MRCPsych Paper 1: 600 MCQs Ashok G Patel, Roshelle Ramkisson, Raman Sharma
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Test questions: 1Chapter 1

Questions: MCQs
For each question, select one answer option.
HISTORY AND MENTAL STATE EXAMINATION
  1. A 69-year-old woman presented with severe depression and short-term memory problems. Which of the following tests is most appropriate to assess her short-term memory?
    1. Copying a clock
    2. Copying pentagons
    3. Orientation to time and place
    4. Serial sevens
    5. Three-word recall
  2. Which of the following statements regarding frontal lobe dysfunction is correct?
    1. The ability to plan ahead is preserved
    2. Agnosia is a diagnostic feature
    3. Dyscalculia is often present
    4. Long-term memory loss is a consistent feature
    5. Perseveration is a sign of a frontal lobe lesion
  3. A 70-year-old man undertakes a Mini-Mental State Examination (MMSE). He asks what is being assessed when he is instructed to take away serial 7s from 100 and then repeat the result. Which of the following is the most appropriate response?
    1. Attention
    2. Language
    3. Remote memory
    4. Verbal memory
    5. Working memory
  4. Which of the following statements regarding epileptic automatism is correct?
    1. Consciousness is preserved
    2. The control of posture is lost
    3. An epileptic automatism lasts from seconds to minutes
    4. The muscle tone is preserved
    5. The recall of events is accurate
  5. Which of the following about Ganser's syndrome is correct?
    1. Accurate answers
    2. Amnesia of the episode2
    3. Clear consciousness
    4. Orientation to time and person
    5. Right-left disorientation
  6. A 21-year-old man takes a large number of paracetamol tablets with alcohol after an argument with his girlfriend. On examination, he displays fluctuating consciousness, irritable mood, agitation, restlessness and impaired concentration. His MMSE score is 22/30. What is the most likely diagnosis?
    1. Acute psychotic episode
    2. Acute stress reaction
    3. Adjustment disorder
    4. Delirium
    5. Panic disorder
COGNITIVE ASSESSMENT
  1. A 62-year-old man presents with significant cognitive impairment accompanied by disinhibition, recklessness and a lack of concern towards others. Taking into consideration the type of dementia that he might have, which of the following language deficits could this patient experience initially?
    1. Dysarthria
    2. Dyslexia
    3. Fluent expressive dysphasia
    4. Non-fluent expressive dysphasia
    5. Receptive dysphasia
  2. Which of the following conditions is commonly associated with a catastrophic reaction?
    1. Bipolar affective disorder
    2. Borderline personality disorder
    3. Cocaine misuse
    4. Schizophrenia
    5. Vascular dementia
  3. Which of the following is a test for working memory?
    1. The behavioural inattention test
    2. The Hayling and Brixton tests
    3. The token test
    4. The trail making test
    5. The zoo map
  4. Which of the following is a non-verbal performance component of the Wechsler adult intelligence scale (WAIS)?
    1. Arithmetic
    2. Comprehension
    3. Digit span
    4. Matrix reasoning
    5. Similarities
  5. A 70-year-old woman was assessed in the memory assessment clinic. She was asked about the Royal wedding in 2011, which she found difficult to answer. Which part of her memory was being tested?
    1. Immediate
    2. Procedural3
    3. Recent
    4. Remote
    5. Working
  6. A 32-year-old man was seen following a road traffic accident. He was confused, but he opened his eyes on painful stimuli. On the Glasgow coma score (GCS) scale, what is his eye-opening grade?
    1. 1
    2. 2
    3. 3
    4. 4
    5. 5
  7. Which of the following tests measures intelligence that is relatively independent of educational background?
    1. The California verbal learning test
    2. The Cambridge contextual reading test
    3. The national adult reading test
    4. Raven's progressive matrices
    5. The Wechsler abbreviated scale of intelligence
  8. In which of the following conditions are the NINDS-AIREN criteria useful in their diagnosis?
    1. Alzheimer's dementia
    2. Dementia due to normal pressure hydrocephalus
    3. Lewy body dementia
    4. Parkinson's dementia complex
    5. Vascular dementia
  9. Which of the following is a verbal component of the WAIS?
    1. Arithmetic
    2. Block design
    3. Digit symbol
    4. Matrix reasoning
    5. Picture completion
NEUROLOGICAL EXAMINATION
  1. A 45-year-old man undergoes a routine physical examination. He previously had retrobulbar neuritis in his left eye, from which he apparently made complete recovery. What is the most likely sign on examination of the pupils?
    1. An irregular left pupil
    2. Left pupil completely unreactive to light
    3. Unilateral pupillary constriction on the left with slight ptosis
    4. When light shone back to the left eye from the right, the pupil dilates
    5. When light shone in the right eye both pupils dilate
  2. A 25-year-old man presented with impairment of auditory comprehension and repetition. He had an intact speech and an intact ability to write and read. Which of the following is the most likely presenting feature?
    1. Broca's aphasia
    2. Pure agraphia4
    3. Pure word blindness
    4. Pure word deafness
    5. Wernicke's aphasia
  3. A 61-year-old man developed bitemporal hemianopia. Where is the lesion most likely to be located?
    1. Left optic tract
    2. Optic chiasma
    3. Occipital lobe
    4. Right optic nerve
    5. Right optic radiation
  4. A 29-year-old African man presented to the emergency department confused and irritable, with a headache and a high temperature. He is HIV positive and MRI of the brain showed multiple ring-shaped lesions. What is the most likely diagnosis?
