Questions

Question 1

[] personality disorder: prefer to be alone, don’t like relationships, low libido

Answer 1

Schizoid personality disorder:
- prefer to be alone, don’t like relationships, low libido

Could be avoidant personality disorder at first, the key difference is that in this example (schizoid), he doesn’t care about praise/criticism from his colleagues

schizoid sounds like android. So they are robotic in character: little interest in sex, solitary, indifferent.

NB:
- Whilst being asexual is recognised as being part of the LGBTQ+ spectrum both the DSM-5 and ICD-10 list lack of interest in sex as being part of the diagnostic criteria:

Question 2

You are a GP.

A patient presents to you with symptoms of hypomania.

How do you manage them? [1]

Answer 2

Symptoms of hypomania in primary care: routine referral to CMHT

Question 3

ECT can cause memory impairment.

Which type? [1]

Answer 3

Retrograde amnesia (remembering events prior to the insult) is far more common that anterograde amnesia (loss of ability to form new memories after the insult)

Question 4

Describe the difference between SSRI tx for OCD vs depression [2]

Answer 4

When treating OCD, compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response

Question 5

A patient is presenting with severe anorexia.

Describe what you might when ascultating their chest.
Explain [2]

Answer 5

Severe anorexia nervosa can lead to loss of cardiac muscle, resulting in mitral valve prolapse with associated complications such as shortness of breath and heart murmers.

Question 6

In patients suspected of having bulimia nervosa, investigation for electrolyte imbalances, specifically [], is crucial due to frequent self-induced vomiting and laxative use.

Answer 6

In patients suspected of having bulimia nervosa, investigation for electrolyte imbalances, specifically hypokalaemia, is crucial due to frequent self-induced vomiting and laxative use.

Question 7

You suspect a patient is suffering from bulimia nervosa.

Which electrolyte changes should you investigate? [3]

Answer 7

. Calcium, phosphate and magnesium should be part of the investigations.

Question 8

You suspect someone has LBD.

What is the underlying pathological change in their brain? [1]

Answer 8

Alpha-synuclein cytoplasmic inclusions in the substantia nigra and paralimbic areas.

Question 9

The antipsychotics most commonly used in the treatment of manic episodes or mixed episodes in bipolar affective disorder are [4]

Answer 9

The antipsychotics most commonly used in the treatment of manic episodes or mixed episodes in bipolar affective disorder are quetiapine, olanzapine, risperidone and haloperidol.

Question 10

Which conditions should you cholinesterase inhibitors with caution? [2]

Answer 10

sick sinus syndrome and peptic ulcer disease

Question 11

Describe the treatment plan for post-partum depression [4]

Answer 11

First-line treatments typically involve self-help strategies and psychological therapies such as Cognitive Behavioural Therapy (CBT) or Interpersonal Therapy (IPT).

High severity: SSRIs
- Paroxetine and Sertraline (safe in breastfeeding)
- Assess if admission needed

Question 12

When does grief reaction expire? [1]

Answer 12

starts within 3 months of the stressor and does not persist for longer than 6 months.
- if longer then probably depression

Question 13

FTD is strongly associated with [],

Answer 13

Amyotrophic lateral sclerosis
- around 40% of people with FTD carry the same genetic mutations that are also implicated in ALS, such as mutations in the C9ORF72 gene. This overlap makes ALS a recognised comorbidity in patients with FTD.

Question 14

Which drugs are used first line for acute mania and why?

Answer 14

antipsychotics are used first line for acute mx, as lithium takes a couple of weeks to work

Question 15

A patient has an infection, they take clozapine.

What would indicate someone has clozapine toxicity (as opposed to neutrophilia?)

Answer 15

symptoms of clozapine toxicity – confusion, drowsiness, ataxia and tachycardia

NB - clozapine is metabolised by CYP450 enzymes, it is postulated that downregulation of these enzymes by cytokines in an infection/inflammation decreases the metabolism of clozapine, leading to a raised clozapine level.

Question 16

During which time period is postpartum psychosis most likely to be seen? [1]

Answer 16

Postpartum psychosis can include paranoia, delusions, hallucinations, mania, depression or confusion, and generally develops within the first two weeks of giving birth.

Question 17

Describe an occular side effect of TCA use [1]

Answer 17

Blurred vision

Question 18

Which of the following might be side effects of his sodium valproate?

Hair loss, weight gain and tremor

Confusion, ataxia and bone marrow suppression

Hirsutism, gingival hyperplasia and lymphadenopathy

Weight gain, hyperglycaemia and hypertriglyceridaemia

Tremor, hypothyroidism, nephrogenic diabetes insipidus

Answer 18

Hair loss, weight gain and tremor

Question 19

The main side effects of valproate can be remembered with the mnemonic “VALPROATE”
What are the side effects? [+]

Answer 19

Vomiting
Alopecia
Liver toxicity
Pancreatitis/Pancytopenia
Retention of fats (ie. weight gain)
Oedema
Anorexia
Tremor
Enzyme inhibition

Question 20

A 57 year old man is referred to the neurology clinic with memory problems. He was, until recently, a lawyer. He has stopped working after being disciplined at work for inappropriate behaviour and he was recently given a caution by the police for stealing chocolate from a shop.
Which of the following signs would he be most likely to exhibit?

Constructional apraxia
1

Orofacial apraxia
2

Shuffling gait
3

Vivid visual hallucinations
4

Slurred speech

Answer 20

Constructional apraxia
- This patient most likely has frontotemporal dementia, a relatively rapidly progressive dementia affecting younger people. Patients have marked personality change and MRI shows significant atrophy of the frontal and temporal lobes. Constructional apraxia i.e. failure to draw interlocking pentagons may be a key feature in the early stages

Question 21

What sleep pattern. is pathognomonic of depression? [1]

Answer 21

Early morning waking

Question 22

A patient’s symptoms suggest frontotemporal dementia (FTD).

