MRCP-Psychiatry

[veterinarian]

Psychiatry Best of Five

1) Which of the following features is most strongly suggestive of a diagnosis of somatisation disorder?

1 ) below average intelligence

2 ) female gender

3 ) having a close relative with a physical illness

4 ) many admissions to medical wards as an adult

5 ) symptoms of a bizarre nature

2) Which feature is most strongly suggestive of a diagnosis of somatisation disorder?

1 ) Below average intelligence

2 ) Female gender

3 ) Having a close relative with a physical illness

4 ) Many admissions to medical wards as an adult

5 ) Symptoms of a bizarre nature

3) Frontal lobe brain damage is associated with:

1 ) astereognosis

2 ) auditory agnosia

3 ) dressing apraxia

4 ) focal epileptic fits

5 ) perseveration

4) A 17 year old female is admitted with an oculogyric crisis. Which of the following statements concerning this case is correct?

1 ) She should be observed without treatment

2 ) She is likely to have been prescribed Olanzapine

3 ) She should be treated with parenteral procyclidine

4 ) She should receive procyclidine as long-term prophylaxis

5 ) She is unlikely to have a recurrence

5) A 40 year old ex-footballer presents requesting treatment for alcoholism and is prescribed disulfiram. What is the mode of action of Disulfiram?

1 ) Decreases severity of alcohol withdrawal

2 ) Helps alcoholics to drink safely

3 ) Inhibits acetaldehyde dehydrogenase activity

4 ) Inhibits alcohol dehydrogenase activity

5 ) Reduces the desire for alcohol

6) A 50-year-old woman presents with symptoms that are 'functional' in nature (somatisation disorder).Which of the following statements concerning her management is correct?

1 ) An understanding of her early childhood experiences is necessary

2 ) Antidepressant medication is unlikely to help

3 ) Her progress will be slower if she thinks her doctors do not believe her

4 ) Medical staff need to minimise their contact with her relatives

5 ) She should be persuaded to understand that her symptoms are psychological

7) A 78-year-old man presented with an unsteady gait. He was noted to be becoming impaired with his memory and agitated at nights. His GP started an antidepressant. He was incontinent of urine. He was a heavy smoker and had lost 2 stones in weight over 2 months. His blood sugar was 10 mmol/l.Which is the next best investigation?

1 ) CT Head

2 ) CXR

3 ) Glycosylated Hb

4 ) Thyroid function test

5 ) Urinary Sodium

8) A 68 year-old man is referred to A+E because of difficulty coping at home. Which one of the following features makes the diagnosis more likely to be dementia than depression?

1 ) acute onset

2 ) delusions of grandeur

3 ) insomnia

4 ) Poor score on memory tests

5 ) weight loss

9) A 22 year old woman complains of haemoptysis, abdominal pains and pyrexia for a month.

She is admitted to hospital and found to be apyrexial and not distressed. There are numerous crusted, linear lesions on her forearms.What is the most likely diagnosis?

1 ) Acute intermittent Porphyria

2 ) Factitious disorder

3 ) Systemic lupus erythematosus

4 ) TB

5 ) Wegener's granulomatosis

10) A 17 year old female is referred with a six month history of amenorrhoea and weight loss, for which no organic cause can be found. Which of the following features would support a diagnosis of anorexia nervosa?

1 ) Delusions of poisoning

2 ) Hypetrichosis

3 ) Hypergonadotrophic hypogonadism

4 ) Delsuion of being overweight

5 ) Watery diarrhoea

11) A 79 year-old male is admitted with acute confusion. His relatives who accompany him assert that he had been entirely self-caring, does not drink alcohol and was taking no previous medication. He was diagnosed with a urinary tract infection and commenced antibiotics but remained agitated and distressed. Which ONE of the following treatments is the most appropriate for his agitation?

1 ) chlorpromazine

2 ) Diazepam

3 ) Haloperidol

4 ) Temazepam

5 ) Trazadone

12) An 18 year old female is reluctant to eat food that is prepared for her. Which one of the following would be most consistent with a diagnosis of anorexia nervosa?

1 ) she believes the food is poisoned

2 ) she has a full-time job

3 ) she has bouts of heavy drinking

4 ) she regards herself as ill

5 ) she secretly abuses anabolic steroids

13) All of the following lead to the increased risk of developing schizophrenia or a schizophrenic-like illness, EXCEPT:

1 ) Amphetamine addiction

2 ) Being brought up in an institution

3 ) Sibling with schizophrenia

4 ) Social Class V

5 ) Temporal lobe epilepsy

14) The incidence of Down syndrome in children born to women aged < 30 years is approx.