    1. Cryptococal meningitis
    2. Cytomegalovirus encephalitis
    3. Progressive multifocal leukoencephalopathy
    4. Toxoplasma encephalitis
    5. Viral meningitis
ASSESSMENT
  1. A 39-year-old woman presented with depression, apathy, weakness, fatigue and loss of weight. On clinical examination, she had areas of pigmentation on her body. A blood test revealed hypokalaemia. Which of the following is most likely to be found on further investigation?
    1. Abnormal Synacthen test
    2. Acanthosis
    3. Hyponatraemia
    4. Low serum ceruloplasmin
    5. Low vitamin B6
  2. A 19-year-old woman presents with emotional lability, behavioural disturbance and stiffness of joints. On examination she has mild jaundice and hepatomegaly. An MRI of the brain showed cortical atrophy and hypodense areas in the basal ganglia. Which of the following will be seen on further investigation?
    1. Decreased 24-hour urinary copper
    2. Decreased hepatic copper
    3. Increased total serum copper
    4. Increased free serum copper
    5. Increased serum ceruloplasmin
  3. A 44-year-old woman presented with severe panic attacks, pronounced tachycardia, headache and vomiting. In between these episodes, she reported feeling exhausted. On clinical examination, her blood pressure was 175/105. On investigation, her blood glucose was elevated. Which of the following is most likely to be found on further investigation?
    1. Hypokalaemia
    2. Hyponatraemia
    3. Low folic acid
    4. Low vitamin B12
    5. Raised urinary catecholamine5
  4. You are asked to assess an 80-year-old widow in primary care whose family tells you that they cannot manage her at home, as she has been verbally abusive and threatening. Which of the following neuropsychological tests would be most appropriate to assess her mood?
    1. General health questionnaire
    2. Geriatric depression scale
    3. Mini-mental state examination
    4. Present state examination
    5. Wisconsin card sorting test
  5. You are asked to assess an 80-year-old widow whose family tells you that they cannot manage her at home, as she has been verbally abusive and threatening. Which of the following neuropsychological tests is most appropriate to assess if the patient had a global deterioration in her cognition?
    1. Burden interview
    2. Clinical dementia rating scale
    3. Clock-drawing test
    4. Hachinski's ischaemia score
    5. Mini-mental state examination
  6. You are asked to assess an 80-year-old widow whose family tells you that they cannot manage her at home as she has been aggressive and threatening towards them. Her global cognition is within normal range. Which of the following tests would be most appropriate to assess whether she had a specific frontal lobe deficit?
    1. Clinical dementia rating scale
    2. Hachinski's ishaemia score
    3. Mini-mental state examination
    4. Quality of life – Alzheimer's disease scale
    5. Wisconsin card sorting test
  7. A 50-year-old divorced man was rushed to the emergency department when he was found to be confused and vomiting at home. He has a long history of alcohol abuse and presented with a patchy history about his problems. He complained of severe difficulties with his vision and walking. A diagnosis of Wernicke's encephalopathy is considered. Which of the following features would help to confirm the diagnosis?
    1. Acalculia
    2. Apathy
    3. Finger agnosia
    4. Ophthalmoplegia
    5. Peripheral neuropathy
  8. A 59-year-old man with a long history of alcohol abuse was referred to the outpatient clinic for psychiatric assessment. He complained of memory problems with periods of mental confusion for several months. A diagnosis of Korsakoff's syndrome is considered. Which of the following features will help to confirm the diagnosis?
    1. Acalculia
    2. Anterograde amnesia
    3. Aphasia
    4. Euphoria
    5. Retrograde amnesia
  9. A 25-year-old single man presented to the outpatient clinic. He suddenly became very threatening and potentially violent towards the doctor. What is the most appropriate action to manage the immediate situation?
    1. Attempt to restrain the patient
    2. Calmly leave the interview room6
    3. Confront the patient about his behaviour
    4. Ensure that you collect all the necessary clinical information before leaving
    5. Ignore the patient's behaviour and continue assessing him
  10. A 35-year-old, recently separated man presented to the emergency department having taken an overdose of 45 paracetamol tablets. What is the single most significant factor used to assess his current suicide risk?
    1. Employment status
    2. Gender
    3. Marital status
    4. Mental status
    5. Overdose when alone in hotel room
AETIOLOGY
  1. Some individuals are genetically predisposed to particular complications of alcohol misuse. Which enzyme deficiency is implicated in development of organic brain complications?
    1. Alcohol dehydrogenase
    2. Aldehyde dehydrogenase
    3. Guanylyl cyclase
    4. Phospholipase A2
    5. Transketolase
  2. Which of the following parental styles is the strongest predictor of future offending?
    1. Cold emotional relationships
    2. Limited parental involvement
    3. Limited parental reinforcement
    4. Poor discipline
    5. Poor parental supervision
  3. Which of the following is most likely to be associated with attention deficit hyperactivity disorder in a 14-year-old girl?
    1. Behaviourally inhibited temperament
    2. Enmeshment in family
    3. Functional abnormalities in the prefrontal area
    4. Parental divorce
    5. Rise in oestrogen levels in female puberty
  4. Which pathophysiological factor is most likely related to the reward mechanism in alcohol abuse?
    1. β-Amyloid precursor protein
    2. Mammillary body α-ketoglutarate
    3. Subcortical leukomalacia
    4. Tau protein
    5. Ventral tegmental area dopamine and enkephalin
  5. Which of the following is most highly determined by behavioural patterns at 10 years of age?
    1. Alcohol misuse
    2. Antisocial behaviour
    3. Bulimia nervosa
    4. Depression
    5. Drug abuse7
  6. Which of the following is most likely to be associated with an increased risk of developing schizophrenia?
    1. Being born in an urban area
    2. Being recurrently placed in a ‘double-bind’ situation as a child
    3. Experiencing high expressed emotions in the family home
    4. Maternal alcohol use during pregnancy
    5. Maternal cannabis use during pregnancy
DIAGNOSIS
  1. An 80-year-old man has developed bilateral cataracts over the past few years. He is physically well. However, he presented with increased paranoia over the past 6 months. He has been observed talking to imaginary people in his room. What is the most likely diagnosis?