What drug can you use to manage behavioural symptoms such as disinhibition? [1]

Answer 22

SSRIs can help manage behavioural symptoms such as disinhibition, which are common in FTD.

Question 23

A patient is started on Memantine.
Which of the following is most likely to be a side effect of this therapy?

Diarrhoea
1

Constipation
2

Drooling
3

Bradycardia
4

Urinary incontinence

Answer 23

Constipation
- think anticholinergic side effects = cant see pee sht or spit = blur vision, urine retention, constipation, dry mouth

Question 24

Which medication already being prescribed would mean that wouldn’t use an SSRI first line for depression? [1]

Answer 24

An SSRI is associated with an increased risk of bleeding when prescribed with anticoagulants, especially among the elderly

Question 25

A 65-year-old patient with frontotemporal dementia presents with behavioural changes, disinhibition, and apathy. Which of the following is a recommended first-line intervention for managing these symptoms? Atypical antipsychotics 1 Antidepressants 2 Antiepileptic drugs 3 Behavioural interventions and environmental modifications 4 Cholinesterase inhibitors

Answer 25

**Behavioural interventions and environmental modifications**

Question 26

Which drugs are indicated for postpartum psychosis? [2]

Answer 26

**olanzapine** and **quetiapine**.

Question 27

What would indicate that someone has undergone a TCA overdose? [+] Describe the ECG changes? [2] What would blood gas show? [1]

Answer 27

**confusion**, **seizure**, **tachycardia**, **hypotension** and **dilated** **pupils** (mydriasis) **prolonged QRS duration** and **QTc interval** Leads to **metabolic acidosis**

Question 28

How long do you continue SSRI tx to ensure successful management of a patients: - OCD? [1] - GAD/depression? [1]

Answer 28

**OCD** - continue for 12 months **GAD/Depression** - 6 months

Question 29

If CBT or EMDR therapy are ineffective in PTSD, the first line drug treatments are [2]

Answer 29

If CBT or EMDR therapy are ineffective in PTSD, the first line drug treatments are **venlafaxine or a SSRI**

Question 30

According to ICD-10 criteria, how long must symptoms last to be classified as a depressive episode? [1]

Answer 30

**2 weeks**

Question 31

A patient you are looking after is started on imipramine for depression. Which combination of side-effects is most likely to be seen in a patient taking this class of antidepressants? Dry mouth + urinary frequency Hypertension + sweating Gastrointestinal bleeding + dyspepsia Headache + myoclonus Blurred vision + dry mouth

Answer 31

**Blurred vision + dry mouth** - Impramine = TCA

Question 32

The risk of developing schizophrenia if one monozygotic twin is affected is approximately: 10% 20% 50% 75% >95%

Answer 32

**50%**

Question 33

What do the following terms mean? - Loss of ideation - Thought expulsion - Ideas of reference - Tactile hallucination - Thought withdrawal

Answer 33

**Loss of ideation** - Unable to form ideas or concepts **Thought expulsion** - Made up rubbish **Ideas of reference** - belief or perception that irrelevant, unrelated or innocuous things in the world are referring to them directly or have special personal significance. **Tactile Hallucination** - a false perception of tactile sensory input that creates a hallucinatory sensation of physical contact with an imaginary object. **Thought withdrawal** - The belief that an external force is extracting thoughts from your mind.

Question 34

Which one of the risks is associated with zopiclone use in the elderly? Convulsions Tremor Hyperventilation Diarrhoea Increased risk of falls

Answer 34

**Zopiclone increases the risk of falls in elderly patients**

Question 35

Describe what characterises a BPD? [1] How do people with BPD often view other people? [2]

Answer 35

Borderline personality disorder (BPD) is characterised by **challenging behaviours** to **try and cope** with **strong emotions** when **relationships are strained.** - **Devaluation** is a defence mechanism whereby the **individual** **suggests things or people are worthless**: patients often quickly **switch their emotions**, there is no middle ground

Question 36

**[]** can be an effective treatment for BPD.

Answer 36

**Dialectical behaviour therapy** can be an effective treatment for BPD.

Question 37

A patient is taking lithium for their bipolar disease. What finding might you see on a FBC? [1]

Answer 37

**Lithium** can precipitate a **benign** **leucocytosis**

Question 38

A psychiatrist wants to change a patient's lithium dose. When would it be most appropriate to re-check her levels? In 1 month In 1 week In 3 days In 3 months In 6 months

Answer 38

After a change in dose, lithium levels should be taken a week later and weekly until the levels are stable **Lithium levels are normally measured one week after starting treatment, one week after every dose change, and weekly until the levels are stable. Once levels are stable, levels are usually measured every 3 months.** ## Footnote **NB**: specifically: the sample should be **taken 12 hours post-dose**

Question 39

Describe a change in behaviour that is associated with a poor prognosis with schizophrenia? [1] What are other risk factors for a poor prognosis

Answer 39

A **prodromal phase of social withdrawal** is associated with a poor prognosis in schizophrenia Also: * **strong family history** * **gradual onset** * **low IQ** * **lack of obvious precipitant**

Question 40

**[Drug class]** should be avoided in patients taking a SSRI - Describe why? [2]

Answer 40

**Triptans** should be **avoided in patients taking a SSRI** - **Triptans x SSRIs precipitate serotonin syndrome** (agitation, restlessness, confusion, muscle rigidity, hyperreflexia, dilated pupils and flushed skin.)

Question 41

Whats a mneumonic for remembering the side effects of SSRIs? [4]

Answer 41

**SSSSRIs** **S**tomach Upset **S**exual Dysfunction **S**odium Low **S**erotonin Syndrome

Question 42

. The GP also notices that the patient repeats the last word of any question that he is asked. What is this phenomena called? Copropraxia Echolalia Echopraxia Neologism Palilalia

Answer 42

Echolalia

Question 43

What do the following mean [3] Copropraxia Echopraxia Palilalia

Answer 43

**Copropraxia**: a motor tick, involuntarily repeating inappropriate or rude gestures. **Echopraxia**: Repeating someone else's movements involuntarily. **Palilalia**: Repeating words or sounds over and over, like a broken record.

