PSYCHIATRY
Questions&Answers
Q-1
A 16 year old girl was brought to Accident and Emergency with the
complaint of sudden loss of consciousness. This occurred while shopping
with her mother a few hours ago. The episode lasted for less than a minute
followed by full recovery. There was no head injury. The mother informed
the staff that her daughter had not eaten anything for the last four days
because she is extremely fanatic about losing weight. She began a strict
diet and exercise regimen to lose weight a few months ago. Her mother
appears distressed as she has tried everything to get her daughter to eat,
but to no avail. The patient herself is adamant that she is fat and that her
goal is to lose weight until she is 35 kg. The patient has no past medical
history of note and is not taking any regular medications. On examination,
the patient was found to be sweaty and wearing a baggy dress.
Weight 49 kilgrams
Height 165 centimetres
BMI 18 kg/m2
Capillary blood glucose 2.1 mmol/L
It was proposed that the patient be admitted but when the subject was
broached to the patient, she began to scream and demanded to be
released. What is the SINGLE best treatment option in this patient?
A. Compulsory admission
B. Refer for cognitive behavioural therapy
C. Refer to psychiatrist as outpatient
D. Seek legal advice
E. Allow home after signing self discharge
ANSWER:
Compulsory admission
EXPLANATION:
Regardless of the BMI, if there are medical complications such as electrolyte
disturbances, hypoglycaemia or bradycardia, you should admit the patient. Since
this patient has a history of loss of consciousness, a low blood glucose, lacks
insight and is refusing voluntary admission, admission under the Mental Health
Act would be appropriate. An official assessment of her mental capacity would
,need to be performed to look for an impairment or disturbance that leaves the
patient unable to make a decision.
ANOREXIA NERVOSA
Anorexia nervosa is the most common cause of admissions to child and
adolescentpsychiatric wards. It is most commonly seen in young women in which
there ismarked distortion of body image, pathological desire for thinness, and
self-inducedweight loss by a variety of methods.
Majority of those with eating disorders are women and so in the exam you should
expect a teenage female in the stem.
Features
• BMI <17.5kg/m2 or < 85% of that expected
• Self-induced weight loss → reduce food intake, vomiting, purging, excessive
exercise.
• Intense fear of being obese
• Disturbance of weight perception
• Endocrine disorders such that cause amenorrhoea, reduced sexual
nterest/impotence,
raised GH levels, raised cortisol, altered TFTs, abnormal insulin
secretion
• Bradycardia
• Hypotension
• Fatigue
• Muscle weakness
• Intolerance to cold
Q-2
A 22 year old woman thinks she is overweight. She has a body mass index
of 21.8 kg/m2. She often has constipation and abdominal pain. She eats
uncontrollably and feels guilty resulting in a self-induced vomiting.
Sometimes to compensate for her big meal, she would exercise intensively.
What is the SINGLE most likely diagnosis?
A. Anorexia nervosa
B. Pituitary tumour
C. Hypothyroidism
D. Bulimia nervosa
E. Prader Willi syndrome
ANSWER:
Bulimia nervosa
EXPLANATION:
Bulimia nervosa
Bulimia nervosa is an eating disorder characterised by repeated episodes
ofuncontrolled overeating (binges) followed by compensatory weight loss
behaviours.
,Features:
• Excessive preoccupation with body weight and shape
• Compensatory weight control mechanisms which can be:
• Self-induced vomiting
• Fasting
• Intensive exercise
• Abuse of medication such as laxatives, diuretics, thyroxine oramphetamines
Note that a person with bulimia nervosa does not necessarily need to be thin.
Theysometimes maintained a BMI above 17.5 kg/m 2.
Examination:
• Salivary glands (especially the parotid) may be swollen.
• Russell's sign may be present (calluses form on the back of the hand, causedby
repeated abrasion against teeth during inducement of vomiting).
• There may be erosion of dental enamel due to repeated vomiting.
Q-3
A 34 year old ptient was admitted for severe depression and suicidal
thoughts. He attempted to commit suicide. He has been on sertraline for
the past year which he had stopped a month ago. He had been admitted in
the psychiatric ward two years ago for mania. On discharge, the patient
wishes to know if he can be started on a long-term medication to alleviate
his symptoms. What SINGLE medication will be most useful for his
disorder?
A. Amitryptiline
B. Lithium
C. Diazepam
D. Haloperidol
E. Fluoxetine
ANSWER:
Lithium
EXPLANATION:
The patient is suffering from bipolar disorder. Long-term management requires
mood stabilisers and therefore lithium is the best option.