    1. Charles Bonnet syndrome
    2. Delirium tremens
    3. Dementia
    4. Diogenes syndrome
    5. Frégoli syndrome
  2. A 30-year-old single woman developed rapid onset of bad dreams and nightmares with increased startle reaction. She has difficulty in relaxing and sustaining attention. Her symptoms are worse at night. What is the most likely diagnosis?
    1. Acute stress reaction
    2. Delirium
    3. Generalised anxiety disorder
    4. Post-traumatic stress disorder
    5. Somnambulism
  3. A 35-year-old woman has been feeling anxious and distressed following a road traffic accident. She has reduced awareness of her surroundings and experiences symptoms of dissociation. She is fearful and transiently disoriented. What is the most likely diagnosis?
    1. Acute stress reaction
    2. Adjustment disorder
    3. Generalised anxiety disorder
    4. Intracranial bleed
    5. Post-traumatic stress disorder
  4. A 50-year-old man experienced a traumatic event while travelling on public transport. He started to experience fragments of images and memories of the event 6 months after the incident. He has sleep disruptions with nightmares and distressing dreams. He avoids going out and gets panicky when he has to use public transport. What is the most likely diagnosis?
    1. Acute stress reaction
    2. Adjustment disorder
    3. Agoraphobia
    4. Dissociative disorder
    5. Post-traumatic stress disorder8
CLASSIFICATION
  1. According to the International Classification of Disease, 10th revision (ICD-10), which category describes neurasthenia?
    1. Adjustment disorders
    2. Dissociative disorders
    3. Other anxiety disorders
    4. Other neurotic disorders
    5. Somatoform disorders
  2. Which of the following statements with regard to ICD-10 classification is correct?
    1. Operational classification system
    2. Rigid in its definitions
    3. Suitable for research purposes
    4. More user friendly than the DSM-IV
    5. Widely used in USA
  3. Which of the following statements distinguishes the Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV) from the ICD-10?
    1. Bipolar I and bipolar II are differentiated in the ICD-10
    2. Borderline personality disorder is classified as impulsive and borderline in the ICD-10
    3. Personality disorder is classified on a separate axis in the DSM-IV
    4. Recurrent brief depressive disorder is a new addition to the DSM-IV
    5. Schizotypal disorder is with personality disorders in the DSM-IV
  4. Which of the following statements regarding the differences between the ICD-10 and the DSM-IV is correct?
    1. The ICD-10 has one version whereas the DSM-IV has different versions
    2. The ICD-10 is available in English only whereas the DSM-IV is available in all widely spoken languages
    3. The ICD-10 is a five-axis system classification whereas the DSM-IV is a three-axis classification
    4. The ICD-10 was developed by the World Health Organization whereas the DSM-IV was developed by the American Psychiatric Association
    5. The ICD-10 includes social consequences of disorders whereas the DSM-IV includes only clinical consequences of disorder
  5. Which of the following is included in axis V of the DSM-IV classification?
    1. General medical conditions
    2. Global assessment of functioning
    3. Learning disabilities
    4. Personality disorders
    5. Psychosocial and environmental problems
BASIC PSYCHOPHARMACOLOGY
  1. Which of the following statements regarding the pharmacokinetic properties of diazepam is correct?
    1. Desmethyldiazepam is an active metabolite
    2. Its elimination half-life is 10 times greater in elderly people than in young adults9
    3. The presence of food reduces the extent of its absorption
    4. There is 95% protein binding
    5. There is 50% bioavailability after oral administration
  2. Which of the following statements regarding the physiological effects of benzodiazepines at therapeutic doses is correct?
    1. Neuroendocrine systems are affected
    2. Stimulation of the afferent pathway results in muscle relaxation
    3. The dexamethasone suppression test is unaffected
    4. They have little effects on autonomic functions
    5. They induce hepatic microsomal enzymes
  3. Which of the following statements regarding the pharmacokinetics of psychotropic drugs is correct?
    1. First-order kinetics is a non-reversible reaction
    2. The concentration of an intravenously administered drug declines exponentially
    3. The metabolism of alcohol follows first-order kinetics
    4. The term ‘bioavailability’ refers to the fraction of drug that has been metabolised
    5. Two dose forms of the same drug with an equal bioavailability are bioequivalent
  4. Which drug should be prescribed with caution in conjunction with fluvoxamine?
    1. Amitriptyline
    2. Amlodipine
    3. Chlorpromazine
    4. Naproxen
    5. Paracetamol
  5. A 30-year-old man was stable on regular antipsychotic medication until 4 days ago when he was admitted with a severe acute psychotic episode. Since then, he has developed hyperpyrexia, muscular rigidity, profuse sweating and disorientation. What is the most likely diagnosis?