1 ) 1:500

2 ) 1:1000

3 ) 1:5000

4 ) 1:10000

5 ) 1:15000

15) A 60-year-old man presents with an episode of memory loss. Three days earlier he had become confused. His wife led him into the house - he apparently sat down at her request, and had a cup of tea. He then wandered around the house, confused, but remained conscious and able to have some conversation with his wife, though continuing to ask similar questions repeatedly. After three hours, he abruptly returned to normal and had no recollection of the events. What is the most likely diagnosis?

1 ) alcohol related amnesia

2 ) chronic subdural haematoma

3 ) complex partial status epilepticus

4 ) hysterical fugue state

5 ) transient global amnesia

16) A 27 year old woman complained of palpitations, breathlessness and chest pain, radiating to the left arm. These symptoms had developed six weeks previously, after she had witnessed her father dying from a myocardial infarction. In the past 10 years she had been investigated for abdominal pain, headaches, joint pains, and dyspareunia, without serious cause being found for these symptoms.What is the most likely diagnosis?

1 ) Depressive episode

2 ) Factitious disorder

3 ) Generalized anxiety disorder

4 ) Hypochondriasis

5 ) Somatization disorder

17) A 21 year old woman is known to suffer from anorexia nervosa. Which of the following metabolic disturbances would be a characteristic finding?

1 ) a decrease in Cortisol levels

2 ) an increase in LH levels

3 ) hyperkalaemia

4 ) impaired glucose tolerance

5 ) raised androgen levels

18) You are asked to consent a patient for Electroconvulsive Therapy (ECT). Which of the following is not a hazard of ECT?

1 ) Amenorrhoea

2 ) Crush fracture of the vertebral bodies

3 ) Induction of cardiac arrhythmia

4 ) Induction of dementia

5 ) Memory loss

19) A 76 year old male attends clinic with his wife who states that her husband has become disinterested and withdrawn.Which of the following would favour a diagnosis of dementia rather than depression?

1 ) Agitation

2 ) Poor short term memory

3 ) Reduced libido

4 ) Self-reported concern of poor memory

5 ) Urinary incontinence

20) Psychiatric illness rather than an organic brain disorder is suggested by:

1 ) Onset for the first time at the age of 55 years

2 ) A family history of major psychiatric illness

3 ) Impaired short term memory

4 ) No previous history of psychiatric illness

5 ) Clouding of conciousness

21) Which of the following statements concerning the causation and dynamics of schizophrenia is correct?

1 ) Decline in IQ scores during childhood may be a harbinger of psychotic symptoms in adults.

2 ) Schizophrenia is commoner in individuals in unstable relationships

3 ) Schizophrenia is commoner in higher socio-economic groups

4 ) In monozygotic twins the risk of the second twin developing schizophrenia if the first is affected is of the order of 10%

5 ) The lifetime risk of developing schizophrenia if one parent is affected is of the order of 50%

22) A 63-year-old man was found collapsed. A Department of Psychiatry outpatient Card was found in his jacket, together with a bottle of procyclidine tablets. He was febrile (38.2°C), conscious but unresponsive to commands. The blood pressure was 160/105 mmHg and there was marked muscle rigidity.What is the most likely diagnosis?

1 ) acute catatonic schizophrenia

2 ) bacterial meningitis

3 ) cerebral malaria

4 ) neuroleptic malignant syndrome

5 ) procyclidine overdose

23) A 30 year old male presented with a paranoid psychosis accompanied by visual hallucinations which resolved over the next three days. Which one of the following is the most likely diagnosis?

1 ) Alcohol withdrawal.

2 ) Diazepam dependence.

3 ) Fluoxetine overdose.

4 ) Heroin withdrawal.

5 ) Smoking cannabis.

24) A 25 year old male with learning difficulties presents with behavioural problems. He confessed to smoking the occasional cannabis joint. Which of the following is most likely to be the cause of his behavioural problems?

