Passmedicine Mcqs Psychiatry

PSYCHIATRY MCQs
Q-1
A woman who gave birth 5 days ago presents for review as she is concerned about her mood. She is
having difficulty sleeping and feels generally anxious and tearful. Since giving birth she has also found
herself snapping at her husband. This is her first pregnancy, she is not breast feeding and there is no
history of mental health disorders in the past. What is the most appropriate management?
A. Explanation and reassurance

B. Cognitive behavioural therapy
C. Trial of fluoxetine
D. Trial of citalopram
E. Discuss with psychiatric team to consider admission to mother and baby unit
ANSWER:
A. Explanation and reassurance
EXPLANATION:
This woman has the baby-blues which is seen in around two-thirds of women. Whilst poor sleeping can be
a sign of depression it is to be expected with a new baby!
Please see Post-Partum Mental Health Problems
Q-2
A 65-year-old female with a history of ischaemic heart disease is noted to be depressed following a recent
myocardial infarction. What would be the most appropriate antidepressant to start?
A. Paroxetine
B. Imipramine
C. Flupentixol
D. Venlafaxine
E. Sertraline
ANSWER:
E. Sertraline
EXPLANATION:
Sertraline is the SSRI of choice post myocardial infarction
Sertraline is the preferred antidepressant following a myocardial infarction as there is more evidence for
its safe use in this situation than other antidepressants
Please see Selective Serotonin Reuptake Inhibitors and Their Side Effects
Q-3
A 14-year-old boy is brought for review. He is normally fit and well and hasn't seen a doctor for over five
years. His mother has been increasingly concerned about his behaviour in the past few weeks. She
describes him staying up late at night, talking quickly and being very irritable. Yesterday he told his
mother he was planning to 'take-over' the school assembly and give 'constructive criticism' to his teachers
in front of the other pupils. He feels many of his teachers are 'underperforming' and need to be 'retaught'
their subjects by him. He admits to trying cannabis once around six months ago and has drank alcohol 'a
few times' in the past year, the last time being two weeks ago. Prior to his deterioration a few weeks ago
his mother describes him as a happy, well-adjusted, sociable young man. Which one of the following is the
most likely diagnosis?
A. Hypomania
B. Cannabis-induced psychosis
C. Mania
D. Alcoholic hallucinosis
E. Asperger's syndrome
ANSWER:
C. Mania
EXPLANATION:
Cannnabis and alcohol related problems are very unlikely given how long ago he used those substances.
The delusions of grandeur imply this is mania rather than hypomania.
Please see Hypomania vs. Mania
Q-4
Which one of the following symptoms may indicate mania rather than hypomania?
A. Predominately elevated mood

B. Delusions of grandeur
C. Increased appetite
D. Flight of ideas
E. Irritability
ANSWER:
B. Delusions of grandeur
EXPLANATION:
Whilst criteria vary (e.g. ICD-10, DSM-5) the consistent difference between mania and hypomania is the
presence of psychotic symptoms.
Q-5
A 32-year-old woman is brought to the Emergency department by the police. She was found preaching
outside the local supermarket, telling people that she is god's disciple and has been sent to prevent them
from wasting money. It transpires that she has also spent up to her limit on her bank card. She began
treatment with fluoxetine some 3 weeks ago for reactive depression after splitting from her husband. A
limited physical examination due to poor compliance is unremarkable, as is a routine blood screen.
Which of the following is the most likely diagnosis?
A. Psychotic depression
B. Munchausen's syndrome
C. Schizophrenia
D. Viral encephalitis
E. Mania
ANSWER:
E. Mania
EXPLANATION:
Key features here include clear evidence of delusions of grandeur, coupled with starting treatment for
fluoxetine some 3 weeks ago. Taken together these factors suggest possible mania. it is most likely to be
related to selective serotonin reuptake inhibitor prescription for her depression.
Psychotic depression is unlikely given there are no delusions related to illness, loss of self-worth or other
features usually expected. Schizophrenia is also unlikely given the absence of features such as auditory
hallucinations or delusions of reference. Rather than being associated with agitation and hyperactivity,
drowsiness and memory loss are more common features of viral encephalitis. The proximity to fluoxetine
prescription, and the fact features of her illness fit so well with mania, make Munchausen's syndrome
unlikely.
Q-6
Victoria has recently been diagnosed with agoraphobia and the psychiatrist plans to start medical
treatment. Which is the first line medication used for agoraphobia?
A. Fluoxetine
B. Sertraline
C. Citalopram
D. Mirtazapine
E. Venlafaxine
ANSWER:
B. Sertraline
EXPLANATION:
Agoraphobia is usually managed with sertraline
Agoraphobia is usually managed with sertraline. The other antidepressants may be used as second-line
therapy depending on the patient's specific symptoms.
Please see Agoraphobia

Q-7
A 30-year-old patient with schizophrenia is brought to the emergency department (ED) by the police. He is
awaiting a mental health assessment. The patient mentions that he was prescribed an anti-psychotic
years ago but is unable to remember which. He also alludes to gaining weight after starting the
medication. While in ED he agrees to have his blood taken which shows the following:
Hb 160 g/L Male: (135-180)
Platelets 350 * 109/L (150 - 400)
WBC 6 * 109/L (4.0 - 11.0)
HDL 1 mmol/l (>1)
LDL 6 mmol/l (<3)
Triglycerides 3 mmol/l (<2)
Total cholesterol 7 mmol/l (<5)
Which of the following antipsychotics was the patient likely taking?
A. Clozapine
B. Prochlorperazine
C. Haloperidol
D. Olanzapine
E. Chlorpromazine
ANSWER:
D. Olanzapine
EXPLANATION:
Olanzapine has a higher risk than other atypicals for dyslipidemia and obesity
This patient has hyperlipidaemia which is most commonly associated with the atypical antipsychotic
olanzapine. The mechanism is thought to be due to occurs due to increased appetite and insulin resistance.
Clozapine can cause agranulocytosis, cardiomyopathy and myocarditis and must be monitored regularly.
Conventional antipsychotics such as chlorpromazine, haloperidol and prochlorperazine have a large side
effect profile some of which include extrapyramidal side effects, drowsiness,
gynaecomastia/galactorrhoea and hyperglycaemia.
Please see Antipsychotics
Q-8
A 45-year-old man is admitted due to haematemesis. He reports drinking 120 units of alcohol a week.
When is the peak incidence of seizures following alcohol withdrawal?
A. 2 hours
B. 6 hours
C. 12 hours
D. 24 hours
E. 36 hours
ANSWER:
E. 36 hours
EXPLANATION:
Alcohol withdrawal
 symptoms: 6-12 hours
 seizures: 36 hours
 delirium tremens: 72 hours
Please see Alcohol Withdrawal
Q-9
A 33-year-old female is diagnosed with a personality disorder by her community psychiatrist. She has
struggled to hold down a job as an assistant store manager as she often finds her colleagues to be lacking
in morals or values and is reluctant to delegate work to them. She feels that her colleagues are lazy and do
not perform their duties to a sufficiently high standard, as a result, she is often overwhelmed with
outstanding tasks that she cannot complete and ends up staying late to get things right.
What personality disorder is she most likely to have been diagnosed with?
A. Avoidant
B. Dependant
C. Narcissistic
D. Schizoid
E. Obsessive-compulsive
ANSWER:
E. Obsessive-compulsive
EXPLANATION:
Patients with obsessive-compulsive personality can be rigid with respect to morals, ethics and values and
often are reluctant to surrender work to others
The correct answer here is an obsessive-compulsive personality disorder. This differs to obsessive-
compulsive disorder in which patients typically become consumed with repetitive compulsions such as
hand washing or checking lights. Patients with obsessive-compulsive personality disorder are often
meticulous and rigid with respect to moral, ethics and values and can be unwilling to change their mindset
on these. They also exhibit features of perfectionism which can often render them unable to complete
tasks or only able to complete them at the expense of social activities. They often struggle to delegate or
trust others with their work. In this stem the patient has had prevailing problems with perfectionism and
inability to delegate which have impacted on her ability to keep a job but also her free time, making this
the most likely answer.
Patients with avoidant personality disorder tend to avoid social contact/relationships due to fear of being
criticised, rejected or embarrassed. They view themselves as inferior to others and so are not keen to be
involved unless they are certain of being liked. This does not fit with the description of the patient in the
stem.
Patients with dependent personality disorder struggle to make everyday life decisions and require
reassurance and support from others as opposed to being reluctant to delegate or unable to trust in others
ability to perform a task.
Patients with narcissistic personality disorder have a heightened impression of self-importance and
entitlement often believing they have unlimited abilities to succeed, become powerful or look beautiful.
Whilst the patient in the stem believes others lack morals and values and is reluctant to delegate tasks for
fear they will not be done correctly, there is nothing to suggest this is because she feels she is more
important or entitled. Additionally, patients lack empathy and will happily take advantage of others to
achieve their own need. There is nothing to suggest this in the stem.
Option 4 is incorrect, patients with schizoid personality disorder tend to lack close friendship/companions
and are indifferent to praise making, however, do not hold strong moral values and lack the perfectionist
traits seen in this stem.
Please see Personality Disorders
Q-10
You are considering prescribing a selective serotonin reuptake inhibitor for a patient with depression.
Which class of drug is most likely to interact with a selective serotonin reuptake inhibitor?
A. Beta-blocker
B. Thiazolidinediones
C. Tetracycline
D. Statin
E. Triptan
ANSWER:
E. Triptan
EXPLANATION:
Triptans should be avoided in patients taking a SSRI
Triptans should be avoided in patients taking a selective serotonin reuptake inhibitor due to the increased
risk of serotonin syndrome.
Q-11
A 26-year-old female presents to the Emergency Department feeling suicidal after the breakdown of her
relationship two weeks ago. She reports being fearful of being on her own as he had made all major
decisions in their relationship as she is not capable of making correct choices. She has tried online dating
since her relationship broke down but despite multiple dates has not yet found a new partner.
She advises you she was previously diagnosed with a personality disorder. What is the most likely
diagnosis?
A. Borderline personality disorder