    1. Akathisia
    2. Dystonic reaction
    3. Extrapyramidal side effects
    4. Neuroleptic malignant syndrome
    5. Serotonin syndrome
  6. Which of the following is the most common side effect of acamprosate?
    1. Hair loss
    2. Headache
    3. Nausea
    4. Stomach cramps
    5. Vomiting
  7. Which statement regarding serotonin (5-HT2A) agonism is correct?
    1. 5-HT2A-receptors decrease extrapyramidal side effects
    2. 5-HT2A-receptors have no role in sleep regulation
    3. 5-HT2A-receptors increase dopamine release
    4. 5-HT2A-receptors increase glutamate release
    5. 5-HT2A-receptors inhibit cortical pyramidal neurons
  8. Which of the following noradrenergic receptors is presynaptic?
    1. α1
    2. α210
    3. α1
    4. 2
    5. 3
  9. Which of the following statements regarding monoamine interactions in the central nervous system is correct?
    1. Noradrenaline can control serotonin release only using feedback inhibition
    2. Serotonin has bidirectional control of noradrenaline release
    3. Stimulation of 5-HT2A-receptors leads to noradrenaline release
    4. Stimulation of α1-receptors leads to serotonin release
    5. Stimulation of α2-receptors leads to serotonin release
  10. What is the most likely mechanism of action of mirtazapine?
    1. 5-HT2A-receptor agonism
    2. 5-HT2C-receptor agonism
    3. α2-Receptor agonism
    4. α2-Receptor antagonism
    5. Blocking serotonin reuptake
  11. Which of the following neurotransmitters does venlafaxine act on?
    1. Dopamine only
    2. Noradrenaline only
    3. Serotonin and noradrenaline only
    4. Serotonin, noradrenaline and dopamine
    5. Serotonin only
  12. Which of the following drugs is a dopamine-2 (D2) antagonist?
    1. Amitriptyline
    2. Buspirone
    3. Diazepam
    4. Fluoxetine
    5. Zolpidem
  13. Which of the following drugs is most useful in the treatment of Gilles de la Tourette's syndrome?
    1. Amitriptyline
    2. Carbamazepine
    3. Dexamphetamine
    4. Haloperidol
    5. Methylphenidate
BASIC PSYCHOLOGICAL PROCESSES
  1. Which of the following is the gestalt determinant of grouping?
    1. Delusional set
    2. Discontinuation
    3. Dissimilarity
    4. Figure-ground differentiation
    5. Irreversible figures11
  2. A 5-year-old boy is unable to see the world from his father's point of view and his thinking is dominated by his own perspective. Which stage of Piaget's cognitive development does this best describe?
    1. Concrete operational stage
    2. Formal operational stage
    3. Postconventional stage
    4. Preoperational stage
    5. Sensorimotor stage
  3. A 13-year-old boy has developed logical thinking and the ability to test a hypothesis. At which stage of Piaget's cognitive development is the boy most likely to be?
    1. Concrete operational stage
    2. Formal operational stage
    3. Preconventional stage
    4. Preoperational stage
    5. Sensorimotor stage
  4. An 18-month-old boy discovers that he can make things happen. According to Piaget's cognitive development, which phenomenon of sensorimotor stage has this boy developed?
    1. Centation
    2. Circular reaction
    3. Egocentrism
    4. Object permanence
    5. Symbolic thought
  5. An 8-year-old boy refuses to go out with his friends and says that he will not go out because he does not want to be punished by his parents. At which stage of Kohlberg's model of development is the boy most likely to be?
    1. Conventional morality
    2. Maintaining social order and law
    3. Postconventional morality
    4. Preconventional morality
    5. Universal principle of justice
  6. A 13-year-old boy always does the right thing because he wants people to like him. At which stage of Kohlberg's model of development is the boy most likely to be?
    1. Conventional morality
    2. Maintaining social order and law
    3. Postconventional morality
    4. Preconventional morality
    5. Universal principle of justice
  7. A child starts to say understandable single words, such as ‘mummy’, ‘papa’, ‘doggie’. What is the most likely age of this child?
    1. 3 months
    2. 9 months
    3. 12 months
    4. 18 months
    5. 24 months12
  8. A girl has recently developed a fear of cats and dogs on the street. She has never behaved like this in the past. What is the most likely age of the girl?
    1. 3 years
    2. 5 years
    3. 5 years plus
    4. 10 years age
    5. Teenage onwards
  9. A boy used to pick things using his whole palm and all his fingers, but now he picks up objects using his index finger and thumb. What is his most likely age?
    1. 2 months
    2. 3 months
    3. 5 months
    4. 6 months
    5. 9 months
  10. A boy is going through the life stage of initiative versus guilt and has a fear of punishment. According to Erikson's stages of psychosocial development, what is his most likely age group?
    1. 0–18 months
    2. 18 months to 3 years
    3. 3–5 years
    4. 6–11 years
    5. 12–18 years
HUMAN PSYCHOLOGICAL DEVELOPMENT
  1. According to Mary Ainsworth's strange situation procedure, a 15-month-old infant tends not to protest or be distressed when the infant's mother leaves the room, and on reunion he or she ignores her and focuses on the environment. Which of the following best describes this attachment pattern?