1 ) cannabis

2 ) Dementia

3 ) Depression

4 ) Mania

5 ) schizophrenia

25) Which of the following statements is INCORRECT regarding the Mental Health Act of 1959:

1 ) Emergency admission for 72 hours requires the signature of only one doctor

2 ) For admission up to 28 days the signature of two doctors, one with psychiatric knowledge, is required

3 ) a mental institution can refuse to accept a patient

4 ) It allows a patient to be detained in hospital if a danger to himself or to society

5 ) It is not applicable to criminal psychiatric patients

26) Regarding puerperal psychosis which of the following statements are true?

1 ) usually begins after the second week of the puerperium

2 ) often takes the form of schizophrenia

3 ) recurrence of perperal psychosis in subsequent pregnancies is the rule

4 ) the onset is usually insidious

5 ) the prognosis is usually good

27) A 17 year old student presented with recurrent attacks of dizziness. Which one of the following additional features is most suggestive that she has an anxiety disorder?

1 ) elevated diastolic blood pressure

2 ) nocturia

3 ) paraesthesiae in the hands

4 ) rotational vertigo

5 ) tinnitus

28) A 50 year old business man who has been drinking heavily for at least two years, states that he drinks alcohol on his way into work as he suffers from anxiety attacks. Which one of the following statements is true regarding these episodes?

1 ) they are imagined

2 ) they are not accompanied by tremor

3 ) they are still present after drinking

4 ) they will improve with three weeks of abstinence from alcohol

5 ) they will worsen with three weeks of abstinence from alcohol

29) A 52-year-old male is admitted after taking an overdose.

Which single feature best suggests a high risk of future suicide?

1 ) Making plans before the overdose to avoid discovery

2 ) Ingestion of alcohol with the overdose drug

3 ) Ingestion of more than one drug

4 ) Ingestion of more than 100 tablets

5 ) Previous history of overdose

30) Which of the following is a characteristic feature of transient global amnesia?

1 ) abnormal behaviour

2 ) apraxia

3 ) confabulation

4 ) loss of personal identity

5 ) normal perception

31) A 60 year-old man presents with a 2 month history of progressive confusion, gait disturbance, and urinary incontinence. Examination reveals mild global cognitive dysfunction and gait ataxia. CT brain shows enlarged ventricles with no evidence of obstruction to CSF outflow. Lumbar puncture reveals normal CSF pressure and constituents. Which one of the following managements steps is likely to be most helpful?

1 ) CSF drainage via repeated lumbar puncture

2 ) EEG

3 ) Intracranial pressure monitoring

4 ) MRI brainstem

5 ) Serum B12 and folate levels

32) With respect to symptoms of withdrawal related to chronic alcohol use, which of the following statements is correct?

1 ) Withdrawal reflects enhanced neurotransmission in Type A gamma-aminobutyric acid pathways.

2 ) Withdrawal reflects reduced neurotransmission in N-methyl-D-aspartate pathways. 3 ) Phenytoin is an effective treatment for seizures related to alcohol withdrawal.

4 ) Benzodiazepines are ineffective in the treatment of seizures secondary to alcohol withdrawal, due to cross tolerance with ethanol at Type A gamma amino-aminobutyric acid receptor.

5 ) Carbamazepine is as effective as Benzodiazepines in the acute treatment of the symptoms of alcohol withdrawal.

33) Characteristic features of schizophrenia include:

1 ) incongruity of affect

2 ) auditory hallucinations with clouding of consciousness

3 ) memory impairment

4 ) feelings of panic in buses and shops

5 ) grandiose

34) Which of the following symptoms is more suggestive of a functional disorder:

1 ) disorientation in time

2 ) visual hallucinations

3 ) inability to retain new information

4 ) mutism

5 ) perseveration

35) A 30 year old male is admitted to the psychiatric unit after abnormal behaviour in a police cell. He told police that there was a conspiracy against him and he began behaving irrationally. 36 hours after admission to the psychiatric unit the patient has a grand-mal seizure. The most likely cause of the seizure is:

1 ) Amphetamine withdrawal

2 ) Hypercalcaemia

3 ) Idiopathic epilepsy

4 ) LSD withdrawal

5 ) Withdrawal from barbiturates

36) A 70-year-old woman had a major depressive disorder which was unresponsive to antidepressant medication.

Which one of the following statements is correct?

1 ) Associated dementia is unlikely

2 ) Electroconvulsive therapy is likely to improve her mood

3 ) If she recovers, relapse is unlikely

4 ) The risk of suicide is low

5 ) Underlying physical illness is unlikely

37) In obsessional neurosis:

1 ) patients have good insight

2 ) patients often act on their aggressive impulses

3 ) Low intelligence is a common feature

4 ) the onset is usually after the age of 50 years

5 ) there is often a history of faulty toilet training

38) Which of the following is true regarding Depersonalisation Syndrome?