B. Paranoid personality disorder
C. Narcissistic personality disorder
D. Dependent personality disorder
E. Avoidant personality disorder
ANSWER:
D. Dependent personality disorder
EXPLANATION:
Patients with dependant personality disorder require excessive reassurance from others, seek out
relationships and require others to take responsibility for major life decisions
The correct answer is dependent personality disorder. The patient in the question is struggling to cope
after the breakdown of a relationship. Patients with this personality disorder struggle to make everyday
life decisions and require reassurance and support from others. They feel they are unable to look after
themselves and become fearful when left to do so. As in this patient whose relationship only broke down 2
weeks ago but has already been on multiple dates, they cope best when in a relationship and urgently
seek out new relationships if one fails. They will often passively comply with the wishes of others.
Borderline personality disorder is characterised by emotional instability, impulsive behaviour and intense
but unstable relationships with others. Patients often fear abandonment but do not seek out excessive
reassurance and are able to make life decisions making this the incorrect answer.
In contrast to dependent personality disorder, paranoid personality disorder presents in patients who are
reluctant to confide in others, question the loyalty of friends and family and can be unforgiving.
Narcissistic personality disorder is incorrect. These patients have an over-exaggerated sense of self-
importance, lack empathy and tend to have a sense of entitlement.
Avoidant personality disorder is different from dependent personality disorder in that patients avoid social
contact/relationships due to fear of being criticised, rejected or embarrassed. Patients view themselves as
inferior to others and so are not keen to be involved unless they are certain of being liked.
Further information on personality disorder can be found in the ICD 10 guide -

http://apps.who.int/classifications/icd10/browse/2016/en#/F66
Q-12
A 23-year-old male presents to his GP two weeks after a road traffic accident concerned about increased
anxiety levels, lethargy and headache. At the time he had a CT brain after banging his head on the steering
wheel, which revealed no abnormality. Six months following this episode his symptoms have resolved.
What did his original symptoms likely represent?
A. Conversion disorder
B. Post-traumatic stress disorder
C. Somatisation disorder
D. Generalised anxiety disorder
E. Post-concussion syndrome
ANSWER:
E. Post-concussion syndrome
EXPLANATION:
In post-traumatic stress disorder the onset of symptoms is usually delayed and it tends to run a prolonged
course
Please see Post-Concussion Syndrome
Q-13
An 84-year-old female has been an inpatient in a psychiatric ward for the past 6 months with a fixed belief
that her insides are rotting as she is deceased.
This type of delusion is known as which of the following?
A. Cotard delusion
B. Othello delusion
C. De Clerambault syndrome
D. Ekbom syndrome
E. Capgras delusion
ANSWER:
A. Cotard delusion
EXPLANATION:
Othello syndrome is a delusional belief that a patients partner is committing infidelity despite no evidence
of this. It can often result in violence and controlling behaviour.
De Clerambault syndrome (otherwise known as erotomania), is where a patient believes that a person of a
higher social or professional standing is in love with them. Often this presents with people who believe
celebrities are in love with them.
Ekbom syndrome is also known as delusional parasitosis and is the belief that they are infected with
parasites or have 'bugs' under their skin. This can vary from the classic psychosis symptoms in narcotic use
where the user can 'see' bugs crawling under their skin or can be a patient who believes that they are
infested with snakes.
Capgras delusion is the belief that friends or family members have been replaced by an identical looking
imposter.
Please see Cotard Syndrome
Q-14
A 24-year-old man tells you he is unable to go outside without first sanitizing the door handle in a certain
way. He also washes his hands before and after he leaves the house. He goes on to explain that if he
doesn't do these things in a certain order he gets very anxious and uptight.
This has been going on for two years and is upsetting him deeply.
What is the most appropriate treatment for the likely diagnosis?
A. Eye Movement Desensitization and Reprocessing Therapy (EMDR)

B. Trauma-focused CBT
C. Olanzapine
D. Dialectical behaviour therapy (DBT)
E. Exposure-response prevention (ERP) therapy
ANSWER:
E. Exposure-response prevention (ERP) therapy
EXPLANATION:
An obsession is an intrusive, unpleasant and unwanted thought. A compulsion is a senseless action taken
to reduce the anxiety caused by the obsession
This question requires you to identify the symptoms of Obsessive Compulsive Disorder (OCD) and know the
best initial intervention.
Eye Movement Desensitization and Reprocessing Therapy (EMDR) - this is not the most appropriate
answer. EMDR is used for patients suffering with Post-Traumatic Stress Disorder (PTSD)
Trauma-focused CBT - this is not the most appropriate answer. Trauma-focussed CBT is also used for
patients suffering with Post-Traumatic Stress Disorder (PTSD)
Olanzapine - this is not the most appropriate answer. Olanzapine is an atypical antipsychotic medication
and is not used first line to treat OCD.
Dialectical behaviour therapy (DBT) - this is not the most appropriate answer. DBT is a psychological
intervention for patients with borderline personality disorder.
Exposure-response prevention (ERP) therapy - this is the correct answer. ERP therapy, as well as cognitive
behavioural therapy, is recommended and a first line intervention for OCD.
Please see OCD
Q-15
You are considering prescribing a tricyclic antidepressant for a patient who has not responded to two
different types of selective serotonin reuptake inhibitors. Which one of the following tricyclic
antidepressants is most dangerous in overdose?
A. Dosulepin
B. Imipramine
C. Clomipramine
D. Nortriptyline
E. Lofepramine
ANSWER:
A. Dosulepin
EXPLANATION:
Dosulepin – avoid as dangerous in overdose
Please see Tricyclic Antidepressants
Q-16
A 42-year-old woman presents for review. Her husband reports that she has had an argument with their
son which resulted in him leaving home. Since this happened she has not been able to speak. Clinical
examination of her throat and chest is unremarkable. Which one of the following terms best describes this
presentation?
A. Aprosodia
B. Schizophasia
C. Expressive aphasia
D. Akinetic mutism
E. Psychogenic aphonia
ANSWER:
E. Psychogenic aphonia
EXPLANATION:
Psychogenic aphonia is considered to be a form of conversion disorder. Please see the link for more details.
Please see Aphonia
Q-17
A 34-year-old man originally from West Africa is seen in January with depression. There is no past medical
history of note but he is known to smoke cannabis. He has had similar episodes for the past two winters.
What is the most likely diagnosis?
A. Cyclothymic disorder
B. Atypical depression
C. Seasonal affective disorder
D. Schizophrenia
E. Drug-induced depression
ANSWER:
C. Seasonal affective disorder
EXPLANATION:
Please see Seasonal Affective Disorder
Q-18
You a reviewing a 24-year-old man who complains of auditory hallucinations. These have become
increasingly common and are now happening on a daily basis. Which one of the following factors in his
history is the strongest risk factor for psychotic disorders?
A. Indian subcontinent ethnicity

B. Having a parent with schizophrenia
C. A history of long-term cannabis use
D. A history of being sexually abused when younger
E. Working in the performing arts
ANSWER:
B. Having a parent with schizophrenia
EXPLANATION:
Family history is the strongest risk factor for psychotic disorders
Please see Schizophrenia: Epidemiology
Q-19
Which one of the following statements regarding post-partum mental health problems is NOT true?
A. Post-natal depression is seen in around 2-3% of women

B. Puerperal psychosis has a recurrence rate of around 20%
C. Baby-blues are seen in the majority of women
D. Post-natal depression usually develops within the first month
E. Sertraline can be used whilst mothers are breast feeding
ANSWER:
A. Post-natal depression is seen in around 2-3% of women
EXPLANATION:
Post-natal depression is seen in around 10% of women
Q-20
A 34-year-old ex-soldier with a history of post-traumatic stress disorder returns for review. He has had a
course of eye movement desensitisation and reprocessing therapy which was not helpful and is reluctant
to try cognitive behavioural therapy. Of the options listed, which medication may be useful in such
patients?
A. Haloperidol
B. Diazepam
C. Venlafaxine
D. Topiramate
E. Bupropion
ANSWER:
C. Venlafaxine
EXPLANATION:
If CBT or EMDR therapy are ineffective in PTSD, the first line drug treatments are venlafaxine or a SSRI
Please see Post-Traumatic Stress Disorder
Q-21
The sister of a 34-year-old man comes to see you in clinic as she is worried her brother may have a
personality disorder. She reports her brother has always had a heightened opinion of himself and often
expresses delusional thoughts regarding his potential for success as a banker believing he is capable of
making millions. He does not seem perturbed by bringing others down in the process and appears pleased
when he talks of others failures. She remembers he behaved similarly when they were growing up and
was unsympathetic towards her when she had to resit her finals due to ill health.
What personality disorder is she describing?
A. Antisocial personality disorder

B. Schizoid personality disorder
C. Schizotypal personality disorder
D. Borderline personality disorder
E. Narcissistic personality disorder
ANSWER:
E. Narcissistic personality disorder
EXPLANATION:
Narcisstic personalities lack empathy, have a sense of entitlement and take advantage of others to
achieve their own need
The correct answer is narcissistic personality disorder. Whilst her brother may not actually qualify for
having a personality disorder if his behaviour does not cause him personal distress or prevent him
functioning socially, many of these features are seen in narcissistic behaviour. These patients have a
heightened impression of self-importance and entitlement often believing they have unlimited abilities to
succeed, become powerful or look beautiful. Additionally, they lack empathy and will happily take
advantage of others to achieve their own need. In keeping with many personality disorders his symptoms
appear to have been present since childhood and into adult life.
Patients with antisocial personality disorder also lack empathy or feelings of guilt/remorse. Similarly to
narcissistic personalities they can be deceitful when wanting to achieve their own need. However, in
contrast to narcissists they often fail to comply with rules or laws resulting in criminal offences and are
prone to getting into fights. As such the patient in the stem fits more closely with narcissistic personality
disorder.
Patients with schizoid personality disorder tend to have a lack of interest in sexual interactions are cold
and lack close friendships preferring to spend time alone. They are also indifferent to praise making this
unlikely to be the correct answer.
Option 3 is incorrect. Patients with schizotypal personality disorder can have odd/eccentric beliefs or
behaviour. They can also struggle to make friends and can be paranoid/suspicious as opposed to lacking
empathy or having a sense of entitlement.
Option 5 is also incorrect, borderline personality disorder is characterized by emotional instability,