    1. Ambivalent
    2. Anxious avoidant
    3. Disorganised
    4. Resistant
    5. Secure
  2. Which of the following occurs before the onset of object constancy?
    1. Conventional morality stage
    2. Oral phase
    3. Sensorimotor stage
    4. Separation anxiety
    5. Stranger anxiety
  3. Which of the following is most closely associated with the New York longitudinal study by Thomas and Chess?
    1. Attachment
    2. Imprinting
    3. Object constancy
    4. Temperament
    5. Theory of mind13
  4. Which of the following is included in sensori motor stage of Piaget's cognitive development?
    1. Animistic thinking
    2. Conservation
    3. Egocentric thinking
    4. Object permanence
    5. Transitive inference
  5. Which of the following statements about cognitive development is correct?
    1. Each stage is a prerequisite for the next stage of development
    2. Cognitive development is described by Jean Piaget in six stages
    3. It is described by Mary Ainsworth in four stages
    4. It leads to capacity for infant thought processes
    5. It pertains to monkeys as described by Harry Harlow
  6. Which of the following statements about learning is correct?
    1. Classic conditioning results from a person's actions
    2. Learning is defined as a change in cognitive functioning
    3. Operant learning is a result of environmental events
    4. Social learning incorporates both classic and operant models
    5. There are several types of learning processes
  7. Which of the following statements about learning theory is correct?
    1. Aversive conditioning punishment is used to reduce the frequency of target behaviour
    2. Classic conditioning is the association of a neutral stimulus with a conditioned stimulus, which brings the response originally elicited by an unconditioned stimulus
    3. In habituation, the response to a repeated stimulus increases over time
    4. In operant conditioning, behaviour frequency is altered by observational learning
    5. Instrumental learning means something that is pivotal in the learning process
SOCIAL PSYCHOLOGY
  1. A 37-year-old man was overlooked for a job position that he really wanted. He told himself that he did not want the job because of the long hours and burden of responsibility. This is an example of cognitive dissonance and a strategy to achieve cognitive consistency. Which of the following strategies would most likely achieve cognitive consistency?
    1. Adding new cognitions that are not consistent with pre-existing ones
    2. Changing cognitions involved in the dissonant relationship
    3. Changing the behaviour that is consistent with the cognitions
    4. Gathering new information to substantiate the original beliefs
    5. Holding on to previously held beliefs despite evidence to the contrary
  2. Which of the following statements about the Likert scale is correct?
    1. It has a lower sensitivity compared with a dichotomous scale
    2. It is a four-point scale that indicates the level of agreement with presented statements
    3. It is difficult to administer
    4. It leads to the same mean score in different response patterns
    5. Ranking is biased14
  3. Which of the following theories suggests that, when two beliefs are mutually inconsistent, the one that is less firmly held will change?
    1. Festinger's cognitive dissonance theory
    2. Heider's balance theory
    3. Osgood and Tannenbaum's congruity theory
    4. Post-decision dissonance
    5. Self-evaluation maintenance theory
  4. Which of the following theories suggests that people prefer relationships that appear to offer an optimum cost-benefit ratio?
    1. Attribution theory
    2. Equity theory
    3. Proxemics theory
    4. Reinforcement theory
    5. Social exchange theory
DESCRIPTION AND MEASUREMENT
  1. Which of the following statements about the Wisconsin card sorting test (WCST) is correct?
    1. It is administered to detect parietal lobe lesions
    2. It consists of 100 cards
    3. It consists of cards that differ solely in terms of colour
    4. It is useful in detecting frontal lobe lesions
    5. The Weschler adult intelligence scale is a part of the WCST
  2. Which of the following has the highest life change value according to Holmes and Rahe's social adjustment rating scale?
    1. Birth of a child
    2. Death of a spouse/partner
    3. Divorce
    4. Marriage
    5. Separation from a spouse/partner
  3. Which of the following statements is consistent with a selective attention task?
    1. Non-target stimuli are represented among a series of random stimuli on a computer screen
    2. The task is measured by the serial sevens test
    3. The Stroop colour word test assesses selective attention maintained in the face of interference
    4. The target appears on the screen along with randomly distributed target stimuli
    5. The WCST is used to determine selective attention
  4. Which of the following statements indicates that a test to measure cognitive function has good construct validity?
    1. The test appears to be good at measuring cognitive function
    2. The test correlates well with other established tests of cognitive function
    3. The test covers most of the important aspects of cognitive function that need to be assessed
    4. The test measures cognitive function accurately
    5. The test produces similar findings when repeated15
  5. Which of the following statements is consistent with Beck's depression inventory?
    1. It consists of 21 items
    2. It focuses on somatic and behavioural symptoms
    3. It has the highest possible score of 42
    4. It is a clinician-administered scale
    5. It rates symptoms over the last 5 days
BASIC PSYCHOLOGICAL TREATMENTS
  1. In cognitive therapy, what does the term ‘cognition’ refer to?
    1. Attitude
    2. Beliefs
    3. Dissonance
    4. Events
    5. Impairment
  2. A 34-year-old depressed man was assessed for cognitive-behavioural therapy. He admitted that he sees things as good or bad, right or wrong. Which of the following cognitive distortions describes this best?
    1. Arbitrary inference
    2. Categorisation
    3. Dichotomous reasoning
    4. Overgeneralisation
    5. Selective abstraction
  3. A 54-year-old, married, depressed woman was assessed for cognitive-behavioural therapy (CBT). Which of the following statements about CBT is correct?
    1. It includes optimistic expectation of the future
    2. It includes understanding of the importance of dreams
    3. It suggests that life events play an important part in the genesis of depression
    4. It uses the concept of positive reinforcement
    5. It was influenced by the work of Albert Ellis
  4. A 32-year-old woman with agoraphobia was assessed for behaviour therapy. Which of the following is she fearful of?
    1. Family history
    2. Crowds
    3. Heights
    4. Open spaces
    5. Recent life events
  5. A 24-year-old man with social anxiety disorder was assessed for behaviour therapy. Which of the following is included in behavioural assessments?
