeah. Them that follow me. They hear everything I say - and even my thoughts when it’s quiet. I’m tired of it…

A

E. Reflection

5
Q
A. Summarising
B. Active listening techniques
C. Question funnelling
D. Linking
E. Reflection
F. Platitudes
G. Paternalism
H. Empathy
I. Motivational interviewing
J. Bargaining

Jean: I need something to help me sleep, Doc. I can’t seem to drop off at night, and then I wake up really early.

Student: I’d imagine that would leave you feeling really tired. Have you noticed that you don’t have as much energy recently?

Jean: Yeah, it’s really hard to get going lately. Everything seems like a battle…

Student: I’m so sorry… How long have you been feeling like this?

A

D. Linking

6
Q
A. Akathisia
B. Parkinsonism
C. Tardive dyskinesia
D Mannerisms
E. Stereotypies
F. Tics
G. Compulsions
H. Catatonia
I. Intention tremor
J. Dystonia

You are a junior doctor working in general practice. Mrs Patel is a 78 year old woman who comes to see you complaining that her hands have been shaking for a few weeks, her left worse than the right. She thought it would pass but it hasn’t. She keeps knocking drinks over and is finding it difficult to write.

A

I. Intention tremor

7
Q
A. Akathisia
B. Parkinsonism
C. Tardive dyskinesia
D Mannerisms
E. Stereotypies
F. Tics
G. Compulsions
H. Catatonia
I. Intention tremor
J. Dystonia

Gustav Erikson is a 46 year old man who has been treated for paranoid schizophrenia for the last 12 years. His family have noticed that recently he has been grimacing and pulling faces. It seems to be getting worse and they are concerned that he is reacting to hallucinations again.

A

Tardive dyskinesia

usually a delayed side effect of antipsychotic use

8
Q
A. Akathisia
B. Parkinsonism
C. Tardive dyskinesia
D Mannerisms
E. Stereotypies
F. Tics
G. Compulsions
H. Catatonia
I. Intention tremor
J. Dystonia

Esther Smithson is a 24 year old woman who was admitted with an acute psychotic episode and has been taking risperidone for 3 weeks. You are a senior house officer working on her ward, and have been asked to see her by nursing staff, since she “keeps pacing by the door”. Staff are concerned that she is trying to abscond. During the consultation you notice that she seems on edge and unable to settle. On several occasions she rises from her seat to pace up and down.

A

Akathisia

is an unpleasant subjective sense of restlessness, and is an extrapyramidal side effect of antipsychotic use.

9
Q
A. Akathisia
B. Parkinsonism
C. Tardive dyskinesia
D Mannerisms
E. Stereotypies
F. Tics
G. Compulsions
H. Catatonia
I. Intention tremor
J. Dystonia

Charles Crawford is a 26 year old man, who has been brought to see you by his wife, Cindy. He was playing football in the garden with their son, Michael, and had to stop because his eyes “got stuck looking up”. He is very frightened, and says his eyes hurt. You note that he is taking quetiapine following a manic episode.

A

Dystonia

A common extrapyramidal side effect of antipsychotic use. This particular dystonia is an oculogyric crisis.

10
Q
A. Akathisia
B. Parkinsonism
C. Tardive dyskinesia
D Mannerisms
E. Stereotypies
F. Tics
G. Compulsions
H. Catatonia
I. Intention tremor
J. Dystonia

Sebastian Epstein is a 54 year old who has been treated with haloperidol for 10 years. His wife has noticed that he has become very shaky. When he is watching television is unable to keep his hands still. It seems to be getting worse.

A

Parkinsonism

A common extrapyramidal side effect of antipsychotic use.

11
Q
A. Dysarthria
B. Dysphasia
C. Clang associations
D. Punning
E. Neologisms
F. Pressure of speech
G. Poverty of speech
H. Flight of ideas
I. Perseveration
J. Loosening of associations

You are a house officer attached to a general medical firm. You are asked to assess the mental state of Johan Wicklestein. Johan is a 62 year old man with Parkinson’s disease. The nursing staff, who know him from previous admissions, have noticed that he seems to have low mood. During your assessment you notice that although he understands you and answers all questions appropriately, he seems to have problems articulating his words.

A

Dysarthria

Describes problems with articulation of speech - the brain knows what it wants to say, but problems with the speech apparatus makes this difficult.

12
Q
A. Dysarthria
B. Dysphasia
C. Clang associations
D. Punning
E. Neologisms
F. Pressure of speech
G. Poverty of speech
H. Flight of ideas
I. Perseveration
J. Loosening of associations

You are a final year medical student on a psychiatry firm. You are asked to assess the mental state of Marjorie Wilson. Marjorie’s speech is coherent and does not seem to jump from topic to topic, but she speaks so quickly that you find her uninterruptible, and struggle to keep up with her.

A

Pressure of speech

Describes speech that is very fast and full of thoughts. It reflects underlying pressure of thought, and can feel a little like machine gun fire!

13
Q
A. Dysarthria
B. Dysphasia
C. Clang associations
D. Punning
E. Neologisms
F. Pressure of speech
G. Poverty of speech
H. Flight of ideas
I. Perseveration
J. Loosening of associations

You are a final year medical student on a psychiatry firm. You interview Marcus Steinway, a 32 year old man. He was brought into hospital by his wife, after she became concerned that his mood seemed ‘very black’. Marcus is quiet and withdrawn. He takes a long time to answer your questions and gives mostly monosyllabic answers, struggling to fill out any details.

A

Poverty of speech

The speech is slow with very few thoughts. It reflects underlying poverty of thought.

14
Q
A. Dysarthria
B. Dysphasia
C. Clang associations
D. Punning
E. Neologisms
F. Pressure of speech
G. Poverty of speech
H. Flight of ideas
I. Perseveration
J. Loosening of associations

You asked your student, Helen, to clerk Wallace Guilfoye, a 32 year old man with schizophrenia. After an hour, Helen returns, exasperated. She tells you, “I couldn’t follow anything he said - I kept thinking I’d got a hold on what he meant, and then he’d confuse me! He couldn’t get through more than a sentence or two without losing me.”

A

Loosening of associations

Describes the loss of normal links between thoughts.

15
Q
A. Dysarthria
B. Dysphasia
C. Clang associations
D. Punning
E. Neologisms
F. Pressure of speech
G. Poverty of speech
H. Flight of ideas
I. Perseveration
J. Loosening of associations

You are a house officer working in accident and emergency. You see Mr McKeen, a 25 year old man who is experiencing psychotic symptoms. He talks in detail about the “interphalancrial business” and the “hemislayer” that have been persecuting him.

A

Neologisms

“new words” invented by the patient.

16
Q
A. Grandiose
B. Thought withdrawal
C. Nihilistic
D. Erotomanic 
E. Thought broadcasting
F. Jealousy
G. Reference
H. Guilt
I. Hypochondrial
J. Persecutory

Steve is a 22 year old physics student. His flat mate, Hussein, brings him to your GP surgery. Hussein tells you how Steve has become increasingly withdrawn, refusing to leave his room for days at a time. Steve insists on wearing a thick hat in all weathers, which he says is “for protection”. On close questioning, Steve explains that his lecturers have been “spraying” his thoughts across the lecture hall with mobile phone technology. He hates knowing that all the other students know what he is thinking.

A

E. Thought broadcasting

17
Q
A. Grandiose
B. Thought withdrawal
C. Nihilistic
D. Erotomanic 
E. Thought broadcasting
F. Jealousy
G. Reference
H. Guilt
I. Hypochondrial
J. Persecutory

Mary Hamilton is a 36 year old woman who has been referred by her GP to your psychiatry outpatient clinic. She has received a verbal warning from the police after allegedly stalking the chief executive at the firm where she works as a cleaner. She has been sending him love letters and presents. Mary is convinced that he loves her, and says that the police warning is “just for show”, to hide their love from her colleagues. Her manager is openly gay, and now off work due to the stress associated with Mary’s behaviour.

A

D. Erotomanic

Erotomanic delusions are those in which there is a false belief that someone (often of higher status) is in love with the patient. They are more common in women and sometimes called “amorous delusions”.

18
Q
A. Grandiose
B. Thought withdrawal
C. Nihilistic
D. Erotomanic 
E. Thought broadcasting
F. Jealousy
G. Reference
H. Guilt
I. Hypochondrial
J. Persecutory

Nigel Pieterson is a 54 year old man, referred to you by the police after he walked into his local police station and confessed to the murder of his mother. There were concerns that he was mentally ill, and he was brought to hospital. You contact his younger sister, who explains that their mother died 52 years before, in childbirth.

A

H. Guilt

This is a delusion of guilt. Mr Pieterson clearly had nothing to do with his mother’s death while she gave birth to his younger sibling

19
Q
A. Grandiose
B. Thought withdrawal
C. Nihilistic
D. Erotomanic 
E. Thought broadcasting
F. Jealousy
G. Reference
H. Guilt
I. Hypochondrial
J. Persecutory

Stephano Romero is a 25 year old man who has been brought to Accident and Emergency by his mother. She noted that he has been acting strangely for some weeks, laughing to himself and spending a lot of time at the local church. This evening, he pointed out eight people crossing the road ahead, and nodded sagely, telling her that this meant that The End Was Nigh.

A

G. Reference

Delusions of reference are those in which special meaning, signs or signals are found in everyday events.

20
Q
A. Grandiose
B. Thought withdrawal
C. Nihilistic
D. Erotomanic 
E. Thought broadcasting
F. Jealousy
G. Reference
H. Guilt
I. Hypochondrial
J. Persecutory

Gloria Bunford is a 57 year old woman, who attends your GP surgery to make you aware that she died last Thursday.

A

C. Nihilistic

The belief that you are dead is classed as a nihilistic delusion. Nihilism is to do with the absence of things - in this case, the absence of life.

21
Q
A. Manic episode
B. Cyclothymia
C. Schizoaffective disorder
D. Delirium
E. Bipolar affective disorder
F. Schizophrenia
G. Depressive episode
H. Pseudodementia

Persecutory delusions and auditory hallucinations without a strong mood component.