impulsive behaviour, feelings of emptiness and recurrent attempts at self-harm.
Q-22
A 30-year-old man presents to his doctor as he has been feeling generally 'out of sorts' for the past few
weeks. He is accompanied by his girlfriend who says he has 'not been himself'. She is worried and feels he
may need to see a psychiatrist. There is no history of past mental health problems. Which one of the
following symptoms would be most suggestive of depression?
A. Palpitations
B. Nausea before certain situations e.g. getting on a bus
C. Early morning waking
D. Excessive gambling
E. Flash-backs to childhood problems
ANSWER:
C. Early morning waking
EXPLANATION:
Early morning waking is a classic somatic symptom of depression and often develops earlier than general
insomnia.
Palpitations and nausea and more common with anxiety. Excessive gambling may suggest either a simple
gambling addiction or be part of a hypomanic/manic disorder.
Flash-backs are common in post-traumatic stress disorder.
Please see Depression: Screening and Assessment
Q-23
A 65-year-old woman is prescribed duloxetine for a major depressive episode after having no response to
citalopram or fluoxetine.
What is the mechanism of action of the drug that has just been added?
A. Selective serotonin reuptake inhibitor
B. Alpha blocker
C. Serotonin and noradrenaline reuptake inhibitor
D. Atypical antidepressant
E. Tricyclic antidepressant
ANSWER:
C. Serotonin and noradrenaline reuptake inhibitor
EXPLANATION:
Duloxetine mechanism of action = serotonin and noradrenaline reuptake inhibitor
Duloxetine is of the serotonin and noradrenaline reuptake inhibitor class of antidepressants.
NICE: although all antidepressants have roughly equal efficacy, choice of antidepressant depends on
patient preference, previous sensitisation, risk in overdose and cost. Selective serotonin reuptake
inhibitors (SSRIs) are usually used first-line, as they have a good risk-to-benefit ratio.
Please see Serotonin and Noradrenaline Reuptake Inhibitors
Q-24
A 82-year-old female who has glaucoma starts to experience visual hallucinations which include seeing
goldfish, black boxes and mud sliding down shelves. She is completely blind in the right eye and only
partially sighted in the left eye. What is the most likely diagnosis?
A. Schizophrenia
B. Delirium
C. Charles Bonnet syndrome
D. Peduncular hallucinosis
E. Anton's syndrome
ANSWER:
C. Charles Bonnet syndrome
EXPLANATION:
In a patient who is partially or fully blind and experiencing visual hallucinations, Charles Bonnet syndrome
should be considered. Delirium and schizophrenia also present with visual hallucinations, but with the
history of blindness, Charles Bonnet syndrome is the more likely diagnosis.
Anton's syndrome is is a rare symptom of brain damage occurring in the occipital lobe characterised by
cortical blindness, but will not accept they are blind despite being told that they are. They don't have
visual hallucinations
Peduncular hallucinosis is a rare neurological disorder that causes vivid visual hallucinations in dark
environments which last for several minutes. They typically occur after a midbrain stroke. This diagnosis is
less likely given the history of blindness.
Please see Charles-Bonnet Syndrome
Q-25
You are a junior doctor on the acute medical take. Your next patient has been admitted with an
exacerbation of heart failure.
Whilst exploring his past medical history he confides in you he was in a road traffic collision 3 months ago
in which a family friend was killed.
He explains he is struggling to sleep and feels he is constantly re-living the accident. He states he is afraid
to leave the house in case it was to happen again and that any loud noises cause him to panic. He has
increased his alcohol intake to try and forget about it and to help him sleep.
Which of the following treatments is most likely to help this man?
A. Olanzapine
B. Eye movement desensitisation and reprocessing (EMDR) therapy
C. GP to review in one month
D. Single-session debrief therapy
E. Tricyclic antidepressant
ANSWER:
B. Eye movement desensitisation and reprocessing (EMDR) therapy
EXPLANATION:
PTSD management - trauma-focused cognitive behavioural therapy or EMDR
Olanzapine along with most other antipsychotics are not used in the management of post-traumatic stress
disorder (PTSD). NICE recommends a trial of risperidone in patients with severe cases of PTSD.
EMDR therapy and cognitive behavioural therapy (CBT) can be trialled in patients were severe cases of
post-traumatic stress disorder.
In mild cases lasting less than 4 weeks watchful waiting can be used. It may be appropriate in these
scenarios for a GP to regularly review the patient. However in the above case, given the man in the above
scenario has experienced severe symptoms for the past 12 weeks, this option would not be appropriate.
Single-session debrief therapy is not recommended following traumatic events and so this option is not
correct.
Tricyclic antidepressants are not recommended in PTSD. If drug therapy is the be tried then SSRIs such as
sertraline or venlafaxine (SNRI) can be tried.
Q-26
A 65-year-old male with a background of chronic alcohol excess and previous Wernicke's encephalopathy
is admitted to the acute medical take with behavioural disturbance. He has not consumed alcohol in the
past 2 years.
Which of the following phenomena is he likely to display on further assessment?
A. Confabulation
B. Dysthymia
C. Hydrophobia
D. Lilliputians
E. Perseveration
ANSWER:
A. Confabulation
EXPLANATION:
Confabulation in a patient with chronic alcoholism points towards Korsakoff's syndrome
Korsakoff's is characterised by confabulation and amnesia, typically occurring in alcoholics secondary to

chronic vitamin B1 (thiamine) deficiency. Dysthymia refers to mild depression; hydrophobia is a feature of
rabies; lilliputians may be observed in delirium tremens; perseveration is repetitive speech patterns,
commonly seen after traumatic brain injury.
Please see Korsakoff’s Syndrome
Q-27
A 54-year-old man presents with a variety of physical symptoms that have been present for the past 9
years. Numerous investigations and review by a variety of specialties have indicated no organic basis for
his symptoms. This is an example of:
A. Munchausen's syndrome
B. Hypochondrial disorder
C. Dissociative disorder
D. Somatisation disorder
E. Conversion disorder
ANSWER:
D. Somatisation disorder
EXPLANATION:
Unexplained symptoms
Somatisation = Symptoms
hypoChondria = Cancer
Somatisation disorder is the correct answer as the patient is concerned about persistent, unexplained
symptoms rather than an underlying diagnosis such as cancer (hypochondrial disorder). Munchausen's
syndrome describes the intentional production of symptoms, for example self poisoning
Please see Unexplained Symptoms
Q-28
Which one of the following is not a recognised feature of anorexia nervosa?
A. Hypokalaemia
B. Low LH
C. Impaired glucose tolerance
D. Low FSH
E. Reduced growth hormone levels
ANSWER:
E. Reduced growth hormone levels
EXPLANATION:
Anorexia features
most things low
G's and C's raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
Please see Anorexia Nervosa: Features
Q-29
You review a patient who has been taking citalopram for the past two years to treat depression. He has
felt well now for the past year and you agree a plan to stop the antidepressant. How should the
citalopram be stopped?
A. Can be stopped immediately

B. Withdraw gradually over the next 3 days
C. Withdraw gradually over the next week
D. Withdraw gradually over the next 2 weeks
E. Withdraw gradually over the next 4 weeks
ANSWER:
E. Withdraw gradually over the next 4 weeks
EXPLANATION:
When stopping a SSRI the dose should be gradually reduced over a 4 week period
This not necessary with fluoxetine due to its longer half-life.
Q-30
A 24-year-old female is reviewed following a course of cognitive behaviour therapy for bulimia. She feels
there has been no improvement in her condition and is interested in trying pharmacological treatments.
Which one of the following is most suitable?
A. Low-dose citalopram
B. Low-dose fluoxetine
C. Low-dose amitriptyline
D. High-dose amitriptyline
E. High-dose fluoxetine
ANSWER:
E. High-dose fluoxetine
EXPLANATION:
Please see Bulimia Nervosa
Q-31
The risk of developing schizophrenia if one monozygotic twin is affected is approximately:
A. 10%
B. 20%
C. 50%
D. 75%
E. >95%
ANSWER:
C. 50%
EXPLANATION:
Please see Schizophrenia: Epidemiology
Q-32
A 36-year-old patient presents with nausea, headaches and palpitations. He has had multiple previous
admissions with such symptoms over the past 2 years, each time no organic cause was found. What kind
of disorder is this likely to represent?
A. Munchausen's syndrome
D. Conversion disorder
E. Dissociative disorder
ANSWER:
EXPLANATION:
Q-33
A slim 22 year-old drama student presents with weakness and muscle cramps. She has a past medical
history of reflux and asthma, for which she takes lansoprazole 30mg once daily, inhaled salbutamol PRN,
and once-daily inhaled corticosteroid. She reports feeling stressed lately as she has a leading role in a
significant stage production due to open in one week. Her heart rate is 87bpm, blood pressure
103/71mmHg, respiratory rate 13/min. Her blood results are shown:
pH 7.46
Na+ 137 mmol/L
K+ 2.6 mmol/L
Chloride 93 mmol/L
Magnesium 0.61 mmol/L
What is the most likely cause for her symptoms?
A. Diuretic abuse
B. Steroid use
C. Stress
D. Bulimia
E. Gitelman Syndrome
ANSWER:
D. Bulimia
EXPLANATION:
This is a hard question reflecting a difficult real-world challenge: differentiating between causes of
hypochloraemia, which can be caused (amongst others) by Gitelman syndrome, bulimia and diuretic
abuse. Inhaled steroid use and stress would not be responsible for such marked electrolyte derangement.
Gitelman syndrome, although fitting, is very rare and would not be considered the most likely diagnosis.
As such the two remaining options are bulimia and diuretic abuse. The scales are tipped towards bulimia
by the mild metabolic alkalosis and history of gastroesophageal reflux (more prevalent in bulimia)
requiring high-dose PPI to control - an unusual requirement in a young slim patient. Other potential signs
would be parotid gland swelling and dental enamel erosion induced by regular vomiting. Diuretic abuse
tends to give a hypochloraemic acidosis.
Please see Bulimia Nervosa
Q-34
A 21-year-old female is admitted to the acute medical unit after a paracetamol overdose. She later admits
to multiple episodes of impulsive self-harm and overdoses. She reports that her recent overdose was
triggered by a fight with her dad and concerns that he will no longer want to see her. She describes long-
standing feelings of emptiness and does not like the way she looks.
What is the most likely underlying personality disorder?
A. Narcissistic personality disorder

C. Borderline personality disorder
D. Dependant personality disorder
ANSWER:
EXPLANATION:
Borderline personality disorder is associated with impulsivity, feelings of emptiness, fear of abandonment
and unstable self image
The correct answer is borderline personality disorder. Patients with personality disorder have disturbances
in behaviour and personality that result in considerable personal and social distress across all areas of life.
Borderline or emotionally unstable personality disorder is characterised by emotional instability, impulsive
behaviour and intense but unstable relationships with others. Patients often fear abandonment of those
close to them and may idolise these people. As in the patient described, they often have feelings of
emptiness, poor self-image and recurrent attempts at self-harm. There is an association between the
development of borderline personality disorder and history of trauma or abuse in childhood.
Narcissistic personality disorder is incorrect. These patients have an over exaggerated sense of self-
importance, lack empathy and tend to have a sense of entitlement.
Option 2 is incorrect. Paranoid personality disorder presents in patients who are reluctant to confide in
others. They often question the loyalty of friends and family and can be unforgiving. They can see hidden
meaning in things or are concerned about conspiracy theories.
reassurance and support from others. They cope best when in a relationship and fear being alone. Whilst
there are features in the stem of the patient idolising her father there is no evidence of dependent
personality disorder.
Option 5 is also incorrect. Avoidant personality disorder is characterised by avoidance of social

contact/relationships due to fear of being criticised, rejected or embarrassed. Patients view themselves as
inferior to others and so are not keen to be involved unless they are certain of being liked.