    1. Assimilation
    2. Habituation
    3. Incubation
    4. Preparedness
    5. Resistance16
PREVENTION OF PSYCHIATRIC DISORDER
  1. A 24-year-old woman had had psychotic symptoms for several months before seeking treatment. Which of the following statements about the duration of an untreated first-episode psychosis (DUP) is correct?
    1. The benefits of reducing the DUP have not been established
    2. The benefits of reducing the DUP appear to be long-lasting
    3. There is no significant difference in the outcome if treated early
    4. Only the negative symptoms of psychosis improve with a short DUP
    5. Only the positive symptoms of psychosis improve with a short DUP
  2. An 18-year-old man with sub-threshold symptoms of psychosis is prescribed low-dose risperidone along with CBT. Which of the following statements is correct with regard to the transition to first-episode psychosis after treatment?
    1. Sixty per cent of patients transition to first-episode psychosis
    2. An antipsychotic alone is as effective as combination therapy
    3. Negative symptoms are a strong predictor for transition
    4. The onset of a first-episode psychosis is delayed
    5. There is no effect on the severity of the neurotic symptoms
  3. A 60-year-old man with a 30-year history of bipolar affective disorder has been stable on lithium for many years. His serum urea and creatinine levels have recently been steadily increasing above the normal levels. Which of the following is the most appropriate treatment to maintain his current level of stability?
    1. Chlorpromazine
    2. Depot antipsychotics
    3. Lamotrigine
    4. Sodium valproate
    5. Trifluoperazine
  4. A 35-year-old woman with a history of recurrent depressive disorder has been stable for a long time on sertraline 100 mg/day. She wishes to conceive and is considering whether or not to taper and stop medication before attempting conception. Which of the following is the most likely scenario if this woman decided to do so?
    1. She has a two-fold risk of relapse
    2. She has a five-fold risk of relapse
    3. She has a ten-fold risk of relapse
    4. She has an approximately 30% increased risk of relapse
    5. She will remain well as women are uniquely protected against depressive relapse during pregnancy
DESCRIPTIVE PSYCHOPATHOLOGY
  1. A 74-year-old man is reviewed in the outpatient clinic after a stroke. It is observed that he has severe lability of mood, and involuntary episodes of crying and laughing. What is the most likely psychopathology seen in his case?
    1. Depression
    2. Emotional incontinence
    3. Mania
    4. Mixed affective state
    5. Rapid cycling affective disorder17
  2. An 80-year-old woman diagnosed with severe depression believes that her intestines have stopped working and her other internal organs are degenerating, suggesting that she is dead and a walking corpse. Which of the following delusions is most appropriate to describe her belief?
    1. Grandiose delusions
    2. Guilt delusions
    3. Infidelity delusions
    4. Nihilistic delusions
    5. Persecutory delusions
  3. A 33-year-old man with schizophrenia takes the offered hand but withdraws it several times without shaking hands. Which of the following symptoms is he exhibiting?
    1. Ambitendence
    2. Ambivalence
    3. Chorea
    4. Negativism
    5. Stereotypy
  4. A 10-year-old boy speaks clearly and fluently in school but becomes mute when at home. Which phenomenon is described in this case?
    1. Akinetic mutism
    2. Elective mutism
    3. Poverty of speech
    4. Selective mutism
    5. Stammering
  5. A 23-year-old man's mother died in an accident. Instead of feeling sad, he laughs and makes jokes with others. Which of the following terms describes this behaviour?
    1. Alexithymia
    2. Blunted affect
    3. Flat affect
    4. Incongruent affect
    5. Labile affect
  6. Which of the following is a formal thought disorder?
    1. Delusions of persecution
    2. Tangentiality
    3. Thought broadcasting
    4. Thought insertion
    5. Thought withdrawal
  7. A 33-year-old woman with an obsessive-compulsive disorder gets intrusive thoughts about the safety of her husband. To cope with these thoughts, she prays three times, buys things in multiples of three and washes her hands three times on each occasion that she experiences these thoughts. Which of the following is most appropriate to describe her behaviour?
    1. Compulsions
    2. Coping skills
    3. Delusions
    4. Flight of ideas
    5. Normal behaviour18
  8. A 40-year-old woman feels odd sensations such as electric shocks coming from her feet and that she is having sexual intercourse while asleep. Which of the following is most likely to describe her experience?
    1. Delusions of persecution
    2. Overvalued idea
    3. Passivity phenomenon
    4. Nihilistic delusions
    5. Somatic hallucinations
  9. A 22-year-old African man covers his head with a cap. He claims that he is doing this to prevent people from hearing his thoughts, which apparently can be transmitted from his head. What is the most likely description?
    1. Over-valued idea
    2. Thought blocking
    3. Thought broadcasting
    4. Thought echo
    5. Thought insertion
  10. A 35-year-old woman believes that Bill Clinton is in love with her. She has never met Bill Clinton. However, she believes that he is posting her love letters through adverts in the newspaper. Which of the following terms is most appropriate to describe her belief?
    1. Capgras' delusion
    2. Cotard's syndrome
    3. Couvade's syndrome
    4. De Clerambault's delusion
    5. Othello's syndrome
  11. A 32-year-old woman with a diagnosis of schizophrenia believes that she had a sex change operation at the age of 7 years and since then became a female. Which of the following terms best describes her experience?
    1. Delusional memory
    2. Delusional mood
    3. Depression
    4. Negative symptoms
    5. Positive symptoms
  12. An 18-year-old man was recently diagnosed with a first episode of psychosis. He has a sense of perplexity and uncertainty, and feels that something is wrong around him, but can't describe what it is. What is he most likely experiencing?
