PSYCHIATRY MCQs

Q-1 The following 'low-intensity psychosocial interventions' may

A woman with mild depression comes for review. She asks be useful:
for advice about whether an antidepressant would be
beneficial. Following recent NICE guidelines which one of the Interventions should:
following factors would favour the use of an antidepressant?
• include written materials (or
A. If work commitments make psychosocial interventions alternative media)
impractical • be supported by a trained
B. If patient has previously had benefit from St John's Wort practitioner who reviews
C. If she is greater than 40 years old progress
Individual guided self-help
D. A past history of mild depression based on CBT principles • consist of up to 6-8 sessions
E. If her depression complicates a chronic health problem (face-to-face and by telephone)
(Includes behavioural over 9-12 weeks, including
e.g. Compliance with COPD medication
activation and problem- follow-up
solving techniques)
ANSWER:
If her depression complicates a chronic health problem e.g. Computerised CBT Interventions should:

Compliance with COPD medication

• explain the CBT model, encourage
EXPLANATION: tasks between sessions, and use
thought-
DEPRESSION: MANAGEMENT OF SUBTHRESHOLD
• challenging and active monitoring
DEPRESSIVE SYMPTOMS OR MILD DEPRESSION
of behaviour, thought patterns
and outcomes
NICE produced updated guidelines in 2009 on the • be supported by a trained
management of depression in primary and secondary care. practitioner who reviews progress
Patients are classified according to the severity of the and outcome typically take place
depression and whether they have an underlying chronic over 9-12 weeks, including follow-
physical health problem. up

Please note that due to the length of the 'quick' reference A structured group physical Interventions should:
guide the following is a summary and we would advise you activity programme
follow the link for more detail. • typically consist of 3 sessions per
week (lasting 45 minutes to 1
Persistent subthreshold depressive symptoms or mild to hour) over 10-14 weeks
moderate depression

General measures An alternative is group-based CBT

• sleep hygiene • be based on a model such as 'Coping with depression'
• active monitoring for people who do want an • be delivered by two trained and competent practitioners
intervention • consist of 10-12 meetings of 8-10 participants
• typically take place over 12-16 weeks, including follow-up
Drug treatment For patients with chronic physical health problems NICE also
• do not use antidepressants routinely but consider them recommend considering a group-based peer support
for people with: programme:
• a past history of moderate or severe depression or • focus on sharing experiences and feelings associated with
• initial presentation of subthreshold depressive symptoms having a chronic physical health problem
that have been present for a long period (typically at least • consist typically of 1 session per week over 8-12 weeks
2 years) or
• subthreshold depressive symptoms or mild depression Q-2
that persist(s) after other interventions A 19-year-old patient who suffers from panic attacks asks
• if a patient has a chronic physical health problem and the GP if there is any medication he could take for his
mild depression complicates the care of the physical condition. Which of the following medications is likely to be
health problem the most suitable first-line choice for treating panic disorder,
according to NICE?
 • step 3: review and consideration of alternative
A. Lorazepam treatments
B. Diazepam • step 4: review and referral to specialist mental health
C. Buspirone services
D. Paroxetine • step 5: care in specialist mental health services
E. Imipramine
Treatment in primary care
ANSWER: • NICE recommend either cognitive behavioural therapy or
Paroxetine drug treatment
• SSRIs are first-line. If contraindicated or no response after
EXPLANATION: 12 weeks then imipramine or clomipramine should be
AKT summary report April 2014 noted candidates struggled offered
with questions on mental health, in particular with anxiety
diagnosis and management, and advised they review current Q-3
national guidance on these disorders. A 58-year-old lady presents to her GP concerned her partner
is being unfaithful. She appears very distressed by this yet
NICE guidance currently recommends that a selective- after further questioning does not appear to have any
serotonin reuptake inhibitor licensed for panic disorder, such evidence to support her claims, yet she is convinced she is
as paroxetine, should be the first-line choice if right. What might this concern be a symptom of?
pharmacological management is chosen. Imipramine or
clomipramine are suggested as second-line if there is A. Capgras' delusion
inadequate response at 12 weeks. NICE states that B. Grandiose delusion
benzodiazepines (lorazepam and diazepam in the example C. de Clérambault's syndrome
above), buspirone and sedating antihistamines have no place D. Othello's syndrome
in the management of panic disorder. E. Charles Bonnet syndrome

GENERALISED ANXIETY DISORDER AND PANIC DISORDER ANSWER:

Anxiety is a common disorder that can present in multiple Othello's syndrome
ways. NICE define the central feature as an 'excessive worry EXPLANATION:
about a number of different events associated with De Clérambault's syndrome also called erotomania is a
heightened tension.' delusional belief that someone else is in love with the
patient. Charles Bonnet syndrome is the experience of
Management of generalised anxiety disorder (GAD) complex visual hallucinations in patients with partial or
severe blindness.
NICE suggest a step-wise approach:
• step 1: education about GAD + active monitoring OTHELLO'S SYNDROME
• step 2: low intensity psychological interventions Othello's syndrome is pathological jealousy where a person is
(individual non-facilitated self-help or individual guided convinced their partner is cheating on them without any real
self-help or psychoeducational groups) proof. This is accompanied by socially unacceptable behaviour
• step 3: high intensity psychological interventions linked to these claims.
(cognitive behavioural therapy or applied relaxation) or
drug treatment. See drug treatment below for more Q-4
information Jason, a 24 year old male with treatment resistant
• step 4: highly specialist input e.g. Multi agency teams schizophrenia, was started on clozapine 2 weeks ago. Prior
to this he was prescribed olanzapine, which was reduced
Drug treatment down prior to commencement of clozapine. He also takes
• NICE suggest sertraline should be considered the first-line sertraline for depression. His psychiatric symptoms have
SSRI improved since starting clozapine, however he is now feeling
under the weather, describing a sore throat, and on
• interestingly for patients under the age of 30 years NICE
examination is found to have a fever of 38 degrees. Which of
recommend you warn patients of the increased risk of
the following blood tests would be the most useful in this
suicidal thinking and self-harm. Weekly follow-up is
case?
recommended for the first month
A. CRP
Management of panic disorder B. LFT
Again a stepwise approach: C. D-Dimer
• step 1: recognition and diagnosis D. U&E
• step 2: treatment in primary care - see below E. FBC
 • amisulpride
ANSWER:
FBC Clozapine, one of the first atypical agents to be developed,
carries a significant risk of agranulocytosis and full blood
EXPLANATION: count monitoring is therefore essential during treatment. For
Agranulocytosis is a condition where an individual has a this reason clozapine should only be used in patients resistant
severe leukopaenia (decreased white blood cell count), most to other antipsychotic medication
commonly caused by a neutropaenia (decreased neutrophil
count). This makes individuals extremely susceptible to Adverse effects of clozapine
serious infections due to their immunosuppression. • agranulocytosis (1%), neutropaenia (3%)
• reduced seizure threshold - can induce seizures in up to
Individuals with agranulocytosis can present as 3% of patients
asymptomatic, or with clinical features such as fever, rigors
and sore throat. Infection of any organ can be rapid, e.g. Q-5
pneumona, urinary tract infection, and sepsis may also A 19-year-old patient who suffers from panic attacks is
develop. reviewed 3 months after starting a selective serotonin
reuptake inhibitor (SSRI). He feels that there has been no
There are a lot of drugs that can cause agranulocytosis. real difference in the frequency of the episodes. Which of
These include: the following medications does NICE suggest as second-line
• Antipsychotics (predominantly Clozapine) pharmacological therapy for panic disorder?
• Antiepileptics
• Antithyroid Drugs (Carbimazole) A. Quetiapine
• Antibiotics (Penicillin, Chloramphenicol and Co- B. Pregabalin
Trimoxazole) C. Buspirone
• Cytotoxic Drugs D. Imipramine
• Gold E. Diazepam
• NSAIDs (Naproxen, Indomethacin)
• Allopurinol ANSWER:
• Mirtazapine Imipramine

The diagnosis is made using a full blood count, which will EXPLANATION:
show an absolute neutrophil count < 500 cells/mm³. The AKT summary report April 2014 noted candidates struggled
main treatment of agranulocytosis consists of the removal of with questions on mental health, in particular with anxiety
the offending drug, in this case clozapine. diagnosis and management, and advised they review current
national guidance on these disorders.
ATYPICAL ANTIPSYCHOTICS
Atypical antipsychotics should now be used first-line in NICE guidance currently recommends that a selective-
patients with schizophrenia, according to 2005 NICE serotonin reuptake inhibitor licensed for panic disorder, such
guidelines. The main advantage of the atypical agents is a as paroxetine, should be the first-line choice if
significant reduction in extra-pyramidal side-effects. pharmacological management is chosen. Imipramine or
clomipramine are suggested as second-line if there is
Adverse effects of atypical antipsychotics inadequate response at 12 weeks. NICE states that
• weight gain benzodiazepines (diazepam in the example above),
• clozapine is associated with agranulocytosis (see below) buspirone and sedating antihistamines have no place in the
management of panic disorder. Quetiapine is a new-
The Medicines and Healthcare products Regulatory Agency generation antipsychotic which is also used as a mood
has issued specific warnings when antipsychotics are used in stabiliser.
elderly patients: Q-6
• increased risk of stroke (especially olanzapine and A 25-year-old woman with mild depression comes for
risperidone) review. She has no chronic physical health problems.
Following recent NICE guidelines on depression, which one
• increased risk of venous thromboembolism
of the following interventions is NOT recommended?
Examples of atypical antipsychotics
A. Computerised CBT
• clozapine
B. A structured group physical activity programme
• olanzapine
C. Group-based peer support
• risperidone
D. Group-based CBT
• quetiapine
E. Individual guided self-help based on CBT principles
A. Typically takes place over 18-20 weeks, including follow-
ANSWER: up
Group-based peer support B. Web-based programmes are acceptable
C. Should not be used if there is a significant component of
EXPLANATION: anxiety
NICE only recommend group-based peer support for patients D. Should be reserved for patients with moderate or severe
with chronic physical health problems. depression
E. Review by a trained practitioner should occur every 4
Please see Q-1 for Depression: Management of Subthreshold weeks
Depressive Symptoms or Mild Depression
ANSWER:
Q-7 Web-based programmes are acceptable
A 52-year-old female patient has come to see you for a
review of her sertraline medication, which was increased to EXPLANATION:
the maximum therapeutic dose 2 months ago for generalised
anxiety disorder. She denies that the medication has had any Please see Q-1 for Depression: Management of Subthreshold
impact on his symptoms and insists she has been compliant Depressive Symptoms or Mild Depression
with the regime. Of the options below, which is the best
management option for the patient? Q-9
Which one of the following statements regarding anorexia
A. Start pregabalin nervosa is correct?
B. Switch to venlafaxine
C. Continue the sertraline for another month and review A. The BMI should be < 16.5 kg/m^2 before making the
D. Switch to amitriptyline diagnosis
E. Increase the dose of sertraline B. If amenorrhoea is present a hormonal disorder needs to
be excluded
ANSWER: C. It is the most common cause of admissions to child and
Switch to venlafaxine adolescent psychiatric wards
D. Around 75-80% of the patients are female
EXPLANATION: E. Has a good prognosis if treated
Option 2 is correct. If the patient is already on a maximum
dose of a SSRI for 2 months and is not showing improvement, ANSWER:
this should then be switched to either another SSRI or an It is the most common cause of admissions to child and
SNRI, like venlafaxine. Therefore, options 3, 4 and 5 are adolescent psychiatric wards
incorrect. Pregabalin is considered if a patient is intolerant of
SSRIs and SNRIs. EXPLANATION:
ANOREXIA NERVOSA
NICE Clinical Knowledge Summaries - Generalised Anxiety Anorexia nervosa is the most common cause of admissions to
Disorder child and adolescent psychiatric wards.

'Anxiety and depression are common problems, which may Epidemiology

not respond to first line treatments. Candidates should be • 90% of patients are female
familiar with second and third line treatments, which some • predominately affects teenage and young-adult females
GPs may initiate and others may take over prescribing after • prevalence of between 1:100 and 1:200
specialist advice. In both cases, the GP becomes responsible
for long-term monitoring and safety, including awareness of Diagnosis (based on the DSM-IV criteria)
potential dug interactions.' • person chooses not to eat - BMI < 17.5 kg/m^2, or < 85%
of that expected
Please see Q-2 for Generalized Anxiety Disorder and Panic • intense fear of being obese
Disorder • disturbance of weight perception
• amenorrhoea = 3 consecutive cycles

Q-8 The prognosis of patients with anorexia nervosa remains poor.