Q-35
A 39-year-old patient is taking phenelzine, a monoamine oxidase inhibitor, for the treatment of
depression. Which one of the following foods can the patient safely eat?
A. Bovril
B. Cheese
C. Oxo
D. Eggs
E. Broad beans
ANSWER:
D. Eggs
EXPLANATION:
Please see Monoamine Oxidase Inhibitors
Q-36
A 25-year-old man with a history of schizophrenia is prescribed olanzapine. Which one of the following
adverse effects is he most likely to experience?
A. Anorexia
B. Parkinsonism
C. Hypertension
D. Weight gain
E. Agranulocytosis
ANSWER:
E. Weight gain
EXPLANATION:
Weight gain is an extremely common adverse effect of atypical antipsychotics such as olanzapine
Please see Atypical Antipsychotics
Q-37
A 35-year-old man with a history of schizophrenia is transferred to the Emergency Department due to an
oculogyric crisis. What is the most appropriate treatment?
A. Selegiline
B. Haloperidol
C. Procyclidine
D. Bromocriptine
E. Cabergoline
ANSWER:
C. Procyclidine
EXPLANATION:
Benztropine is also an appropriate treatment
Q-38
A 23-year-old man presents as he is concerned about a number of recent episodes related to sleep. He
finds when he wakes up and less often when he is falling asleep he is 'paralysed' and unable to move. This
sometimes associated with what the patient describes as 'hallucinations' such as seeing another person in
the room. He is becoming increasingly anxious about these recent episodes. What is the most likely
diagnosis?
A. Frontal lobe epilepsy
B. Generalised anxiety disorder
C. Sleep paralysis
D. Night terrors
E. Acute schizophrenia
ANSWER:
C. Sleep paralysis
EXPLANATION:
Please see Sleep Paralysis
Q-39
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?
A. Atrial fibrillation
B. Myocardial infarction
C. Aspiration pneumonia
D. Stroke
E. Breast cancer
ANSWER:
D. Stroke
EXPLANATION:
Antipsychotics in the elderly - increased risk of stroke and VTE
Q-40
Which one of the following selective serotonin reuptake inhibitors has the highest incidence of
discontinuation symptoms?
A. Paroxetine
B. Citalopram
C. Escitalopram
D. Fluoxetine
E. Sertraline
ANSWER:
A. Paroxetine
EXPLANATION:
Paroxetine - higher incidence of discontinuation symptoms
Q-41
A 64-year-old woman presents as she is feeling down and sleeping poorly. After speaking to the patient
and using a validated symptom measure you decide she has moderate depression. She has a past history
of ischaemic heart disease and currently takes aspirin, ramipril and simvastatin. What is the most
appropriate course of action?
A. Stop aspirin, start sertraline

B. Start venlafaxine
C. Start sertraline + lansoprazole
D. Stop aspirin, start clopidrogrel + sertraline
E. Start sertraline
ANSWER:
C. Start sertraline + lansoprazole
EXPLANATION:
SSRI + NSAID = GI bleeding risk - give a PPI
There is an increased incidence of gastrointestinal bleeding when aspirin / NSAIDs are combined with
selective serotonin reuptake inhibitors. This patient should therefore also be offered a proton pump
inhibitor such as lansoprazole. It would be inappropriate to stop aspirin in a patient with a history of
ischaemic heart disease.
Note the use of sertraline in this patient, the first-choice SSRI in patients with a history of cardiovascular
disease.
Q-42
A 27-year-old woman is brought in by her husband. She has been refusing to go outside for the past 3
months, telling her husband she is afraid of catching avian flu. On exploring this further she is concerned
due to the high number of migrating birds she can see in her garden. She reports that the presence of her
husbands socks on the washing line in the garden alerted her to this. What is the most likely diagnosis?
A. Depression
C. Formal thought disorder
E. Acute paranoid schizophrenia
ANSWER:
E. Acute paranoid schizophrenia
EXPLANATION:
The washing line comment is an example of a delusional perception - see below
Please see Schizophrenia: Features
Q-43
A 45-year-old man who takes chlorpromazine for schizophrenia presents with severe restlessness. What
side-effect of antipsychotic medication is this an example of?
A. Akathisia
B. Neuroleptic malignant syndrome
C. Acute dystonia
D. Tardive dyskinesia
E. Parkinsonism
ANSWER:
A. Akathisia
EXPLANATION:
Antipsychotics may cause akathisia (severe restlessness)
Q-44
A 62-year-old man is brought to the doctors by his daughter. Four weeks ago his wife died from metastatic
breast cancer. He reports being tearful every day but his daughter is concerned because he is constantly
'picking fights' with her over minor matters and issues relating to their family past. The daughter also
reports that he has on occasion described hearing his wife talking to him and on one occasion he prepared
a meal for her.
Despite this he has started going walking again with friends and says that he is determined to get 'back on
track'.
A. Atypical grief reaction

B. Depression without psychotic features
C. Delusional disorder
D. Depression with psychotic features
E. Normal grief reaction
ANSWER:
E. Normal grief reaction
EXPLANATION:
Please see Grief Reaction
Q-45
You review a 45-year-old man with a long history of bipolar disorder. According to NICE and National
Patient Safety Agency (NPSA) guidelines, how often should lithium levels be checked once a stable dose
has been achieved?
A. Every month
B. Every 2 months
C. Every 3 months
D. Every 4 months
E. Every 6 months
ANSWER:
C. Every 3 months
EXPLANATION:
Lithium levels should be checked every 3 months once a stable dose has been achieved
Please see Lithium
Q-46
A 25-year-old man demands a CT scan of his abdomen in clinic. He states it is 'obvious' he has cancer
despite previous negative investigations. This is an example of a:
A. Hypochondrial disorder
B. Conversion disorder
C. Munchausen's syndrome
D. Dissociative disorder
E. Somatisation disorder
ANSWER:
EXPLANATION:
Q-47
A young couple enters the general practice. The wife explains how her partner has been acting out of
character, specifically, checking on their daughter subtly throughout the day and even during the night.
On average, he would check ten to twenty times. When asked, he explains that last month he nearly lost
his daughter in the park where it was a scary ordeal and he repeatedly relives what happened in his mind.
The husband says that he does not go to the park anymore, feels anxious and has difficulty sleeping. There
is no past medical or psychiatric history of note.
Which of the following is the most likely diagnosis?
A. Generalised anxiety disorder (GAD)

B. Obsessive compulsive disorder (OCD)
C. Panic disorder
D. Paranoid delusion disorder (PDD)
E. Post traumatic stress disorder (PTSD)
ANSWER:
E. Post traumatic stress disorder (PTSD)
EXPLANATION:
Common features of PTSD
 re-experiencing e.g. flashbacks, nightmares
 avoidance e.g. avoiding people or situations
 hyperarousal e.g.hypervigilance, sleep problems
With this history, the most likely is diagnosis is PTSD. An incident must occur which elicit the following
features; flashbacks, hyperarousal and avoidance. For a diagnosis, symptoms must persist for over a
month.
GAD and OCD could present in a similar fashion with constant anxiety and the behaviours exhibited. GAD
tends to slowly progress starting in the teenage years. OCD can develop in the early 20's but would be less
likely than PTSD to develop straight after the incident in the park.
Panic disorder presents differently, it occurs when the sympathetic system is stimulated causing an intense
episode of fight or flight when there is no matching stimulus.
PDD is a self-referential delusion, the patient does not hold fixed false beliefs about himself.
Q-48
A 23-year-old man asks to be referred to a plastic surgeon. From his records you can see he has been
treated for anxiety and depression with fluoxetine previously and has been off work with back pain for
the past three months. He is concerned that his ears are too big in proportion to his face. He reports that
he now seldom leaves the house because of this. On examination his ears appear to be within normal
limits. What is the most appropriate description of this behaviour?
A. Hypochondriasis
B. Generalised anxiety disorder
C. Somatisation
D. Malingering
E. Dysmorphophobia
ANSWER:
E. Dysmorphophobia
EXPLANATION:
Please see Body Dysmorphic Disorder
Q-49
A 33-year-old female is brought to the GP by her concerned mother. The patient reports that the prime
minister is secretly in love with her, despite her mother protesting there has never been any contact
between them. Which psychiatric disorder does this fit with?
A. Couvade syndrome
B. Bouffée délirante
C. Fregoli delusion
D. Capgras delusion
E. De Clerambault's syndrome
ANSWER:
E. De Clerambault's syndrome
EXPLANATION:
Bouffée délirante is an acute psychotic disorder in which hallucinations, delusions or perceptual
disturbances are obvious but markedly variable, changing from day to day or even from hour to hour.
Fregoli delusion is the mistaken belief that some person currently present in the deluded person's
environment (typically a stranger) is a familiar person in disguise.
Capgras delusion is the belief that significant others have been replaced by impostors, robots or aliens.
Couvade is the common but poorly understood phenomenon whereby the expectant father experiences
somatic symptoms during the pregnancy for which there is no recognised physiological basis.
Please see De Clerambault’s Syndrome
Q-50
A 73-year-old male patient who lives alone presents with recurrent episodes of pleasant visual
hallucinations but no clouding of consciousness or confusion. He tells you he knows the hallucinations are
not real. He is normally fit and well with the exception of visual impairment.
Given the likely diagnosis, what ophthalmic condition is he most likely to suffer from?
A. Glaucoma
B. Diabetic retinopathy
C. Retinal detachment
D. Age-related macular degeneration
E. Cataract
ANSWER:
D. Age-related macular degeneration
EXPLANATION:
Age-related macular degeneration is associated with Charles-Bonnet syndrome
This patient has Charles-Bonnet syndrome (CBS) as evidenced by visual hallucinations with normal insight
on a background of visual impairment. He also lives alone which could be another risk factor for CBS if this
leads to him becoming socially isolated. 11-15% of patient with severe visual impairment are thought to
have coexisting CBS and experience recurrent, persistent or episodic visual or auditory hallucinations. The
most common ophthalmological condition associated with CBS is age-related macular degeneration and
hence this is the correct answer.
Glaucoma and cataract are the next most common causes of visual impairment associated with CBS. CBS
can, however, occur in any ophthalmic condition making 1,2,3 and 5 all possible but less common causes
than age-related macular degeneration.
It is important to note that the hallucinations are related to failing eyesight and are not a sign of an
underlying psychiatric condition.
Q-51
A 21-year-old female patient is being investigated for a personality disorder. She is found to be low in self-
esteem and fearful of criticism or rejection, particularly in social situations. She reports struggling to make
friends at work despite being desperate to be liked. She feels that her colleagues are much better at her
job than her. She becomes very anxious every day on the way to work as she worries she will make a fool
of herself. As a result, she struggles to hold down a job often moving jobs regularly. She has had the same
experience with relationships out of work as she does not feel good enough for anyone.
A. Dependant personality disorder

D. Histrionic personality disorder
ANSWER:
EXPLANATION:
Patients with avoidant personality disorder are fearful of criticism, being unliked, rejection and ridicule
The correct answer here is 5 - avoidant personality disorder. Patients with personality disorder have
disturbances in behaviour and personality that result in considerable personal and social distress across all
areas of life. As in the stem, patients with avoidant personality disorder tend to avoid social
contact/relationships due to fear of being criticised, rejected or embarrassed. They view themselves as
inferior to others and so are not keen to be involved unless they are certain of being liked. They sometimes
have an overwhelming sense of tension or apprehension.
reassurance and support from others. They tend to lack initiative and feel they are unable to look after
themselves. They cope best when in a relationship and fear being alone. As such this not the correct
answer.
Paranoid personality disorder presents in patients who are reluctant to confide in others. They often
question the loyalty of friends and family and can be unforgiving. They can see hidden meaning in things
or are concerned about conspiracies. There is no evidence of paranoid personality disorder in this stem.
Borderline personality disorder is characterized by emotional instability, impulsive behaviour and intense
but unstable relationships with others. They often have feelings of emptiness, poor self-image and
recurrent attempts at self-harm. Again making this an incorrect answer.
Histrionic personality disorder is seen in patients who crave being the centre of attention, they can be
sexually inappropriate in behaviour or appearance and suggestible. These are not the features described
in the stem.