A

F. Schizophrenia

22
Q
A. Manic episode
B. Cyclothymia
C. Schizoaffective disorder
D. Delirium
E. Bipolar affective disorder
F. Schizophrenia
G. Depressive episode
H. Pseudodementia

Labile mood, boundless energy, reduced sleep and past history of depression.

A

E. Bipolar affective disorder

23
Q
A. Manic episode
B. Cyclothymia
C. Schizoaffective disorder
D. Delirium
E. Bipolar affective disorder
F. Schizophrenia
G. Depressive episode
H. Pseudodementia

Anergia, anhedonia, low mood.

A

G. Depressive episode

24
Q
A. Manic episode
B. Cyclothymia
C. Schizoaffective disorder
D. Delirium
E. Bipolar affective disorder
F. Schizophrenia
G. Depressive episode
H. Pseudodementia

Persistent instability of mood with mild episodes of elation and low mood.

A

B. Cyclothymia

25
Q
A. Manic episode
B. Cyclothymia
C. Schizoaffective disorder
D. Delirium
E. Bipolar affective disorder
F. Schizophrenia
G. Depressive episode
H. Pseudodementia

Labile mood, boundless energy, reduced sleep. No previous history of mood disorder.

A

A. Manic episode

26
Q
A. Antidepressant and antipsychotic
B. Cognitive behavioural therapy and antidepressant
C. Supportive counselling
D. Antidepressant
E. Mood stabiliser or antipsychotic
F. Mood stabiliser and antidepressant
G. Electroconvulsive therapy (ECT)
H. Mood stabiliser and antipsychotic

Severe depression with life-threatening anorexia and dehydration.

A

G. Electroconvulsive therapy (ECT)

ECT can be life-saving in severe depression, since it is a very fast and effective treatment.

27
Q
A. Antidepressant and antipsychotic
B. Cognitive behavioural therapy and antidepressant
C. Supportive counselling
D. Antidepressant
E. Mood stabiliser or antipsychotic
F. Mood stabiliser and antidepressant
G. Electroconvulsive therapy (ECT)
H. Mood stabiliser and antipsychotic

Mild depression.

A

C. Supportive counselling

Supportive counselling is often sufficient, though mildly depressed patients should still be reviewed to ensure that they are not deteriorating, despite the counselling.

28
Q
A. Antidepressant and antipsychotic
B. Cognitive behavioural therapy and antidepressant
C. Supportive counselling
D. Antidepressant
E. Mood stabiliser or antipsychotic
F. Mood stabiliser and antidepressant
G. Electroconvulsive therapy (ECT)
H. Mood stabiliser and antipsychotic

Moderate depression.

A

B. Cognitive behavioural therapy and antidepressant

This combination is the ideal, though be aware that CBT waiting lists can be long (e.g. 6 months), so this is not always achievable.

29
Q
A. Antidepressant and antipsychotic
B. Cognitive behavioural therapy and antidepressant
C. Supportive counselling
D. Antidepressant
E. Mood stabiliser or antipsychotic
F. Mood stabiliser and antidepressant
G. Electroconvulsive therapy (ECT)
H. Mood stabiliser and antipsychotic

Psychotic depression.

A

A. Antidepressant and antipsychotic

Both are required to effectively treat the two aspects of this diagnosis: psychosis and depression.

30
Q
A. Antidepressant and antipsychotic
B. Cognitive behavioural therapy and antidepressant
C. Supportive counselling
D. Antidepressant
E. Mood stabiliser or antipsychotic
F. Mood stabiliser and antidepressant
G. Electroconvulsive therapy (ECT)
H. Mood stabiliser and antipsychotic

Initial treatment of acute mania.

A

E. Mood stabiliser or antipsychotic

Addictionally, antidepressants and other exacerbating medications should be stopped. A short course of benzodiazepines may be additionally needed for sedation. Is symptoms are severe or don’t respond to a mood stabiliser or antipsychotic alone, they may need to be combined.

31
Q

A. Unreliable oral contraceptive pill cover
B. Hypertensive crisis following ingestion of yeast extracts
C. Amnesia
D. Anaemia
E. Foetal spina bifida
F. Malnutrition
G. Foetal Ebstein’s anomaly
H. Depression
Instructions: For each treatment below, choose the single most likely side-effect from the above list of options. Each option may be used once, more than once, or not at all.

Electroconvulsive therapy (ECT).

A

C. Amnesia

Most other side effects from ECT relate to use of the general anaesthetic (e.g. risk of death).

32
Q

A. Unreliable oral contraceptive pill cover
B. Hypertensive crisis following ingestion of yeast extracts
C. Amnesia
D. Anaemia
E. Foetal spina bifida
F. Malnutrition
G. Foetal Ebstein’s anomaly
H. Depression
Instructions: For each treatment below, choose the single most likely side-effect from the above list of options. Each option may be used once, more than once, or not at all.

Monoamine oxidase inhibitors (MAOIs).

A

B. Hypertensive crisis following ingestion of yeast extracts

Other side effects of MAOIs include hypotension, dizziness, drowsiness, insomnia, headache, blurred vision, constipation, nausea and vomiting.

33
Q

A. Unreliable oral contraceptive pill cover
B. Hypertensive crisis following ingestion of yeast extracts
C. Amnesia
D. Anaemia
E. Foetal spina bifida
F. Malnutrition
G. Foetal Ebstein’s anomaly
H. Depression
Instructions: For each treatment below, choose the single most likely side-effect from the above list of options. Each option may be used once, more than once, or not at all.

St John’s wort.

A

A. Unreliable oral contraceptive pill cover

St John’s Wort is an enzyme inducer, causing some drugs (like the OCP) to be metabolised more quickly, making them ineffective.

34
Q

A. Unreliable oral contraceptive pill cover
B. Hypertensive crisis following ingestion of yeast extracts
C. Amnesia
D. Anaemia
E. Foetal spina bifida
F. Malnutrition
G. Foetal Ebstein’s anomaly
H. Depression
Instructions: For each treatment below, choose the single most likely side-effect from the above list of options. Each option may be used once, more than once, or not at all.

Lithium.

A

G. Foetal Ebstein’s anomaly

This is a risk when lihium is used during pregnancy.

Ebstein anomaly is a congenital malformation of the heart that is characterized by apical displacement of the septal and posterior tricuspid valve leaflets, leading to atrialization of the right ventricle with a variable degree of malformation and displacement of the anterior leaflet.

35
Q

A. Unreliable oral contraceptive pill cover
B. Hypertensive crisis following ingestion of yeast extracts
C. Amnesia
D. Anaemia
E. Foetal spina bifida
F. Malnutrition
G. Foetal Ebstein’s anomaly
H. Depression
Instructions: For each treatment below, choose the single most likely side-effect from the above list of options. Each option may be used once, more than once, or not at all.

Sodium valproate.

A

E. Foetal spina bifida

This is a risk when sodium valproate (or carbamazapine) is used during pregnancy.

36
Q
A. 1 hour
B. 2 hours
C. 6 hours
D. 12 hours
E. 1 week
F. 2 weeks
G. 4-6 weeks
H. 6 months
I. 8-9 months
J. 1 year

Appropriate post-dose timing of blood samples for lithium levels.

A

E. 1 week

37
Q
A. 1 hour
B. 2 hours
C. 6 hours
D. 12 hours
E. 1 week
F. 2 weeks
G. 4-6 weeks
H. 6 months
I. 8-9 months
J. 1 year

Delay in antidepressant effect.

A

G. 4-6 weeks

38
Q
A. 1 hour
B. 2 hours
C. 6 hours
D. 12 hours
E. 1 week
F. 2 weeks
G. 4-6 weeks
H. 6 months
I. 8-9 months
J. 1 year

Early morning wakening is defined as waking at least this much earlier than usual.

A

B. 2 hours

39
Q
A. 1 hour
B. 2 hours
C. 6 hours
D. 12 hours
E. 1 week
F. 2 weeks
G. 4-6 weeks
H. 6 months
I. 8-9 months
J. 1 year

Average duration of an untreated depressive episode.

A

I. 8-9 months

40
Q
A. 1 hour
B. 2 hours
C. 6 hours
D. 12 hours
E. 1 week
F. 2 weeks
G. 4-6 weeks
H. 6 months
I. 8-9 months
J. 1 year

Duration of antidepressant treatment of a first depressive episode once symptoms have resolved.

A

H. 6 months

41
Q
A. Hypnotherapy
B. Social intervention
C. Interpersonal therapy (IPT)
D. Problem-solving approach
E. Automatic recognition therapy
F. Relationship focus therapy
G. Cognitive behavioural therapy (CBT)
H. Psychodynamic psychotherapy

Helps the patient to recognise negative automatic thoughts.

A

G. Cognitive behavioural therapy (CBT)

Negative Automatic Thoughts (NATs) are the unhelpful, negative thoughts, typical of depression, that pop into a person’s mind as a knee-jerk reaction to everyday situations. They are often overly pessimistic or critical, and contribute to low mood and further depressive thoughts, which trap the person in their depression. E.g. in response to someone not greeting them at work, a depressed person may think, “He hates me” or “No-one likes me.” These are identified in CBT and the patient works with the therapist to consider how true they really are. Logic and practical testing of NATs can usually show that they are at some level erroneous. The patient is helped to recognise these NATs, recognise underlying thinking errors and think more positively and realistically, in order to combat depression.

42
Q
A. Hypnotherapy
B. Social intervention
C. Interpersonal therapy (IPT)
D. Problem-solving approach
E. Automatic recognition therapy
F. Relationship focus therapy
G. Cognitive behavioural therapy (CBT)
H. Psychodynamic psychotherapy

Makes use of transference to understand the patient’s problems.

A

H. Psychodynamic psychotherapy

Transference describes the emotions that a patient feels towards the therapist. It can be used to interpret the patient’s problems, and help the patient to think about relationships outside the therapy session - since it usually sheds light on the way they view other people and interact with them.

43
Q
A. Hypnotherapy
B. Social intervention
C. Interpersonal therapy (IPT)
D. Problem-solving approach
E. Automatic recognition therapy
F. Relationship focus therapy
G. Cognitive behavioural therapy (CBT)
H. Psychodynamic psychotherapy

Makes use of behavioural experiments to help the patient re-evaluate their beliefs.