A patient with mild depression asks about computerised Up to 10% of patients will eventually die because of the
cognitive behavioural therapy (CCBT). Which one of the disorder.
following statements regarding CCBT is correct?
Q-10 AKT summary report April 2014 noted candidates struggled
A 36-year-old woman who has frequently attended in the with questions on mental health, in particular with anxiety
past with multiple somatic complaints is diagnosed with diagnosis and management, and advised they review current
generalised anxiety disorder. She is initially treated with a national guidance on these disorders.
low intensity psychological interventions, which
unfortunately fails to improve her symptoms. What is the The NICE guidance on Panic Disorder advise that a choice of
most appropriate medication to offer her next line? psychological therapy, pharmacological therapy or guided
self-help should be offered to patients, with evidence
A. Fluoxetine suggesting that psychological therapy gives the best result in
B. Propranolol terms of length of effect. Patients may wish to use a
C. Citalopram combination approach and of course lifestyle advice can still
D. Imipramine be a useful adjunct.
E. Sertraline

ANSWER: Please see Q-2 for Generalized Anxiety Disorder and Panic
Sertraline Disorder

EXPLANATION: Q-13
Which one of the following statements regarding the
Please see Q-2 for Generalized Anxiety Disorder and Panic Hospital Anxiety and Depression (HAD) scale assessment tool
Disorder for depression is correct?

Q-11 A. Consists of 10 questions, 5 for anxiety and 5 for

Following recent NICE guidelines on depression, which one depression
of the following interventions is not recommended for B. A score of 6 indicates either mild anxiety or depression
patients with subthreshold depressive symptoms or mild C. Produces a score out of 30 for both anxiety and
depression? depression
D. Patients should be encouraged to answer the questions
A. Individual guided self-help based on CBT principles
quickly
B. Offering advice about sleep hygiene
E. Should not be used in primary care
C. A structured group physical activity programme
D. Behavioural couples therapy
ANSWER:
E. Computerised CBT
Patients should be encouraged to answer the questions
ANSWER: quickly
Behavioural couples therapy
EXPLANATION:
EXPLANATION: DEPRESSION: SCREENING AND ASSESSMENT
NICE only recommend behavioural couples therapy for
patients with moderate or severe depression. Screening
The following two questions can be used to screen for
Please see Q-1 for Depression: Management of Subthreshold
depression
Depressive Symptoms or Mild Depression
• 'During the last month, have you often been bothered by
Q-12 feeling down, depressed or hopeless?'
A 19-year-old patient makes an appointment with his GP to • 'During the last month, have you often been bothered by
discuss his regular panic attacks. The GP explains the having little interest or pleasure in doing things?'
different treatments available. Which of the following
management options has been found to produce the A 'yes' answer to either of the above should prompt a more in
longest-lasting improvements in panic disorder? depth assessment.
A. Pharmacological therapy Assessment
B. Psychological therapy eg. CBT There are many tools to assess the degree of depression
C. Self-help (book-guided) including the Hospital Anxiety and Depression (HAD) scale and
D. Electroconvulsive therapy the Patient Health Questionnaire (PHQ-9).
E. Lifestyle modification eg. alcohol & caffeine
consumption Hospital Anxiety and Depression (HAD) scale
ANSWER:
• consists of 14 questions, 7 for anxiety and 7 for
Psychological therapy eg. CBT
depression
• each item is scored from 0-3
EXPLANATION:
• produces a score out of 21 for both anxiety and
depression Overview
• severity: 0-7 normal, 8-10 borderline, 11+ case • serotonin and noradrenaline are metabolised by
• patients should be encouraged to answer the questions monoamine oxidase in the presynaptic cell
quickly
Non-selective monoamine oxidase inhibitors
Patient Health Questionnaire (PHQ-9) • e.g. tranylcypromine, phenelzine
• asks patients 'over the last 2 weeks, how often have you • used in the treatment of atypical depression (e.g.
been bothered by any of the following problems?' hyperphagia) and other psychiatric disorder
• 9 items which can then be scored 0-3 • not used frequently due to side-effects
• includes items asking about thoughts of self-harm
• depression severity: 0-4 none, 5-9 mild, 10-14 moderate, Adverse effects of non-selective monoamine oxidase
15-19 moderately severe, 20-27 severe inhibitors
• hypertensive reactions with tyramine containing foods
NICE use the DSM-IV criteria to grade depression: e.g. cheese, pickled herring, Bovril, Oxo, Marmite, broad
• Depressed mood most of the day, nearly every day beans
• Markedly diminished interest or pleasure in all, or almost • anticholinergic effects
all, activities most of the day, nearly every day
• Significant weight loss or weight gain when not dieting or Q-15
decrease or increase in appetite nearly every day A 55 year-old obese man with type 2 diabetes and
• Insomnia or hypersomnia nearly every day schizophrenia asks to see you about a personal problem. He
• Psychomotor agitation or retardation nearly every day tells you when he has sexual intercourse he is unable to
• Fatigue or loss of energy nearly every day ejaculate.
• Feelings of worthlessness or excessive or inappropriate
guilt nearly every day Which of the following drugs may cause this side effect?
• Diminished ability to think or concentrate, or
indecisiveness nearly every day A. orlistat
B. sitagliptin
• Recurrent thoughts of death, recurrent suicidal ideation
C. procyclidine
without a specific plan, or a suicide attempt or a specific
D. metformin
plan for committing suicide
E. zuclopenthixol
Subthreshold
depressive symptoms Fewer than 5 symptoms ANSWER:
Mild depression Few, if any, symptoms in excess of the 5 Zuclopenthixol
required to make the diagnosis, and symptoms
result in only minor functional impairment EXPLANATION:
Moderate depression Symptoms or functional impairment are Sexual dysfunction can be caused by antipsychotic
between 'mild' and 'severe' medication. As these drugs are dopamine antagonists, they
Severe depression Most symptoms, and the symptoms markedly often cause high prolactin, which causes reduced libido. In
interfere with functioning. Can occur with or addition some antipsychotics are alpha1- adrenoreceptor
without psychotic symptoms
antagonists which can cause ejactulatory failure and erectile
dysfunction.
Q-14
A 39-year-old patient is taking phenelzine, a monoamine Risperidone and haloperidol are commonly associated with
oxidase inhibitor, for the treatment of depression. Which sexual dysfunction. Treatment options are lowering the dose
one of the following foods can the patient eat safely? or changing to a different antipsychotic.

A. Bovril ANTIPSYCHOTICS
B. Cheese Antipsychotics act as dopamine D2 receptor antagonists,
C. Oxo blocking dopaminergic transmission in the mesolimbic
D. Eggs pathways. Conventional antipsychotics are associated with
E. Broad beans problematic extrapyramidal side-effects which has led to the
development of atypical antipsychotics such as clozapine
ANSWER:
Eggs Extrapyramidal side-effects
• Parkinsonism
EXPLANATION: • acute dystonia (e.g. torticollis, oculogyric crisis)
MONOAMINE OXIDASE INHIBITORS • akathisia (severe restlessness)
• tardive dyskinesia (late onset of choreoathetoid
movements, abnormal, involuntary, may occur in 40% of Conversion disorder
patients, may be irreversible, most common is chewing • typically involves loss of motor or sensory function
and pouting of jaw) • the patient doesn't consciously feign the symptoms
(factitious disorder) or seek material gain (malingering)
The Medicines and Healthcare products Regulatory Agency • patients may be indifferent to their apparent disorder - la
has issued specific warnings when antipsychotics are used in belle indifference - although this has not been backed up
elderly patients: by some studies
• increased risk of stroke
• increased risk of venous thromboembolism Dissociative disorder
• dissociation is a process of 'separating off' certain
Other side-effects memories from normal consciousness
• antimuscarinic: dry mouth, blurred vision, urinary • in contrast to conversion disorder involves psychiatric
retention, constipation symptoms e.g. Amnesia, fugue, stupor
• sedation, weight gain • dissociative identity disorder (DID) is the new term for
• raised prolactin: galactorrhoea, impaired glucose multiple personality disorder as is the most severe form
tolerance of dissociative disorder
• neuroleptic malignant syndrome: pyrexia, muscle
stiffness Munchausen's syndrome
• reduced seizure threshold (greater with atypicals) • also known as factitious disorder
• prolonged QT interval (particularly haloperidol) • the intentional production of physical or psychological
symptoms
Q-16
A 18-year-old sprinter who is currently preparing for a Malingering
national athletics meeting asks to see the team doctor due • fraudulent simulation or exaggeration of symptoms with
to an unusual sensation in his legs. He describes a numb the intention of financial or other gain
sensation below his knee. On examination the patient there
is apparent sensory loss below the right knee in a non- Q-17
dermatomal distribution. The team doctor suspects a non- Dave is a 30-year-old married man with two children. He
organic cause of his symptoms. This is an example of a: presents to you distressed and feeling suicidal. He states he
has thought about taking an overdose. He has no previous
A. Conversion disorder suicide or self-harm attempts, and no psychiatric history. He
B. Hypochondrial disorder has a caring family and enjoys his job. Which of the following
C. Somatisation disorder is a risk factor for suicide?
D. Malingering
E. Munchausen's syndrome A. First presentation to mental health services
B. Male gender
ANSWER: C. Age 20-30 years
Conversion disorder D. Female gender
E. Being married
EXPLANATION:
UNEXPLAINED SYMPTOMS ANSWER:
There are a wide variety of psychiatric terms for patients who Male gender
have symptoms for which no organic cause can be found:
EXPLANATION:
Somatisation disorder The only correct option from the above list is 'male gender'.
• multiple physical SYMPTOMS present for at least 2 years
• patient refuses to accept reassurance or negative test The following is a list of suicide risk factors taken from the
results Preventing suicide in England paper from the Government:
• Gender - males are three times as likely to take their
own life as females
• Age - people aged 35-49 years now have the highest
Hypochondrial disorder suicide rate
• persistent belief in the presence of an underlying serious • Mental illness
DISEASE, e.g. cancer • The treatment and care they receive after making a
• patient again refuses to accept reassurance or negative suicide attempt
test results
 • Physically disabling or painful illnesses including B. Weight gain
chronic pain C. Galactorrhoea
• Alcohol and drug misuse D. Parkinsonism
• The loss of a job E. Tardive dyskinesia
• Debt
• Living alone - becoming socially excluded or ANSWER:
isolated; Weight gain
• Bereavement
• Family breakdown and conflict including divorce and EXPLANATION:
family mental health problems Atypical antipsychotics commonly cause weight gain
• Imprisonment
Please see Q-4 for Atypical Antipsychotics
SUICIDE: RISK FACTORS
Q-19
The risk stratification of psychiatric patients into 'high', The risk of developing schizophrenia if one monozygotic twin
'medium' or 'low risk' is common in clinical practice. Questions is affected is approximately:
based on a patient's suicide risk are therefore often seen.
However, it should be noted that there is a paucity of A. 10%
evidence addressing the positive predictive value of individual B. 20%
risk factors. An interesting review in the BMJ (BMJ C. 50%
2017;359:j4627) concluded that 'there is no evidence that D. 75%
these assessments can usefully guide decision making' and E. >95%
noted that 50% of suicides occur in patients deemed 'low risk'.
ANSWER:
Whilst the evidence base is relatively weak, there are a 50%
number of factors shown to be associated with an increased
risk of suicide EXPLANATION:
• male sex (hazard ratio (HR) approximately 2.0) SCHIZOPHRENIA: EPIDEMIOLOGY
• history of deliberate self-harm (HR 1.7)
The strongest risk factor for developing a psychotic disorder
• alcohol or drug misuse (HR 1.6)
(including schizophrenia) is family history. Having a parent
• history of mental illness (depression, schizophrenia)
with schizophrenia leads to a relative risk (RR) of 7.5.
• history of chronic disease
• advancing age Risk of developing schizophrenia
• unemployment or social isolation/living alone • monozygotic twin has schizophrenia = 50%
• being unmarried, divorced or widowed • parent has schizophrenia = 10-15%
• sibling has schizophrenia = 10%
If a patient has actually attempted suicide, there are a number
• no relatives with schizophrenia = 1%
of factors associated with an increased risk of completed
suicide at a future date:
Other selected risk factors for psychotic disorders include:
• efforts to avoid discovery
• Black Caribbean ethnicity - RR 5.4
• planning
• Migration - RR 2.9
• leaving a written note
• Urban environment- RR 2.4
• final acts such as sorting out finances
• Cannabis use - RR 1.4
• violent method
Q-20
Protective factors
According to NICE and National Patient Safety Agency (NPSA)
There are, of course, factors which reduce the risk of a patient
guidelines, what monitoring blood tests, excluding lithium
committing suicide. These include
levels, should a patient taking lithium have?
• family support
• having children at home A. Full blood count + thyroid + renal function every 3
• religious belief months
Q-18 B. Full blood count + thyroid + liver function every 3
Which one of the following side-effects is more common months
with atypical than conventional anti-psychotics? C. Thyroid + liver + renal function every 6 months
D. Thyroid + renal function every 3 months
A. Akathisia E. Thyroid + renal function every 6 months
 ELECTROCONVULSIVE THERAPY
ANSWER: Electroconvulsive therapy is a useful treatment option for
Thyroid + renal function every 6 months patients with severe depression refractory to medication or
those with psychotic symptoms. The only absolute
EXPLANATION: contraindications is raised intracranial pressure.
LITHIUM
Lithium is mood stabilising drug used most commonly Short-term side-effects
prophylatically in bipolar disorder but also as an adjunct in • headache
refractory depression. It has a very narrow therapeutic range • nausea
(0.4-1.0 mmol/L) and a long plasma half-life being excreted • short term memory impairment
primarily by the kidneys. • memory loss of events prior to ECT
• cardiac arrhythmia
Mechanism of action - not fully understood, two theories:
• interferes with inositol triphosphate formation Long-term side-effects
• interferes with cAMP formation • some patients report impaired memory