1 ) precedes the onset of schizophrenia

2 ) is a feeling that other people have changed

3 ) is associated with depression

4 ) is an indication for Electrocunvulsive Therapy (ECT)

5 ) characteristically precedes derealisation

39) A student is worried that she may not be able to take her final University examinations in three months time because she says she becomes faint and dizzy when she does examinations.

What is the most appropriate course of action?

1 ) Advise her to withdraw from examinations on medical grounds

2 ) 24 hour ECG monitoring

3 ) Arrange counselling, with relaxation training

4 ) Prescribe diazepam

5 ) Prescribe fluoxetine

40) An 18 year old man had repeated episodes of breathlessness and palpitations, lasting about 20 minutes and resolving gradually. There were no abnormal physical signs.

What is the most likely cause of these features?

1 ) Drug abuse

2 ) Panic disorder

3 ) Paroxysmal supraventricular tachycardia

4 ) Personality disorder

5 ) Thyrotoxicosis

41) A 70-year-old woman presented with episodic impairment of consciousness.

Which of the following is the most likely cause?

1 ) Alzheimer type dementia

2 ) chronic sub-dural haematoma

3 ) Creutzfeldt-Jacob disease

4 ) depressive stupor

5 ) normal pressure hydrocephalus

42) In which of the following is mental retardation an expected finding?

1 ) Alkaptonuria

2 ) Cystinuria

3 ) Glycogen storage disease

4 ) Lactose intolerance

5 ) Maple syrup urine disease

43) A patient on the ward is diagnosed with schizophrenia. You are asked to speak with the mother and father of the patient. They ask you about prognostic features of schizophrenia. Which of the following features of their sons illness, character, and lifestyle, which they raise are poor prognostic indicators in schizophrenia?

1 ) Sudden onset of symptoms

2 ) High intelligence

3 ) Unstable social background

4 ) Strong family history

5 ) A preciptitating cause

44) Which of the following features is characteristic of early Alzheimer's disease?

1 ) ataxic gait

2 ) impaired short term memory

3 ) myoclonic jerks

4 ) urinary incontinence

5 ) visual hallucinations

Psychiatry Best of Five-Answers

1) 5

Somatization disorder is characterised by multiple recurring pains and gastrointestinal, sexual, and pseudo-neurologic symptoms that occur over a period of years. To meet the diagnostic criteria for somatization disorder, the patients' physical complaints must not be intentionally induced and must result in medical attention or significant impairment in social, occupational, or other important areas of functioning. By definition, the first symptoms appear in adolescence and the full criteria are met by 30 years of age.

2) 5

Somatisation means the expression of psychological distress into bodily complaints for which medical help is sought. Somatisation disorder is characterized by multiple, recurrent and changing symptoms for which no physical cause can be found. Other forms of persistent somatisation include hypochondriasis, dysmorphophobia and psychogenic pain.

3) 5

Frontal lobe brain damage is classically associated with personality change and deterioration in intellect, but perseveration may also occur. The lesion for astereognosis and acalculia would be in the parietal lobe and dressing apraxia in the dominant parietal lobe. Focal epileptic fits, and auditory agnosia are characteristically associated with temporal lobe damage. Apraxia may result from lesions in the temporopatietal cortex, dominant frontal cortex and corpus callosum.

4) 3

Oculogyric crisis is an acute dystonic reaction of the face/eyes and is usually a consequence of typical neuroleptic drugs such as Haloperidol, Chlorpromazine but is unusual with newer agents such as Olanzapine, Clozapine. The condition is often precipitated by re-introduction of the agent. The condition should be treated with procyclidine (usually IV or IM) or Benztropine. Chronic treatment beyond a couple of days is not required.

5) 3

Alcohol is mainly metabolized in the liver to acetaldehyde by alcohol dehydrogenase. Acetaldehyde is then oxidized to acetate by acetaldehyde dehydrogenase (AcDH). Disulfiram irreversibly inhibits the oxidation of acetaldehyde by competing with the cofactor nicotinamide adenine dinucleotide (NAD) for binding sites on (AcDH). The increased acetaldehyde levels are thought to produce the unpleasant side effects associated with acetaldehyde syndrome such as headaches, nausea, flushing etc.