A

G. Cognitive behavioural therapy (CBT)

Behavioural experiments are practical and logical tests, which help patients do as “homework” in their own time, to test out their beliefs.

44
Q
A. Hypnotherapy
B. Social intervention
C. Interpersonal therapy (IPT)
D. Problem-solving approach
E. Automatic recognition therapy
F. Relationship focus therapy
G. Cognitive behavioural therapy (CBT)
H. Psychodynamic psychotherapy

The relationship between the therapist and the patient is the key issue in this therapy.

A

H. Psychodynamic psychotherapy

The relationship that is built in the session gives insight into the relationships and relationship difficulties outside the therapy.

45
Q
A. Hypnotherapy
B. Social intervention
C. Interpersonal therapy (IPT)
D. Problem-solving approach
E. Automatic recognition therapy
F. Relationship focus therapy
G. Cognitive behavioural therapy (CBT)
H. Psychodynamic psychotherapy

Focuses on themes of unresolved loss, psychosocial transitions, relationship conflicts and social skills deficit.

A

C. Interpersonal therapy (IPT)

46
Q
A. Acute and transient psychotic episode
B. Schizophrenia
C. Drug induced psychosis
D. Mania
E. Personality disorder
F. Bipolar affective disorder
G. Drug induced psychosis
H. Alcohol dependence
I. Depression	
J. Delirium tremens

A 24 year old woman, treated for a drug induced psychosis last year, presents complaining of voices commanding her to kill herself. She denies drug use since the last episode, but explains that the voices never fully resolved, and she is “sick of them taking her thoughts for their own purposes.” She is now seriously considering suicide, “To shut them up for good”.

A

B. Schizophrenia

Schizophrenia is the most likely diagnosis, in view of ongoing (>1 month) symptoms, in the absence of ongoing drug misuse. The symptom of thought withdrawal is not diagnostic in its own right (first rank symptoms can occur in other disorders, e.g. organic), but again supports the diagnosis of schizophrenia.

47
Q
A. Acute and transient psychotic episode
B. Schizophrenia
C. Drug induced psychosis
D. Mania
E. Personality disorder
F. Bipolar affective disorder
G. Drug induced psychosis
H. Alcohol dependence
I. Depression	
J. Delirium tremens

A 48 year old man took an overdose of 38 paracetamol tablets with a bottle of gin. He is intoxicated and smells strongly of alcohol. His wife states that he has been very low in mood for the past 3 months, doesn’t seem to enjoy spending time with their children anymore, and “drags himself around the house like an old man”. He has not been eating well and wakes very early in the morning. She says that he doesn’t normally drink heavily. His LFTs and MCV are normal.

A

I. Depression

Depression is the most likely diagnosis, since this man has core and biological features sufficient to make the diagnosis, and symptoms have been ongoing for greater than two weeks. The recent alcohol misuse does not amount to alcohol dependence, and this is supported by the normal blood results.

48
Q
A. Acute and transient psychotic episode
B. Schizophrenia
C. Drug induced psychosis
D. Mania
E. Personality disorder
F. Bipolar affective disorder
G. Drug induced psychosis
H. Alcohol dependence
I. Depression	
J. Delirium tremens

A 29 year old man with a history of childhood abuse presents with lacerations to his shins. He states he is depressed and cut himself with a razor following his girlfriend’s decision to break up with him; he hoped that would show her how much he loved her, and make her change her mind. He reports that he has had a “very short fuse” since he was a teenager, losing his temper easily, which has caused break ups with all his previous girlfriends, and the loss of a number of jobs. He describes his mood as “always being very up and down,” and was feeling “great” until she “dumped him” earlier today. He says he cuts himself or smokes cannabis to calm down when his anger gets too much.

A

Personality disorder is the most likely diagnosis, though note that, even with a clear history of personality difficulties, this diagnosis is not always reliable after a single interview, and the diagnostic label can be stigmatising rather than helpful. That stated, there is evidence from the history that this man’s personality has caused him chronic difficulties (e.g. impulsivity and outbursts of anger; ongoing affective instability). With closer questioning, it should be possible to elicit elements such as ongoing fears of abandonment or intense and unstable relationships, etc - sufficient to decide whether he fulfils criteria for emotionally unstable personality disorder.

49
Q
A. Acute and transient psychotic episode
B. Schizophrenia
C. Drug induced psychosis
D. Mania
E. Personality disorder
F. Bipolar affective disorder
G. Drug induced psychosis
H. Alcohol dependence
I. Depression	
J. Delirium tremens

A 32 year old woman presents to A&E with two deep lacerations to her wrists. She has no past psychiatric history. Having snorted cocaine at a friend’s house, she reported feeling cockroaches crawling under her skin, which she then tried to remove with a knife. Nothing like this has ever happened before. She uses cocaine intermittently, and drinks around 4-6 units of alcohol each Friday and Saturday night.

A

C. Drug induced psychosis

A drug induced psychosis is the most likely diagnosis, due to the temporal relationship between the use of cocaine and onset of psychotic symptoms, as well as the fact that this symptom (formication) being well-recognised in cocaine use. Symptoms should resolve with cessation of coke use. Although her pattern of alcohol use does not suggest dependency, and the clinical picture is more suggestive of coke intoxication than alcohol withdrawal/ delirium tremens. She should be given advice on her harmful levels of alcohol use, as well as the dangers of cocaine - but this is best done once she is medically fit, and once the cockroaches have stopped running about under her skin…

50
Q
A. Acute and transient psychotic episode
B. Schizophrenia
C. Drug induced psychosis
D. Mania
E. Personality disorder
F. Bipolar affective disorder
G. Drug induced psychosis
H. Alcohol dependence
I. Depression	
J. Delirium tremens

A 42 year old plumber is brought to hospital by the police, after walking along railway lines. He explains that God started talking to him two weeks ago, and an angel announced that he had been chosen to “fulfil the prophecy”. He was going to “sacrifice himself for the sake of mankind” by “allowing” a train to hit him. He says he hasn’t been sleeping, since he stays up all night painting and writing prophecies. His mood is very labile: he is tearful at times, but also jokes with the police; at one point he becomes aggressive and hits one of the officers. He suffered an episode of depression in the past, but now says he has “never felt better.” He denies substance misuse.

A

F. Bipolar affective disorder

Bipolar affective disorder is the preferred diagnosis, in view of a previous affective episode (depression) - this can no longer be viewed as a single manic episode.

51
Q

A. Informal admission to a psychiatric ward
B. Reduce opiate dose prior to discharge
C. Commence antidepressants
D. Give naloxone
E. Discharge with a psychiatric clinic appointment in a week’s time
F. Mental Health Act assessment
G. Check paracetamol levels in 2 hours’ time
H. Discharge with a Community Mental Health Team visit within the next 48 hours
I. Give N-acetylcysteine
J. Discharge with a psychiatric clinic appointment in 1 month

A 28 year old woman had considered jumping out of her 5th floor apartment and contacted her parents for help. They stayed with her overnight and brought her to hospital this morning for an assessment. Her parents are retired and say that she can come home with them if you are willing to discharge her. She says she has been feeling low for a few months but couldn’t kill herself as she is a strong Catholic. She is very close to her parents, and states that she can tell them if her suicidal thoughts worsen or she feels she will act upon them. Her parents tell you they are confident they could bring her back to hospital urgently if they thought she was deteriorating. There is no previous history of self-harm.

A

H. Discharge with a Community Mental Health Team visit within the next 48 hours

More information is needed before making a final decision, but the family’s plan sounds both safe and practical. The Community Mental Health Team may have a Home Treatment Team, who should be contacted to try and arrange a visit as soon as possible, but certainly within the week. When discharging someone home, always make sure that they know to attend casualty for review if they feel their situation is worsening.

52
Q

A. Informal admission to a psychiatric ward
B. Reduce opiate dose prior to discharge
C. Commence antidepressants
D. Give naloxone
E. Discharge with a psychiatric clinic appointment in a week’s time
F. Mental Health Act assessment
G. Check paracetamol levels in 2 hours’ time
H. Discharge with a Community Mental Health Team visit within the next 48 hours
I. Give N-acetylcysteine
J. Discharge with a psychiatric clinic appointment in 1 month

A 30 year old woman who frequently attends A&E reports that she took an overdose of 42 paracetamol tablets, 14 hours ago. Her paracetamol levels are above the “high-risk” treatment line, but below the “normal” treatment line. She appears well. She explains that it was a mistake and wants to go home to her parents. She is taking phenytoin for epilepsy.

A

I. Give N-acetylcysteine

A graph of plasma paracetamol concentrations against time should be used clinically to assess whether paracetamol levels require treatment with N-acetylcysteine. For most patients, the levels need to be above the normal treatment line before they require treatment. A second line shows lower levels of plasma paracetamol concentrations for assessment of “high-risk” patients, who are at risk of liver damage from lower levels of paracetamol. High risk includes those who are malnourished (e.g. in anorexia, alcohol dependency), or using enzyme inducing drugs (e.g. phenytoin, St. John’s wort, carbamazepine). Once she has been medically cleared, you can further assess her and make a decision about her future management, e.g. admission / discharge / follow-up plans.

53
Q

A. Informal admission to a psychiatric ward
B. Reduce opiate dose prior to discharge
C. Commence antidepressants
D. Give naloxone
E. Discharge with a psychiatric clinic appointment in a week’s time
F. Mental Health Act assessment
G. Check paracetamol levels in 2 hours’ time
H. Discharge with a Community Mental Health Team visit within the next 48 hours
I. Give N-acetylcysteine
J. Discharge with a psychiatric clinic appointment in 1 month

You are on-call in casualty, and are asked to assess a 68 year old woman with breast carcinoma and bony metastases. Due to severe pain she receives paracetamol, oramorph and gabapentin. Her son brought her in, after making a surprise visit at lunchtime. On admission, she was drowsy, with pinpoint pupils and a reduced respiratory rate on admission. She has been treated and medically cleared, and now states that although she has been understandably low due to the pain and diagnosis, the overdose was accidental. She says she will be more careful in future and would like to return home. You raise the possibility of an admission to hospital for psychiatric assessment, but she adamantly refuses to consider this and states she will attend a psychiatric appointment in a week’s time.