    1. Delusional memory
    2. Delusional mood
    3. Depression
    4. Negative symptoms
    5. Positive symptoms
  13. A 40-year-old man with alcohol dependence saw his wife talking to her boss at work. Since then he believes that she was having an affair with her boss that involved a sexual relationship, despite a lack of evidence. Which of the following is most likely to describe his belief?
    1. Capgras' delusion
    2. Cotard's syndrome
    3. Couvade's syndrome
    4. De Clerambault's delusion
    5. Othello's syndrome19
  14. An 82-year-old woman believes that her body was infested by parasites. She brought her skin scrapings in a box to the outpatient clinic saying that these were the mites. Which of the following is most likely to explain her presentation?
    1. Capgras' delusion
    2. Cotard's syndrome
    3. Couvade's syndrome
    4. Delusory cleptoparasitosis
    5. Ekbom's syndrome
  15. A 19-year-old male student was in a rush to catch the last flight to Poland. In his haste, he read Holland as Poland and reached the wrong terminal. Which of the following terms is most likely to describe his behaviour?
    1. Affect illusion
    2. Completion illusion
    3. Delusion
    4. Hallucination
    5. Pareidolic illusion
  16. A 40-year-old woman with a phobia of the dark sees a figure of a ‘ghost’ when she looks at a tree on a dark night. Which of the following terms is most likely to describe her experience?
    1. Affect illusion
    2. Completion illusion
    3. Delusion
    4. Hallucination
    5. Pareidolic illusion
  17. A 7-year-old boy sees the figure of a car when he looks into the clouds. Which of the following terms is most likely to describe his experience?
    1. Affect illusion
    2. Completion illusion
    3. Delusion
    4. Hallucination
    5. Pareidolic illusion
  18. A 36-year-old man with a diagnosis of schizophrenia hears the voice of his dead mother whenever he hears the noise of water running from a tap. Which hallucination is most likely being described?
    1. Elementary hallucination
    2. Extracampine hallucination
    3. Functional hallucination
    4. Reflex hallucination
    5. Reverse hallucination
  19. A 36-year-old man with a diagnosis of schizophrenia sees different colours in the sky whenever he hears the noise of water running from a tap. Which hallucination is most likely being described?
    1. Elementary hallucination
    2. Extracampine hallucination
    3. Functional hallucination
    4. Reflex hallucination
    5. Reverse hallucination20
  20. A 40-year-old man with a diagnosis of schizophrenia hears the voice of his dead sister who was buried in another village 30 miles away from his town. Which hallucination is most likely being described?
    1. Elementary hallucination
    2. Extracampine hallucination
    3. Functional hallucination
    4. Reflex hallucination
    5. Reverse hallucination
DYNAMIC PSYCHOPATHOLOGY
  1. A 29-year-old male CT3 psychiatric trainee was put down badly by his consultant in a ward round. He wasn't able to say anything to the consultant when the consultant shouted at him. When he returned home, he became verbally abusive and aggressive towards his wife. What is the most likely phenomenon?
    1. Displacement
    2. Identification
    3. Projection
    4. Reaction formation
    5. Regression
  2. A 26-year-old male CT1 psychiatric trainee was put down badly by his consultant in a ward round and the consultant shouted at him. After work, he went to see his mother and started to present childish behaviour such as playing with his old toy cars. Which is the most likely defence mechanism?
    1. Displacement
    2. Isolation
    3. Projection
    4. Regression
    5. Sublimation
  3. A 27-year-old male CT2 psychiatric trainee was put down by his consultant in a ward round and the consultant shouted at him. After work, he went to the gym and exercised for half an hour more than usual. What is the most likely phenomenon?
    1. Reaction formation
    2. Repression
    3. Sublimation
    4. Turning against self
    5. Undoing
  4. A 40-year-old male follower of Mahatma Gandhi does not cooperate with the extra and unnecessary tasks given to him by his manager at work. He never displays his anger by shouting or becoming physically aggressive. What is the most likely phenomenon?
    1. Aggression
    2. Isolation
    3. Passive aggression
    4. Regression
    5. Repression21
HISTORY OF PSYCHIATRY
  1. In which year was Sigmund Freud born?
    1. 1852
    2. 1854
    3. 1856
    4. 1858
    5. 1860
  2. Where was Sigmund Freud born?
    1. America
    2. Brazil
    3. Czech Republic
    4. Germany
    5. Spain
BASIC ETHICS AND PHILOSOPHY OF PSYCHIATRY
  1. The police arrived on your ward and enquired about one of your patients. Under which circumstances would you be able to breach patient confidentiality?
    1. Domestic dispute
    2. Investigation of a serious crime
    3. Participation in riots
    4. Possession of cannabis for personal use
    5. Patient caught shop-lifting
  2. Which statement is correct about the consent to participate in clinical research?
    1. All clinical drug trials require adult participants to give informed consent
    2. Consent must be witnessed by someone who is independent and part of the trial team
    3. Consent must be written to be valid
    4. Information sheets for research must refer to the evidence base for the trial
    5. Participants can withdraw consent to all data collected at any time during the study
  3. Thought insertion, withdrawal, broadcasting, and delusions of perception and control are all the first rank symptoms of schizophrenia. Who first proposed these first rank symptoms?
    1. Carl Schneider
    2. Emil Kraepelin
    3. Eugene Bleuler
    4. Kurt Schneider
    5. Sigmund Freud
  4. A 20-year-old man presented with shallow mood and his thoughts were disorganised. He was diagnosed with hebephrenic schizophrenia. Who described hebephrenic schizophrenia?