6) 3

This is quite a tough question. The College has asked about Somatisation disorder in at least 4 recent exams so they must think it's quite important.

Knowledge of early childhood experiences is not necessary, depression is often found so antidepressives are useful, relatives should be involved and empathy, not persuasion, is the key to management.

7) 1

The triad of unsteady gait, memory impairment and urinary incontinence suggests the diagnosis of normal pressure hydrocephalus. CT head of the brain is the investigation of choice to show enlarged ventricles out of proportion of cerebral atrophy.

8) 4

The failure on memory testing such as Mini Mental Score Evaluation would suggest a diagnosis of dementia rather than depression. Depression would be associated with delusions, insomnia, may be acute onset and is also associated with weight loss.

9) 2

The history is very vague and the patient has no clinical features other than a rash which sounds typical of dermatitis artifacta.

10) 4

Features of AN include a phobic avoidance of normal weight, relentless dieting, self-induced vomiting, laxative use, excessive exercise, amenorrhoea, lanugo hair, hypotension, denial, concealment, overperception of body image, enmeshed families.

11) 3

The best agent for acute agitation in this elderly patient would be Haloperidol probably administered IM. Diazepam is too short acting to be administered to this patient and may precipitate respiratory depression whilst Temazepam oral has too long a duration of action to be of any use as an acute sedative in the elderly. Trazadone an anti-depressant is useful orally as a chronic anxiolytic. Other useful agents would be Lorazepam IM or Respiridone.

12) 2

Anorexia nervosa is associated with the abnormal perception of body image. They generally feel well despite the protestations of others who feel that they look awful. They exercise avidly and until the very late stages of the disease hold down full time jobs. There is no delusion with regard to the food being poisoned. Heavy drinking associated with food refusal would suggest alcoholism and alcoholic gastritis. The secretive abuse of laxatives would fit with the diagnosis rather than anabolic agents.

13) 2

Nurture in an institution does not pre-dispose individuals to schizophrenia. Schizophrenia is however more common in social classes IV and V. The lifetime risk of developing schizophrenia in the UK is 1%. If there is an affected sibling the risk increases to 8-10%. Temporal lobe epilepsy may cause hallucinations, mimicking schizophrenia, and amphetamines may cause a state resembling hyperactive paranoid schizophrenia with hallucinations.

14) 2

The exact figure is 1 in 1200 births. Maternal age also affects incidence of hydrocephalus, anencephaly and achondroplasia.

15) 5

This is the typical clinical description of transient global amnesia which represent a transient vascular insufficency of both hippocampi.

16) 5

Although the brief scenario does not have quite enough criteria to fulfill a diagnosis there is enough to make somatization disorder the most likely answer. Somatization disorder is characterized by multiple recurring pains and gastrointestinal, sexual, and pseudo-neurologic symptoms that occur over a period of years. To meet the diagnostic criteria for somatization disorder, the patients' physical complaints must not be intentionally induced and must result in medical attention or significant impairment in social, occupational, or other important areas of functioning. By definition, the first symptoms appear in adolescence and the full criteria are met by 30 years of age. Of all the other disorders "factitious disorder" would seem the least likely. The other three are possible explanations but not as likely as somatization.

17) 4

Malnutrition is another cause of diabetes. (Can you name the others? ... Type 1 and Type 2 OK ... but what about gestational or post panceatitis / pancreatectomy ... do you know the others?

Cortisol and growth hormone levels are elevated.LH and FSH would be low and LH response to LHRH is impaired when weight loss is severe.

Hypokalaemia (not hyperkalaemia may be seen). Also there may be hypoalbuminaemia, anaemia, leukopenia, and raised serum carotene.

18) 4

Side effects of ECT are rare. Over the course of ECT, it may be more difficult for patients to remember newly learned information, though this difficulty disappears over the days and weeks following completion of the ECT course. Some patients also report a partial loss of memory for events that occurred during the days, weeks, and months preceding ECT. While most of these memories typically return over a period of days to months following ECT, some patients report longer-lasting problems with recall of these memories. Other individuals report improved memory ability following ECT, because of its ability to remove the amnesia sometimes associated with severe depression. Cardiac arrhythmia may be stimulated by the electrical shock of ECT. Musculoskeletal injury has been reported after ECT, but with adequate anaesthetisation, this is rare. Dementia is an organic illness which is not induced by ECT.