Question 44

Which class of drug have the Medicines and Healthcare products Regulatory Agency warned may be associated with an increased risk of venous thromboembolism in elderly patients? Tricyclic antidepressants 5HT3 antagonists Third generation cephalosporins Benzodiazepines Atypical antipsychotics

Answer 44

**Antipsychotics in the elderly** - increased risk of stroke and VTE

Question 45

What are two examples of features of an atypical grief reaction? [2]

Answer 45

**delayed grief**: sometimes said to occur when more than 2 weeks passes before grieving begins **prolonged grief:** difficult to define. Normal grief reactions may take up to and beyond 12 months

Question 46

Which of the following is most likely to cause a rise in clozapine blood levels? Alcohol abstinence Omitting doses Smoking cessation Stress Weight gain

Answer 46

**Smoking cessation** - it is the TAR in cigarettes that induce the CYP450 (1A2) activity, causing an increased metabolism of Clozapine = Lower blood levels in smokers.

Question 47

Mnemonic for side effects of lithium? [+]

Answer 47

**LITHIUM:** **L**ethargy **I**nsipidus (diabetes) **T**remor **H**ypothyroidism **I**nsides (gastrointestinal) **U**rine (increased) **M**etallic taste

Question 48

What is a useful way of remembering the beneficial side effects of mitrazapine? [2]

Answer 48

**M**irta**Z**apine. **M** is for '**Mmmm**' (increases appetite) **Z** if for **'Zzzzz'** (makes you sleepy)

Question 49

Clomipramine is used to treat which pathology? [1] What is the MoA? [1] What is are side effects? [3]

Answer 49

**Clomipramine**, a tricyclic antidepressant (**TCA**) used in **OCD treatment**, can cause **anticholinergic** side effects like **dry mouth, blurred vision, and weight gain** due to its cholinergic receptor antagonism and antihistaminic effects.

Question 50

Describe what a conversion disorder is [1] Which clinical test can be used to assess for it? [1] - Describe how to perform it [3]

Answer 50

This condition commonly presents with a **loss of motor and sensory function**, which typically **arises during periods of stress** **Hoover's sign is a clinical test used to evaluate functional neurological disorders**: assessing for discrepancies between voluntary and involuntary hip extension. - In cases of **genuine limb paresis**, both **voluntary and involuntary hip extension would be rated as 0/5 in strength**. - To perform the test, voluntary hip extension is **initially assessed in the 'weak' limb**. Should this reveal weakness, the **examiner subsequently tests hip flexion in the contralateral limb while placing their hand beneath the heel of the patient's 'weak' limb**. - Ordinarily, **hip flexion on one side results** in **automatic contralateral hip extension**. Absence of this response may indicate true weakness; however, if involuntary hip extension is observed, it **suggests an inconsistency between voluntary and involuntary movements'raising suspicion** for a functional neurological disorder

Question 51

A patient want to abruptly stop their SSRIs. What should you advise may happen if they do so? [1]

Answer 51

**Gastrointestinal side-effects** such as diarrhoea are seen in SSRI discontinuation syndrome - **diarrhoea is most likely**

Question 52

What is the a general difference in the description of signs of dyskinesia vs dystonia? [1]

Answer 52

**lip puckering** is a classic sign of **tardive dyskinesia** A **dystonia** is more likely to present with **oculogyric crisis/torticollis/trismus** **Oculogyric Crisis:** - This is a type of acute dystonia characterized by involuntary, sustained spasms of the extraocular muscles, leading to a deviation of the eyes, often upward. **Torticollis:** * This refers to a condition where the neck muscles contract, causing the head to be twisted or tilted to one side. **Trismus:** * This is a condition characterized by spasms of the jaw muscles, leading to difficulty opening the mouth.

Question 53

This man has been diagnosed with mild Alzheimer's disease and started on first-line pharmacological therapy, which will be an acetylcholinesterase inhibitor such as Donepezil, Galantamine or Rivastigmine. Which of the following is most likely to be a side effect of this therapy? Constipation Tachycardia Urinary retention Dry mouth Diarrhoea

Answer 53

These drugs cause cholinergic side effects such as **diarrhoea, nausea and vomiting, bradycardia, increased salivary production and urinary incontinence**

Question 54

How do you differentiate between a delusional perception and grandiose delusion? [1]

Answer 54

**Delusional perception** is a delusion that is formed in **response to an external stimulus without any logical sense**. **Grandiose delusion** may be present **without any external stimuli.**

Question 55

An acute presentation of a patient with chronic alcohol use should prompt a possible complication of **[]**, as it is a medical emergency that should not be missed. Hence, **[]** is the next best investigation for a patient presenting with ?alcohol intoxication

Answer 55

An acute presentation of a patient with chronic alcohol use should prompt a possible complication of **hypoglycaemia**, as it is a medical emergency that should not be missed. Hence, **blood glucose** is the next best investigation for this man.

Question 56

What area of the brain is responsible for the activation of the 'flight or fight' response? Hippocampus 1 The amygdala 2 The substantia nigra 3 The frontal cortex 4 The hypothalamus

Answer 56

**The amygdala**

Question 58

Which anti-pyschotic is best for treating negative symptoms of schizphrenia? [1]

Answer 58

**Clozapine**

Question 59

A 45-year-old man with schizophrenia taking chlorpromazine develops an oculogyric crisis. What side-effect of antipsychotic medication is this an example of? Neuroleptic malignant syndrome Parkinsonism Acute dystonia Tardive dyskinesia Akathisia

Answer 59

**Acute dystonia** - **prolonged involuntary upward deviation of the eyes, is a type of acute dystonia** Tardive dyskinesia is another potential side effect of long-term use of antipsychotic medications, but it typically presents with repetitive, involuntary movements such as grimacing, tongue protrusion or rapid blinking rather than oculogyric crisis.