Bipolar affective disorder (commonly known as manic depression)
Classically, periods of prolonged and profound depression alternate with periods
ofexcessively elevated and irritable mood, known as mania.
Most people who battle with the effects of the disorder would rather live a
normallife, free from the unpredictability of mood swings, which most of us take
for granted.
The symptoms of mania characteristically include:
• Decreased need for sleep
• Pressured speech
• Increased libido
, • Reckless behaviour without regard for consequences
• Grandiosity
• More talkative than usual
These symptoms of mania would alternate with depression
Treatment
Mood stabilizers (Lithium)- Despite problems with tolerability, lithium still
remainsthe gold standard in the treatment of bipolar affective disorder.
Q-4
A 24 year old depressed man has neglected his personal hygiene and
physical health. He denies the existence of his bowels and believes that
his bowels are blocked. He also believes that his limbs are missing and
that no one cares about it. What SINGLE kind of delusion is he suffering
from?
A. Nihilistic delusions
B. Delusion of guilt
C. Persecutory delusion
D. Fregoli delusion
E. Clang association
ANSWER:
Nihilistic delusions
EXPLANATION:
Nihilistic delusions → is the delusional belief that the patient has died or no
longerexists or that the world has ended or is no longer real. Nothing matters any
longerand continued effort is pointless. It is a feature of psychotic depressive
illness. Patientmay believe that he/she is dead and may ask people to bury them.
Delusion of guilt → involves feeling guilty or remorseful for no valid reason.
Anexample would be someone that believes they were responsible for a war in
anothercountry or hurricane damage in another state. The object of delusion
believes thatthey deserve to be punished for their sins.
Persecutory delusion → is a delusional belief that one’s life is being interfered
with ina harmful way. It refers to false beliefs or perceptions in which a person
believes thatthey are being treated with malicious intent, hostility, or harassment
despitesignificant evidence to suggest otherwise. This may occur in the context
of beingtormented, followed, or spied on.
Frégoli delusion → is when a person holds a delusional belief that different
peopleare in fact a single person who changes appearance or is in disguise.
Clang association → is an abnormality of speech where the connection
betweenwords is their sound rather than their meaning. May occur during manic
flight ofideas. Clang associations generally sound a bit like rhyming poetry,
except that thepoems don't seem to make any sense. Example, one may say
Questions&Answers
Q-1
A 16 year old girl was brought to Accident and Emergency with the
complaint of sudden loss of consciousness. This occurred while shopping
with her mother a few hours ago. The episode lasted for less than a minute
followed by full recovery. There was no head injury. The mother informed
the staff that her daughter had not eaten anything for the last four days
because she is extremely fanatic about losing weight. She began a strict
diet and exercise regimen to lose weight a few months ago. Her mother
appears distressed as she has tried everything to get her daughter to eat,
but to no avail. The patient herself is adamant that she is fat and that her
goal is to lose weight until she is 35 kg. The patient has no past medical
history of note and is not taking any regular medications. On examination,
the patient was found to be sweaty and wearing a baggy dress.
Weight 49 kilgrams
Height 165 centimetres
BMI 18 kg/m2
Capillary blood glucose 2.1 mmol/L
It was proposed that the patient be admitted but when the subject was
broached to the patient, she began to scream and demanded to be
released. What is the SINGLE best treatment option in this patient?
A. Compulsory admission
B. Refer for cognitive behavioural therapy
C. Refer to psychiatrist as outpatient
D. Seek legal advice
E. Allow home after signing self discharge
ANSWER:
Compulsory admission
EXPLANATION:
Regardless of the BMI, if there are medical complications such as electrolyte
disturbances, hypoglycaemia or bradycardia, you should admit the patient. Since
this patient has a history of loss of consciousness, a low blood glucose, lacks
insight and is refusing voluntary admission, admission under the Mental Health
Act would be appropriate. An official assessment of her mental capacity would
,need to be performed to look for an impairment or disturbance that leaves the
patient unable to make a decision.
ANOREXIA NERVOSA
Anorexia nervosa is the most common cause of admissions to child and
adolescentpsychiatric wards. It is most commonly seen in young women in which
there ismarked distortion of body image, pathological desire for thinness, and
self-inducedweight loss by a variety of methods.
Majority of those with eating disorders are women and so in the exam you should
expect a teenage female in the stem.
Features
• BMI <17.5kg/m2 or < 85% of that expected
• Self-induced weight loss → reduce food intake, vomiting, purging, excessive
exercise.