A

F. Mental Health Act assessment

This woman is at high risk of suicide, and she will probably require admission for her own safety and a full assessment of her mental state. Her refusal of admission leaves you no choice other than to organise a Mental Health Act assessment, and she should not leave hospital until this has been carried out. Accidental overdoses do happen (not everyone is suicidal!) but this woman’s circumstances should raise your suspicion that she will not be alive in a week’s time for an outpatient appointment.

54
Q

A. Informal admission to a psychiatric ward
B. Reduce opiate dose prior to discharge
C. Commence antidepressants
D. Give naloxone
E. Discharge with a psychiatric clinic appointment in a week’s time
F. Mental Health Act assessment
G. Check paracetamol levels in 2 hours’ time
H. Discharge with a Community Mental Health Team visit within the next 48 hours
I. Give N-acetylcysteine
J. Discharge with a psychiatric clinic appointment in 1 month

A 17 year old woman is brought to hospital by her parents. They had come home to find a suicide note on the kitchen table. After driving around their village, they found their tearful daughter standing on the platform at their local station; she admitted that she was planning to jump in front of a train. They explain that she has been “quite down on herself” for the past two months; she has rarely attended college, and is sleeping and eating poorly. During the interview, she is very subdued and intermittently tearful. She is ambivalent about whether she wants to die, but says that her life has “collapsed” since her boyfriend left her, and she “can’t see a way forward”. When you ask her if she would come into a psychiatric hospital, she nods. Her parents offer to take her home with them, and state that they can check on her by telephone while they are out at work.

A

A. Informal admission to a psychiatric ward

It would be a very brave / foolhardy doctor who would send this woman home to an empty house, even with Community Mental Health Team input. Though her parents are willing to maintain telephone contact with their daughter, this really doesn’t provide the level of monitoring and support needed to feel that she is safe by herself, and her suicidal behaviour happened when they were out (presumably at work) today. She appears willing to come into hospital voluntarily, and no matter how severe her mental illness, there is no need for a Mental Health Act assessment to enable this.

55
Q

A. Informal admission to a psychiatric ward
B. Reduce opiate dose prior to discharge
C. Commence antidepressants
D. Give naloxone
E. Discharge with a psychiatric clinic appointment in a week’s time
F. Mental Health Act assessment
G. Check paracetamol levels in 2 hours’ time
H. Discharge with a Community Mental Health Team visit within the next 48 hours
I. Give N-acetylcysteine
J. Discharge with a psychiatric clinic appointment in 1 month

A 22 year old man is a voluntary inpatient on a psychiatric ward. He has previously expressed suicidal ideation and on admission reported command hallucinations instructing him to do things including burning himself. He now denies experiencing any voices. He appears agitated and distracted during the interview, refusing to discuss his experiences and stating he wants to leave as he is not ill.

A

F. Mental Health Act assessment

A Section 5(2) may be required to prevent this man leaving the ward until a formal Mental Health Act Assessment can be arranged to consider him for a Section 2 or 3.

56
Q
A. Second person auditory hallucinations
B. Persecutory delusion
C. Thought broadcasting
D. Thought echo
E. Delusional perception
F. Thought broadcasting
G. Third person auditory hallucinations
H. Thought withdrawal
I. Passivity
J. Thought repetition

“A black Mercedes drove past me and I realised that the German prime minister was going to assassinate me. It was the first clue I had that anything was going on.”

A

E. Delusional perception

This is an example of delusional perception: a two-stage process whereby a real perception is then interpreted in a delusional way. It is classified as a primary delusion (i.e. arising “out of the blue” and not preceded by prior symptoms of mental illness like hallucinations) - and as such, is relatively rare. If the example given was in the context of pre-existing mental health symptoms (i.e. not the first symptom of something “going on”), it would be classed as a delusion of reference.

57
Q
A. Second person auditory hallucinations
B. Persecutory delusion
C. Thought broadcasting
D. Thought echo
E. Delusional perception
F. Thought broadcasting
G. Third person auditory hallucinations
H. Thought withdrawal
I. Passivity
J. Thought repetition

“He makes the most excruciating pains shoot down my arm. He decides when to do it and there’s nothing I can do to stop it.”

A

I. Passivity

Passivity phenomena are delusional beliefs that movement, sensation, emotion or impulse are controlled by an outside force. In this example, a real or hallucinatory sensation (pain) is attributed to the deliberate control of another person.

58
Q
A. Second person auditory hallucinations
B. Persecutory delusion
C. Thought broadcasting
D. Thought echo
E. Delusional perception
F. Thought broadcasting
G. Third person auditory hallucinations
H. Thought withdrawal
I. Passivity
J. Thought repetition

“I think in my head, ‘I’m going to watch TV’ and then she says ‘I’m going to watch TV.’”

A

D. Thought echo

In thought echo, the patient’s thoughts are said aloud. This is not the same as the normal experience of “thinking in your head”. There are two types: Gedankenlautwerden is when the thought and voice occur together; echo de la pensées is when the voice comes immediately after the thought.

59
Q
A. Second person auditory hallucinations
B. Persecutory delusion
C. Thought broadcasting
D. Thought echo
E. Delusional perception
F. Thought broadcasting
G. Third person auditory hallucinations
H. Thought withdrawal
I. Passivity
J. Thought repetition

“Yesterday, when I thought I was alone, they started on me again… One said, “Look, she’s an idiot!” The other said, “You’d think she’d have learned her lesson by now!” Then the first one said, “She’s always going to be a failure”.

A

G. Third person auditory hallucinations

Third person auditory hallucinations are voices talking about the person. Voices discussing or arguing about the patient, as in this example, are classed as first rank symptoms.

60
Q
A. Second person auditory hallucinations
B. Persecutory delusion
C. Thought broadcasting
D. Thought echo
E. Delusional perception
F. Thought broadcasting
G. Third person auditory hallucinations
H. Thought withdrawal
I. Passivity
J. Thought repetition

“People know everything I think. Aerials track my thoughts and transmit them to a person who says them aloud on the radio.”

A

F. Thought broadcasting

Thought broadcasting is the delusional belief that thoughts are not contained privately in the person’s head, but somehow broadcast to other people so that people know what they are thinking.

61
Q
A. Procyclidine
B. Risperidone
C. Olanzapine
D. Propranolol
E. Chlordiazepoxide
F. Flupenthixol
G. Clozapine
H. Sertraline
I. Chlorpromazine
J. Fluoxetine

Instructions: For each description below, choose the single most likely drug from the above list of options. Each option may be used once, more than once, or not at all.

An atypical antipsychotic available both as a tablet and as a depot injection.

A

B. Risperidone

Risperidone is the only atypical antipsychotic available as a long-acting injection (depot), and in this form can be given once a fortnight. Depot medications are used when people find daily medication concordance problematic.

62
Q
A. Procyclidine
B. Risperidone
C. Olanzapine
D. Propranolol
E. Chlordiazepoxide
F. Flupenthixol
G. Clozapine
H. Sertraline
I. Chlorpromazine
J. Fluoxetine

Instructions: For each description below, choose the single most likely drug from the above list of options. Each option may be used once, more than once, or not at all.

This atypical antipsychotic causes agranulocytosis in 0.7% of patients.

A

G. Clozapine

Clozapine was withdrawn for some years due to the risk of agranulocytosis and death. It was only reintroduced with strict monitoring of the white cell count, in order to pick up early signs of neutropenia. All patients in the UK must be registered with a clozapine monitoring agency, before they can start clozapine.

63
Q
A. Procyclidine
B. Risperidone
C. Olanzapine
D. Propranolol
E. Chlordiazepoxide
F. Flupenthixol
G. Clozapine
H. Sertraline
I. Chlorpromazine
J. Fluoxetine

Instructions: For each description below, choose the single most likely drug from the above list of options. Each option may be used once, more than once, or not at all.

This typical antipsychotic is not available as a depot medication.

A

I. Chlorpromazine

64
Q
A. Procyclidine
B. Risperidone
C. Olanzapine
D. Propranolol
E. Chlordiazepoxide
F. Flupenthixol
G. Clozapine
H. Sertraline
I. Chlorpromazine
J. Fluoxetine

Instructions: For each description below, choose the single most likely drug from the above list of options. Each option may be used once, more than once, or not at all.

A recognised treatment for acute dystonia.

A

A. Procyclidine

Procyclidine is an anticholinergic drug, and effective treatment for acute dystonias (painful muscle spasms, e.g. torticollis). IM injection may be needed where a fast treatment is required, or where the patient’s ability to swallow safely is compromised by the spasms.

65
Q
A. Procyclidine
B. Risperidone
C. Olanzapine
D. Propranolol
E. Chlordiazepoxide
F. Flupenthixol
G. Clozapine
H. Sertraline
I. Chlorpromazine
J. Fluoxetine

Instructions: For each description below, choose the single most likely drug from the above list of options. Each option may be used once, more than once, or not at all.

Effective in treatment-resistant schizophrenia.

A

G. Clozapine

Clozapine is the only antipsychotic with proven efficacy in schizophrenia that has been shown to be resistant to other antipsychotics. In the UK, the NICE guidelines advise that it is used when a patient has failed to respond to two antipsychotics - one of which should be an atypical - given at therapeutic doses for at least 6 weeks each.

66
Q
A. Flumazenil
B. Chlordiazepoxide and thiamine
C. Naltrexone
D. Rehydration
E. Methadone
F. Naloxone
G. N-acetyl cysteine
H. 5% glucose (bolus)

Instructions: For each of the scenarios below, choose the single most appropriate treatment from the above list of options. Each option may be used once, more than once, or not at all.