Question 60

A 16-year-old girl attends the eating disorders clinic with her parents, who report a significant reduction in her food intake over two months. The patient has a fear of gaining weight and perceives herself as overweight, despite evidence to the contrary, which has led to a decrease in her caloric intake. She denies low mood or any other anxieties. On examination, she has a BMI of 17 kg/m², a heart rate of 60 beats per minute, and a blood pressure of 100/80 mmHg. Blood tests are normal. Alongside a structured eating plan, what is the first-line therapy for this patient's condition? Adolescent-focused psychotherapy Anorexia-focused family therapy Dialectical behavioural therapy Eating disorder focused cognitive behavioural therapy Fluoxetine

Answer 60

**Anorexia focused family therapy** is the first-line treatment for children and young people with anorexia nervosa

Question 61

What advise do you give for switching between SSRIs? [1]

Answer 61

Switching from fluoxetine to another SSRI - w**ithdraw then leave a gap of 4-7 days** (as it has a long half-life) **before starting a low dose of the alternative SSR**I

Question 62

**[]** has the most tolerable side effect profile of the atypical antispsychotics, particularly for prolactin elevation

Answer 62

**Aripiprazole** has the most tolerable side effect profile of the atypical antispsychotics, particularly for prolactin elevation

Question 63

A person comes in with an aucte history of pyschotic symptoms. **[]** could easily cause a psychotic picture and is important to rule out. **How**?

Answer 63

**Drug intoxication** could easily cause a psychotic picture and is important to rule out - **Urine toxicology**

Question 64

Which of the following is a cardinal feature of lithium toxicity? Hyperthermia Cog-wheel rigidity Bradycardia Coarse tremor Fine tremo

Answer 64

**Coarse tremor** - A fine tremor may be seen in patients taking lithium at a therapeutic dosage, this does not indicate toxicity.

Question 65

A patient is exhibiting features of severe lithium toxicity, which is generally seen if serum levels are above **[] mmol/l**

Answer 65

patient is exhibiting features of severe lithium toxicity, which is generally seen if serum levels are above **3.5 mmol/l** ## Footnote NB: Generally speaking, raised lithium levels above 4 regardless of whether any symptoms are present or not, would prompt dialysis.

Question 66

What is the first-line management of panic disorder? Fluoxetine 1 Cognitive behavioural therapy (CBT) 2 Eye movement desensitisation and reprocessing (EMDR) therapy 3 Diazepam 4 Sertraline

Answer 66

**Cognitive behavioural therapy (CBT)**

Question 67

A patient is on put on sertraline Which of the following is most commonly associated with this drug? Galactorrhoea 1 Blurred vision 2 Hypersalivation 3 Diarrhoea 4 Hypernatraemia

Answer 67

**Diarrhoea** - Sertraline increases serotonin activity in the gut, leading to increased motility. Patients should be informed that these side effects often improve with time. - Sertraline commonly causes gastrointestinal side effects, particularly diarrhoea, especially during the initial weeks of treatment.

Question 68

64-year-old man is admitted from his care home after suffering from recurrent falls. His most recent fall was unwitnessed and may have hit his head. His carers report that he hasn't quite been himself in the past twelve months. He has been more difficult to manage as he often wets himself and now has difficulty mobilising. He has not had any headaches, nausea nor vomiting. What is the dx? [1]

Answer 68

This man is is presenting with the triad of "**Wet, Wobbly & Weird"**. This is typical of Normal Pressure Hydrocephalus

Question 69

A 64-year-old man is admitted from his care home after suffering from recurrent falls. His most recent fall was unwitnessed and may have hit his head. His carers report that he hasn't quite been himself in the past twelve months. He has been more difficult to manage as he often wets himself and now has difficulty mobilising. He has not had any headaches, nausea nor vomiting. **Which imaging would you use to investigate further? [1]** **What would imaging show? [2]**

Answer 69

**Enlarged ventricles and absent sulci seen on CT brain scan** - The sulci are absent because they are compressed by the ventricles which allows for the pressure to be normal despite the CSF increase

Question 70

Which of the following phenomena are most characteristic of emotionally unstable personality disorder? Law breaking 1 Splitting 2 Sexual inappropriateness 3 Grandiosity 4 Magical thinking

Answer 70

**Splitting** - Splitting is a phenomenon sometimes seen in EUPD, whereby relationships alternate between idealisation and devaluation. As a result, patients may regard others as either wholly good, or wholly bad, often without reasonable grounds to hold such opinions.

Question 71

A patient has lithium toxicity, with levels above 3.5 mmol/. How would you tx? [1]

Answer 71

This patient is exhibiting features of severe lithium toxicity, which is generally seen if serum levels are above 3.5 mmol/l. **Haemodialysis** is appropriate for patients experiencing severe lithium toxicity because left untreated they will develop sustained seizure activity

Question 72

If left untreated, lithium toxicity can progress to more severe neurological symptoms such as **[3]**

Answer 72

If left untreated, lithium toxicity can progress to more severe neurological symptoms such as **visual disturbances, including blurred vision or nystagmus, seizures, and coma.**

Question 73

If CBT or EMDR therapy are ineffective in PTSD, the first line drug treatments are **[]** or a **[]**

Answer 73

If CBT or EMDR therapy are ineffective in PTSD, the first line drug treatments are **venlafaxine** or a **SSRI**

Question 74

A 33-year-old woman is brought to the psychiatry clinic by her friend. The friend reports that the patient has been exhibiting unusual behaviour. This behaviour includes staying up all night, talking rapidly, excessive gambling, and saying she will conquer the stock market and become a billionaire. The patient has a background of depression for which she takes sertraline. On examination of her mental state, there is evidence of overly familiar behaviour, pressured speech, and flight of ideas. **What is the most appropriate pharmacological treatment**

Answer 74

Management of mania/hypomania in patients taking antidepressants: **consider stopping the antidepressant and start antipsychotic therapy** e.g. **olanzapine**

Question 75

Pseudohallucinations are more common after **[]** and do not imply psychosis - Which key distinguishing feature seperates pseudo- with a true hallucination? [1]

Answer 75

Pseudohallucinations are more common after **bereavement** and do not imply psychosis - **Insight** seperates pseudo and true hallucinations.