19) 5

Urinary incontinence would be particularly unusual in association with a depression and would be far more typical of dementia/normal pressure hydrocephalus. The other symptoms may be found in dementia particularly impaired memory and concern over memory deficits.

20) 2

B is especially associated with depressive illness. The rest all suggest an organic brain disorder.

21) 2

Schizophrenia occurs twice as often in unmarried and divorced people as in married or widowed individuals. Furthermore, people with schizophrenia are eight times more likely to be in the lowest socioeconomic groups. These statistics are likely to reflect the alienating effects of this disease rather than any causal relationship or risk factor associated with poverty or a single life. Nevertheless, low income and poverty may increase the risk for exposure to biological factors (e.g., infections or toxins) or social stressors that could trigger the illness in susceptible people. Monozygotic Twins may have a 50% concordance and 10% of offspring may be affected suggesting strong inheritance.

22) 4

The symptoms are typical of neuroleptic malignant syndrome (NMS). NMS is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction. Procyclidine is used to treat the Parkinsonian side-effects of neuroleptics: its presence in the patient's pocket implies that he was taking neuroleptics. Signs of procyclidine overdose include agitation, confusion, and sleeplessness lasting up to 24 hours or more. Pupils are dilated and unreactive to light. Visual and auditory hallucinations and tachycardia have also been reported.

23) 1

The paranoid psychosis with visual hallucinations is highly suggestive of delirium tremens – alcohol withdrawal.

24) 3

This one chap may be frustrated by his incapacity and would appear to having behavioural problems as a manifestation of his depression. Cannabis may actually relive these frustrations. There are no features to suggest an organic brain syndrome.

25) 5

Sections 60-80 of the Act cover criminal patients. Any registered practitioner may carry out an emergency section for 72 hours observation provided he has seen the patient within 24 hours of signing.

26) 5

Puerperal psychosis is a relatively rare complication of childbirth affecting 1 - 2 per 1000 births. (Postnatal depression is much commoner affecting 100 - 150 women per 1000 births). Puerperal psychosis is a mood disorder with features of loss of contact with reality, hallucinations, thought disorder and abnormal behaviour. It usually presents rapidly in the first month but most often starts in the first week. Prognosis is good.

27) 3

Parasthesiae is often associated with anxiety of any description. Rotational vertigo and tinnitus suggest an organic disorder, whilst anxiety disorder would normally be associated with raised systolic blood pressure

28) 4

This patient has anxiety symptoms due to withdrawal from alcohol. The typical symptoms include agitation, fever, sweats and tremor which are relived by alcohol. These symptoms usually peak after about 72 hours and may last a week or more but should have improved after three weeks.

29) 1

The effort to conceal the overdose suggests a serious intent to commit suicide.

30) 5

Transient Global Amnesia is a syndrome in which a previously well person suddenly becomes confused and amnesic. The person appears bewildered and repeatedly asks questions about present and recent events e.g., "Where am I?" T.G.A. is characterised by the brains sudden inability to form new memory traces (Antrograde amnesia) plus retrograde memory loss for events of the preceding days, weeks or in some cases years. During the attack, which affects both verbal and nonverbal memory, the patient is bewildered and anxious. Self identification is preserved. Behaviour is otherwise normal and appropriate. 'Characteristic' means that absence of the symptom would make you doubt the diagnosis. Presence of A, B, C or D would suggest an alternative diagnosis.

31) 1

Normal pressure hydrocephalus presents with the triad of dementia, gait disturbance and incontinence. It is associated with episodes of increased pressure related to impaired CSF absorption and therefore may benefit from CSF shunting. Although the ventricular enlargement described in this case may derive from global atrophy and need not represent hydrocephalus the other features of the case strongly point to the diagnosis. In equivocal cases therapeutic CSF drainage via lumbar puncture is performed to identify the patients likely to benefit from permanent drainage. Intracranial pressure monitoring to demonstrate the episodes of increased pressure is a more invasive alternative.

32) 5

Carbamazepine at a starting dose of 800mg per 24hours has been shown to be as effective as oxazepam in the treatment of acute alcohol withdrawal. Phenytoin is not effective in the treatment of alcohol withdrawal-related seizures. Alcohol withdrawal reflects the damping of neurotransmission through Type A gamma-amino-butyric pathways, and enhanced neurotransmission through N-methyl-D-aspartate pathways.