Heroin overdose

A

F. Naloxone

Naloxone is an opiate antagonist, and is the antidote for opiate overdoses. It works very quickly, and plunges patients into immediate withdrawal. Once injected, be ready to stand back - patients tend not to be very happy about being “saved” from their euphoric near-death experience, and are unsurprisingly a little angry when they wake up…

67
Q
A. Flumazenil
B. Chlordiazepoxide and thiamine
C. Naltrexone
D. Rehydration
E. Methadone
F. Naloxone
G. N-acetyl cysteine
H. 5% glucose (bolus)

Instructions: For each of the scenarios below, choose the single most appropriate treatment from the above list of options. Each option may be used once, more than once, or not at all.

Paracetamol overdose

A

G. N-acetyl cysteine

68
Q
A. Flumazenil
B. Chlordiazepoxide and thiamine
C. Naltrexone
D. Rehydration
E. Methadone
F. Naloxone
G. N-acetyl cysteine
H. 5% glucose (bolus)

Instructions: For each of the scenarios below, choose the single most appropriate treatment from the above list of options. Each option may be used once, more than once, or not at all.

Ecstasy use

A

D. Rehydration

One of the complications of ecstasy use is dehydration, and this should be reversed to prevent further complications.

69
Q
A. Flumazenil
B. Chlordiazepoxide and thiamine
C. Naltrexone
D. Rehydration
E. Methadone
F. Naloxone
G. N-acetyl cysteine
H. 5% glucose (bolus)

Instructions: For each of the scenarios below, choose the single most appropriate treatment from the above list of options. Each option may be used once, more than once, or not at all.

Alcohol detoxification

A

B. Chlordiazepoxide and thiamine

Chlordiazepoxide is a long-acting benzodiazepine that replaces alcohol at receptor level to prevent withdrawal symptoms. It can be gradually withdrawn and stopped. Thiamine is prescribed as prophylaxis against Wernicke’s encephalopathy.

70
Q
A. Flumazenil
B. Chlordiazepoxide and thiamine
C. Naltrexone
D. Rehydration
E. Methadone
F. Naloxone
G. N-acetyl cysteine
H. 5% glucose (bolus)

Instructions: For each of the scenarios below, choose the single most appropriate treatment from the above list of options. Each option may be used once, more than once, or not at all.

Benzodiazepine overdose

A

A. Flumazenil

Flumazenil is a benzodiazepine antagonist, and thus the antidote to benzodiazepine overdose.

71
Q
A. Ketamine
B. Cannabis
C. Ecstasy
D. Amphetamine
E. Barbiturates
F. Cocaine
G. Codeine
H. Solvents

Instructions: For each list of intoxication symptoms below, choose the single most likely substance from the above list of options.

Euphoria, bradycardia, respiratory depression

A

G. Codeine

Codeine and other opiate (e.g. heroin) produce a pleasant feeling of euphoria, warmth and well-being, along with sedation and anaesthesia. The side effects include nausea and vomiting, bradycardia and respiratory depression. Death can result from respiratory failure or aspiration of vomit.

72
Q
A. Ketamine
B. Cannabis
C. Ecstasy
D. Amphetamine
E. Barbiturates
F. Cocaine
G. Codeine
H. Solvents

Instructions: For each list of intoxication symptoms below, choose the single most likely substance from the above list of options.

Hunger, anxiety, paranoia

A

B. Cannabis

The effects of cannabis vary with expectation and mood before use: paranoia, euphoria and anxiety are all common. Hunger is sometimes called “the munchies” and people tend to want to eat sweet foods.

73
Q
A. Ketamine
B. Cannabis
C. Ecstasy
D. Amphetamine
E. Barbiturates
F. Cocaine
G. Codeine
H. Solvents

Instructions: For each list of intoxication symptoms below, choose the single most likely substance from the above list of options.

Euphoria, disinhibition, hallucinations, nausea

A

H. Solvents

Solvents produce a “drunken” feeling, with euphoria, disinhibition, ataxia, nausea, vomiting, dizziness, hallucinations and confusion, at differing levels. Coma can occur, and can cuase death if vomit is aspirated.

74
Q
A. Ketamine
B. Cannabis
C. Ecstasy
D. Amphetamine
E. Barbiturates
F. Cocaine
G. Codeine
H. Solvents

Instructions: For each list of intoxication symptoms below, choose the single most likely substance from the above list of options.

Synaesthesia, hallucinations, visual distortions

A

A. Ketamine

Ketamine is a member of the hallucinogens, which cause hallucinations, visual distortions and synaethesia (the experience of one perception in another modality). Due to its anaesthetic properties, people can cause themselves great harm while under its influence. Other drugs in this group include LSD, PCP and magic mushrooms.

75
Q
A. Ketamine
B. Cannabis
C. Ecstasy
D. Amphetamine
E. Barbiturates
F. Cocaine
G. Codeine
H. Solvents

Instructions: For each list of intoxication symptoms below, choose the single most likely substance from the above list of options.

Euphoria, energy, empathic feelings

A

C. Ecstasy

Ecstasy is a cross between a stimulant and a hallucinogen. Users get a sense of enhanced empathy, and increased energy - users appear excessively friendly, and energetic. Side effects include nausea, vomiting, sweating, dehydration and death.

76
Q
A. Pre-Contemplation
B. Contemplation
C. Relapse
D. Pre-Preparation
E. Preparation
F. Detoxification
G. Action
H. Maintenance
I. Lapse
J. Denial

Instructions: Regarding the stages of change model, for each scenario below, choose the single most likely stage from the above list of options.

A 25 year old doctor has been a non-smoker for 3 months. During a particularly difficult night on call, a patient dies while under his care and he gives in, smoking three cigarettes to cope with the stress he feels. This is the first time he has smoked since quitting smoking.

A

This is relapse: falling back into use after an attempt at abstinence.

77
Q
A. Pre-Contemplation
B. Contemplation
C. Relapse
D. Pre-Preparation
E. Preparation
F. Detoxification
G. Action
H. Maintenance
I. Lapse
J. Denial

Instructions: Regarding the stages of change model, for each scenario below, choose the single most likely stage from the above list of options.

A 34 year old lawyer attended his GP for a routine appointment and was shocked to learn that he was drinking three times the safe weekly limit of alcohol. He agreed to cut down his intake to 21 units per week, and has never drunk more than this since the appointment, 5 years ago.

A

H. Maintenance

Maintenance is when someone is able to maintain abstinence (or safe usage).

78
Q
A. Pre-Contemplation
B. Contemplation
C. Relapse
D. Pre-Preparation
E. Preparation
F. Detoxification
G. Action
H. Maintenance
I. Lapse
J. Denial

Instructions: Regarding the stages of change model, for each scenario below, choose the single most likely stage from the above list of options.

A 58 year old teacher attends Alcoholics Anonymous and is able to stop drinking alcohol entirely; she has now been abstinent for a whole year.

A

H. Maintenance

Maintenance is when someone is able to maintain abstinence (or safe usage).

79
Q
A. Pre-Contemplation
B. Contemplation
C. Relapse
D. Pre-Preparation
E. Preparation
F. Detoxification
G. Action
H. Maintenance
I. Lapse
J. Denial

Instructions: Regarding the stages of change model, for each scenario below, choose the single most likely stage from the above list of options.

A 28 year old actor smokes three spliffs of cannabis each evening. He enjoys smoking and feels that it helps him to relax. He states that it has never caused him any problems and he does not want to give up smoking.

A

A. Pre-Contemplation

Pre-contemplation is when the person doesn’t see or a problem, or doesn’t have any intention to change their usage.

80
Q
A. Pre-Contemplation
B. Contemplation
C. Relapse
D. Pre-Preparation
E. Preparation
F. Detoxification
G. Action
H. Maintenance
I. Lapse
J. Denial

Instructions: Regarding the stages of change model, for each scenario below, choose the single most likely stage from the above list of options.

A 30 year old sex worker has been injecting heroin for the past eight years. Her boyfriend has stated that he wants to settle down with her, but has begged her to change her lifestyle. She decides she will “go cold turkey” in a month and begins to stockpile anti-emetics and benzodiazepines for her home “detox”.

A

E. Preparation

Preparation is when the person is willing to change, and is planning to do this soon.

81
Q
A. Neurobiological theories
B. Cognitive behavioural theory
C. Skinnerian conditioning
D. Peer facilitation theory
E. Psychobiological conditioning
F. Social learning theory
G. Pavlovian conditioning
H. Natural learning theory

Behaviours that are rewarded are repeated.

A

C. Skinnerian conditioning

Skinnerian (or operant) conditioning depends on repetitive behaviours having predictable outcomes. Positive conditioning is when behaviours that are rewarded are repeated.

82
Q
A. Neurobiological theories
B. Cognitive behavioural theory
C. Skinnerian conditioning
D. Peer facilitation theory
E. Psychobiological conditioning
F. Social learning theory
G. Pavlovian conditioning
H. Natural learning theory

Substance misuse can result from peer pressure.

A

F. Social learning theory

Social learning theory (or vicarious learning) is the idea that we learn by copying the behaviours of those around us.

83
Q
A. Neurobiological theories
B. Cognitive behavioural theory
C. Skinnerian conditioning
D. Peer facilitation theory
E. Psychobiological conditioning
F. Social learning theory
G. Pavlovian conditioning
H. Natural learning theory

Cues can trigger craving.

A

G. Pavlovian conditioning

Pavlovian (or classical) conditioning occurs in substance misuse when cravings become conditioned to cues, such as walking past a pub.

84
Q
A. Neurobiological theories
B. Cognitive behavioural theory
C. Skinnerian conditioning
D. Peer facilitation theory
E. Psychobiological conditioning
F. Social learning theory
G. Pavlovian conditioning
H. Natural learning theory

Artificial stimulation of the reward pathways affects the emotional brain.

A

A. Neurobiological theories

Neurobiological theories of substance misuse focus on the way that drugs affect dopamingeric “reward” pathways in the brain.

85
Q
A. Neurobiological theories
B. Cognitive behavioural theory
C. Skinnerian conditioning
D. Peer facilitation theory
E. Psychobiological conditioning
F. Social learning theory
G. Pavlovian conditioning
H. Natural learning theory

Behaviours that relieve unpleasant experiences are repeated.