Question 76

What is the difference between a conversion disorder and somatisation disorder? [2]

Answer 76

**Functional neurological disorder (conversion disorder)** - typically involves **LOSS of motor or sensory function** **Somatisation disorder** is the repeated presentation with m**edically unexplained symptom**s, and the **WITH** **distress and anxiety** associated with these. ## Footnote NB: Conversion disorders - a person CONVERTS an emotionally charged event into a physical symptom

Question 77

What are the three corse features of PTSD? [3] What is a pneumonic for the features? [5]

Answer 77

Common features of PTSD **re-experiencing** e.g. flashbacks, nightmares **avoidance** e.g. avoiding people or situations - including emotional detachment **hyperarousal** e.g.hypervigilance, sleep problems **HEART**: **H**yperarousal **E**motional numbing **A**voidance of triggers **R**e-experiencing **T**ime

Question 78

**[2]** symptoms and global memory loss point to a diagnosis of depression rather than dementia

Answer 78

**Rapid onset, biological** symptoms and global memory loss point to a diagnosis of depression rather than dementia

Question 79

**[]** is the inability to answer a question without giving excessive, unnecessary detail

Answer 79

**Circumstantiality** is the inability to answer a question without giving excessive, unnecessary detail

Question 80

Describe the treatment plan for OCD If it is causing severe functional impairment [3]

Answer 80

**refer** to the **secondary care mental health team** for assessment whilst awaiting assessment - offer: - **combined treatment with an SSRI and CBT** (including ERP) or **consider clomipramine as an alternative**

Question 81

**[]** presents after taking antipsychotics for a **long period of time** - Describe this [3]

Answer 81

**Tardive dyskinesia** presents after taking antipsychotics for a long period of time - **lip smacking, difficulty swallowing and excessive blinking** ## Footnote NB: **Tardive** = late -> symptoms will come on later on

Question 82

Antidepressants should be continued for at least **[]** months after remission of symptoms to decrease risk of relapse

Answer 82

Antidepressants should be continued for at least **6 months** after remission of symptoms to decrease risk of relapse

Question 83

When starting an SSRI how long after should you check on a patient if they are under 30? [1] Why? [1]

Answer 83

Therefore, it is essential to conduct a follow-up **within one week** of commencing treatment in this age group. - **risk of suicide**

Question 84

Catatonia can be managed using **[drug class]** and some centres may use **[] therapy.**

Answer 84

Catatonia can be managed using **benzodiazepines** and some centres may use **electroconvulsive therapy.**

Question 85

What's a way of remembering when a seizure vs DT will occur after stopping alcohol? [2]

Answer 85

**Day one and a bit** (**36hrs**) -> have a **fit** **DTs**-> **Deux-Trois**, **days 2-3 (48-72 hrs)**

Question 86

**[]** is the most likely SSRI to lead to QT prolongation and Torsades de pointes

Answer 86

**Citalopram** is the most likely SSRI to lead to QT prolongation and Torsades de pointes

Question 87

**[]** is the SSRI of choice post myocardial infarction

Answer 87

**Sertraline** is the SSRI of choice post myocardial infarction

Question 88

**[]** should be used first-line for acute stress disorders

Answer 88

**Trauma-focused cognitive-behavioural therapy (CBT)** should be used first-line for acute stress disorders

Question 89

A patient presents with depression. Based off their symptoms you determine them to have severe depression. What PHQ score would this mean they have above? [1] What would this mean with regards to their initial treatment plan? [1]

Answer 89

**PHQ score of over 15 / 16** indicating 'more severe' depression - NICE **most strongly recommend a combination of individual cognitive behavioural therapy and an antidepressant** as this has been found to be the most clinical and cost-effective treatment for 'more severe' depression - **Sertraline** is **first line** unless under 18, in which it is **flouxetine**

Question 90

**[]** is the strongest risk factor for psychotic disorders

Answer 90

**Family history** is the strongest risk factor for psychotic disorders

Question 91

**OCD**: all patients with **[]** should be referred to the secondary care mental health team - treatment can be started whilst waiting for assessment

Answer 91

**OCD: all patients with severe functional impairment** should be referred to the secondary care mental health team - treatment can be started whilst waiting for assessment

Question 92

What is meant by circumstantiality? [1]

Answer 92

**Circumstantiality** is the inability to answer a question without giving excessive, unnecessary detail

Question 93

Tricyclic antidepressants may cause **[]**, particularly in patients with BPH

Answer 93

**Tricyclic antidepressants may cause urinary retention, particularly in patients with BPH**

Question 94

What is a key cognitive side effect of lorazepam that need to know? [1]

Answer 94

One of the side effects of this drug is that this can cause **anterograde amnesia.** - memory recall and the creation of new memories is significantly impaired

Question 95

How do you differentiate OCD from pyschosis? [1]

Answer 95

Obsessive-compulsive disorder can be differentiated from psychosis by the **level of insight into their actions** (OCD has insight)

Question 96

Venlafaxine and other serotonin noradrenaline reuptake inhibitors (SNRIs) are associated with the development of **[cardiac issue]**.

Answer 96

Venlafaxine and other serotonin noradrenaline reuptake inhibitors (SNRIs) are associated with the development of **hypertension**.