Adverse effects Q-22

• nausea/vomiting, diarrhoea A 24-year-old male has recently been diagnosed with
• fine tremor schizophrenia after developing severe psychosis where he
• nephrotoxicity: polyuria, secondary to nephrogenic suffered hallucinations and delusions with no insight into his
diabetes insipidus illness. Two weeks ago his psychiatrist started him on
• thyroid enlargement, may lead to hypothyroidism olanzapine depot injections to help reduce his psychotic
• ECG: T wave flattening/inversion symptoms, a full blood count, urea and electrolytes and liver
• weight gain function test was completed beforehand. If the patient were
• idiopathic intracranial hypertension to remain on olanzapine long term, how often should these
parameters be measured?
Monitoring of patients on lithium therapy
• inadequate monitoring of patients taking lithium is A. Fortnightly
common - NICE and the National Patient Safety Agency B. Monthly
(NPSA) have issued guidance to try and address this. As a C. 6 Monthly
result it is often an exam hot topic D. Annually
• lithium blood level should 'normally' be checked every 3 E. If there is a suspicion of adverse effects
months. Levels should be taken 12 hours post-dose
• thyroid and renal function should be checked every 6 ANSWER:
months Annually
• patients should be issued with an information booklet,
alert card and record book EXPLANATION:
Option 4 is correct. Full blood count, urea and electrolytes
Q-21 and liver function test should be performed before
Which one of the following is least recognised as a potential commencing a patient on antipsychotics and annually
adverse effect of electroconvulsive therapy? thereafter. The other options in this question for this
scenario are therefore incorrect. Some other antipsychotics
A. Nausea do however have different monitoring requirements and you
B. Epilepsy should consult the BNF for more details if you are unsure or
C. Cardiac arrhythmias unfamiliar with antipsychotic drugs.
D. Short term memory impairment
E. Headache 'Candidates appeared unaware of monitoring requirements
for commonly prescribed psychiatric drugs.'
ANSWER: ANTIPSYCHOTICS: MONITORING
Epilepsy
The monitoring requires for patients taking antipsychotic
medication are extensive. This is on top of the clinical follow-
EXPLANATION: up that such patients clearly require. The BNF advises the
Although electroconvulsive therapy, by definition, causes a following*:
controlled seizure there is no increased risk of epilepsy in the Test Frequency
long-term. Full blood count (FBC), urea and • at the start of therapy
electrolytes (U&E), liver function • annually
Test Frequency • low-dose amitriptyline is commonly used in the
tests (LFT) • clozapine requires much management of neuropathic pain and the prophylaxis of
more frequent monitoring of headache (both tension and migraine)
FBC (initially weekly) • lofepramine has a lower incidence of toxicity in overdose
• amitriptyline and dosulepin (dothiepin) are considered
Lipids, weight • at the start of therapy the most dangerous in overdose
• at 3 months
More sedative Less sedative
• annually
Amitriptyline Imipramine
Clomipramine Lofepramine
Fasting blood glucose, prolactin • at the start of therapy Dosulepin Nortriptyline
• at 6 months Trazodone*
• annually
*trazodone is technically a 'tricyclic-related antidepressant'
Blood pressure • baseline
• frequently during dose
Q-24
titration A 34-year-old man originally from West Africa is seen by his
GP in January with depression. There is no past medical
Electrocardiogram
history of note but he is known to smoke cannabis. He has
• baseline
had similar episodes for the past two winters. What is the
most likely diagnosis?
Cardiovascular risk assessment • annually
A. Cyclothymic disorder
B. Atypical depression
*please see the BNF for more details. There are a number of C. Seasonal affective disorder
specific recommendations for individual drugs, the above is a D. Schizophrenia
general summary E. Drug-induced depression
Q-23
Which of the following types of tricyclic antidepressant is ANSWER:
considered the safest in overdosage? Seasonal affective disorder

A. Nortriptyline EXPLANATION:
B. Imipramine SEASONAL AFFECTIVE DISORDER
C. Dosulepin Seasonal affective disorder (SAD) describes depression which
D. Lofepramine occurs predominately around the winter months. SAD should
E. Clomipramine be treated the same way as depression, therefore as per the
ANSWER: NICE guidelines for mild depression, you would begin with
Lofepramine psychological therapies and follow up with the patient in 2
weeks to ensure that there has been no deterioration.
EXPLANATION: Following this an SSRI can be given if needed. In seasonal
Lofepramine - the safest TCA in overdosage affective disorder, you should not give the patient sleeping
tablets as this can make the symptoms worse. Finally, the
TRICYCLIC ANTIDEPRESSANTS evidence for light therapy is limited and as such it is not
Tricyclic antidepressants (TCAs) are used less commonly now routinely recommended.
for depression due to their side-effects and toxicity in
overdose. They are however used widely in the treatment of Q-25
neuropathic pain, where smaller doses are typically required. Which of the following conditions is least associated with
Common side-effects obsessive compulsive disorder?
• drowsiness
A. Tourette's syndrome
• dry mouth
B. Anorexia nervosa
• blurred vision C. Schizophrenia
• constipation D. Depression
• urinary retention E. Wilson's disease

Choice of tricyclic ANSWER:

Wilson’s disease

EXPLANATION:
OCD • phenytoin is said not to be as effective in the treatment
of alcohol withdrawal seizures
Pathophysiology
some research suggest childhood group A beta-haemolytic Q-27
streptococcal infection may have a role A patient with a history of depression presents for review.
Which one of the following suggests an increased risk of
Associations suicide?
• depression (30%)
• schizophrenia (3%) A. Being 25-years-old
• Sydenham's chorea B. History of arm cutting
• Tourette's syndrome C. Being married
• anorexia nervosa D. Female sex
E. Having a busy job
Q-26
A 45-year-old man is admitted due to haematemesis. He ANSWER:
reports drinking 120 units of alcohol a week. When is the History of arm cutting
peak incidence of seizures following alcohol withdrawal?
EXPLANATION:
A. 2 hours Whilst arm cutting may sometimes be characterised as
B. 6 hours attention-seeking or 'releasing the pain' studies show that
C. 12 hours any history of deliberate self harm significantly increases the
D. 24 hours risk of suicide. Employment is a protective factor
E. 36 hours
Please see Q-17 for Suicide: Risk Factors
ANSWER:
36 hours Q-28
An elderly patient in a nursing home is started on quetiapine
EXPLANATION: due to persistent aggressive behaviour that has not
Alcohol withdrawal responded to non-pharmacological approaches. Which of the
• symptoms: 6-12 hours following adverse effects do antipsychotics increase the risk
• seizures: 36 hours of in elderly patients?
• delirium tremens: 72 hours
A. Atrial fibrillation
ALCOHOL WITHDRAWAL B. Myocardial infarction
C. Aspiration pneumonia
Mechanism D. Stroke
• chronic alcohol consumption enhances GABA mediated E. Breast cancer
inhibition in the CNS (similar to benzodiazepines) and
inhibits NMDA-type glutamate receptors ANSWER:
• alcohol withdrawal is thought to be lead to the opposite Stroke
(decreased inhibitory GABA and increased NMDA
glutamate transmission) EXPLANATION:
Antipsychotics in the elderly - increased risk of stroke and
Features VTE
• symptoms start at 6-12 hours: tremor, sweating,
Please see Q-15 for Antipsychotics
tachycardia, anxiety
• peak incidence of seizures at 36 hours
Q-29
• peak incidence of delirium tremens is at 48-72 hours:
Which class of drug have the Medicines and Healthcare
coarse tremor, confusion, delusions, auditory and visual
products Regulatory Agency warned may be associated with
hallucinations, fever, tachycardia
an increased risk of venous thromboembolism in elderly
patients?
Management
• first-line: benzodiazepines e.g. chlordiazepoxide. Typically
given as part of a reducing dose protocol
• carbamazepine also effective in treatment of alcohol A. Tricyclic antidepressants
withdrawal B. 5HT3 antagonists
C. Third generation cephalosporins
D. Benzodiazepines NICE produced updated guidelines in 2009 on the
E. Atypical antipsychotics management of depression in primary and secondary care.
Patients are classified according to the severity of the
ANSWER: depression and whether they have an underlying chronic
Atypical antipsychotics physical health problem.
EXPLANATION:
Antipsychotics in the elderly - increased risk of stroke and Please note that due to the length of the 'quick' reference
VTE guide the following is a summary and we would advise you
follow the link for more detail.
Please see Q-15 for Antipsychotics
Persistent subthreshold depressive symptoms or mild to
Q-30 moderate depression with inadequate response to initial
A 36 year old man presents to your surgery with low mood. interventions, and moderate and severe depression
He describes anhedonia, fatigue, weight loss, insomnia and
agitation. He scores 20 on the PHQ-9 score. For these patients NICE recommends an antidepressant
(normally a selective serotonin reuptake inhibitor, SSRI)
What is the best management?
The following 'high-intensity psychological interventions' may
A. Start venlafaxine and refer to psychiatry be useful:
B. Start fluoxetine
C. Start citalopram and refer for CBT Delivery
D. Refer for CBT
E. Watch and wait
• typically 16-20 sessions over 3-4 months
ANSWER: • consider 3-4 follow-up sessions over the
Start citalopram and refer for CBT next 3-6 months
• for moderate or severe depression,
EXPLANATION: consider 2 sessions per week for the first 2-
This man's PHQ-9 score suggests that he has a severe 3 weeks
depression. Given the varied symptoms this would also Individual CBT
support this diagnosis. Current guidelines from NICE say that Interpersonal Delivery
for a severe depression, a combination of an antidepressant therapy (IPT)
with a psychological intervention is indicated. Guidelines
also suggest that the first line antidepressant used should be • typically 16-20 sessions over 3-4 months
an SSRI. Therefore, citalopram with CBT would be indicated • for severe depression, consider 2 sessions per
in this case. week for the first 2-3 weeks

Venlafaxine would not be a first choice antidepressant, but Behavioural Delivery

would be used later down the line if other antidepressants activation
hadn't worked. A referral to psychiatry is also not indicated
from above symptoms. • typically 16-20 sessions over 3-4 months
• consider 3-4 follow-up sessions over the next
Fluoxetine would be a good choice first line antidepressant, 3-6 months
but guidelines for severe depression suggest that it should be • for moderate or severe depression, consider 2
combined with a psychological intervention. sessions per week for the first 3-4 weeks

CBT would be a good first line treatment for somebody with Behavioural Delivery
a mild-moderate depression when it is indicated without an couples therapy
antidepressant. However, for a severe depression the
guidelines suggest an antidepressant should be used in • typically 15-20 sessions over 5-6 months
combination.