33) 1

Incongruity of affect is emotion inappropriate to circumstances. There may be intellectual defects from prolonged institutionization or treatment rather than the illness itself.

34) 4

Functional refers to an illness that is without a structural defect. Organic brain syndromes are physical conditions including structural brain disease and metabolic disturbances causing mental dysfunction. Mutism is the more likely of the symptoms described to be associated with a functional disorder but is associated with schizophrenia or autism.

35) 5

LSD withdrawal is not reported to cause seizures, and amphetamine withdrawal is associated with depression, intense hunger and lethargy, but not with seizures. There is nothing to suggest hypercalcaemia in this patient as the cause for fits but hyponatraemia associated with water intoxication following Ecstasy abuse would be a possibility. Barbiturate withdrawal in an habitual abuser is a well recognised cause of fits togther with the altered behaviour. It is unlikely, given the circumstances, that this is new onset epilepsy, although it remains a differential diagnosis.

36) 3

Depression in the elderly is a widespread problem that is often not diagnosed and frequently undertreated. Depression can also be a sign of a medical problem. It may be complicated by brain disorders associated with the aging process such as Alzheimers disease. Suicide risk in the elderly is an important consideration, and is at least as common as in younger age groups. Relapse of depressive symptoms is common in the elderly. ECT is indicated in patients who derive no benefit from antidepressant medication.

37) 1

Obsessional neurosis is associated with rituals, fears (eg hurting others but never carried out), thoughts abhorrent to the patient and ruminations. The illness is distressing to them and may cause depression. It usually starts in early adult life with equal sex-incidence. The intelligence of these subjects is often above average.

38) 3

1- depersonalisation is not exclusively seen in schizophrenics 2 - this is derealisation see below 3 - Depersonalisation may occur in almost all major psychiatric disorders, drug abuse, migraine, epilepsy, SLE and, transiently, in normal individuals. 4 - ECT has been tried in the past. SSRI antidepressants and coping strategies are useful. 5 - derealisation is a separate pathology Depersonalisation is a change in an individuals self-awareness such that they feel detached from their own experience with the self, the body and mind seeming alien. Derealisation is a change in an individuals experience of the environment where the world around them feels unreal and unfamiliar.

39) 3

The symptoms the student describes are characteristic of stress and are quite common. They should be reassured. ECG monitoring would support their fears of organic disease. Diazepam would impair their exam performance and fluoxetine may increase feelings of anxiety.

40) 2

Drug abuse is unlikely since ther symptoms are quite short lived. We sould expect other symptoms such as GI disturbance, headaches or hypertension to accompany a variety of drug abuse causes. Paroxysmal SVT would start and stop suddenly, not gradually. Personality disorder and thyrotoxicosis would both be expected to lead to symptoms of longer duration with other associated symptoms. This leaves 'panic disorder' as the most likely diagnosis.

41) 2

This is quite a grey question. The clinical scenario is very brief with no mention of any neurological signs so a logical deduction must be made.

Alzheimer's disease would be expected to have a continous impairment of consciousness in its advanced stages but could be episodic if there were variation in drugs therapy or concurrent illnesses. Similarly Normal Pressure Hydrocephalus, Creutzfeld-Jacob and depression would present with dementia (or apparent dementia) but not fluctuant.

Of all those listed subdural haematoma is classically associated with fluctuating level of consciousness. This would make it the most likely.

42) 5

MENTAL RETARDATION. Fragile X syndrome-commonest male cause. Hypoxia at birth, intaventricular haemorrhage, rhesus disease, Congenital infections -toxoplasmosis, CMV, rubella, herpes), hypoglycaemia, meningitis, hypothyroidism (cretinism, tuberous sclerosis, Down's, Tay-Sach's, Cornelia De Lange, Hartnup - biochemical, treatable with diet. -homocystinuria, phenylketonuria -maple syrup urine disease, tryptophanuria -galactosaemia

43) 3

Close social ties and a stable background indicate a favourable prognosis in schizophrenia. A family history is not related to prognosis in schizophrenia. Insidious onset confers a poor prognosis, and a precipitating cause and high intelligence are favourable prognostic indicators.

44) 2

Alzheimer's disease is characterised early in the disease by short term memory loss. The other features listed here would suggest an alternative diagnosis such as normal pressure hydrocephalus (gait ataxia and urinary incontinence), Creutzfeld-Jacob disease (myoclonic jerks) and delirium or vascular dementia (visual hallucinations).