Question 97

Some anti-psychotic medications and antidepressants are associated with weight gain, for example, **[]**

Answer 97

Although some anti-psychotic medications and antidepressants are associated with weight gain, for example, **mirtazapine**

Question 98

What is a potential risk of fluoxetine when used in the third trimester of pregnancy? Persistent pulmonary hypertension Congenital heart defects Intrauterine growth restriction Spina bifida Patent ductus arteriosus

Answer 98

**Persistent pulmonary hypertension**

Question 99

What class of drugs does mirtazapine belong to? Selective serotonin reuptake inhibitors Serotonin-noradrenaline reuptake inhibitors Monoamine oxidase inhibitors Noradrenergic and specific serotonergic antidepressants Tricyclic antidepressants

Answer 99

Mirtazapine is a noradrenergic and specific serotonergic antidepressant which **increases release of neurotramsitters by blocking alpha2 adrenoreceptors**

Question 100

For moderate/severe OCD, **[]** may be used as an alternative first-line drug treatment to an SSRI if the person prefers [] or has had a previous good response to it, or if an SSRI is contraindicated

Answer 100

For moderate/severe OCD, **clomipramine** may be used as an alternative first-line drug treatment to an SSRI if the person prefers clomipramine or has had a previous good response to it, or if an SSRI is contraindicated

Question 101

Describe what is meant by catatonia [1]

Answer 101

**Stopping of voluntary movement or staying still in an unusual position** = catatonia

Question 102

You decide together to try venlafaxine as a second-line option. What should be monitored at initiation and dose titration of this medication?

Answer 102

**Blood pressure** - Venlafaxine and other serotonin noradrenaline reuptake inhibitors (SNRIs) are associated with the **development of hypertension.**

Question 103

You review a 47-year-old man with a history of moderate to severe depression. He has a past medical history of type 2 diabetes and also pericarditis following a viral illness. He has a family history of hypertension. He has previously tried fluoxetine without a significant improvement in his mood. His wife finds her citalopram prescription very helpful for her generalised anxiety disorder. He now wishes to try citalopram himself. **What should be monitored prior to starting citalopram in this patient?**

Answer 103

The BNF states that '**QT prolongation, and/or ventricular arrhythmias including torsade de pointes** have been reported in people taking **citalopram or escitalopram**.' The BNF advises taking an ECG and measuring the QT interval in patients with a history of cardiac disease prior to starting citalopram. Given this man's history of pericarditis, ECG is the correct answer.

Question 104

Which specific cardiac issues are associated with citalopram? [3]

Answer 104

The BNF states that '**QT prolongation, and/or ventricular arrhythmias including torsade de pointes** have been reported in people taking citalopram or escitalopram.' The BNF advises taking an ECG and measuring the QT interval in patients with a history of cardiac disease prior to starting citalopram. Given this man's history of pericarditis, ECG is the correct answer.

Question 105

A 75-year-old woman presents to the emergency department with new onset confusion. She has a past medical history of depression, for which she takes sertraline, and oesophagitis for which she takes omeprazole. She also has a diagnosis of type 2 diabetes. Her dose of sertraline was last increased two weeks ago. Her physical observations are within normal parameters. **What would you perform first to identify the cause of this patient's confusion?**

Answer 105

**Urea and electrolytes** - The BNF advises when starting a serotonin specific reuptake inhibitor (SSRI) to 'observe all people taking antidepressants for signs of **hyponatraemia**.

Question 106

How often should you monitor for hyponatraemia in U&Es? [3]

Answer 106

For people at high risk, measure the serum sodium level **before starting treatment,** **2-4 weeks after starting** treatment and **every 3 months thereafter.'**

Question 107

I''m walking to the shop hop slop flip-flop'. What type of thought disorder is this? [1]

Answer 107

**Clang** **associations** - ideas related only by rhyme or being similar sounding

Question 108

Antidepressants should be continued for at least **[]** after remission of symptoms to decrease risk of relapse

Answer 108

Antidepressants should be continued for at least **6 months** after remission of symptoms to decrease risk of relapse

Question 109

A 45-year-old man presents to the emergency department with agitation, confusion, and tremors. Despite none being present, he is complaining of severe itching due to a termite infestation affecting his skin and is insistent on their presence. The patient admits to chronic excessive alcohol consumption. How long has it most likely been since the patient's last drink? 4 hours ago 6 hours ago 12 hours ago 36 hours ago 72 hours ago

Answer 109

**delusions 48-72 hours after admission → ?delirium tremens** ## Footnote **NB**: DT = Day Three and Delirium Tremens OR DTs-> Deux-Trois, days 2-3 (48-72 hrs) **Day one and a bit (36hrs)** -> have a **fit**

Question 110

How do you differentiate between schizotypal, schizoid and paranoid personailty disorders? [3]

Answer 110

**Schizoid** * **social isolation in SzPD tends to be more extreme; patients often lack relationships even with family and may entirely detach from society**. * SzPD is characterised by '**negative**' **symptoms** **only** and is not associated with 'positive' symptoms such as overvalued ideas and odd beliefs. * Patients tend to have **obscure interests, particularly in fantasy.** * Indifference to praise and criticism * Preference for solitary activities * Lack of interest in sexual interactions * Lack of desire for companionship * Emotional coldness * Few interests * Few friends or confidants other than family **Schizotypal** * Ideas of reference (differ from delusions in that some **insight** is retained) * Odd beliefs and magical thinking * Unusual perceptual disturbances * Paranoid ideation and suspiciousness * Odd, eccentric behaviour * Lack of close friends other than family members * Inappropriate affect * Odd speech without being incoherent **Paranoid** * Hypersensitivity and an unforgiving attitude when insulted * Unwarranted tendency to questions the loyalty of friends * Reluctance to confide in others * Preoccupation with conspirational beliefs and hidden meaning * Unwarranted tendency to perceive attacks on their character ## Footnote **NB**: schizoid pd = social isolation - odd beliefs **schizoptypical pd** = **social isolation + odd beliefs**