Q-52
Rachel is a 45-year-old who has routine bloods for a health check. Blood tests show the following:
Na+ 125 mmol/l
K+ 4.3 mmol/l
Urea 5.3 mmol/l
Creatinine 60 µmol/l
She takes the following medications: sertraline, carbimazole, amlodipine, metformin, aspirin. Which of
her medications is likely to be the cause of her hyponatraemia?
A. Aspirin
B. Metformin
C. Amlodipine
D. Carbimazole
E. Sertraline
ANSWER:
E. Sertraline
EXPLANATION:
SSRIs are associated with hyponatraemia
Out of the list above sertraline is the medication known to cause hyponatraemia.
Other common drug causes of low sodium include: chlorpropramide, carbamazepine, selective serotonin
reuptake inhibitor (SSRI) antidepressants, tricyclic antidepressants, lithium, MDMA/ecstasy, tramadol,
haloperidol, vincristine, desmopressin, fluphenazine.
Q-53
A 58-year-old lady presents to her GP concerned her partner is being unfaithful. She appears very
distressed by this yet after further questioning does not appear to have any evidence to support her
claims, yet she is convinced she is right. What might this concern be a symptom of?
A. Capgras' delusion
B. Grandiose delusion
C. de Clérambault's syndrome
D. Othello's syndrome
E. Charles Bonnet syndrome
ANSWER:
D. Othello's syndrome
EXPLANATION:
De Clérambault's syndrome also called erotomania is a delusional belief that someone else is in love with
the patient. Charles Bonnet syndrome is the experience of complex visual hallucinations in patients with
partial or severe blindness.
Please see Othello’s Syndrome
Q-54
Enid, an 87-year-old lady, is experiencing disturbing visual hallucinations. She sees 'evil' looking faces on
the walls and snakes and insects on the floor. She knows that these are not real. She has no auditory
hallucinations. She is otherwise well. She has a history of hypertension, depression, hearing loss and
macular degeneration. What is the most likely cause of her hallucinations?
A. Lewy body dementia

B. Psychotic depression
C. Acute psychosis
D. Charles Bonnet syndrome
E. Normal pressure hydrocephalus
ANSWER:
D. Charles Bonnet syndrome
EXPLANATION:
Charles-Bonnet syndrome causes unpleasant visual hallucinations in a third of sufferers
The cause of this lady's visual hallucinations is Charles Bonnet syndrome. Around a third of sufferers may
experience disturbing or unpleasant hallucinations.
Lewy body dementia may involve visual hallucinations alongside fluctuating cognitive impairment, but in
the absence of any current neuropsychiatric symptoms this makes this a less likely diagnosis.
Acute psychosis tends to involve auditory hallucinations associated with delusions.
Psychotic depression would usually involve severe symptoms of depression with the development of
psychotic symptoms.
Normal pressure hydrocephalus does not usually involve visual hallucinations.
Q-55
A 93-year-old female patient on the ward is brought to your attention by the nurses. They are concerned
she is experiencing visual hallucinations. She was admitted following a decline in mobility that was
thought to be secondary to a urinary tract infection (UTI). She has improved clinically and biochemically
during her time on the ward and she is awaiting a increase package of care before discharge.
You review the patient who tells you she earlier saw very small children running across the end of the
bed. She reports she regularly sees similar images at home and has done so for many years. She has a
background of hypertension, depression and age-related macular degeneration. What is the most
appropriate step in this patient's management?
A. Reassure the patient

B. Urgent psychiatric evaluation
C. Consider treatment failure of her UTI
D. Prescribe 40mg of chlordiazepoxide
E. Consider commencing an antidepressant
ANSWER:
A. Reassure the patient
EXPLANATION:
This most likely represents Charles Bonnet syndrome. Reassurance is usually the best treatment, helping
people to understand and come to terms with their hallucinations. It is importance to ensure there is not
an alternative cause e.g. infection, psychosis, dementia (particularly Lewy body dementia), intoxication,
metabolic abnormalities, focal neurological illness.
Q-56
A 29-year-old fireman presents following a recent traumatic incident where a child died in a house fire. He
describes recurrent nightmares and flashbacks which have been present for the past 3 months. A
diagnosis of post-traumatic stress disorder is suspected. What is the most appropriate first-line
treatment?
A. Arrange a CT head to exclude an organic cause

B. Cognitive behavioural therapy or eye movement desensitisation and reprocessing therapy
C. Cognitive behavioural therapy or graded exposure therapy
D. Cognitive behavioural therapy or psychodynamic therapy
E. Watchful waiting
ANSWER:
B. Cognitive behavioural therapy or eye movement desensitisation and reprocessing therapy
EXPLANATION:
PTSD management - trauma-focused cognitive behavioural therapy or EMDR
Q-57
A 31-year-old woman who gave birth two weeks ago presents for review with her husband. He is worried
by her mood as she now seems depressed and is interacting poorly with the baby. He describes her mood
three days ago being much different, when she was talking in a rapid and incoherent fashion about the
future. The mother denies any hallucinations but states that her child has been brought into a 'very bad
world'. What is the most appropriate management?
A. Start fluoxetine
B. Reassurance + review by health visitor
C. Cognitive behavioural therapy
D. Start lithium
E. Arrange urgent admission
ANSWER:
E. Arrange urgent admission
EXPLANATION:
The mother may be suffering from puerperal psychosis and needs urgent admission to allow psychiatric
evaluation.
Whilst there is not a full complement of psychotic features there are a number of pointers towards
significant mental health problems:
poor interaction with the baby: this is very unusual, including in women with postnatal depression
'talking in an incoherent fashion about the future'
stating that the baby 'has been brought into a very bad world' is odd and somewhat worrying
For these reasons, the mother should have an urgent psychiatric evaluation.
Q-58
A 63-year-old man presents to his GP for support following the breakdown of his marriage. He has been
consuming a bottle of vodka a day for the last month and states that he drinks upon waking in the
morning to relieve his feelings of anxiety, however, he has not drunk this morning and now feels unwell.
He is markedly tremulous when sitting, sweating profusely and reports some hallucinations at times when
he has abstained from alcohol. His GP arranges for an ambulance and the patient agrees to attend the
hospital for further assessment. Whilst waiting for the ambulance to arrive, the patient collapses in the
waiting room and has a tonic-clonic seizure. His seizure resolves spontaneously after 45 seconds and the
ambulance team escorts him to hospital.
Which of the following describes the most appropriate treatment plan for this patient?
A. He can be commenced on an outpatient detoxification regime
B. The patient has alcoholic hallucinosis and requires a psychiatric review
C. He requires an inpatient detoxification regime with community follow up
D. He can be discharged 24 hours post seizure if no further seizures with no further input
E. None of the above
ANSWER:
C. He requires an inpatient detoxification regime with community follow up
EXPLANATION:
Patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts)
should be admitted to hospital for monitoring until withdrawals stabilised
This patient presents with alcohol dependency and complex withdrawal symptoms i.e. history of
hallucinations suggestive of delirium tremens (hallucinations occur with abstinence from alcohol) and
withdrawal seizures.
Alcoholic hallucinosis is characterised by auditory hallucinations, delusions and changes in mood during or
following chronic alcohol misuse, with symptoms mimicking those seen in patients with schizophrenia. Our
patient describes acute symptoms and there is no evidence of delusions, hence alcoholic hallucinosis is
unlikely.
All patients with complex withdrawals require a longer period of assessment and should ideally complete
a detoxification regime as an inpatient.
Outpatient detoxification is contraindicated in patients with a history of complex withdrawals.
Please see Alcohol Withdrawal
Q-59
A 47-year-old alcoholic has been brought to the emergency department by his brother. His brother states
that he has been confused for the last few days and has fallen over a few times. On examination, he has
an unsteady gait. He cannot remember the first female prime minister of the UK or the journey to the
emergency department. He claimed he went to the park yesterday - which his brother states are untrue.
Considering the clinical picture, what is the most likely diagnosis?
A. Wernicke's encephalopathy
B. Korsakoff's syndrome
C. Alzheimer's disease
D. Acute delirium
E. Lewy-body dementia
ANSWER:
B. Korsakoff's syndrome
EXPLANATION:
Korsakoff’s syndrome is a complication of Wernicke’s encephalopathy. It's features include: anterograde
amnesia, retrograde amnesia, and confabulation
Wernicke's encephalopathy is characterised by ataxia, ophthalmoplegia and confusion. This patient had
confusion and an unsteady gait (a sign of ataxia). However, the patient has symptoms of Korsakoff's
syndrome: anterograde amnesia (unable to form new memories), retrograde amnesia (unable to recall
past memories) and confabulation (making up new memories) suggesting his Wernicke's encephalopathy
has progressed.
Alzheimer's disease generally affects memory in a stepwise progression. Lewy-body dementia classically
has signs of parkinsonism and also hallucinations.
Please see Korsakoff’s Syndrome
Q-60
A 84-year-old female attends clinic with her daughter. She has a past medical history of hypertension and
a fractured neck of femur six months ago. Her daughter reports over the last few months she has become
highly preoccupied with her blood pressure and diet measuring her blood pressure multiple times per day.
Her daughter feels that her concerns over her physical health are affecting her mood. She becomes easily
agitated and often snaps at her daughter. The patient denies any problems with her memory or mood but
does report difficulty in getting to sleep.
A. Alzheimers' disease
B. Lewy body dementia
C. Depression
D. Vascular dementia
E. Hypochondriasis
ANSWER:
C. Depression
EXPLANATION:
Elderly patients with depression are less likely to complain of low mood and instead may present with
health anxiety, agitation and sleep disturbance
Depression in elderly patients can be challenging to diagnose and less commonly presents with low mood
or classical features of depression. Patients often present with health anxiety, poor sleep and agitation as
in the question here making 3 the most correct answer. Her recent hip fracture and subsequent
hospitalisation may have acted as a trigger of the low mood.
The patient does not report any memory problems and there is nothing else in the history to suggest
significant memory impairment or Parkinson's like symptoms. Whilst vascular dementia can present with
a change in personality there is no suggestion of altered executive function or confusion and hypertension
is her only vascular risk factor. As such 1,2 and 4 are less likely than depression given the history. Memory
problems should however be ruled out with a MMSE as patients will often not report concerns with their
memory and depression can be associated with memory impairment.
There are features of health anxiety or hypochondriasis in this stem, however together with agitation and
poor sleep, depression is a more likely answer.
Please see Depression in Older People
Q-61
An 88-year-old woman is brought to her GP by her daughter because of new memory problems. She did
not want to attend as she is worried about her memory and does not want to be diagnosed with
dementia. She scores 12 out of 30 on a mini-mental state exam.
Her memory is globally impaired with failure to retain new information as well as failure to remember
important events from her life. Her daughter reports this has been the case for the past two months and
she was previously fine and had no cognitive concerns. Her daughter also reports she is struggling with
sleep and her appetite has reduced significantly in this time although the patient does not think this is the
case.
What is the most likely cause of her memory impairment?
A. Alzheimer’s disease
B. Chronic small vessel ischaemia
C. Lewy body disease
D. Acute delirium
E. Depression
ANSWER:
E. Depression
EXPLANATION:
Severe depression can mimic dementia but gives a pattern of global memory loss rather than short-term
memory loss - this is called pseudodementia
It can often be difficult to ascertain the cause of memory impairment off a single encounter but there are
three main causes to consider:
 A dementia process.
 An acute delirium.
 Depression (also called pseudodementia).
The key features here which indicate it is not a dementia process are the short length of time (less than six
months) and global memory loss. The biological symptoms of poor sleep and loss of appetite as well as
worry about memory would also not fit with a dementia process. You would expect an early stage
dementia patient to remember significant life events which occurred many years earlier as the first
memory issues that occur are usually related to loss of short-term memory and inability to remember new
things.
Depression can produce a dementia-like picture in a very short time period in the elderly and for this
reason it is sometimes known as pseudo-dementia.
Please see Depression vs. Dementia
Q-62
Which one of the following is least recognised as a potential adverse effect of electroconvulsive therapy?
A. Nausea
B. Epilepsy
C. Cardiac arrhythmias
D. Short term memory impairment
E. Headache
ANSWER:
B. Epilepsy
EXPLANATION:
Although electroconvulsive therapy, by definition, causes a controlled seizure there is no increased risk of
epilepsy in the long-term.
Please see Electroconvulsive Therapy
Q-63
Which one of the following features is least recognised in long-term lithium use?
A. Alopecia
B. Weight gain
C. Fine tremor
D. Goitre
E. Diarrhoea
ANSWER:
A. Alopecia
EXPLANATION:
All the above side-effects, with the exception of alopecia, may be seen in patients taking lithium
Please see Lithium
Q-64
Which one of the following side-effects is more common with atypical than conventional anti-psychotics?
A. Akathisia
B. Weight gain
C. Galactorrhoea
D. Parkinsonism
E. Tardive dyskinesia
ANSWER:
B. Weight gain
EXPLANATION:
Atypical antipsychotics commonly cause weight gain
Please see Atyptical Antipsychotics
Q-65
A 24-year-old male is admitted to the Emergency Department complaining of severe abdominal pain. On
examination he is shivering and rolling around the trolley. He has previously been investigated for
abdominal pain and no cause has been found. He states that unless he is given morphine for the pain he
will kill himself. This is an example of:
B. Conversion disorder
C. Malingering
D. Munchausen's syndrome
ANSWER:
C. Malingering
EXPLANATION:
Lying or exaggerating for financial gain is malingering, for example someone who fakes whiplash after a
road traffic accident for an insurance payment
This is difficult as the patient may well be an opiate abuser who is withdrawing. However, given the above
options the most appropriate term to use is malingering as the patient is reporting symptoms with the
deliberate intention of getting morphine
Q-66
A 68-year-old gentleman is brought into hospital by his husband who says he has reported seeing flashing
images of foxes and badgers in their living room. This is something that is extremely distressing to the
patient, and has made him reluctant to venture into some areas of the house. You wonder if this might be
Charles-Bonnet syndrome.
Which of the following risk factors may pre-dispose this gentleman to Charles-Bonnet syndrome?
A. Caucasian
B. Peripheral visual impairment
C. Male gender
D. Hypertension
E. Occupational history of working in sewers
ANSWER:
B. Peripheral visual impairment
EXPLANATION:
Charles-Bonnet syndrome - peripheral visual impairment is a risk factor
Charles-Bonnet syndrome is characterised by visual hallucinations associated with eye disease.
Most common visual hallucinations are faces, children and wild animals.
It occurs in patients of increasing age; equally amongst males and females; and with no known increased
risk with family history.
Q-67
A 72-year-old man who is having trouble sleeping is prescribed temazepam. What is the mechanism of
action of temazepam?
A. Inhibits the effect of acetylcholine