Watch and wait is often used well for a mild depression, but
intervention would be indicated in this case.
For people who decline the options above, consider:
DEPRESSION: MANAGEMENT OF UNRESPONSIVE,
MODERATE AND SEVERE DEPRESSION
• counselling for people with persistent subthreshold
depressive symptoms or mild to moderate depression; Selective serotonin reuptake inhibitors (SSRIs) are considered
offer 6-10 sessions over 8-12 weeks first-line treatment for the majority of patients with
• short-term psychodynamic psychotherapy for people with depression.
mild to moderate depression; offer 16-20 sessions over 4- • citalopram (although see below re: QT interval) and
6 months fluoxetine are currently the preferred SSRIs
• sertraline is useful post myocardial infarction as there is
For patients with chronic physical health problems the more evidence for its safe use in this situation than other
following should be offered: antidepressants
• group-based CBT • SSRIs should be used with caution in children and
• individual CBT adolescents. Fluoxetine is the drug of choice when an
antidepressant is indicated
Q-31
Which one of the following is not an example of an atypical Adverse effects
antipsychotic? • gastrointestinal symptoms are the most common side-
effect
A. Clozapine • there is an increased risk of gastrointestinal bleeding in
B. Olanzapine patients taking SSRIs. A proton pump inhibitor should be
C. Risperidone prescribed if a patient is also taking a NSAID
D. Flupentixol • patients should be counselled to be vigilant for increased
E. Quetiapine anxiety and agitation after starting a SSRI
• fluoxetine and paroxetine have a higher propensity for
ANSWER: drug interactions
Flupentixol
Citalopram and the QT interval
EXPLANATION: • the Medicines and Healthcare products Regulatory
Please see Q-4 for Atypical Antipsychotics Agency (MHRA) released a warning on the use of
citalopram in 2011
Q-32 • it advised that citalopram and escitalopram are
A 64-year-old woman presents as she is feeling down and associated with dose-dependent QT interval prolongation
sleeping poorly. After speaking to the patient and using a and should not be used in those with: congenital long QT
validated symptom measure you decide she has moderate syndrome; known pre-existing QT interval prolongation;
depression. She has a past history of ischaemic heart disease or in combination with other medicines that prolong the
and currently takes aspirin, ramipril and simvastatin. What is QT interval
the most appropriate course of action? • the maximum daily dose is now 40 mg for adults; 20 mg
for patients older than 65 years; and 20 mg for those with
A. Stop aspirin, start sertraline hepatic impairment
B. Start venlafaxine
C. Start sertraline + lansoprazole Interactions
D. Stop aspirin, start clopidrogrel + sertraline • NSAIDs: NICE guidelines advise 'do not normally offer
E. Start sertraline SSRIs', but if given co-prescribe a proton pump inhibitor
• warfarin / heparin: NICE guidelines recommend avoiding
ANSWER: SSRIs and considering mirtazapine
Start sertraline + lansoprazole • aspirin: see above
• triptans: avoid SSRIs
EXPLANATION:
SSRI + NSAID = GI bleeding risk - give a PPI
Following the initiation of antidepressant therapy patients
There is an increased incidence of gastrointestinal bleeding
should normally be reviewed by a doctor after 2 weeks. For
when aspirin / NSAIDs are combined with selective serotonin
patients under the age of 30 years or at increased risk of
reuptake inhibitors. This patient should therefore also be
suicide they should be reviewed after 1 week. If a patient
offered a proton pump inhibitor such as lansoprazole. It
makes a good response to antidepressant therapy they should
would be inappropriate to stop aspirin in a patient with a
continue on treatment for at least 6 months after remission as
history of ischaemic heart disease.
this reduces the risk of relapse.
Note the use of sertraline in this patient, the first-choice SSRI
When stopping a SSRI the dose should be gradually reduced
in patients with a history of cardiovascular disease.
over a 4 week period (this is not necessary with fluoxetine).
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
Paroxetine has a higher incidence of discontinuation Q-35
symptoms. Following recent NICE guidelines on depression, which one
of the following best describes the most appropriate
Discontinuation symptoms management of a patient who presents with severe
• increased mood change depression?
• restlessness
• difficulty sleeping (SSRI = selective serotonin reuptake inhibitor)
• unsteadiness
• sweating A. SSRI
• gastrointestinal symptoms: pain, cramping, diarrhoea, B. High-intensity psychosocial interventions
vomiting C. SSRI + counselling
• paraesthesia D. SSRI + low-intensity psychosocial interventions
E. SSRI + high-intensity psychological interventions
Q-33
A 46-year-old man with schizophrenia is brought to the ANSWER:
surgery by one of his carers. His current medication includes SSRI + high-intensity psychological interventions
clozapine and procyclidine. His carer reports that he is more
tired than usual and generally unwell. She also thinks he may EXPLANATION:
have put on weight. What is the most important test to In this situation NICE recommend 'for people with moderate
perform? or severe depression, combine antidepressants with a high-
intensity psychological intervention (CBT or IPT)'. Please see
A. Blood sugar the guidelines for more details.
B. Full blood count
C. Urea and electrolytes Please see Q-30 for Depression: management of
D. Urine dipstick for protein unresponsive, moderate and severe depression
E. Liver function tests
Q-36
ANSWER: Which one of the following selective serotonin reuptake
Full blood count inhibitors has the highest incidence of discontinuation
symptoms?
EXPLANATION:
Clozapine - check FBC A. Paroxetine
The most important complication of clozapine therapy to B. Citalopram
exclude is agranulocytosis. Weight gain is common in C. Escitalopram
patients taking an antipsychotic D. Fluoxetine
E. Sertraline
Please see Q-4 for Atypical Antipsychotics
ANSWER:
Q-34 Paroxetine
Which one of the following statements regarding the Patient
Health Questionnaire (PHQ-9) assessment tool for EXPLANATION:
depression is correct? Paroxetine - higher incidence of discontinuation symptoms

A. Assesses symptoms over the past 2 months Please see Q-32 for Selective Serotonin Reuptake Inhibitors
B. Maximum score is 30
C. A score of 6 indicates no depression Q-37
D. Is primarily designed to be a screening tool for patients You receive a letter from the consultant psychiatrist about
with chronic health problems one of your patients. The psychiatrist advises that the
E. Includes questions about thoughts of self-harm patient has bipolar disorder and should be started on lithium
carbonate.
ANSWER:
Includes questions about thoughts of self-harm Assuming the patient is otherwise fit and well, which one of
the following is correct in terms of monitoring when on
EXPLANATION: lithium?

A. Renal function: Assess at baseline and then every 6

Please see Q-13 for Depression: Screening and Assessment months
Thyroid function: Assess every 6 months
B. Renal function: Assess at 1, 3 and 6 months
Thyroid function: Assess at 1, 3 and 6 months A. Neuroleptic malignant syndrome
C. Renal function: Assess yearly B. Parkinsonism
Thyroid function: Assess yearly C. Acute dystonia
D. Cardiac function: Assess by monthly ECG D. Tardive dyskinesia
Renal function: Assess at baseline, 3 and 6 months E. Akathisia
Thyroid function: Assess at baseline, 3 and 6 months
E. Cardiac function: Assess by 6 monthly ECG and cardiac ANSWER:
troponin level Acute dystonia
Renal function: Assess every 6 months
Thyroid function: Assess every 6 months EXPLANATION:
Please see Q-15 for Antipsychotics
ANSWER:
Renal function: Assess at baseline and then every 6 months Q-40
Thyroid function: Assess every 6 months 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
EXPLANATION: mother has been increasingly concerned about his behaviour
The BNF advises that if patients are on lithium therapy then in the past few weeks. She describes him staying up late at
thyroid function should be monitored every 6 months (more night, talking quickly and being very irritable. Yesterday he
often if there is any evidence of deterioration). Renal told his mother he was planning to 'take-over' the school
function should be monitored at baseline and then every 6 assembly and give 'constructive criticism' to his teachers in
months thereafter (more often if there is any evidence of front of the other pupils. He feels many of his teachers are
deterioration or if the there are other risk factors, such as 'underperforming' and need to be 'retaught' their subjects
starting ACE inhibitors, NSAIDs, or diuretics). by him. He admits to trying cannabis once around six months
ago and has drank alcohol 'a few times' in the past year, the
Please see Q-20 for Lithium last time being two weeks ago. Prior to his deterioration a
few weeks ago his mother describes him as a happy, well-
Q-38 adjusted, sociable young man. Which one of the following is
Which one of the following is not associated with a poor the most likely diagnosis?
prognosis in schizophrenia?
A. Psychotic depression
A. Acute onset B. Cannabis-induced psychosis
B. Strong family history C. Mania
C. Low IQ D. Alcoholic hallucinosis
D. Premorbid history of social withdrawal E. Asperger's syndrome
E. Lack of obvious precipitant
ANSWER:
ANSWER: Mania
Acute onset
EXPLANATION:
EXPLANATION: Cannnabis and alcohol related problems are very unlikely
A gradual, rather than acute, onset is associated with a poor given how long ago he used those substances.
prognosis
HYPOMANIA VS. MANIA
SCHIZOPHRENIA: PROGNOSTIC INDICATORS
The presence of psychotic symptoms differentiates mania
Factors associated with poor prognosis from hypomania
• strong family history
• gradual onset Psychotic symptoms
• low IQ • delusions of grandeur
• premorbid history of social withdrawal • auditory hallucinations
• lack of obvious precipitant
The following symptoms are common to both hypomania and
Q-39 mania
A 45-year-old man with schizophrenia taking chlorpromazine
develops an oculogyric crisis. What side-effect of Mood
antipsychotic medication is this an example of? • predominately elevated
• irritable • an Approved Mental Health Professional (AMHP) or rarely
the nearest relative (NR) makes the application on the
Speech and thought recommendation of 2 doctors
• pressured • one of the doctors should be 'approved' under Section
• flight of ideas 12(2) of the Mental Health Act (usually a consultant
• poor attention psychiatrist)

Behaviour Section 3
• insomnia • admission for treatment for up to 6 months, can be
• loss of inhibitions: sexual promiscuity, overspending, risk- renewed
taking • AMHP along with 2 doctors, both of which must have
• increased appetite seen the patient within the past 24 hours

Q-41 Section 4
You are called by the husband of a 45-year-old patient who • 72 hour assessment order
is registered at your practice. Her only history of note is type • used as an emergency, when a section 2 would involve an
2 diabetes mellitus treated with metformin. For the past unacceptable delay
three days he states that she has been 'talking nonsense' and • a GP and an AMHP or NR
starting to hallucinate. An Approved Mental Health • often changed to a section 2 upon arrival at hospital
Professional is contacted and makes her way to the patient's
house. On arrival you find a thin, unkempt lady who is sat on Section 5(2)
the pavement outside her house, threatening to 'kick your • a patient who is a voluntary patient in hospital can be
head in'. What is the most appropriate action? legally detained by a doctor for 72 hours

A. Ask her husband to restrain her Section 5(4)

B. Lorazepam IM 1mg • similar to section 5(2), allows a nurse to detain a patient
C. Haloperidol IM 5mg who is voluntarily in hospital for 6 hours
D. Call the police
E. Check her blood sugar Section 17a
• Supervised Community Treatment (Community
ANSWER: Treatment Order)
Call the police
Section 135
EXPLANATION: • a court order can be obtained to allow the police to break
The police have a legal duty to ensure a sectioned patient is into a property to remove a person to a Place of Safety
taken to a place of safety. Metformin would not cause
hypoglycaemia. Section 136
• someone found in a public place who appears to have a
What would you do if the patient was inside her own home? mental disorder can be taken by the police to a Place of
The police could not remove the patient using a Section 136. Safety
One option would be for the police to obtain a Section 135 to
allow them to enter the patient's property, although this Q-42
could take time. Regardless, the police should be contacted A 52-year-old man is admitted to hospital with acute
given the patient's apparent mental health disorder and pancreatitis. He drinks 90 units of alcohol per week. When is
threats of violence - it is difficult to conceive of a practical the peak incidence of delirium tremens following alcohol
way forward without involving them. withdrawal?