Question 111

A 23-year-old man undergoes electroconvulsive therapy (ECT) for treatment-resistant depression. Which of the following side effects is he most likely to experience? Constipation Retrograde amnesia Anterograde amnesia Galactorrhea Hypothermia

Answer 111

**Retrograde amnesia** - Retrograde amnesia (remembering events prior to the insult) is far more common that anterograde amnesia (loss of ability to form new memories after the insult) ## Footnote elecTROconvulsive therapy reTROgrade amnesia OR RECTum Retrograde amnesia due to ECT

Question 112

What is torticollis? [1] What may cause it? [1]

Answer 112

or 'wry' neck can be diagnosed where there is **unilateral pain and deviation of the neck** with **pain on palpation and restricted range of motion.** - commencing a **typical antipsychotic - haloperidol.**

Question 113

Duloxetine mechanism of action = ?

Answer 113

Duloxetine mechanism of action = **serotonin and noradrenaline reuptake inhibitor** ## Footnote Dulo = duel = serotonin and noradrenaline reuptake inhibitor

Question 114

How would you differentiate between pseudodementia (from depression) and dementia? [1] Describe a classic presentation [1]

Answer 114

**Pseudodementia**: * key feature present is a **global memory** loss affecting **both short and longer-term memory** - its **short-term** however it affects **both short and long-term memory** E.g *increasing forgetfulness. Her daughter is worried that over the last four weeks her mother has been forgetting her grandchildren's names and stories from her upbringing*

Question 115

What is the mechanism of action of temazepam? Inhibits the effect of acetylcholine Enhances the effect of gamma-aminobutyric acid Inhibits the effect gamma-aminobutyric acid Inhibits the effect of glutamate Inhibits the effect of noradrenaline

Answer 115

Enhances the effect of gamma-aminobutyric acid

Question 116

When is electroconvulsive therapy (ECT) indicated? [3]

Answer 116

**catatonia** **a prolonged or severe manic episode** **severe** **depression** that is **life-threatening**

Question 117

What would indicate someone is suffering from SSRI discontinuation syndrome? [3] - How would you differentiate this from NMS? [2]

Answer 117

may present with **dizziness / imbalance**, **electric shock sensations / paraesthesia**, and **anxiety** - NMS: is a rare reaction that can occur with antipsychotic use. It may present with **fever, confusion and muscle rigidity.**

Question 118

Mneumonic for SSRI discontin. syndrome? [6]

Answer 118

Sx of SSRI discontinuation syndrome - **FINISH**: **Flu-like sx** (headache, myalgia, lethargy) **Imbalance** (vertigo, lightheadedness) **Nausea** (vomiting, diarrhoea) **Insomnia** **Sensory disturbances** (electric shocks, paraesthesia, numbness) **Hyperarousal** (agitation, tremor).

Question 119

Describe how people with OC personality disorders present with regards to views of others [2]

Answer 119

Patients with obsessive-compulsive personality can be **rigid with respect to morals, ethics and values** and often are **reluctant to surrender work to others**

Question 120

How do you differentiate between someone with illness anxiety disorder and somatisation disorder [1]

Answer 120

**Unexplained symptoms** **S**omatisation = **S**ymptoms hypo**C**hondria = **C**ancer People w somatisation focus on the symptoms, whereas hypochondria focus on the diagnosis.

Question 121

Give classic presentation of schizoid vs schizoidal personality disorder? [2]

Answer 121

**Schizoid personality disorder** is the most likely diagnosis in this case based on his general lack of interest in social relationships. Individuals usually live a solitary lifestyle and **show a lack of emotion towards others or apathy**. In this case, the patient seems unbothered by his solitary lifestyle, making schizoid personality disorder the most likely option - **Schizoid = android = like a robot.** **Schizotypal** **personality** **disorder** presents more typically with **positive psychotic symptoms** such as thought disorder, hallucinations and unconventional 'magical' beliefs. Individuals may have transient psychosis and show paranoia towards others. also **odd beliefs and magical thinking**

Question 122

What type of urinary incontinence is the most associated with amitriptyline? [1]

Answer 122

Amitriptyline belongs to the drug class of tricyclic antidepressants (TCAs). TCAs have **anticholinergic effects which may lead to urinary retention**, leading to **frequent leaking.**

Question 123

An effective treatment for borderline personality disorder is **[]** - Describe this treatment [1]

Answer 123

An effective treatment for borderline personality disorder is **dialectical behaviour therapy (DBT)** - a targeted therapy that is based CBT, but has been adapted to help people who experience emotions very intensely.

Question 124

Which of the following features is needed to make a diagnosis of a personality disorder? The presence of psychotic symptoms The presence of a concurrent physical health condition A history of substance abuse Over 18 years of age A family history of mental health disorders

Answer 124

**Over 18 years of age**

Question 125

When stopping a SSRI the dose should be gradually reduced over a **[]** week period

Answer 125

When stopping a SSRI the dose should be gradually reduced over a **4 week period**

Question 126

NSAID x which antidepressant = increased risk of GI bleed? [1]

Answer 126

**SSRI** + **NSAID** = GI bleeding risk - give a **PPI**

Question 127

An elderly patient in a nursing home is started on quetiapine due to persistent aggressive behaviour that has not responded to non-pharmacological approaches. Which of the following adverse effects do antipsychotics increase the risk of in elderly patients? Atrial fibrillation Myocardial infarction Aspiration pneumonia Stroke Breast cancer

Answer 127

**Stroke**

Question 128

DT x seizures = how many hours ago stopped drinkin? [1]

Answer 128

seizures: 36 hours **delirium tremens**: **72 hours**

Question 129

A 35-year-old man with no known psychiatric history is admitted to the psychiatry ward, after presenting to the emergency department with delusions and homicidal ideations. Following a negative drugs screen, antipsychotic treatment is initiated with haloperidol. The patient is reviewed 3-hours after the initiation of treatment and is noted to have a sustained upward deviation of both eyes. When asked, he reports that his eyes are extremely painful. **Based on the likely diagnosis, what initial management option is most appropriate?** [1]

Answer 129

Acute dystonia secondary to antipsychotics is usually managed with **procyclidine** ## Footnote **NB**: The scenario described refers to an oculogyric crisis, an acute dystonic reaction that can occur as part of the spectrum of extrapyramidal side-effects (EPSEs) of antipsychotics.