B. Enhances the effect of gamma-aminobutyric acid
C. Inhibits the effect gamma-aminobutyric acid
D. Inhibits the effect of glutamate
E. Inhibits the effect of noradrenaline
ANSWER:
B. Enhances the effect of gamma-aminobutyric acid
EXPLANATION:
Benzodiazepines enhance the effect of GABA, the main inhibitory neurotransmitter
Please see Benzodiazepines
Q-68
A 60-year-old male is admitted to the in-patient psychiatric unit last night. On reviewing him this morning,
he is a poor historian, answering most questions minimally and stating he does not need to be here as he
is deceased, and hospitals should be for living patients.
What is the name of this delusional disorder and which condition is it most commonly associated with?
A. De Clerambault's syndrome and Major Depressive Disorder

B. Cotard syndrome and Major Depressive Disorder
C. Othello syndrome and Paranoid Schizophrenia
D. Capgras delusion and Dementia
E. Charles de Bonnet syndrome and Bipolar Disorder
ANSWER:
B. Cotard syndrome and Major Depressive Disorder
EXPLANATION:
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. This is seen most commonly in severe depression,
but is also associated with schizophrenia.
Q-69
A 39-year-old man comes for review. Six months ago he was started on paroxetine for depression. Around
five days ago he stopped taking the medication as he felt that it was having no benefit. His only past
medical history of note is asthma. For the past two days he has experienced increased anxiety, sweating,
headache and the feeling of a needle like sensation in his head. During the consultation he is pacing
around the room. What is the most explanation for his symptoms?
A. Bipolar disorder
B. Malingering
C. Selective serotonin reuptake inhibitor discontinuation syndrome
D. Migraine
E. Generalised anxiety disorder
ANSWER:
C. Selective serotonin reuptake inhibitor discontinuation syndrome
EXPLANATION:
Paroxetine has a higher incidence of discontinuation symptoms than other selective serotonin reuptake
inhibitors.
Q-70
A 46-year-old man is seen by an occupation health doctor due to long-term sickness leave. He states
chronic lower back pain prevents him from working but examination findings are inconsistent and the
doctor suspects a non-organic cause of his symptoms. This is an example of a:
C. Malingering
D. Hypochondrial disorder
ANSWER:
C. Malingering
EXPLANATION:
Lying or exaggerating for financial gain is malingering, for example someone who fakes whiplash after a
road traffic accident for an insurance payment
Q-71
An 80-year-old man presents with recurrent episodes of hallucinations. He describes often seeing faces
smaller than normal or other objects out of proportion. He finds these episodes distressing although he
says he knows they're not real. His past medical history includes macular degeneration and an episode of
depression 20 years ago following the death of his wife. Neurological examination is unremarkable. What
is the most likely diagnosis?
A. Schizophrenia
B. Charles-Bonnet syndrome
C. Psychotic depression
D. Cerebral tumour
E. Alzheimer's disease
ANSWER:
B. Charles-Bonnet syndrome
EXPLANATION:
Q-72
A 84-year-old patient is brought to see you by his wife as she is worried about hallucinations he has been
experiencing. She reports that he regularly sees cats walking around the house although they have never
owned a cat. He is otherwise well in himself with no other concerns and does not seem troubled by the
visions. He has a past medical history of hypertension, diabetes and cataracts and drinks approximately 20
units of alcohol per week.
A. Schizophrenia
B. Parkinson's disease
C. Alzheimer's disease
D. Alcohol excess
E. Charles-Bonnet Syndrome
ANSWER:
E. Charles-Bonnet Syndrome
EXPLANATION:
Patients with Charles-Bonnet syndrome experience persistent or recurrent complex visual or auditory
hallucinations however generally have full insight into their condition
The correct answer is Charles-Bonnet Syndrome. This classically presents as recurrent visual or auditory
hallucinations in patients with failing eyesight. It is thought that as the brain receives less visual stimulus
than it is used to, it begins to fill in the gaps with previously stored images. Hallucinations can either be
simple as in patterns or lines or complex as in people or animals. They are usually pleasant hallucinations
and most patients retain insight. In this patient with a history of cataract Charles-Bonnet syndrome is
most likely.
Whilst hallucinations can occur in both Alzheimer's Disease and Parkinson's Disease, there is nothing in the
history to suggest any problems with memory or a tremor, making 2 and 4 unlikely. Likewise other than
hallucinations there is no further evidence of schizophrenia in particular no 1st rank symptoms such as
delusions, thought insertion, removal or broadcasting. Additionally patients with Alzheimer's tend to
experience auditory as opposed to visual hallucinations.
Whilst 20 units of alcohol a week is over the revised recommend weekly intake it is unlikely significant
enough to cause any serious medical complications. Furthermore there is nothing else in the history to
suggest alcoholism as a cause of his symptoms.
Q-73
A 34-year-old male comes to clinic for an asthma review. He tells you he has recently been diagnosed with
a personality disorder. The diagnosis came about after he was referred by his boss to occupational health
for being overly sensitive and getting angry when colleagues told him how to do his job. He feels his
diagnosis is unjustified and is all a set up as his boss, who used to be a good friend, knows he is better at
his job than him.
What diagnosis is he most likely to have received?
A. Schizoid personality disorder

B. Narcissistic personality disorder
C. Paranoid personality disorder
ANSWER:
C. Paranoid personality disorder
EXPLANATION:
Paranoid personality disorder may be diagnosed in patients who are overly sensitive and can be
unforgiving if insulted, question loyalty of those around them and are reluctant to confide in others
The correct answer is paranoid personality disorder. Patients with paranoid personality disorder are over
sensitive, unforgiving and perceive feedback as attacks on their character. They can be preoccupied with
conspiracy theories and tend to question the loyalty of others. Based on the patients' description, this is
the most likely diagnosis.
Option 2 is incorrect. Patients with schizoid personality disorder tend to have a lack of interest in sexual
interactions are cold and lack close friendships preferring to spend time alone. They are also indifferent to
praise making this unlikely to be the correct answer.
Narcissistic personality disorder is not the correct answer. These patients have a heightened impression of
self-importance and entitlement often believing they have unlimited abilities to succeed, become powerful
or look beautiful. Additionally, they lack empathy and will happily take advantage of others to achieve
their own need.
Borderline personality disorder is also incorrect. This is characterised by emotional instability, impulsive
behaviour, feelings of emptiness and recurrent attempts at self-harm. Patients often fear abandonment as
opposed to the questioning loyalty of those around them.
criticised, rejected or embarrassed as opposed to being unforgiving, making this less likely the correct
answer.