A

C. Skinnerian conditioning

Skinnerian (or operant) conditioning depends on repetitive behaviours having predictable outcomes. Negative conditioning is when behaviours are repeated if they relieve an unpleasant experience.

86
Q

A. Frontal Lobe
B. Temporal Lobe
C. Parietal Lobe
D. Occipital Lobe

Instructions: For each presentation below, choose the single most likely lobe of the brain to be affected from the above list of options.

A 67 year old man who is unable to dress himself following haemorrhagic stroke, despite intact sensory and motor function.

A

C. Parietal Lobe

Damage to the parietal lobe can cause apraxia - the inability to carry out skilled tasks despite intact sensory and motor function. The example giving is of dressing apraxia.

87
Q

A. Frontal Lobe
B. Temporal Lobe
C. Parietal Lobe
D. Occipital Lobe

Instructions: For each presentation below, choose the single most likely lobe of the brain to be affected from the above list of options.

Following an ischaemic stroke, a 74 year old woman has difficulty communicating, using only short words and sentences. She is able to carry out commands normally.

A

A. Frontal Lobe

This is a Broca’s dysphasia, whereby expression of speech is poor, but comprehension is normal. Broca’s area lies within the left frontal lobe in right-handed people and the majority of left-handed people.

88
Q

A. Frontal Lobe
B. Temporal Lobe
C. Parietal Lobe
D. Occipital Lobe

Instructions: For each presentation below, choose the single most likely lobe of the brain to be affected from the above list of options.

Following an open head injury, a 34 year old man repeatedly takes off his clothes and is sexually inappropriate toward the ward staff.

A

A. Frontal Lobe

This is suggestive of frontal lobe damage, though a more generalised delirium state should be excluded first.

89
Q

A. Frontal Lobe
B. Temporal Lobe
C. Parietal Lobe
D. Occipital Lobe

Instructions: For each presentation below, choose the single most likely lobe of the brain to be affected from the above list of options.

An 82 year old man who presents to A+E with severe blurring of vision, but on examination his pupillary responses to light are intact.

A

D. Occipital Lobe

The primary visual cortex lies within the occipital lobe. Damage here can cause visual disturbances.

90
Q

A. Frontal Lobe
B. Temporal Lobe
C. Parietal Lobe
D. Occipital Lobe

Instructions: For each presentation below, choose the single most likely lobe of the brain to be affected from the above list of options.

A

B. Temporal Lobe

This is strongly suggestive of temporal lobe epilepsy.

91
Q
A. Amnesic syndrome
B. Retrograde amnesia
C. Transient global amnesia
D. Post-concussional syndrome
E. Multiple sclerosis
F. Inflammatory bowel disease
G. Parkinson's disease
H. Frontal lobe damage
I. Co-morbid bipolar affective disorder
J. Co-morbid Alzheimer's disease
K. Medication side effect
L. Endocrine disorder
M. Epilepsy

A 43 year old man attends his GP complaining of labile mood. He has been treated for a chronic neurological illness, which has had a relapsing and remitting course for two years.

A

E. Multiple sclerosis

Multiple sclerosis may run a relapsing and remitting course. Mood changes such as lability, depression and mania are relatively common, and may relate to the disease itself or to the medication used to treat it.

92
Q
A. Amnesic syndrome
B. Retrograde amnesia
C. Transient global amnesia
D. Post-concussional syndrome
E. Multiple sclerosis
F. Inflammatory bowel disease
G. Parkinson's disease
H. Frontal lobe damage
I. Co-morbid bipolar affective disorder
J. Co-morbid Alzheimer's disease
K. Medication side effect
L. Endocrine disorder
M. Epilepsy

A 32 year old man with a chronic illness, who has been receiving treatment for depression kills himself. It is known that people in this group have a suicide rate four times that of the general population.

A

M. Epilepsy

Epilepsy is associated with a fourfold increased risk of suicide, and up to 50% of patients suffer from depression at some point in their illness.
See page 127.

93
Q
A. Amnesic syndrome
B. Retrograde amnesia
C. Transient global amnesia
D. Post-concussional syndrome
E. Multiple sclerosis
F. Inflammatory bowel disease
G. Parkinson's disease
H. Frontal lobe damage
I. Co-morbid bipolar affective disorder
J. Co-morbid Alzheimer's disease
K. Medication side effect
L. Endocrine disorder
M. Epilepsy

You are asked to review a 23 year old girl who was admitted a week ago with an acute exacerbation of ulcerative colitis. Ward staff report that although her symptoms of colitis are improving with treatment, she has become sexually disinhibited, hyperactive and sleeps little.

A

K. Medication side effect

Medications can cause numerous side effects, and in this case, the most likely scenario is that the woman’s colitis has been successfully treated with steroids, and these have triggered a hypomanic / manic presentation.

94
Q
A. Amnesic syndrome
B. Retrograde amnesia
C. Transient global amnesia
D. Post-concussional syndrome
E. Multiple sclerosis
F. Inflammatory bowel disease
G. Parkinson's disease
H. Frontal lobe damage
I. Co-morbid bipolar affective disorder
J. Co-morbid Alzheimer's disease
K. Medication side effect
L. Endocrine disorder
M. Epilepsy

Two weeks following a head injury, a 37 year old English teacher is alert and able to converse with visitors. She can even recite Wordsworth’s ‘Daffodils’ - but does not recognise the doctor who has been treating her every day since admission.

A

A. Amnesic syndrome

In amnesic (or “amnestic”) syndrome, there is a profound anterograde memory loss: the patient cannot lay down new memories. Other aspects of their memory and overall cognition are relatively intact.

95
Q
A. Amnesic syndrome
B. Retrograde amnesia
C. Transient global amnesia
D. Post-concussional syndrome
E. Multiple sclerosis
F. Inflammatory bowel disease
G. Parkinson's disease
H. Frontal lobe damage
I. Co-morbid bipolar affective disorder
J. Co-morbid Alzheimer's disease
K. Medication side effect
L. Endocrine disorder
M. Epilepsy

A 32 year old man presents complaining of severe headache, dizziness, irritability and fatigue 4 months following head injury.

A

D. Post-concussional syndrome

Post-concussional syndrome occurs in up to 50% of people who have suffered a mild head injury with loss of consciousness. Mood, cognitive and somatic symptoms may present, and the patient is usually preoccupied with these symptoms.

96
Q
A. Parkinson's disease
B. Delirium
C. Frontotemporal lobar degeneration
D. Huntington's disease
E. Creutzfeldt-Jakob disease
F. HIV encephalopathy
G. Wilson's disease
H. Tertiary neurosyphilis
I. Dementia with Lewy bodies
J. Alzheimer's Disease

Instructions: For each of the pathological features below, choose the single most likely diagnosis from the above list of options.

Accumulations of insoluble prion protein

A

E. Creutzfeldt-Jakob disease

This is a florid plaque from the brain of a patient with variant Creutzfeldt-Jakob disease. It is not a common disease in old age, but should be considered in patients with early onset dementias.

97
Q
A. Parkinson's disease
B. Delirium
C. Frontotemporal lobar degeneration
D. Huntington's disease
E. Creutzfeldt-Jakob disease
F. HIV encephalopathy
G. Wilson's disease
H. Tertiary neurosyphilis
I. Dementia with Lewy bodies
J. Alzheimer's Disease

Instructions: For each of the pathological features below, choose the single most likely diagnosis from the above list of options.

B-amyloid protein aggregates into insoluble clumps surrounded by dystrophic neurites

A

J. Alzheimer’s Disease

This is a plaque from the brain of a patient with Alzheimer’s disease.

98
Q
A. Parkinson's disease
B. Delirium
C. Frontotemporal lobar degeneration
D. Huntington's disease
E. Creutzfeldt-Jakob disease
F. HIV encephalopathy
G. Wilson's disease
H. Tertiary neurosyphilis
I. Dementia with Lewy bodies
J. Alzheimer's Disease

Instructions: For each of the pathological features below, choose the single most likely diagnosis from the above list of options.

Eosinophilic, intracytoplasmic neuronal structures form in the cingulate gyrus and neocortex.

A

I. Dementia with Lewy bodies

99
Q
A. Parkinson's disease
B. Delirium
C. Frontotemporal lobar degeneration
D. Huntington's disease
E. Creutzfeldt-Jakob disease
F. HIV encephalopathy
G. Wilson's disease
H. Tertiary neurosyphilis
I. Dementia with Lewy bodies
J. Alzheimer's Disease

Instructions: For each of the pathological features below, choose the single most likely diagnosis from the above list of options.

Deposits of abnormal protein cause atrophy of the basal ganglia and thalamus, cortical neurone loss, especially affecting frontal regions. Caudate nucleus atrophy may be visible on MRI / CT scan.

A

D. Huntington’s disease

100
Q
A. Parkinson's disease
B. Delirium
C. Frontotemporal lobar degeneration
D. Huntington's disease
E. Creutzfeldt-Jakob disease
F. HIV encephalopathy
G. Wilson's disease
H. Tertiary neurosyphilis
I. Dementia with Lewy bodies
J. Alzheimer's Disease

Instructions: For each of the pathological features below, choose the single most likely diagnosis from the above list of options.

Neurones contain ‘Pick bodies’ and neurofibrillary tangles

A

C. Frontotemporal lobar degeneration

Frontotemporal lobar degeneration is an umbrella term for a number of disorders united by asymmetrical frontal and / or anterior temporal lobe atrophy. The picture shows Pick bodies, seen in the Pick’s disease subtype. These dementias tend to affect younger patients (under 60).

101
Q
A. Sodium valproate
B. Cognitive behavioural therapy
C. Sertraline
D. Minimise cardiovascular risk factors
E. Donepezil
F. Olanzapine
G. Lithium
H. Levothyroxine
I. Diazepam
J. Encourage to avoid crowded places

You are concerned about a 78 year old man as he did not attend his diabetic clinic appointment. You undertake a home visit. His MMSE score is 14/30 and he is oriented to place but not time. He says he’s been feeling very well recently and hasn’t needed his medications. When he goes to the kitchen to make you a cup of tea, he returns smoking a cigarette instead.