• Intense fear of being obese
• Disturbance of weight perception
• Endocrine disorders such that cause amenorrhoea, reduced sexual
nterest/impotence,
raised GH levels, raised cortisol, altered TFTs, abnormal insulin
secretion
• Bradycardia
• Hypotension
• Fatigue
• Muscle weakness
• Intolerance to cold
Q-2
A 22 year old woman thinks she is overweight. She has a body mass index
of 21.8 kg/m2. She often has constipation and abdominal pain. She eats
uncontrollably and feels guilty resulting in a self-induced vomiting.
Sometimes to compensate for her big meal, she would exercise intensively.
What is the SINGLE most likely diagnosis?
A. Anorexia nervosa
B. Pituitary tumour
C. Hypothyroidism
D. Bulimia nervosa
E. Prader Willi syndrome
ANSWER:
Bulimia nervosa
EXPLANATION:
Bulimia nervosa
Bulimia nervosa is an eating disorder characterised by repeated episodes
ofuncontrolled overeating (binges) followed by compensatory weight loss
behaviours.
,Features:
• Excessive preoccupation with body weight and shape
• Compensatory weight control mechanisms which can be:
• Self-induced vomiting
• Fasting
• Intensive exercise
• Abuse of medication such as laxatives, diuretics, thyroxine oramphetamines
Note that a person with bulimia nervosa does not necessarily need to be thin.
Theysometimes maintained a BMI above 17.5 kg/m 2.
Examination:
• Salivary glands (especially the parotid) may be swollen.
• Russell's sign may be present (calluses form on the back of the hand, causedby
repeated abrasion against teeth during inducement of vomiting).
• There may be erosion of dental enamel due to repeated vomiting.
Q-3
A 34 year old ptient was admitted for severe depression and suicidal
thoughts. He attempted to commit suicide. He has been on sertraline for
the past year which he had stopped a month ago. He had been admitted in
the psychiatric ward two years ago for mania. On discharge, the patient
wishes to know if he can be started on a long-term medication to alleviate
his symptoms. What SINGLE medication will be most useful for his
disorder?
A. Amitryptiline
B. Lithium
C. Diazepam
D. Haloperidol
E. Fluoxetine
ANSWER:
Lithium
EXPLANATION:
The patient is suffering from bipolar disorder. Long-term management requires
mood stabilisers and therefore lithium is the best option.
Bipolar affective disorder (commonly known as manic depression)
Classically, periods of prolonged and profound depression alternate with periods
ofexcessively elevated and irritable mood, known as mania.
Most people who battle with the effects of the disorder would rather live a
normallife, free from the unpredictability of mood swings, which most of us take
for granted.
The symptoms of mania characteristically include:
• Decreased need for sleep
• Pressured speech
• Increased libido
, • Reckless behaviour without regard for consequences
• Grandiosity
• More talkative than usual
These symptoms of mania would alternate with depression
Treatment
Mood stabilizers (Lithium)- Despite problems with tolerability, lithium still
remainsthe gold standard in the treatment of bipolar affective disorder.
Q-4
A 24 year old depressed man has neglected his personal hygiene and
physical health. He denies the existence of his bowels and believes that
his bowels are blocked. He also believes that his limbs are missing and
that no one cares about it. What SINGLE kind of delusion is he suffering
from?
A. Nihilistic delusions
B. Delusion of guilt
C. Persecutory delusion
D. Fregoli delusion
E. Clang association
ANSWER:
Nihilistic delusions
EXPLANATION:
Nihilistic delusions → is the delusional belief that the patient has died or no
longerexists or that the world has ended or is no longer real. Nothing matters any
longerand continued effort is pointless. It is a feature of psychotic depressive
illness. Patientmay believe that he/she is dead and may ask people to bury them.
Delusion of guilt → involves feeling guilty or remorseful for no valid reason.
Anexample would be someone that believes they were responsible for a war in
anothercountry or hurricane damage in another state. The object of delusion
believes thatthey deserve to be punished for their sins.
Persecutory delusion → is a delusional belief that one’s life is being interfered
with ina harmful way. It refers to false beliefs or perceptions in which a person
believes thatthey are being treated with malicious intent, hostility, or harassment
despitesignificant evidence to suggest otherwise. This may occur in the context
of beingtormented, followed, or spied on.
Frégoli delusion → is when a person holds a delusional belief that different
peopleare in fact a single person who changes appearance or is in disguise.
Clang association → is an abnormality of speech where the connection
betweenwords is their sound rather than their meaning. May occur during manic
flight ofideas. Clang associations generally sound a bit like rhyming poetry,
except that thepoems don't seem to make any sense. Example, one may say