Q-74
You are reviewing a 24-year-old PhD student who presents with feeling on edge all of the time. He feels
that nothing specific makes him feel worse. He cannot relax and as a result is not sleeping too well, but his
appetite is good. He tells you that his mood is okay. You have reviewed him for several weeks with the
same symptoms and despite referral to self-help sessions he has made no improvement.
Given the likely diagnosis, which pharmacological option is most likely to be indicated?
A. Beta blocker
B. Pregabalin
C. Benzodiazepine
D. Atypical antipsychotic
E. Selective serotonin reuptake inhibitor (SSRI)
ANSWER:
E. Selective serotonin reuptake inhibitor (SSRI)
EXPLANATION:
SSRIs are the first-line pharmacological therapy for generalised anxiety disorder
This scenario most likely represents generalised anxiety disorder. NICE recommend pharmacological
therapy if low-intensity psychological interventions have been unsuccessful. Sertraline if recommended
first-line, and if contraindicated or not tolerated then any other SSRI or serotonin noradrenaline reuptake
inhibitor (SNRI). Pregabalin is indicated but only if these treatments have failed.
Please see Generalized Anxiety Disorder
Q-75
A 64-year-old male who has been on long term chlorpromazine presents with repetitive eye blinking. He
reports he is unable to control this and is worried about what might be causing it. He is otherwise well in
himself and has no visual disturbance. He has a normal facial and ocular examination with the exception
of excessive rapid blinking.
What is the most likely cause of his symptoms?

A. Parkinsonism
B. Dry eyes
C. Sjogren's syndrome
E. Benign essential blepharospasm
ANSWER:
EXPLANATION:
Tardive kinesia can present as chewing, jaw pouting or excessive blinking due to late onset abnormal
involuntary choreoathetoid movements in patients on conventional antipsychotics
The correct answer is tardive dyskinesia. The patient has been on a long term antipsychotic -
chlorpromazine and has developed late-onset extrapyramidal side effects. Patients most typically develop
lip-smacking, jaw pouting or chewing however repetitive blinking or tongue poking can also occur. This is
often involuntary and difficult to treat. Where possible replacing the antipsychotic may help some patients
or alternatively, a trial of tetrabenazine may provide some relief.
Parkinsonism can occur in patients taking conventional antipsychotics. Patients experience symptoms
similar to those with Parkinson's disease for example tremor, blank facies, bradykinesia and muscle
rigidity. There is no mention of any other symptoms in this stem and you would not expect repetitive
blinking in parkinsonism. As such this option is incorrect.
Dry eyes may lead to eye twitching but repetitive blinking would be unlikely. Furthermore, you would
expect other symptoms to be present such as watering of the eyes or visual disturbance.
Sjogren's syndrome can cause dry eyes but as per the above answer, this in itself should not cause the
repetitive involuntary blinking.
Blepharospasm is involuntary twitching or contraction of the eyelid. It is a focal dystonia which most
commonly lasts only a few days but can be life long. Patients may be light sensitive and experience periods
where the eye clamps shut. The cause is typically unknown but commonly occurs due to stress or fatigue.
Given that the patient in the stem is on chlorpromazine, a typical antipsychotic, it is more likely he is
suffering tardive dyskinesia due to extrapyramidal side effects.
Q-76
Olanzapine is known to block D2 dopamine receptors. What other type of receptor does it mainly act on?
A. Alpha-adrenoceptors
B. Acetylcholine receptors
C. Serotonin receptors
D. D1 dopamine receptors
E. H1 histamine receptors
ANSWER:
C. Serotonin receptors
EXPLANATION:
Olanzapine, like other atypical antipsychotics, is known to block serotonin receptors (especially the 5-HT2
subtype) as well as D2 dopamine receptors
Please see Atypical Antipsychotics
Q-77
Which of the following types of tricyclic antidepressant is considered the safest in overdosage?
A. Nortriptyline
B. Imipramine
C. Dosulepin
D. Lofepramine
E. Clomipramine
ANSWER:
D. Lofepramine
EXPLANATION:
Lofepramine - the safest TCA in overdosage
Q-78
The mother of a 28-year-old male who has been diagnosed with a personality disorder comes to see you.
She reports that her son has been arrested multiple times and can often be aggressive getting into fights.
As a teenager, he would lie to obtain money, played truant and would say unpleasant hurtful things to her
without apology or apparent regret. He has never held down a job and relies on his parents for financial
support.
His mother has the name of the condition he has been diagnosed with and knows you are not able to
discuss the individual case. She asks if you can provide generic information on his condition to aid her
understanding as she has always blamed herself for his behaviour.
What is the most likely condition her son has been diagnosed with?
A. Avoidant personality disorder

B. Antisocial personality disorder
D. Narcissistic personality disorder
E. Histrionic personality disorder
ANSWER:
B. Antisocial personality disorder
EXPLANATION:
Patients with antisocial personality disorder often fail to conform to social norms, and show lack of
remorse, deception and irresponsibility
The correct answer here is 2 - antisocial personality disorder. Patients with this condition often fail to
comply with social norms in terms of lawful behaviour resulting in multiple arrests. They are prone to
getting into fights due to aggressiveness and can be deceitful particularly when seeking material gain.
They can have a disregard for the safety of themselves and others and are irresponsible, failing to support
themselves financially. When they do act inappropriately or in a hurtful way to others, they are unable to
show remorse for their actions. There is often a history of problems such as truancy in childhood. Their
behaviour can have a significant impact on family life and so it is understandable that his mother may
have blamed herself in the past and want more information. It is important to ensure that during this
consultation confidentiality is not breached.
criticised, rejected or embarrassed. They view themselves as inferior to others and so are not keen to be
involved unless they are certain of being liked. Hence this is not the correct answer.
Borderline personality disorder is characterised by emotional instability, impulsive behaviour and intense
but unstable relationships with others. Patients often have feelings of emptiness, poor self-image and
recurrent attempts at self-harm. Again making this an incorrect answer.
Narcissistic personality disorder is also incorrect. These patients have an over exaggerated perception of
self-importance, lack empathy and tend to have a sense of entitlement.
Histrionic personality disorder is seen in patients who crave to be the centre of attention. They can also be
sexually inappropriate and suggestible and as such, this is not the correct answer.
Q-79
A 19-year-old woman presents to the Emergency department having taken an overdose of 40x500mg
paracetamol tablets and 400ml of vodka. She took the overdose because her boyfriend is going away for 2
weeks on a course and she fears abandonment. This is her 4th attendance with an overdose over the past
3 years. She is also known to the police after an episode of reckless driving / road rage. On arrival in the
unit she is tearful and upset, and tells you she did it because her boyfriend is leaving her. Vital signs and
general physical examination are normal apart from evidence of cutting her arms. She is given activated
charcoal. Which of the following is the most likely diagnosis?
A. Bipolar disorder
B. Anti-social personality disorder
D. Endogenous depression
E. Drug induced psychosis
ANSWER:
EXPLANATION:
Borderline personality disorder is marked out by instability in moods, behaviour and relationships.
Diagnosis is confirmed by the presence of at least 5 of the following symptoms;
1) Extreme reactionsincluding panic, depression, rage, or frantic actionsto abandonment, whether real or
perceived
2) A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from
extreme closeness and love to extreme dislike or anger
3) Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings,
opinions, values, or plans and goals for the future (such as school or career choices)
4) Impulsive and often dangerous behaviours, such as spending sprees, unsafe sex, substance abuse,
reckless driving, and binge eating
5) Recurring suicidal behaviours or threats or self-harming behaviour, such as cutting

Intense and highly changeable moods, with each episode lasting from a few hours to a few days
6) Chronic feelings of emptiness and/or boredom
7) Inappropriate, intense anger or problems controlling anger
8) Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from
oneself, observing oneself from outside the body, or losing touch with reality.
There are no features consistent with endogenous depression, such as early morning wakening or loss of
appetite, and no features consistent with hypomania such as pressure of speech, flight of ideas, or over
exuberant behaviour. We are given no indication of drug abuse which may indicate drug induced
psychosis. Anti-social personality disorder is characterised by a failure to conform to social norms, and
repeated law breaking. There is consistent irresponsibility, impulsivity and disregard for both their own
safety and that of others.
Q-80
You review a 55-year-old woman who has become dependant on temazepam, which was initially
prescribed as a hypnotic. She is keen to end her addiction to temazepam and asks for help. Her current
dose is 20mg on. What is the most appropriate strategy?
A. Switch to the equivalent zopiclone dose then slowly withdraw over the next 2 weeks
B. Switch to the equivalent diazepam dose then slowly withdraw over the next 2 weeks
C. Switch to the equivalent zopiclone dose then slowly withdraw over the next 2 months
D. Switch to the equivalent chlordiazepoxide dose then slowly withdraw over the next 2 months
E. Switch to the equivalent diazepam dose then slowly withdraw over the next 2 months
ANSWER:
E. Switch to the equivalent diazepam dose then slowly withdraw over the next 2 months
EXPLANATION:
Please see Benzodiazepines
Q-81
A 18-year-old sprinter who is currently preparing for a national athletics meeting asks to see the team
doctor due to an unusual sensation in his legs. He describes a numb sensation below his knee. On
examination the patient there is apparent sensory loss below the right knee in a non-dermatomal
distribution. The team doctor suspects a non-organic cause of his symptoms. This is an example of a:
D. Malingering
E. Munchausen's syndrome
ANSWER:
EXPLANATION:
Conversion disorder - typically involves loss of motor or sensory function. May be caused by stress
Q-82
A 36-year-old female is started on haloperidol for treatment-resistant schizophrenia. She presents to her
general practitioner with a 1-day history of neck pain and difficulty moving the neck. On examination, she
has normal observation except a mild tachycardia of 105 and neck stiffness with restricted range of
motion. Her neck is involuntarily flexed to the right. She has normal facial movements.
A. Neuroleptic malignant syndrome

B. Oculogyric crisis
C. Torticollis
E. Akathisia
ANSWER:
C. Torticollis
EXPLANATION:
Acute dystonia - sustained muscle contraction such as torticollis or oculogyric crisis
This patient has experienced acute dystonia secondary to commencing a typical antipsychotic -
haloperidol. Torticollis 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.
Neuroleptic malignant syndrome is a medical emergency which occurs in patients taking antipsychotics. It
is characterised by altered mental state, generalised rigidity, fever, fluctuating blood pressure and high
temperature. This patient has a mild tachycardia which could be explained by pain, given the otherwise
normal observations and the lack of any suggestion of altered mental state it is unlikely the correct
diagnosis. It should, however, be considered in patients taking antipsychotics.
An oculogyric crisis is a further example of an acute dystonia. Patients experience sustained upward
deviation of the eyes, clenched jaw and hyperextension of the back/neck with torticollis. Given that this
patient has no facial signs or symptoms, torticollis alone is a more appropriate answer.
Tardive dyskinesia occurs in patients on long term typical antipsychotics and is characterised by
uncontrolled facial movements such as lip-smacking.
Akathisia is characterised by severe restlessness with patients having difficulty in sitting still. Patients may
rock, tap their legs or cross and uncross the legs. It typically occurs with long term use of antipsychotics.
Q-83
Which one of the following is associated with a good prognosis in schizophrenia?
A. Acute onset
B. Strong family history
C. Low IQ
D. Premorbid history of social withdrawal
E. Lack of obvious precipitant
ANSWER:
A. Acute onset
EXPLANATION:
A gradual, rather than acute, onset is associated with a poor prognosis
Please see Schizophrenia: Prognostic Indicators
Q-84
A 54-year-old man with a history of depression presents for review. He was started on fluoxetine eight
weeks ago and is now requesting to stop his medication as he feels so well. What should be
recommended regarding his treatment?
A. It should be stopped straight away