SECTIONING UNDER THE MENTAL HEALTH ACT A. 2 hours

B. 6 hours
This is used for someone over the age of 16 years who will not C. 24 hours
be admitted voluntarily. Patients who are under the influence D. 36 hours
of alcohol or drugs are specifically excluded E. 72 hours

Section 2 ANSWER:
• admission for assessment for up to 28 days, not 72 hours
renewable
EXPLANATION: • trauma-focused cognitive behavioural therapy (CBT) or
Alcohol withdrawal eye movement desensitisation and reprocessing (EMDR)
symptoms: 6-12 hours therapy may be used in more severe cases
seizures: 36 hours • drug treatments for PTSD should not be used as a routine
delirium tremens: 72 hours first-line treatment for adults. If drug treatment is used
then paroxetine or mirtazapine are recommended
Please see Q-26 for Alcohol Withdrawal
Q-44
Q-43 A 46-year-old man is seen by an occupation health doctor
A 34-year-old man confides in you that he experienced due to long-term sickness leave. He states chronic lower
childhood sexual abuse. Which one of the following features back pain prevents him from working but examination
is not a characteristic feature of post-traumatic stress findings are inconsistent and the doctor suspects a non-
disorder? organic cause of his symptoms. This is an example of a:

A. Hyperarousal Conversion disorder

B. Emotional numbing Munchausen's syndrome
C. Nightmares Malingering
D. Loss of inhibitions Hypochondrial disorder
E. Avoidance Somatisation disorder

ANSWER: ANSWER:
Loss of inhibitions Malingering

EXPLANATION: EXPLANATION:
POST-TRAUMATIC STRESS DISORDER Please see Q-16 for Unexplained Symptoms
Post-traumatic stress disorder (PTSD) can develop in people of
any age following a traumatic event, for example a major Q-45
disaster or childhood sexual abuse. It encompasses what A 25-year-old man comes for review of his depression. He
became known as 'shell shock' following the first world war. has now been taking fluoxetine 20mg od for 4 weeks with no
One of the DSM-IV diagnostic criteria is that symptoms have effect on his symptoms. It is decided to switch him to
been present for more than one month citalopram. How should this be done?

Features A. Withdraw fluoxetine with commencement of citalopram

• re-experiencing: flashbacks, nightmares, repetitive and the next day
distressing intrusive images B. 2 week period of overlapping the drugs
• avoidance: avoiding people, situations or circumstances C. Wait 1 week after withdrawing fluoxetine before
resembling or associated with the event commencing citalopram
• hyperarousal: hypervigilance for threat, exaggerated D. 1 week period of overlapping the drugs
startle response, sleep problems, irritability and difficulty E. Wait 2 weeks after withdrawing fluoxetine before
concentrating commencing citalopram
• emotional numbing - lack of ability to experience feelings,
feeling detached ANSWER:
• from other people Wait 1 week after withdrawing fluoxetine before commencing
• depression citalopram
• drug or alcohol misuse
• anger EXPLANATION:
• unexplained physical symptoms DEPRESSION: SWITCHING ANTIDEPRESSANTS
The following is based on the Clinical Knowledge Summaries
Management depression guidelines, which in turn are based on the
• following a traumatic event single-session interventions Maudsley hospital guidelines.
(often referred to as debriefing) are not recommended
• watchful waiting may be used for mild symptoms lasting Switching from citalopram, escitalopram, sertraline, or
less than 4 weeks paroxetine to another SSRI
• military personnel have access to treatment provided by • the first SSRI should be withdrawn* before the alternative
the armed forces SSRI is started
Switching from fluoxetine to another SSRI
• withdraw then leave a gap of 4-7 days (as it has a long EXPLANATION 46 THROUGH 48:
half-life) before starting a low-dose of the alternative SSRI Please see Q-41 for Sectioning Under The Mental Health Act

Switching from a SSRI to a tricyclic antidepressant (TCA) Q-49

• cross-tapering is recommend (the current drug dose is A 36-year-old patient presents with nausea, headaches and
reduced slowly, whilst the dose of the new drug is palpitations. He has had multiple previous admissions with
increased slowly) such symptoms over the past 2 years, each time no organic
cause was found. What kind of disorder is this likely to
- an exceptions is fluoxetine which should be withdrawn represent?
prior to TCAs being started
A. Munchausen's syndrome
Switching from citalopram, escitalopram, sertraline, or B. Hypochondrial disorder
paroxetine to venlafaxine C. Somatisation disorder
cross-taper cautiously. Start venlafaxine 37.5 mg daily and D. Conversion disorder
increase very slowly E. Dissociative disorder

Switching from fluoxetine to venlafaxine ANSWER:

• withdraw and then start venlafaxine at 37.5 mg each day Somatisation disorder
and increase very slowly
EXPLANATION:
*this means gradually reduce the dose then stop Please see Q-16 for Unexplained Symptoms

Q-46 THROUGH 48 Q-50

Theme: Sectioning under the Mental Health Act A 65-year-old female with a history of ischaemic heart
disease is noted to be depressed following a recent
A. Section 2 myocardial infarction. What would be the most appropriate
B. Section 3 antidepressant to start?
C. Section 4
D. Section 5(2) A. Paroxetine
E. Section 5(4) B. Imipramine
F. Section 135 C. Flupentixol
G. Section 136 D. Venlafaxine
E. Sertraline
For each of the following select the above section of the
Mental Health Act which is applicable ANSWER:
Sertraline
Q-46
Allows admission for treatment for up to 6 months EXPLANATION:
Sertraline is the preferred antidepressant following a
ANSWER: myocardial infarction as there is more evidence for its safe
Section 3 use in this situation than other antidepressants
Q-47
Please see Q-32 for Selective Serotonin Reuptake Inhibitors
Allows police to take someone who appears to be mentally
ill from a public place to the Emergency Department
Q-51
ANSWER: According to NICE and National Patient Safety Agency (NPSA)
Section 136 guidelines, how often should lithium levels be checked once
a stable dose has been achieved?
EXPLANATION:
The 'Place of Safety' referred to in sections 135 & 136 also A. Every month
includes Police Stations but in practice this is rarely done B. Every 2 months
C. Every 3 months
Q-48 D. Every 4 months
72 hour assessment order for a patient who is not in hospital E. Every 6 months

ANSWER: ANSWER:
Section 4 Every 3 months
EXPLANATION: ANSWER:
None of the above
Please see Q-20 for Lithium
EXPLANATION:
Q-52 AKT summary report for the April 2014 exam noted
Which one of the following is not a recognised feature of candidates struggled with questions on mental health, in
anorexia nervosa? particular with anxiety diagnosis and management, and
advised they review current national guidance on these
A. Hypokalaemia disorders.
B. Low LH
C. Impaired glucose tolerance NICE guidance currently recommends that a selective-
D. Low FSH serotonin reuptake inhibitor licensed for panic disorder, such
E. Reduced growth hormone levels as paroxetine, should be the first-line choice if
pharmacological management is chosen. Imipramine or
ANSWER: clomipramine are suggested as second-line if there is
Reduced growth hormone levels inadequate response at 12 weeks. NICE states that
benzodiazepines (diazepam and lorazepam in the example
EXPLANATION: above), buspirone and sedating antihistamines
Anorexia features (prochlorperazine in the example above) have no place in the
most things low management of panic disorder. Therefore, the best approach
G's and C's raised: growth hormone, glucose, salivary glands, to managing acute attacks might be teaching the patient
cortisol, cholesterol, carotinaemia psychological techniques to relax or avert attacks rather
than medication.
ANOREXIA NERVOSA: FEATURES
Anorexia nervosa is associated with a number of characteristic Please see Q-2 for Generalized Anxiety Disorder and Panic
clinical signs and physiological abnormalities which are Disorder
summarised below
Q-54
Features A 67-year-old woman with chronic obstructive pulmonary
• reduced body mass index disease is reviewed in surgery. To screen for depression,
• bradycardia which two questions are most useful to ask?
• hypotension
• enlarged salivary glands 'During the past month, have you often been bothered by…'

Physiological abnormalities A. 'having poor concentration or indecisiveness' + 'having

• hypokalaemia little interest or pleasure in doing things'
• low FSH, LH, oestrogens and testosterone B. 'feeling tired or having little energy' + 'having little
• raised cortisol and growth hormone interest or pleasure in doing things'
• impaired glucose tolerance C. 'feeling down, depressed or hopeless' + 'having little
• hypercholesterolaemia interest or pleasure in doing things'
D. 'feeling down, depressed or hopeless' + 'having poor
• hypercarotinaemia
concentration or indecisiveness'
• low T3
E. 'feeling down, depressed or hopeless' + 'feeling tired or
having little energy'
Q-53
A 42-year-old patient who suffers from panic disorder has
ANSWER:
been referred for cognitive behavioural therapy. He doesn’t
'feeling down, depressed or hopeless' + 'having little interest
wish to start any regular medication but asks if there is a
or pleasure in doing things'
tablet he can take on an as required basis. Which of the
following is recommended by NICE for short-term relief of
EXPLANATION:
panic attacks?
Please see Q-13 for Depression: Screening and Assessment
A. Buspirone
Q-55
B. Diazepam
A 23-year-old man presents as he is concerned about a
C. Lorazepam
number of recent episodes related to sleep. He finds when
D. Prochlorperazine
he wakes up and less often when he is falling asleep he is
E. None of the above
'paralysed' and unable to move. This sometimes associated A. Citalopram
with what the patient describes as 'hallucinations' such as B. Fluoxetine
seeing another person in the room. He is becoming C. Paroxetine
increasingly anxious about these recent episodes. What is D. Sertraline
the most likely diagnosis? E. Escitalopram

A. Frontal lobe epilepsy ANSWER:

B. Generalised anxiety disorder Fluoxetine
C. Sleep paralysis EXPLANATION:
D. Night terrors Fluoxetine is the SSRI of choice in children and adolescents
E. Acute schizophrenia
Please see Q-32 for Selective Serotonin Reuptake Inhibitors
ANSWER: Q-58
Sleep paralysis A patient is brought in for an annual medication review. You
notice she is prescribed olanzapine. The nurse has already
EXPLANATION: checked her weight and blood pressure.
SLEEP PARALYSIS
Sleep paralysis is a common condition characterized by Which supplementary tests would you request to complete
transient paralysis of skeletal muscles which occurs when the review?
awakening from sleep or less often while falling asleep. It is
thought to be related to the paralysis that occurs as a natural A. Annual body mass index
part of REM (rapid eye movement) sleep. Sleep paralysis is B. Annual full blood count, renal function, fasting serum
recognised in a wide variety of cultures lipids and glucose, prolactin
C. Annual liver function tests
Features D. Full blood count, renal function, liver function, c-reactive
• paralysis - this occurs after waking up or shortly before protein and erythrocyte sedimentation rate 2-3 monthly
falling asleep E. Thyroid and renal function tests 6-12 monthly
• hallucinations - images or speaking that appear during the
paralysis ANSWER:
Annual full blood count, renal function, fasting serum lipids
Management and glucose, prolactin
• if troublesome clonazepam may be used EXPLANATION:
Olanzapine is used in the treatment of schizophrenia. It can
Q-56 cause various side-effects such as hypercholesterolaemia and
A 45-year-old man taking chlorpromazine for schizophrenia hypertriglyceridaemia, hyperprolactinoma, increased
develops involuntary pouting of the mouth. What side-effect appetite, hyperglycaemia, hypotension. Therefore the
of antipsychotic medication is this an example of? following monitoring is recommended: annual full blood
count, renal function, liver function, fasting serum lipids and
A. Acute dystonia glucose, prolactin, weight and blood pressure.
B. Parkinsonism
C. Tardive dyskinesia The following options are for the relative drugs:
D. Neuroleptic malignant syndrome 1 - Oral combined contraceptive pill
E. Akathisia 3 - Statins
4 - Disease monitoring anti-rheumatic drugs
ANSWER: 5 - Lithium
Tardive dyskinesia
Please see Q-4 for Atypical Antipsychotics
EXPLANATION:
Q-59
A 54-year-old man presents with a variety of physical
Please see Q-15 for Antipsychotics
symptoms that have been present for the past 9 years.
Numerous investigations and review by a variety of
Q-57
specialties have indicated no organic basis for his symptoms.
You review a 17-year-old man with a history of anxiety and
This is an example of:
depression. He is under the care of the Child and Adolescent
Mental Health Service who have recommended the A. Munchausen's syndrome
prescription of a SSRI. What is the most appropriate drug to B. Hypochondrial disorder
prescribe? C. Dissociative disorder
D. Somatisation disorder • Individuals may be distressed by symptoms, but should
E. Conversion disorder be able to continue work and social functioning
ANSWER: Moderate Depressive Episode:
Somatisation disorder • At least 2 of the main 3 symptoms of depression, and at
least three (and preferably four) of the other symptoms,
EXPLANATION:
should be present for a definite diagnosis
Unexplained symptoms
Somatisation = Symptoms • Minimum duration of the whole episode is about 2
hypoChondria = Cancer weeks
Somatisation disorder is the correct answer as the patient is • Individuals will usually have considerable difficulty
concerned about persistent, unexplained symptoms rather continuing with normal work and social functioning
than an underlying diagnosis such as cancer (hypochondrial Severe Depressive Episode:
disorder). Munchausen's syndrome describes the intentional
• All three of the typical symptoms should be present, plus
production of symptoms, for example self poisoning
at least four other symptoms, some of which should be
Please see Q-16 for Unexplained Symptoms of severe intensity
• The minimum duration of the whole episode should last
Q-60 at least 2 weeks, but if the symptoms are particularly
Joseph, a 55 year old man, goes to his GP describing a lack of severe then it may be appropriate to make an early
energy, low mood and lack of pleasure doing activities he diagnosis
normally enjoys for the past 10 days. According to ICD-10 • Can also experience psychotic symptoms with severe
criteria, how long must Joseph's symptoms last to be depressive episodes
classified as a depressive episode? • Individuals show severe distress and/or agitation
A. 4 weeks
Please see Q-13 for Depression: Screening and Assessment
B. 6 weeks
C. 2 weeks Q-61
D. 10 days A patient presents three days after suddenly stopping
E. 1 week diazepam after having taken it for over two years. He feels
generally unwell. Which one of the following features would
ANSWER:
suggest a diagnosis other than benzodiazepine withdrawal
2 weeks
syndrome?
EXPLANATION:
The correct answer is 2 weeks. The ICD-10 criteria for A. Hypothermia
depressive illness are as follows: B. Loss of appetite
C. Tinnitus
In typical depressive episodes, individuals usually suffer from D. Perceptual disturbances
depressed mood, loss of interest in things you would E. Perspiration
normally find pleasure in (anhedonia), and reduced energy
levels (anergia). Other common symptoms include: ANSWER:
• Reduced concentration and attention Hypothermia
• Decreased self-esteem and confidence EXPLANATION:
• Feelings of guilt and unworthiness Hypothermia is not a feature of benzodiazepine withdrawal
• Bleak and pessimistic views of the future syndrome.
• Ideas or acts of self-harm or suicide
• Disturbed sleep BENZODIAZEPINES
• Diminished appetite and weight loss Benzodiazepines enhance the effect of the inhibitory
• Psychomotor agitation or retardation neurotransmitter gamma-aminobutyric acid (GABA) by
• Marked loss of libido increasing the frequency of chloride channels. They therefore
are used for a variety of purposes:
DIAGNOSTIC CRITERIA FOR DEPRESSIVE EPISODES • sedation
Mild Depressive Episode: • hypnotic
• At least 2 of the main 3 symptoms of depression, and at • anxiolytic
least two of the other symptoms, should be present for a • anticonvulsant
definite diagnosis. None of the symptoms should be • muscle relaxant
present to an intense degree
• Minimum duration of the whole episode is about 2 Patients commonly develop a tolerance and dependence to
weeks benzodiazepines and care should therefore be exercised on
prescribing these drugs. The Committee on Safety of
Medicines advises that benzodiazepines are only prescribed following is consistent with a diagnosis of post traumatic
for a short period of time (2-4 weeks). stress disorder?