Question 130

**[]** has the most tolerable side effect profile of the atypical antispsychotics, particularly for **prolactin elevation**

Answer 130

**Aripiprazole** has the most tolerable side effect profile of the atypical antispsychotics, particularly for prolactin elevation ## Footnote **Aripriprazole is Aripropriate** (appropriate) - appropriate drug to give due to low side effect profile :)

Question 131

What's a way of remembering the physiological changes seen in anorexia nervosa? [2]

Answer 131

Anorexia features **most things low** **G's** and **C'**s raised: **g**rowth hormone, **g**lucose, **s**alivary glands, **c**ortisol, **c**holesterol, **c**arotinaemia

Question 132

Patients with poor oral compliance to antipsychotics should be considered for [1]

Answer 132

Patients with poor oral compliance to antipsychotics should be considered for **once monthly IM antipsychotic depot injections**

Question 133

How would you differentiate betwen hypomania and mania with regards to lenght of symptoms and presenting symptoms ? [2] *in SBAs*

Answer 133

mania = psychosis hypomania = no psychosis hypomania < 7 days mania >/= 7 days

Question 134

What is the most appropriate action to take with regards to this medication prior to ECT treatment for this patient? Increase the sertraline daily dose Reduce the sertraline daily dose Stop the sertraline completely Switch sertraline to citalopram Switch sertraline to lithium

Answer 134

**Antidepressant medication should be reduced but not stopped when a patient is about to commence ECT treatment**

Question 135

What is Cotard syndrome ? [1] Which pathology is it associated with? [1]

Answer 135

**Cotard syndrome** is associated with **severe depression** - This patient is presenting with Cotard's syndrome, a rare subtype of nihilistic delusions, in which they believe they or part of them is dead or does not exist

Question 136

A 36-year-old with a long standing history of schizophrenia presents to the emergency department in status epilepticus. Once he is treated, he tells the doctor he has been having a lot of seizures recently. Which of the following medications is most likely to be causing the seizures? Clozapine Diazepam Fluoxetine Haloperidol Olanzapine

Answer 136

**Clozapine** reduces seizure threshold, making seizures more likely

Question 137

A young male with schizophrenia says during the ward round that MI5 is recording his thoughts and watching him around the clock. He says that he often has ideas about internet security but forgets them quickly after they have formed, as MI5 is taking them away from him. **What type of thought disorder is exhibited?**

Answer 137

**Thought withdrawal** is characterised by the belief that one's **thoughts are being taken away**, leading to disruptions in the thought process.

Question 138

A patient has ?NMS. What investigations would support this dx? [4]

Answer 138

Clinical signs and symptoms include fever, muscle rigidity, confusion, rhabdomyolysis (hence the **raised creatine kinase** and subsequent electrolyte derangements such as **hyperkalaemia and hypocalcaemia**), **metabolic acidosis**, autonomic lability, and a **raised white cell count.**

Question 139

Describe how you would manage someone who takes clozapine but has missed their last two doses? [1] - Why? [1]

Answer 139

If doses are missed for more than 2 consecutive days (48 hours), you will **need to restart their clozapine slowly** (like when they first started on it) - This is because when you start Clozapine after a break of >48 hours, it can** make side effects worse, such as blood pressure changes, drowsiness and dizziness.** - If there is a gap in treatment of **3 days (72 hours)** then you may also **require more frequent blood tests for a short period**.

Question 140

Tardive dyskinesia and acute dystonia are both complications of anti-pyschotic use. - When do they occur (with regards to length of tx for pyschosis)? [2] - What can you give to treat each? [2]

Answer 140

**TArdive dyskinesia** - have been **TAking antipsychotics** for **several years** -> give **Tetrabenezine** acute dy**ST**onia – common when **ST**arting antipsychotics -> give **procyclidine**

Question 141

**What is there an increased risk of in the first trimester with sertraline?** Congenital heart defects Ebstein's anomaly Spina bifida Cleft lip and palate Diaphragmatic hernia **What is the risk if used in the third trimester? [1]**

Answer 141

What is there an increased risk of in the first trimester with sertraline? **Congenital heart defects** Use during the **third trimester** can result in **persistent pulmonary hypertension of the newborn**

Question 142

A 37-year-old female complains that she does not want to leave the house, and as a result, her children are missing out, and she is a bad mother. She complains of ‘feeling a little anxious’ most of the time, but when she is out in public, she can feel her heart beat faster, notices her breathing getting too fast and thinks everyone must be staring at her. These symptoms started about three weeks after she began feeling very down after losing her job when the factory in which she worked closed down. She has not been able to enjoy anything much since then and always feels tired. What is the most likely? Generalised anxiety disorder Agoraphobia Panic disorder Depression with secondary anxiety Anxiety with secondary depressive symptoms #15974

Answer 142

**Depression with secondary anxiety**

Question 143

A 20-year-old male with type I diabetes mellitus presents to his General Practitioner (GP). His glycaemic control is getting worse, and his GP is worried about his diet and medication compliance. What is the best method to improve his compliance in a short consultation? Cognitive behavioural therapy (CBT) Motivational interview Self-help materials Psychotherapy Supportive counselling #42962

Answer 143

**Motivational interview**