A

D. Minimise cardiovascular risk factors

On the basis of this history, vascular dementia is a concern, though delirium must be excluded first. Whatever the diagnosis, this gentleman needs to minimise his cardiovascular risk factors by addressing his smoking, concordance and diabetic management.

102
Q
A. Sodium valproate
B. Cognitive behavioural therapy
C. Sertraline
D. Minimise cardiovascular risk factors
E. Donepezil
F. Olanzapine
G. Lithium
H. Levothyroxine
I. Diazepam
J. Encourage to avoid crowded places

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

A

H. Levothyroxine

The slowed thoughts and movements, lethargy and weight gain could all suggest depression, but in the context of her medical history, hypothyroidism should be excluded, since the thyroid gland may have been damaged by radiotherapy. If her TFTs are normal, depression would be the next diagnosis to consider.

103
Q
A. Sodium valproate
B. Cognitive behavioural therapy
C. Sertraline
D. Minimise cardiovascular risk factors
E. Donepezil
F. Olanzapine
G. Lithium
H. Levothyroxine
I. Diazepam
J. Encourage to avoid crowded places

The daughter of a 72 year old man asks you to see him at home as he has been losing weight and no longer leaves the house. When you visit he appears dishevelled. You know him well as you were involved in the palliative care of his wife who died last year, however he doesn’t recognise you. He is orientated to time but not place, and scores 16 / 25 on the MMSE, saying he “doesn’t know” and becoming frustrated with your questioning. He has been feeling very lethargic and sleeps poorly.

A

C. Sertraline

This is depression, presenting as “pseudodementia”.

104
Q
A. Sodium valproate
B. Cognitive behavioural therapy
C. Sertraline
D. Minimise cardiovascular risk factors
E. Donepezil
F. Olanzapine
G. Lithium
H. Levothyroxine
I. Diazepam
J. Encourage to avoid crowded places

On your way home from work you greet a well-known elderly patient who doesn’t recognise you. He says he was on the way to meet some friends but has become lost and tries to shoo away the “dogs” he says have been following him around. You can’t see any dogs but note he has a mild tremor at rest. He denies having had any medical problems recently and says he feels “right as rain”. As you assist him in finding his way you note that his gait is slightly stiff.

A

E. Donepezil

This is likely to be Dementia with Lewy Bodies (suggested by new parkinsonian signs, vivid visual hallucinations). Acetylcholinesterase inhibitors are used in both DLB and Alzheimer’s disease.

105
Q
A. Sodium valproate
B. Cognitive behavioural therapy
C. Sertraline
D. Minimise cardiovascular risk factors
E. Donepezil
F. Olanzapine
G. Lithium
H. Levothyroxine
I. Diazepam
J. Encourage to avoid crowded places

A 68 year old lady presents to you with a 2 year history of panic attacks when she is in crowded places. They are becoming increasingly frequent and she is now reluctant to leave the house at all.

A

B. Cognitive behavioural therapy

This is agoraphobia with panic attacks. Cognitive Behavioural Therapy would incorporate exposure therapy and thought diaries to improve this woman’s ability to cope with crowded places. Avoidance would be unhelpful.

106
Q
A) GAD
B) Agoraphobia
C) Social phobia
D) Specific phobia
E) Phaeochromocytoma
F) OCD
G) PTSD
H) Panic disorder
I) Adjustment disorder
J) Hyperthyroidism

John is a 50 year old vicar. He is finding it increasingly difficult to perform his pastoral duties. During services, he can’t stop imagining himself engaged in sex acts with members of his congregation. He tries to block these thoughts and images out of his mind, but they always return. He has to say a special prayer under his breath to undo the “evil” of his “sordid mind”.

A

F) OCD

Obsessive Compulsive Disorder is characterised by obsessions (in this case, images of sex acts) and compulsions (in this case, the “special prayer”).

107
Q
A) GAD
B) Agoraphobia
C) Social phobia
D) Specific phobia
E) Phaeochromocytoma
F) OCD
G) PTSD
H) Panic disorder
I) Adjustment disorder
J) Hyperthyroidism

Maria, a 32 year old woman, comes to your GP practice. Her mother died last year of a myocardial infarction. Over the past month, Maria has experienced 6 episodes of palpitations, associated with shortness of breath. The episodes come on out of the blue and Maria describes feeling as though she may die. On the last occasion, she had to call for an ambulance. Between episodes she feels well.

A

H) Panic disorder

Maria is suffering from panic attacks, and the pattern of several attacks within a month raises the diagnosis to that of panic disorder.

108
Q
A) GAD
B) Agoraphobia
C) Social phobia
D) Specific phobia
E) Phaeochromocytoma
F) OCD
G) PTSD
H) Panic disorder
I) Adjustment disorder
J) Hyperthyroidism

Lauren is a quiet young woman. She is 19 years old and has just started university. She is painfully shy and rarely goes out with friends from university. She enjoys attending music festivals and is a keen hang-glider. Her friends are concerned that she may be developing a drinking problem, since - when she does join them for dinner - she tends to drink excessively.

A

C) Social phobia

This is a typical presentation of social phobia, where situations are avoided if they could give rise to embarrassment or to scrutiny by others. Lauren’s problems appear limited to these situations, since she clearly copes well with large crowds of people (someone with agoraphobia would have difficulties with music festivals) and doesn’t appear to have an anxious personality (hang-gliding is generally not for the faint-hearted!). Alcohol misuse is common.

109
Q
A) GAD
B) Agoraphobia
C) Social phobia
D) Specific phobia
E) Phaeochromocytoma
F) OCD
G) PTSD
H) Panic disorder
I) Adjustment disorder
J) Hyperthyroidism

This potentially chronic disorder is more common in females. Diagnosis requires autonomic and physical symptoms of anxiety occurring when travelling, in crowds, open spaces, or public places. The anxiety experienced may provoke avoidance of the situation. Depression is commonly comorbid.

A

B) Agoraphobia

Agoraphobia has the potential to cause extreme disability, since people can become completely housebound.

110
Q
A) GAD
B) Agoraphobia
C) Social phobia
D) Specific phobia
E) Phaeochromocytoma
F) OCD
G) PTSD
H) Panic disorder
I) Adjustment disorder
J) Hyperthyroidism

Jill is a 25 year old student. She presents to your GP surgery complaining of headaches (like a “tight band around my head”) and a fast heart beat. She says these symptoms are present “most days” and can occur at any time of the day. She admits to being “very worried”, although she can’t pin down “one big worry”.

A

A) GAD

The fears in generalised anxiety disorder (GAD) are non-specific and the anxiety is “free-floating”. Physical anxiety symptoms (such as tension headaches) are prominent.

111
Q
A) Phaeochromocytoma
B) Hyperthyroidism
C) Parathyroid disease
D) Substance misuse
E) Benign essential tremor
F) Parkinsonism 
G) Alcohol withdrawal
H) Hypoglycaemia
I) Sydenham's chorea

A 65 year old woman attends your GP surgery. She is concerned that her hands seem to shake when she is trying to do things. This was mild initially, but is now so bad that her handwriting has changed. She also says that her head shakes from side to side. She finds the problems resolve when she plays hockey or runs marathons.

A

E) Benign essential tremor

This can be confused with Parkinson’s Disease (PD). Essential tremors are intention tremors and often begin in the hands but can progress to affect the head and voice. In PD, tremors occur at rest and typically affect the hands.

112
Q
A) Phaeochromocytoma
B) Hyperthyroidism
C) Parathyroid disease
D) Substance misuse
E) Benign essential tremor
F) Parkinsonism 
G) Alcohol withdrawal
H) Hypoglycaemia
I) Sydenham's chorea

Mr Claude Jacques, a 64 year old man, is noted by his wife to have increasingly shaky hands. She says that the right seems worse than the left most days, and that Claude seems “very on edge”. He mumbles and rarely smiles. She is concerned that “his nerves” are playing up.

A

F) Parkinsonism

This gentleman has signs of parkinsonism. He has a resting tremor, voice changes and “mask like” facies. It may be Parkinson’s disease, or secondary to other causes (e.g. extrapyramidal side effects from antipsychotic medications).

113
Q
A) Phaeochromocytoma
B) Hyperthyroidism
C) Parathyroid disease
D) Substance misuse
E) Benign essential tremor
F) Parkinsonism 
G) Alcohol withdrawal
H) Hypoglycaemia
I) Sydenham's chorea

Paul Rigby is a 32 year old solicitor. He comes to see you at an out of hours clinic. Paul seems highly anxious and his hands are visibly shaking. He states that he thinks he is having a heart attack and describes tightness in his chest and being very aware of his heartbeat. On further questioning Paul admits he has had 2 similar episodes in the previous few months - both times after smoking - where he also experienced pins and needles and sweating. A friend told him he went very pale. On examination, he is tachycardic and hypertensive; MCV and gamma-GT are normal and a UDS is negative.

A

A) Phaeochromocytoma

In phaeochromocytoma, symptoms mimic those of extreme anxiety and are episodic in nature. Tumours are commonly benign and symptoms will resolve with surgery.

114
Q
A) Phaeochromocytoma
B) Hyperthyroidism
C) Parathyroid disease
D) Substance misuse
E) Benign essential tremor
F) Parkinsonism 
G) Alcohol withdrawal
H) Hypoglycaemia
I) Sydenham's chorea

Roger Knowles is a 48 year old airline pilot. Although he seems relaxed and chats easily with staff during meal breaks throughout the flight, his crew have noted that he becomes sweaty, tremulous and irritable towards the end of long-haul flights. He is a confident pilot, and at the hotel after the flight, always seems back to his usual self.

A

G) Alcohol withdrawal

The inability to drink alcohol while on his flight causes withdrawal symptoms only towards the end of the flight; Roger can access alcohol in the hotels - which causes his symptoms to cease.

115
Q
A) Phaeochromocytoma
B) Hyperthyroidism
C) Parathyroid disease
D) Substance misuse
E) Benign essential tremor
F) Parkinsonism 
G) Alcohol withdrawal
H) Hypoglycaemia
I) Sydenham's chorea

Olivia Kenysham is a 52 year old house wife. Her husband recently left her for a close family friend. You are a junior doctor working in general practice. Olivia comes to see you, complaining of frequent headaches and aching legs. She is unable to localise the pain in her head. Olivia also mentions feeling irritable and she has noticed she feels the need to pass water more regularly. She tells you that she feels very thirsty.