The BNF gives advice on how to withdraw a benzodiazepine. A. Hypervigilance

The dose should be withdrawn in steps of about 1/8 (range B. Auditory hallucinations
1/10 to 1/4) of the daily dose every fortnight. A suggested C. Poor appetite
protocol for patients experiencing difficulty is given: D. Anhedonia
• switch patients to the equivalent dose of diazepam E. Reduced libido
• reduce dose of diazepam every 2-3 weeks in steps of 2 or
ANSWER:
2.5 mg
Hypervigilance
• time needed for withdrawal can vary from 4 weeks to a
year or more EXPLANATION:
Symptoms of PTSD include re-experiencing, flashbacks,
If patients withdraw too quickly from benzodiazepines they nightmares, recurrent distressing images from the event,
may experience benzodiazepine withdrawal syndrome, a avoidance of reminders of the event (for example people the
condition very similar to alcohol withdrawal syndrome. This patient associates with the event), hypervigilance, poor
may occur up to 3 weeks after stopping a long-acting drug. concentration, exaggerated startle responses and sleep
Features include: problems. People may also re-think the event over and over
• insomnia again, impairing their ability to come to terms with it.
• irritability
• anxiety Please see Q-43 for Post-Traumatic Stress Disorder
• tremor Q-64
• loss of appetite A 24-year-old male is admitted to the Emergency
• tinnitus Department complaining of severe abdominal pain. On
• perspiration examination he is shivering and rolling around the trolley. He
• perceptual disturbances has previously been investigated for abdominal pain and no
• seizures cause has been found. He states that unless he is given
morphine for the pain he will kill himself. This is an example
GABAA drugs
of:

• benzodiazipines increase the frequency of chloride channels A. Hypochondrial disorder

• barbiturates increase the duration of chloride channel B. Conversion disorder
opening C. Malingering
D. Munchausen's syndrome
Frequently Bend - During Barbeque E. Somatisation disorder
...or...
Barbidurates increase duration & Frendodiazepines increase frequency ANSWER:
Malingering
Q-62
You are considering prescribing a selective serotonin EXPLANATION:
reuptake inhibitor for a patient with depression. Which class This is difficult as the patient may well be an opiate abuser
of drug is most likely to interact with a selective serotonin who is withdrawing. However, given the above options the
reuptake inhibitor? most appropriate term to use is malingering as the patient is
reporting symptoms with the deliberate intention of getting
A. Beta-blocker morphine
B. Thiazolidinediones
C. Tetracycline Please see Q-16 for Unexplained Symptoms
D. Statin Q-65
E. Triptan A 36-year-old man with a history of asthma and
ANSWER: schizophrenia presents to his local GP surgery. He complains
Triptan of 'tonsillitis' and requests an antibiotic. On examination he
has bilateral inflammed tonsils, temperature is 37.8ºC and
EXPLANATION: the pulse is 90/min. His current medications include
salbutamol inhaler prn, Clenil inhaler 2 puffs bd, co-codamol
Please see Q-32 for Selective Serotonin Reuptake Inhibitors
30/500 2 tabs qds and clozapine 100mg bd. You decide to
Q-63 prescribe penicillin. What is the most appropriate further
A 37 year-old lady presents with difficulty sleeping. She tells action?
you she was sexually assaulted 7 months ago. Which of the
A. Asking him to stop taking the clozapine for the duration • actions/impulses/feelings - experiences which are
of the antibiotic therapy imposed on the individual or influenced by others
B. Check his PEFR
C. Arrange a full blood count Delusional perceptions
D. Prescribe a course of prednisolone as well • a two stage process) where first a normal object is
E. Prescribe a stat dose of oral fluconazole perceived then secondly there is a sudden intense
delusional insight into the objects meaning for the patient
ANSWER: e.g. 'The traffic light is green therefore I am the King'.
Arrange a full blood count
Other features of schizophrenia include
EXPLANATION: • impaired insight
It is extremely important in patients who take clozapine to • incongruity/blunting of affect (inappropriate emotion for
exclude neutropaenia if they develop infections. circumstances)
• decreased speech
Please see Q-4 for Atypical Antipsychotics • neologisms: made-up words
• catatonia
Q-66 • negative symptoms: incongruity/blunting of affect,
A 27-year-old woman is brought in by her husband. She has anhedonia (inability to derive pleasure), alogia (poverty of
been refusing to go outside for the past 3 months, telling her speech), avolition (poor motivation)
husband she is afraid of catching avian flu. On exploring this
further she is concerned due to the high number of migrating *occasionally referred to as thought alienation
birds she can see in her garden. She reports that the
presence of her husbands socks on the washing line in the Q-67
garden alerted her to this. What is the most likely diagnosis? A 23-year-old man presents as he has been feeling down.
Following an assessment you judge he has moderate
A. Depression depression and agree to start a fluoxetine. Following recent
B. Hypochondrial disorder NICE guidelines, when should you review the patient?
C. Formal thought disorder
D. Borderline personality disorder A. After 24 hours
E. Acute paranoid schizophrenia B. After 48 hours
C. After 1 week
ANSWER: D. After 2 weeks
Acute paranoid schizophrenia E. After 3-4 weeks

EXPLANATION: ANSWER:
The washing line comment is an example of a delusional After 1 week
perception - see below
EXPLANATION:
SCHIZOPHRENIA: FEATURES NICE recommend reviewing patients under the age of 30
Schneider's first rank symptoms may be divided into auditory years after 1 week.
hallucinations, thought disorders, passivity phenomena and
delusional perceptions: Please see Q-32 for Selective Serotonin Reuptake Inhibitors

Auditory hallucinations of a specific type: Q-68

• two or more voices discussing the patient in the third During an out of hours shift, you are called to see a 78 year
person old man who has developed acute urinary retention on a
• thought echo background of 2 years of urinary hesitancy and poor stream.
• voices commenting on the patient's behaviour He has a history of ischaemic heart disease, hypertension
and he tells you that his usual GP has recently started him on
Thought disorder*: a new medication for depression as his wife passed away
• thought insertion recently. Which of the following drugs is most likely to have
• thought withdrawal precipitated the urinary retention?
• thought broadcasting A. Diazepam
B. Venlafaxine
Passivity phenomena: C. Amitriptyline
• bodily sensations being controlled by external influence D. Fluoxetine
E. Zopiclone
ANSWER: ANSWER:
Amitriptyline It should be continued for at least another 6 months

EXPLANATION: EXPLANATION:
Amitriptyline has anticholinergic effects being associated This greatly reduces the risk of relapse. Patients should be
with tachycardia, dry mouth, mydriasis and urinary reassured that antidepressants are not addictive.
retention.
Please see Q-32 for Selective Serotonin Reuptake Inhibitors
These features are not typical of selective serotonin reuptake
inhibitors (SSRIs) such as venlafaxine and fluoxetine with Q-71
urinary retention and dry mouth rarely reported. A 45-year-old man who takes chlorpromazine for
schizophrenia presents with severe restlessness. What side-
Diazepam, a benzodiazepine does not have anticholinergic effect of antipsychotic medication is this an example of?
effects.
A. Akathisia
Zopiclone is a benzodiazepine-like agent whose side effects B. Neuroleptic malignant syndrome
include metallic taste and headache. C. Acute dystonia
D. Tardive dyskinesia
Please see Q-23 for Tricyclic Antidepressants E. Parkinsonism

Q-69 ANSWER:
You review a 55-year-old woman who has become Akathisia
dependant on temazepam, which was initially prescribed as
a hypnotic. She is keen to end her addiction to temazepam EXPLANATION:
and asks for help. Her current dose is 20 mg on. What is the
most appropriate strategy? Please see Q-15 for Antipsychotics

A. Switch to the equivalent zopiclone dose then slowly Q-72 THROUGH 74

withdraw over the next 2 weeks Theme: Sectioning under the Mental Health Act
B. Switch to the equivalent diazepam dose then slowly
withdraw over the next 2 weeks A. Section 2
C. Switch to the equivalent zopiclone dose then slowly B. Section 3
withdraw over the next 2 months C. Section 4
D. Switch to the equivalent chlordiazepoxide dose then D. Section 5(2)
slowly withdraw over the next 2 months E. Section 5(4)
E. Switch to the equivalent diazepam dose then slowly F. Section 135
withdraw over the next 2 months G. Section 136

ANSWER: For each of the following select the above section of the
Switch to the equivalent diazepam dose then slowly withdraw Mental Health Act which is applicable
over the next 2 months
Q-72
EXPLANATION: Allows admission for 28 days
Please see Q-61 for Benzodiazepines
ANSWER:
Q-70 Section 2
A 54-year-old man attends his GP. He was started on
fluoxetine eight weeks ago for depression and is now Q-73
requesting to stop his medication as he feels so well. What Allows a doctor to detain a patient who is voluntarily in
should be recommended regarding his treatment? hospital for 72 hours

A. It should be stopped straight away ANSWER:

B. It should be continued for at least another 6 weeks Section 5 (2)
C. It should be continued for at least another 3 months
D. It should be continued for at least another 6 months Q-74
E. It should be continued for at least another 12 months Allows the police to break into a property if someone
appears to be mentally ill
ANSWER: A. Bradycardia
Section 135 B. Stevens-Johnson syndrome
C. Hypersalivation
EXPLANATION Q-72 THROUGH 74: D. Gingival hyperplasia
Please see Q-41 for Sectioning Under The Mental Health Act E. Diarrhoea