B. It should be continued for at least another 6 weeks
C. It should be continued for at least another 3 months
D. It should be continued for at least another 6 months
E. It should be continued for at least another 12 months
ANSWER:
D. It should be continued for at least another 6 months
EXPLANATION:
Antidepressants should be continued for at least 6 months after remission of symptoms to decrease risk of
relapse
This greatly reduces the risk of relapse. Patients should be reassured that antidepressants are not
addictive.
Q-85
A patient reports feeling unwell after suddenly stopping paroxetine. Which one of the following
symptoms is most consistent with selective serotonin reuptake inhibitor discontinuation syndrome?
A. Postural hypotension
B. Diarrhoea
C. Myoclonic jerks
D. Hallucinations
E. Seizures
ANSWER:
B. Diarrhoea
EXPLANATION:
Gastrointestinal side-effects such as diarrhoea are seen in SSRI discontinuation syndrome
Selective serotonin reuptake inhibitor discontinuation syndrome can present with a wide variety of
symptoms including diarrhoea, vomiting and abdominal pain.
Q-86
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?
A. Dry mouth + urinary frequency

B. Hypertension + sweating
C. Gastrointestinal bleeding + dyspepsia
D. Headache + myoclonus
E. Blurred vision + dry mouth
ANSWER:
E. Blurred vision + dry mouth
EXPLANATION:
These antimuscarinic side-effects are more common with imipramine than other types of tricyclic
antidepressants.
Q-87
A 16-year-old girl is brought for review by her father. She is talented violinist and is due to start music
college in a few weeks time. Her parents are concerned she has had a stroke as she is reporting weakness
on her right side. Neurological examination is inconsistent and you suspect a non-organic cause for her
symptoms. Despite reassurance about the normal examination findings the girl remains unable to move
her right arm. What is the most appropriate term for this behaviour?
E. Munchausen's-by-proxy syndrome
ANSWER:
EXPLANATION:
Conversion disorder - typically involves loss of motor or sensory function. May be caused by stress
This is a typical conversion disorder. There may be underlying tension regarding her musical career which
be manifesting itself as apparent limb weakness.
Q-88
Which one of the following interventions is most likely to be beneficial in a patient with schizophrenia?
A. Counselling
B. Supportive psychotherapy
C. Social skills training
D. Adherence therapy
E. Cognitive behavioural therapy
ANSWER:
E. Cognitive behavioural therapy
EXPLANATION:
Please see Schizophrenia: Management
Q-89
A 52-year-old man is brought into the emergency department having attempted to take his own life. He
was found at home with empty packets of paracetamol by his side. He is still conscious. A history is taken
from him to assess his risk of further attempts.
Which of the following is considered to be the strongest risk factor for successful suicide?
A. Being a female
B. Being married
C. Having five children
D. Addiction to opiates
E. Having never seen a General Practitioner
ANSWER:
D. Addiction to opiates
EXPLANATION:
A male with a history of alcohol or drug abuse and deliberate self harm should be considered to be at high
risk of suicide
This question requires you to recall the major risk factors for suicide.
Being a female - This is not the most appropriate answer given the options available. In fact, being male is
one of the most significant risk factors for suicide.
Being married - This is not the most appropriate answer given the options available. Having family support
is an important protective factor for suicide.
Having five children - This is not the most appropriate answer given the options available. Having children
at home is thought to be a protective factor.
Addiction to opiates - This is correct. Alcohol or drug misuse is one of the major risk factors for suicide.
Having never seen a General Practitioner - This is not the most appropriate answer given the options
available. Having a chronic mental or physical condition is however a risk factor for suicide.
Please see Suicide: Risk Factors
Q-90
A patient with a history of depression presents for review. Which one of the following suggests an
increased risk of suicide?
A. Being 25-years-old
B. History of arm cutting
C. Being married
D. Female sex
E. Having a busy job
ANSWER:
B. History of arm cutting
EXPLANATION:
Whilst arm cutting may sometimes be characterised as attention-seeking or 'releasing the pain' studies
show that any history of deliberate self harm significantly increases the risk of suicide. Employment is a
protective factor
Please see Suicide: Risk Factors
Q-91
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?
A. Tricyclic antidepressants
B. 5HT3 antagonists
C. Third generation cephalosporins
D. Benzodiazepines
E. Atypical antipsychotics
ANSWER:
E. Atypical antipsychotics
EXPLANATION:
Antipsychotics in the elderly - increased risk of stroke and VTE
Q-92
Carol is a 57-year-old lady who is under a section 3 at a an inpatient psychiatric hospital. She has stopped
eating or drinking as she believes she is dead and does not require food anymore. Which syndrome is
characterised by a person believing they are dead or non-existent?
A. Cotard syndrome
B. Capgras syndrome
C. Couvade syndrome
D. De Clerambault's syndrome
E. Othello syndrome
ANSWER:
A. Cotard syndrome
EXPLANATION:
Cotard syndrome is characterised by a person believing they are dead or non-existent
Cotard syndrome is characterised by a person believing they are dead or non-existent. It tends to be
related to depression.
Capgras syndrome is characterised by a person believing their friend or relative had been replaced by an
exact double.
Couvade syndrome is also known as ‘sympathetic pregnancy’. It affects fathers, particularly during the
first and third trimesters of pregnancy, who suffer the somatic features of pregnancy.
De Clerambault's syndrome is characterised by a person believing that another individual (often a

celebrity) is deeply in love with them. It typically affects females.
Othello syndrome is when the patient believes their partner is cheating on them. They may be threatening
or stalk their partner. This seems to affect males more than females.
Q-93
A 34-year-old man confides in you that he experienced childhood sexual abuse. Which one of the
following features is not a characteristic feature of post-traumatic stress disorder?
A. Hyperarousal
B. Emotional numbing
C. Nightmares
D. Loss of inhibitions
E. Avoidance
ANSWER:
D. Loss of inhibitions
EXPLANATION:
Q-94
You are looking after a 36-year-old female patient on the ward when you become concerned regarding
her behavior towards you. She has made a number of sexually inappropriate comments and on your last
review she was wearing seductive underwear. She is often disruptive on the ward making a scene and
easily encouraged by other patients. Your consultant advises you to avoid seeing the patient on her own
and that he is aware the patient has a personality disorder.
What is her most likely diagnosis?
A. Histrionic personality disorder

B. Schizoid personality disorder
C. Schizotypal personality disorder
D. Antisocial personality disorder
E. Borderline personality disorder
ANSWER:
A. Histrionic personality disorder
EXPLANATION:
Histrionic personality disorder is characterised by inappropriate sexual seductiveness, suggestibility and
intense relationships
The correct answer is 1 - histrionic personality disorder. This condition is seen in patients who crave being
the center of attention, can be sexually inappropriate in behavior or appearance and are highly
suggestible. They can develop intense relationships but at other times read more into the intimacy of a
relationship that is actually there.
Option 2 is incorrect. Patients with schizoid personality disorder tend to have a lack of interest in sexual
interactions making this an unlikely diagnosis based on the patient in question. They are often cold and
lack close friendships, preferring to spend time alone.
Patients with schizotypal personality disorder can have odd/eccentric beliefs or behavior. Similarly to the
patient in this question they can be inappropriate however struggle to make friends and can be
paranoid/suspicious making this less likely the correct answer.
Patients with antisocial personality disorder often fail to comply to social norms in terms of lawful
behavior resulting in multiple arrests. They are prone to getting into fights due to aggressiveness and can
be deceitful particularly when seeking material gain. They can have a disregard for safety and lack
remorse. This does not describe the patient in the stem.
Option 5 is also incorrect, borderline personality disorder is characterised by emotional instability,

impulsive behavior, feelings of emptiness and recurrent attempts at self harm. Similarly to histrionic
personality disorder they also have intense relationships however these are often unstable.

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What is the most appropriate management for a woman experiencing symptoms of 'baby blues' 5 days after giving birth?

What is the most appropriate management for a woman experiencing symptoms of 'baby blues' 5 days after giving birth?

What would be the most appropriate antidepressant to start for a 65-year-old female with ischaemic heart disease who is depressed following a recent myocardial infarction?

What would be the most appropriate antidepressant to start for a 65-year-old female with ischaemic heart disease who is depressed following a recent myocardial infarction?

PSYCHIATRY MCQs

A. Explanation and reassurance

Please see Post-Partum Mental Health Problems

Please see Hypomania vs. Mania

A. Predominately elevated mood

Please see Hypomania vs. Mania

Please see Hypomania vs. Mania

Please see Agoraphobia

Hb 160 g/L Male: (135-180)

Platelets 350 * 109/L (150 - 400)

WBC 6 * 109/L (4.0 - 11.0)

HDL 1 mmol/l (>1)

LDL 6 mmol/l (<3)

Triglycerides 3 mmol/l (<2)

Total cholesterol 7 mmol/l (<5)

Which of the following antipsychotics was the patient likely taking?

Please see Antipsychotics

Please see Alcohol Withdrawal

Please see Personality Disorders

A. Borderline personality disorder

Further information on personality disorder can be found in the ICD 10 guide -

Please see Personality Disorders

Please see Post-Concussion Syndrome

This type of delusion is known as which of the following?

What is the most appropriate treatment for the likely diagnosis?

A. Eye Movement Desensitization and Reprocessing Therapy (EMDR)

Please see OCD

Please see Tricyclic Antidepressants

Please see Aphonia

Please see Seasonal Affective Disorder

A. Indian subcontinent ethnicity

Please see Schizophrenia: Epidemiology

A. Post-natal depression is seen in around 2-3% of women

Please see Post-Partum Mental Health Problems

Please see Post-Traumatic Stress Disorder

What personality disorder is she describing?

A. Antisocial personality disorder

Option 5 is also incorrect, borderline personality disorder is characterized by emotional instability,

Please see Personality Disorders

Flash-backs are common in post-traumatic stress disorder.

Please see Depression: Screening and Assessment

Duloxetine is of the serotonin and noradrenaline reuptake inhibitor class of antidepressants.

Please see Serotonin and Noradrenaline Reuptake Inhibitors

Which of the following treatments is most likely to help this man?

Please see Post-Traumatic Stress Disorder

Korsakoff's is characterised by confabulation and amnesia, typically occurring in alcoholics secondary to

Please see Korsakoff’s Syndrome

Please see Unexplained Symptoms

Please see Anorexia Nervosa: Features

A. Can be stopped immediately

This not necessary with fluoxetine due to its longer half-life.

Please see Bulimia Nervosa

Na+ 137 mmol/L

Magnesium 0.61 mmol/L

What is the most likely cause for her symptoms?

Please see Bulimia Nervosa