A

B) Hyperthyroidism

Hyperparathyroidism causes raised calcium levels, and problems such as fractures (osteoporosis), renal stones, abdominal pain, low mood: “Bones, stones, groans and psychic moans.” Increased thirst is an associated symptom.

116
Q

A. Exercise avoidance
B. Endoscopy
C. Encourage reattribution of symptoms to non-organic cause
D. Reassure symptoms will resolve quickly
E. CT Head
F. Reassure patient that it is definitely not an organic cause
G. CBT
H. Discharge
I. Diazepam
J. Explain to relatives that symptoms are self-induced

Instructions: For each presentation below, choose the single most appropriate management from the above list of options.

A 72 year old man presents to A&E with right sided loss of motor function and slurred speech which were sudden in onset. He regularly attends A&E and sees a psychiatrist for recurrent episodes of medically unexplained symptoms including paraesthesia, abdominal pain and palpitations. He has previously presented with similar symptoms, which resolved completely and within 24 hours.

A

E. CT Head

The presentation is of a stroke, and no amount of historical medically unexplained symptoms should prevent investigation and treatment in this man’s case! It is likely that his “similar symptoms” represented a transient ischaemic attack.

117
Q

A. Exercise avoidance
B. Endoscopy
C. Encourage reattribution of symptoms to non-organic cause
D. Reassure symptoms will resolve quickly
E. CT Head
F. Reassure patient that it is definitely not an organic cause
G. CBT
H. Discharge
I. Diazepam
J. Explain to relatives that symptoms are self-induced

Instructions: For each presentation below, choose the single most appropriate management from the above list of options.

A 23 year old woman has been attending your GP practice complaining of exhaustion following mild exertion for the past 4 months. You have the final results of her blood tests, which - like her physical examination - are all normal. You spend time explaining and discussing the meaning of the results. She accepts that stress may be a factor in her presentation, and accepts the diagnosis of Chronic Fatigue Syndrome. She asks you what can be done next.

A

G. CBT

Cognitive Behavioural Therapy is of proven benefit in Chronic Fatigue Syndrome.

118
Q

A. Exercise avoidance
B. Endoscopy
C. Encourage reattribution of symptoms to non-organic cause
D. Reassure symptoms will resolve quickly
E. CT Head
F. Reassure patient that it is definitely not an organic cause
G. CBT
H. Discharge
I. Diazepam
J. Explain to relatives that symptoms are self-induced

Instructions: For each presentation below, choose the single most appropriate management from the above list of options.

A 43 year old lady presents with epigastric and central burning chest pain. She has been fully investigated by the gastrointestinal and cardiology clinics, and no organic cause can be found for her symptoms. Her mother died of oesophageal carcinoma 6 months ago aged 75. She requests further investigation as her symptoms are worsening.

A

C. Encourage reattribution of symptoms to non-organic cause

She has been fully investigated and you would be likely to cause further distress and harm by ordering further investigations (as well as annoying your specialist colleagues!). Unresolved stressors and grief issues need to be explored with this woman.

119
Q

A. Exercise avoidance
B. Endoscopy
C. Encourage reattribution of symptoms to non-organic cause
D. Reassure symptoms will resolve quickly
E. CT Head
F. Reassure patient that it is definitely not an organic cause
G. CBT
H. Discharge
I. Diazepam
J. Explain to relatives that symptoms are self-induced

Instructions: For each presentation below, choose the single most appropriate management from the above list of options.

A 32 year old man suddenly loses the ability to speak, after discovering that his wife was having an affair. He presents to A&E with his wife who is very anxious, tearful and worried. Examination is normal, with an intact cough reflex. He does not appear particularly concerned about his symptoms.

A

D. Reassure symptoms will resolve quickly

This is a fairly clear-cut case of conversion aphonia. The acute onset, combined with a recent stressor and “belle indifference” (lack of concern) are the important clues. Reassurance that symptoms will pass soon will help the prognosis, and this man should be encouraged to seek support for his marital problems. Reattribution of symptoms may be tricky in an acute situation like this, but can be tried. The most important thing is to ensure that his symptoms are not reinforced by the acceptance of disability.

120
Q

A. Exercise avoidance
B. Endoscopy
C. Encourage reattribution of symptoms to non-organic cause
D. Reassure symptoms will resolve quickly
E. CT Head
F. Reassure patient that it is definitely not an organic cause
G. CBT
H. Discharge
I. Diazepam
J. Explain to relatives that symptoms are self-induced

Instructions: For each presentation below, choose the single most appropriate management from the above list of options.

A 50 year old woman attends A&E with her sister following a ‘fit’. She has a long history of medically unexplained seizures. She complains to A&E staff that she has been waiting for 3 hours and has not been seen. On returning to the waiting room she starts convulsing again. You note that during the seizure she has been incontinent and has hurt her hand on a chair. She is moved into the Resus area and tolerates a Guedel (oropharyngeal) airway. The seizure is ongoing at 5 minutes from onset.

A

I. Diazepam

A history of “pseudoseizures” does not exclude “organic” seizures, and there is an increased risk of pseudoseizures in people with epilepsy. The history of incontinence and accidental injury are not diagnostic of either type of seizure, but would be more unusual in a pseudoseizure. Insertion of an oropharyngeal airway is not impossible in a pseudoseizure, but would be very unusual (NB: it should not be used as a diagnostic “tool”).

121
Q
A. Chronic fatigue syndrome
B. Schizophrenia
C. Factitious disorder
D. Panic disorder
E. Somatization disorder
F. Hypochondriasis
G. Delusional disorder
H. Malingering
I. Munchausens-by-proxy
J. Bulimia nervosa

A 24 year old man presents complaining of severe, intractable back pain, radiating down his legs and causing difficulty sleeping. He refuses examination and investigation. When you explain the importance of investigation he becomes agitated and demands morphine and diazepam.

A

H. Malingering

Malingering is the deliberate production of symptoms to gain external rewards.This presentation is not diagnostic, since the man may have many reasons behaving in this way, but it should alert you to the possibility that he is feigning symptoms to obtain a reward other than the sick role itself - in this case, the reward is opiates.

122
Q
A. Chronic fatigue syndrome
B. Schizophrenia
C. Factitious disorder
D. Panic disorder
E. Somatization disorder
F. Hypochondriasis
G. Delusional disorder
H. Malingering
I. Munchausens-by-proxy
J. Bulimia nervosa

A 48 year old woman presents with recurrent episodes of epistaxis. Routine investigations and a clotting screen have been sent and she is becoming impatient, demanding that ‘something should be done’. Her daughter arrives in the department and tells you that the family suspect she has been taking the warfarin tablets belonging to her severely disabled husband who suffered a stroke 3 months ago. You note that her INR is greatly raised, at 9.

A

C. Factitious disorder

Please note that the diagnosis of factitious disorder in this woman should not prevent treatment (after a capacity assessment, if the patient refuses treatment), i.e. Vitamin K. Her immediate medical problems must be dealt with, whatever the cause. The concern that she is causing herself to bleed should be discussed with her openly, and a psychiatric referral made. Don’t forget to consider the impact on her husband, who may be under-warfarinised as a result of her use of his tablets. This presentation is sometimes called Munchausen’s syndrome.

123
Q
A. Chronic fatigue syndrome
B. Schizophrenia
C. Factitious disorder
D. Panic disorder
E. Somatization disorder
F. Hypochondriasis
G. Delusional disorder
H. Malingering
I. Munchausens-by-proxy
J. Bulimia nervosa

A 33 year old woman presents to Accident and Emergency, demanding an MRI scan as she is sure she has a brain tumour. She has experienced headaches and intermittent episodes of dizziness when she stands still for extended periods of time. There is nothing to suggest malignancy or a space-occupying lesion from either the history or examination. You call her GP, who explains that she has been fully investigated in the past for this problem.

A

F. Hypochondriasis

Hypochondriasis is an extreme form of health anxiety, whereby the patient believes that they have a specific illness (e.g. a brain tumour) rather than simply presenting with inexplicable symptoms.

124
Q
A. Chronic fatigue syndrome
B. Schizophrenia
C. Factitious disorder
D. Panic disorder
E. Somatization disorder
F. Hypochondriasis
G. Delusional disorder
H. Malingering
I. Munchausens-by-proxy
J. Bulimia nervosa

A 56 year old woman returns to her GP complaining of a loss of sensation in her left hand. Sensory loss does not conform to any dermatome or peripheral nerve supply. She has had multiple previous episodes of parasthesia affecting areas of her arms, legs and face over the past 3 years. Nerve conduction studies performed last month were normal. In the past, she has also suffered from shortness of breath, recurrent headaches, dyspareunia, palpitations, visual blurring and abdominal pain. All were investigated fully, but remained without a medical explanation.

A

E. Somatization disorder

In somatization disorder, there are multiple medically unexplained symptoms, affecting different systems of the body.

125
Q
A. Chronic fatigue syndrome
B. Schizophrenia
C. Factitious disorder
D. Panic disorder
E. Somatization disorder
F. Hypochondriasis
G. Delusional disorder
H. Malingering
I. Munchausens-by-proxy
J. Bulimia nervosa

Mr Noonan, a 41 year old businessman has been referred to the dermatology clinic by his GP. The GP letter states that Mr Noonan has presented repeatedly, complaining of “insects” under his skin and demanding treatment. Despite meticulously following the instructions for malathion on three occasions, he insists that the insects are still there. Skin scrapings were negative for mites and eggs and he has no history of foreign travel or drug use. On examination there is generalized excoriation, though no rash or burrows. Despite the dermatologist’s certainty that this is not scabies, and there is no infestation of any other kind, Mr Noonan adamantly states that he knows they’re there but is unable to explain how. He demands a second opinion.

A

G. Delusional disorder

This particular delusion of infestation, in the absence of any other psychiatric symptoms or systematised delusions, is known as Ekbom’s syndrome.