Q-75 ANSWER:
A 16-year-old girl is brought for review by her father. She is Hypersalivation
talented violinist and is due to start music college in a few
weeks time. Her parents are concerned she has had a stroke EXPLANATION:
as she is reporting weakness on her right side. Neurological Hypersalivation is a well known side effect of clozapine
examination is inconsistent and you suspect a non-organic therapy. It can be treated with hyoscine hydrobromide.
cause for her symptoms. Despite reassurance about the
normal examination findings the girl remains unable to move Please see Q-4 for Atypical Antipsychotics
her right arm. What is the most appropriate term for this
behaviour? Q-78
A 23-year-old male presents to his GP two weeks after a
A. Hypochondrial disorder road traffic accident concerned about increased anxiety
B. Munchausen's syndrome levels, lethargy and headache. At the time he had a CT brain
C. Somatisation disorder after banging his head on the steering wheel, which revealed
D. Conversion disorder no abnormality. Six months following this episode his
E. Munchausen's-by-proxy syndrome symptoms have resolved. What did his original symptoms
likely represent?
ANSWER:
Conversion disorder A. Conversion disorder
B. Post-traumatic stress disorder
EXPLANATION: C. Somatisation disorder
This is a typical conversion disorder. There may be underlying D. Generalised anxiety disorder
tension regarding her musical career which be manifesting E. Post-concussion syndrome
itself as apparent limb weakness.
ANSWER:
Please see Q-16 for Unexplained Symptoms Post-concussion syndrome

Q-76 EXPLANATION:
Following the 2011 NICE guidelines on the management of In post-traumatic stress disorder the onset of symptoms is
panic disorder, what is the most appropriate first-line drug usually delayed and it tends to run a prolonged course
treatment?
POST-CONCUSSION SYNDROME
A. Propranolol
B. Selective serotonin reuptake inhibitor Post-concussion syndrome is seen after even minor head
C. Benzodiazepine trauma
D. Imipramine
E. Amitriptyline Typical features include
• headache
ANSWER: • fatigue
Selective serotonin reuptake inhibitor • anxiety/depression
• dizziness
EXPLANATION:
Q-79
Please see Q-2 for Generalized Anxiety Disorder and Panic A 42-year-old woman presents for review. Her husband
Disorder reports that she has had an argument with their son which
resulted in him leaving home. Since this happened she has
Q-77 not been able to speak. Clinical examination of her throat
A patient is started on clozapine for treatment resistant and chest is unremarkable. Which one of the following terms
schizophrenia. Which one of the following is a recognised best describes this presentation?
side effect of clozapine therapy?
A. Aprosodia ANSWER:
B. Schizophasia Clozapine
C. Expressive aphasia
D. Akinetic mutism EXPLANATION:
E. Psychogenic aphonia The answer here is clozapine which has a risk of neutropenia
and agranulocytosis. It is indicated for use in patients with
ANSWER: Schizophrenia that is resistant to conventional
Psychogenic aphonia antipsychotics. Monitoring for olanzapine should include
blood glucose, lipids and weight monitoring. Haloperidol is
EXPLANATION: not used widely for schizophrenia; a baseline ECG is
Psychogenic aphonia is considered to be a form of conversion recommended prior to use. The BNF has no specific
disorder. Please see the link for more details. monitoring requirements for paliperidone or aripiprazole.

APHONIA Please see Q-15 for Antipsychotics

Aphonia describes the inability to speak. Causes include:
• recurrent laryngeal nerve palsy (e.g. Post-thyroidectomy) Q-82
• psychogenic A 32-year-old female patient has recently been commenced
on clozapine by her psychiatrist for her schizophrenia as she
Q-80 has not responded to previous conventional antipsychotic
A 34-year-old ex-soldier with a history of post-traumatic drugs. The patient started clozapine last week, what further
stress disorder returns for review. He has had a course of eye monitoring, if any, does she require in general practice?
movement desensitisation and reprocessing therapy which
was not helpful and is reluctant to try cognitive behavioural A. No monitoring is required
therapy. Of the options listed, which medication may be B. Full blood count once a week for 18 weeks
useful in such patients? C. Full blood count fortnightly for 18 weeks
D. Full blood count every 4 weeks for 18 weeks
A. Fluoxetine E. Full blood count every 6 months for as long as she is on
B. Citalopram treatment
C. Mirtazapine
D. Topiramate ANSWER:
E. Bupropion Full blood count once a week for 18 weeks

ANSWER: EXPLANATION:
Mirtazapine Option 2 is correct as clozapine requires weekly full blood
counts for the first 18 weeks, then fortnightly for up to a
EXPLANATION: year, then monthly as there is a risk of agranulocytosis. The
other options are therefore incorrect.
Please see Q-43 for Post-Traumatic Stress Disorder
'Candidates appeared unaware of monitoring requirements
Q-81 for commonly prescribed psychiatric drugs.'
A 46-year-old man with schizophrenia was admitted to
psychiatry for a change in his medication. Previously, he had Please see Q-22 for Antipsychotics: Monitoring
been taking quetiapine however recently his behaviour had
become more erratic and he developed new delusions. You Q-83
receive his discharge letter which asks for the practice to Which one of the following features is least recognised in
perform full blood counts every week for a total of 18 weeks, long-term lithium use?
then every 2 weeks thereafter until 1 year of treatment.
Coupled with this new medication, you see he has also been A. Alopecia
started on hyoscine hydrobromide to help with the side B. Weight gain
effect of hypersalivation. What antipsychotic medication has C. Fine tremor
this patient been started on? D. Goitre
E. Diarrhoea
A. Olanzapine
B. Haloperidol ANSWER:
C. Paliperidone Alopecia
D. Aripiprazole
E. Clozapine
EXPLANATION:
Feedback on the January 2016 MRCGP Applied Knowledge
Please see Q-20 for Lithium Test (AKT 26) states 'we regularly feed back on issues
concerning safe prescribing, particularly where the clinical
Q-84 situation is complex, although we had noted an
Which one of the following symptoms may indicate mania improvement in AKT 25'.
rather than hypomania?
Please see Q-32 for Selective Serotonin Reuptake Inhibitors
A. Predominately elevated mood
B. Delusions of grandeur Q-86
C. Increased appetite You are considering prescribing a tricyclic antidepressant for
D. Flight of ideas a patient who has not responded to two different types of
E. Irritability selective serotonin reuptake inhibitors. Which one of the
following tricyclic antidepressants is most dangerous in
ANSWER: overdose?
Delusions of grandeur
A. Dosulepin
EXPLANATION: B. Imipramine
Please see Q-40 for hypomania vs. mania C. Clomipramine
D. Nortriptyline
Q-85 E. Lofepramine
A 58-year-old man has been attending community services
for his hazardous alcohol abuse. He does not enjoy activities ANSWER:
that he used to. He reports that he has difficulty Dosulepin
concentrating when watching television. His appetite is
variable and he struggles to fall asleep most nights. You EXPLANATION:
further assess his symptoms of depression using the PHQ-9 Dosulepin - avoid as dangerous in overdose
(Patient Health Questionnaire). You find that he has
developed symptoms of moderate depression. He is still Please see Q-23 for Tricyclic Antidepressants
drinking 34 units of alcohol a week.
He has been undergoing CBT (cognitive behavioural therapy) Q-87
but this has not helped. Together you decide that it may be Which one of the following symptoms may indicate mania
worth treating his depression medically despite his rather than hypomania?
continuing alcohol intake. Which antidepressant is the most
likely to be effective? A. Auditory hallucinations
B. Increased appetite
A. Mirtazapine C. Insomnia
B. Citalopram D. Pressured speech
C. Sertraline E. Irritability
D. Venlafaxine
E. Nortriptyline ANSWER:
Auditory hallucinations
ANSWER:
Mirtazapine EXPLANATION:
Whilst criteria vary (e.g. ICD-10, DSM-5) the consistent
EXPLANATION: difference between mania and hypomania is the presence of
NICE does recommend treating the alcohol disorder before psychotic symptoms, e.g. auditory hallucinations.
starting antidepressants but this question addresses the
choice of medication if the decision is made to start an Please see Q-40 for hypomania vs. mania
antidepressant.
Q-88
SSRIs do not seem effective in co-morbid alcohol abuse and Nathan is a 25 year old who presents to you with symptoms
depression of severe obsessive compulsive disorder (OCD). According to
NICE guidelines which of the following is an appropriate first
The evidence indicates that mirtazapine improves depression line pharmacological therapy for OCD?
as well as reducing alcohol intake.(J Dual Diag
2012;8(3):200)
A. Sertraline ANSWER:
B. Mirtazapine Interpersonal therapy
C. Aripiprazole
D. Olanzapine EXPLANATION:
E. Amitriptyline
Please see Q-30 for Depression: management of
ANSWER: unresponsive, moderate and severe depression
Sertraline
Q-91
EXPLANATION: You a reviewing a 24-year-old man who complains of
The following guidance is from the 'Obsessive-compulsive auditory hallucinations. These have become increasingly
disorder: Core interventions in the treatment of obsessive- common and are now happening on a daily basis. Which one
compulsive disorder and body dysmorphic disorder' 2005 of the following factors in his history is the strongest risk
NICE Guidance. factor for psychotic disorders?

For adults with OCD, the initial pharmacological treatment A. Indian subcontinent ethnicity
should be one of the following SSRIs: fluoxetine, B. Having a parent with schizophrenia
fluvoxamine, paroxetine, sertraline or citalopram C. A history of long-term cannabis use
D. A history of being sexually abused when younger
Please see Q-25 for OCD E. Working in the performing arts

Q-89 ANSWER:
You review a 25-year-old man who has recently been Having a parent with schizophrenia
diagnosed with generalised anxiety disorder. He agrees to a
trial of sertraline. What is the most appropriate EXPLANATION:
management? Family history is the strongest risk factor for psychotic
disorders
A. Co-prescribe a benzodiazepine for the first two weeks +
review weekly for first month Please see Q-19 for Schizophrenia: epidemiology
B. Warn of increased risk of suicidal thoughts + review
weekly for the first month Q-92
C. Advise treatment will not be effective for first six weeks A 19-year-old female is reviewed in surgery. She describes a
+ review every two weeks for first two months six-month history of self-induced vomiting after eating. Her
D. Co-prescribe a benzodiazepine for the first two weeks + BMI is 24 kg/m^2 and she is otherwise fit and well. There is a
review after two weeks and then two weeks later long history of poor body image and she reports this makes
E. Review after two weeks and then two weeks later her feel depressed a lot of the time. She refuses referral on
for further care. What is the most appropriate management?
ANSWER:
Warn of increased risk of suicidal thoughts + review weekly A. High-dose fluoxetine
for the first month B. Arrange family therapy
C. Low-dose citalopram
EXPLANATION: D. Low-dose amitriptyline
E. Topiramate
Please see Q-2 for Generalized Anxiety Disorder and Panic
Disorder ANSWER:
High-dose fluoxetine
Q-90
Which one of the following is an example of a 'high-intensity EXPLANATION:
psychological intervention', recommended for the treatment Bulimia nervosa
of patients with moderate or severe depression? referral to secondary care
high-dose fluoxetine
A. Interpersonal therapy Clinical Knowledge Summaries recommend referring all
B. A structured group physical activity programme people with an eating disorder to secondary care. This is
C. Computerised CBT most important for patients with anorexia nervosa where
D. Group-based peer support there is a significant associated morbidity and mortality.
E. Individual guided self-help based on CBT principles However, services across the UK are sometimes patchy and
treatment within primary care may be appropriate
BULIMIA NERVOSA A. Suggest 1:1 nursing to help with behaviour
Bulimia nervosa is a type of eating disorder characterised by B. Refer to old age psychiatry
episodes of binge eating followed by intentional vomiting C. Prescribe 0.5 mg lorazepam BD as needed
D. Explain this is likely progression of dementia
Management E. Assess for a cause of delirium
• referral for specialist care is appropriate in all cases
• cognitive behaviour therapy (CBT) is currently consider ANSWER:
first-line treatment Assess for a cause of delirium
• interpersonal psychotherapy is also used but takes much
longer than CBT EXPLANATION:
• pharmacological treatments have a limited role - a trial of Janet appears to have developed a decline in her behaviour
high-dose fluoxetine is currently licensed for bulimia but in the short-term, and although this may be a progression of
long-term data is lacking her dementia it is vital to ensure that any physical causes
including delirium are considered. This is also vital due to the
Q-93 high mortality risk associates with delirium if left untreated.
You receive a fax from psychiatry concerning a 30-year-old
man. The consultant requests that the patient should be The Alzheimer's Society suggests the following causes to be
started on quetiapine. The patient has no significant past considered when investigating challenging behaviour in the
medical history of note and had been referred after elderly:
complaining of psychotic symptoms. You note from the
computer that the patient had a full blood count, urea and • Infections including chest infections and urinary tract
electrolytes, liver function tests and fasting blood glucose in infections (UTIs)
the past two weeks after complaining of being tired all the • Existing injuries such as cuts or bruises
time. Which additional tests are required as a baseline? • Constipation
• Pain
A. Fasting lipids, weight, blood pressure, thyroid function • Existing conditions such as arthritis
tests • Being in an uncomfortable position or being moved in an
B. Weight, blood pressure, prolactin uncomfortable way
C. Fasting lipids, weight, blood pressure, prolactin • Toenails or fingernails that need cutting
D. Fasting lipids, weight, thyroid function tests • Toothache, earache or problems with dentures.
E. Fasting lipids, blood pressure, prolactin
DELIRIUM VS. DEMENTIA
ANSWER:
Fasting lipids, weight, blood pressure, prolactin Factors favouring delirium over dementia
• impairment of consciousness
EXPLANATION: • fluctuation of symptoms: worse at night, periods of
Although psychiatrists are generally responsible for initiating normality
antipsychotics it is not uncommon that GPs either initiate • abnormal perception (e.g. illusions and hallucinations)
therapy (following a psychiatry recommendation) or are • agitation, fear
asked to takeover prescribing for stable patients. We should • delusions
therefore have a basic grasp of the monitoring requirements
to enable safe prescribing. Q-95
A 22-year-old female comes for review of her depression.
An ECG and cardiovascular risk assessment should also be She has now been taking citalopram 20mg od for 4 months
considered depending on the history of the patient. with little to no effect on her symptoms. It is decided to
switch to imipramine. How should this be done?
Please see Q-22 for Antipsychotics: Monitoring
A. Period of cross-tapering of the two drugs
Q-94 B. Wait 1 week after withdrawing citalopram before
Janet is a 93 year old lady with severe dementia. She has commencing imipramine
been relatively settled over the past two years with a C. Wait 4 weeks after withdrawing citalopram before
gradual decline in cognition. The nursing home call to say she commencing imipramine
has been more aggressive, swearing and hitting staff over D. Wait 2 weeks after withdrawing citalopram before
the past month and asks for a review. What would be the commencing imipramine
most appropriate management? E. Stop citalopram with commencement of imipramine the
next day
ANSWER: risk factors include a problematic relationship before death or
Period of cross-tapering of the two drugs if the patient has not much social support.

EXPLANATION: Features of atypical grief reactions include:

Please see Q-45 for Depression: Switching Antidepressants • delayed grief: sometimes said to occur when more than 2
weeks passes before grieving begins
Q-96 • prolonged grief: difficult to define. Normal grief reactions
A 62-year-old man is brought to the doctors by his daughter. may take up to and beyond 12 months
Four weeks ago his wife died from metastatic breast cancer.
He reports being tearful every day but his daughter is Q-97
concerned because he is constantly 'picking fights' with her A 27-year-old male patient comes to see you for a review of
over minor matters and issues relating to their family past. his medication. He has generalised anxiety disorder and
The daughter also reports that he has on occasion described initial drug treatment consisted of sertraline, however, this
hearing his wife talking to him and on one occasion he was quickly stopped due to gastrointestinal upset, the
prepared a meal for her. patient has then changed to venlafaxine one week ago but
has since noticed blurring of his vision and headaches. Of the
Despite this he has started going walking again with friends options below, what is the best way to manage his
and says that he is determined to get 'back on track'. condition?

What is the most likely diagnosis? A. Switch to pregabalin

B. Switch to amitriptyline
A. Atypical grief reaction C. Reduce the dose of venlafaxine
B. Depression without psychotic features D. Switch to fluoxetine
C. Delusional disorder E. Switch to duloxetine
D. Depression with psychotic features
E. Normal grief reaction ANSWER:
Switch to pregabalin
ANSWER:
Normal grief reaction EXPLANATION:
Option 1 is correct as the patient is intolerant to SSRIs and
EXPLANATION: SNRIs, and so pregabalin should be considered as an
GRIEF REACTION alternative. Options 4 and 5 are incorrect as they are SSRIs
It is normal for people to feel sadness and grief following the and option 3 is incorrect as he is suffering adverse effects
death of a loved one and this does not necessarily need to be and this should be stopped. Amitriptyline is not
medicalised. However, having some understanding of the recommended for generalised anxiety disorder.
potential stages a person may go through whilst grieving can
help determine whether a patient is having a 'normal' grief 'Anxiety and depression are common problems, which may
reaction or is developing a more significant problem. not respond to first line treatments. Candidates should be
familiar with second and third line treatments, which some
One of the most popular models of grief divides it into 5 GPs may initiate and others may take over prescribing after
stages. specialist advice. In both cases, the GP becomes responsible
• Denial: this may include a feeling of numbness and also for long-term monitoring and safety, including awareness of
pseudohallucinations of the deceased, both auditory and potential dug interactions.'
visual. Occasionally people may focus on physical objects
that remind them of their loved one or even prepare Please see Q-2 for Generalized Anxiety Disorder and Panic
meals for them Disorder
• Anger: this is commonly directed against other family
members and medical professionals Q-98
• Bargaining A 30-year-old man presents to his doctor as he has been
• Depression feeling generally 'out of sorts' for the past few weeks. He is
• Acceptance accompanied by his girlfriend who says he has 'not been
himself'. She is worried and feels he may need to see a
It should be noted that many patients will not go through all 5 psychiatrist. There is no history of past mental health
stages. problems. Which one of the following symptoms would be
most suggestive of depression?
Abnormal, or atypical, grief reactions are more likely to occur
in women and if the death is sudden and unexpected. Other
A. Palpitations Q-100
B. Nausea before certain situations e.g. getting on a bus A patient you are looking after is started on imipramine for
C. Early morning waking depression. Which combination of side-effects is most likely
D. Excessive gambling to be seen in a patient taking this class of antidepressants?
E. Flash-backs to childhood problems
A. Dry mouth + urinary frequency
ANSWER: B. Hypertension + sweating
Early morning waking C. Gastrointestinal bleeding + dyspepsia
D. Headache + myoclonus
EXPLANATION: E. Blurred vision + dry mouth
Early morning waking is a classic somatic symptom of
depression and often develops earlier than general insomnia. ANSWER:
Blurred vision + dry mouth
Palpitations and nausea and more common with anxiety.
Excessive gambling may suggest either a simple gambling EXPLANATION:
addiction or be part of a hypomanic/manic disorder. These antimuscarinic side-effects are more common with
imipramine than other types of tricyclic antidepressants.
Flash-backs are common in post-traumatic stress disorder.
Please see Q-23 for Tricyclic Antidepressants
Please see Q-13 for Depression: Screening and Assessment
Q-101
Q-99 Which one of the following is not a first-rank symptom of
A 42-year-old male patient has come to see you for a review schizophrenia?
after starting sertraline one week ago for depression. She
does not feel that the drug is affecting her mood and A. Thought broadcasting
mentions to you that not long after she started the B. Visual hallucinations
medication she started getting episodes of abdominal pain, C. Thought withdrawal
nausea and at times diarrhoea. You review her depression D. Delusional perceptions
and feel that she still needs to be on antidepressants. What E. Auditory hallucinations
is the best option to manage this situation?
ANSWER:
A. Stop sertraline immediately Visual hallucinations
B. Reduce the dose of sertraline
C. Continue the sertraline and review in one week EXPLANATION:
D. Increase the dose of sertraline Please see Q-66 for Schizophrenia: Features
E. Stop sertraline and start amitriptyline
Q-102
ANSWER: A 39-year-old man comes for review. Six months ago he was
Continue the sertraline and review in one week started on paroxetine for depression. Around five days ago
he stopped taking the medication as he felt that it was
EXPLANATION: having no benefit. His only past medical history of note is
Option 3 is the correct answer as the patient has only been asthma. For the past two days he has experienced increased
having GI symptoms for one week and so it may be worth anxiety, sweating, headache and the feeling of a needle like
continuing the treatment whilst reviewing them more sensation in his head. During the consultation he is pacing
closely. Therefore options 2, 4 and 5 are less appropriate at around the room. What is the most explanation for his
this stage. Option 1 is incorrect as a patient should be symptoms?
weaned off antidepressants slowly and will also leave her
with nothing to manage her depression. A. Bipolar disorder
B. Malingering
'Anxiety and depression are common problems, which may C. Selective serotonin reuptake inhibitor discontinuation
not respond to first line treatments. Candidates should be syndrome
familiar with second and third line treatments, which some D. Migraine
GPs may initiate and others may take over prescribing after E. Generalised anxiety disorder
specialist advice. In both cases, the GP becomes responsible
for long-term monitoring and safety, including awareness of ANSWER:
potential dug interactions.' Selective serotonin reuptake inhibitor discontinuation
syndrome.
Please see Q-45 for Depression: Switching Antidepressants
EXPLANATION: ANSWER:
Paroxetine has a higher incidence of discontinuation Diarrhoea
symptoms than other selective serotonin reuptake inhibitors.
EXPLANATION:
Please see Q-32 for Selective Serotonin Reuptake Inhibitors Selective serotonin reuptake inhibitor discontinuation
syndrome can present with a wide variety of symptoms
Q-103 including diarrhoea, vomiting and abdominal pain.
Which one of the following is not a recognised feature of
anorexia nervosa? Please see Q-32 for Selective Serotonin Reuptake Inhibitors

A. Raised cortisol levels Q-106

B. Low FSH You review a patient who has been taking citalopram for the
C. Raised growth hormone levels past two years to treat depression. He has felt well now for
D. Hyperkalaemia the past year and you agree a plan to stop the
E. Impaired glucose tolerance antidepressant. How should the citalopram be stopped?

ANSWER: A. Can be stopped immediately

Hyperkalaemia B. Withdraw gradually over the next 3 days
C. Withdraw gradually over the next week
EXPLANATION: D. Withdraw gradually over the next 2 weeks
Anorexia features E. Withdraw gradually over the next 4 weeks
most things low
G's and C's raised: growth hormone, glucose, salivary glands, ANSWER:
cortisol, cholesterol, carotinaemia Withdraw gradually over the next 4 weeks

Please see Q-52 for Anorexia Nervosa: Features EXPLANATION:

This is not necessary with fluoxetine due to its longer half-
Q-104 life.
A 45-year-old man with schizophrenia taking chlorpromazine
develops a bilateral resting tremor. What side-effect of Please see Q-32 for Selective Serotonin Reuptake Inhibitors
antipsychotic medication is this an example of?
Q-107
A. Tardive dyskinesia A 29-year-old fireman presents following a recent traumatic
B. Parkinsonism incident where a child died in a house fire. He describes
C. Acute dystonia recurrent nightmares and flashbacks which have been
D. Akathisia present for the past 3 months. A diagnosis of post-traumatic
E. Neuroleptic malignant syndrome stress disorder is suspected. What is the most appropriate
first-line treatment?
ANSWER:
Parkinsonism A. Arrange a CT head to exclude an organic cause
B. Cognitive behavioural therapy or eye movement
EXPLANATION: desensitisation and reprocessing therapy
C. Cognitive behavioural therapy or graded exposure
Please see Q-15 for Antipsychotics therapy
D. Cognitive behavioural therapy or psychodynamic
Q-105 therapy
A patient reports feeling unwell after suddenly stopping E. Watchful waiting
paroxetine. Which one of the following symptoms is most
consistent with selective serotonin reuptake inhibitor ANSWER:
discontinuation syndrome? Cognitive behavioural therapy or eye movement
desensitisation and reprocessing therapy
A. Postural hypotension
B. Diarrhoea EXPLANATION:
C. Myoclonic jerks
D. Hallucinations Please see Q-43 for Post-Traumatic Stress Disorder
E. Seizures
Q-108
Which one of the following intervention is most likely to be
beneficial in a patient with schizophrenia?

Counselling
Supportive psychotherapy
Social skills training
Adherence therapy
Cognitive behavioural therapy

ANSWER:
Cognitive behavioural therapy

EXPLANATION:
SCHIZOPHRENIA: MANAGEMENT
NICE published guidelines on the management of
schizophrenia in 2009.

Key points:
• oral atypical antipsychotics are first-line
• cognitive behavioural therapy should be offered to all
patients
• close attention should be paid to cardiovascular risk-
factor modification due to the high rates of cardiovascular
disease in schizophrenic patients (linked to antipsychotic
medication and high smoking rates)