    1. Eugen Bleuler
    2. Emil Kraeplin
    3. Ewald Hecker
    4. Kurt Schneider
    5. William Tuke22
  5. A 26-year-old male school teacher presents with anhedonia, which is a lack of pleasure in activities that were previously enjoyable. Who is most closely associated with the term ‘anhedonia’?
    1. Donald Cameron
    2. Karl Kahlbaum
    3. Jabob Moreno
    4. Théodule-Armand Ribot
    5. Peter Sifneos
  6. A 43-year-old man finds it difficult to verbalise his emotions. His psychiatrist friend says that it is alexithymia. Who is most closely associated with the term ‘alexithymia’?
    1. Donald Cameron
    2. Karl Kahlbaum
    3. Jabob Moreno
    4. Théodule-Armand Ribot
    5. Peter Sifneos
STIGMA AND CULTURE
  1. Which of the following is seen in latah?
    1. It is a dissociative state
    2. It is an acute paranoid state that occurs after use of street marijuana
    3. It is closely associated with religion
    4. It is usually found in South America
    5. It is treatable by ‘suggestibility’
  2. Which of the following is consistent with Da Costa's syndrome?
    1. It is a culture-bound syndrome found in North America
    2. It is closely associated with depression
    3. It is treatable by aspirin
    4. Syncope is a prominent symptom
    5. Symptoms are similar to those of cardiac dysfunction
  3. Susto is also translated as ‘fright sickness’. Which statement about susto is correct?
    1. It is a depressive state
    2. It is a psychotic state
    3. It is an obsessive state
    4. It is seen in North America
    5. It responds to antidepressants
  4. When severe, which of the following conditions is called espanto?
    1. Brain-fag syndrome
    2. Da Costa's syndrome
    3. Latah
    4. Susto
    5. Windigo23
  5. Windigo is a culture-bound syndrome. Which statement about windigo is correct?
    1. It is classified as a culture-bound psychotic syndrome in the DSM-IV
    2. It is the compulsive desire to become a cannibal
    3. It is found in South America
    4. It is treated by an antipsychotic drug
    5. It presents mainly with anxiety symptoms
  6. Brain fag is a culture-bound syndrome. Which statement is regarding brain fag is correct?
    1. It causes the patient to have difficulty in remembering and concentrating
    2. It is a condition of fading brain in elderly people
    3. It is a psychotic disorder
    4. It occurs as a result of eating in⊴fected animal's brains
    5. It presents with symptoms that occur in the form of tiredness all over the body
24
Answers: MCQs
  1. E Three-word recall
    Patients with severe depression can present with significant cognitive impairment such as poor concentration and short-term memory problems. Cognitive functions can be clinically evaluated by performing an MMSE. In this test, three-word recall is used to test short-term memory. Drawing intersecting pentagons, naming, repetition, a three-stage command, reading and writing are useful for testing language. Tests of serial sevens and spelling backwards are used to evaluate attention and concentration. In addition, the MMSE includes tests for orientation to time and place. The clock-drawing test is used to screen executive functions, and visuospatial and constructional praxis. It is not a part of the MMSE, although it is usually used alongside this test.
  2. E Perseveration is a sign of a frontal lobe lesion
    Perseveration occurs when mental operations persist beyond the point at which they are relevant. This includes senseless repetition of words, gestures or actions. Perseveration is related to the severity of the task facing the patient. It is common in generalised and focal organic brain disorders. For a person with a frontal lobe lesion, the ability to plan ahead is impaired or lost. Other signs and symptoms of frontal lobe dysfunction include cognitive difficulties such as poor short-term memory, poor working memory and impairment of executive functions, behavioural difficulties such as utilisation, aggression, increased sexuality and emotional difficulties. Agnosis is related to receptive aphasias in which the patient experiences sensory stimuli but cannot recognise objects. Dyscalculia is a specific learning disability involving difficulties with calculations.
  3. A Attention
    The MMSE is a brief structured interview designed to assess cognitive status. It provides quantitative measurements of orientation, memory, calculations and other aspects of the systematic mental state examination. The maximum score is 30 points. The test of serial sevens tests attention and concentration. Registration and recall tests immediate and short-term memory respectively.
  4. D The muscle tone is preserved
    Automatism is defined as a state that occurs during an ictal or post-ictal state and is characterised by clouding of consciousness. In this state, muscle tone and posture are preserved, though there may be limited awareness of action. It lasts from a few minutes to several hours and the individual may have little to no recollection of events. Automatism can be used as a defence in a criminal case. The legal definition of automatism is an act committed during a state of unconsciousness or grossly impaired consciousness. Such an act lacks a guilty mind. There are two types of automatisms: sane and insane. The difference between the two is based on whether the automatism or behaviour leading to the offence is likely to recur. Sane automatisms are considered singular events resulting from exogenous causes, such as confusional states, hypoglycaemia or night terrors. They lead to a full acquittal. Insane automatisms are viewed as events caused by a disease of the mind that are likely to recur. They therefore require control of the individual to ensure public safety and can lead to a verdict of not guilty by reason of insanity.
  5. B Amnesia of the episode
    Ganser's syndrome was first described in 1898 when it was indentified in four criminals. It is characterised by approximate answers, clouding of consciousness, auditory or visual hallucinations, 25and amnesia of the episode. Perseveration, echolalia, echopraxia and hysterical paralysis may be observed. Interestingly, these symptoms are worse when the patient is being observed. It is associated with a recent history of head injury or severe emotional stress, and may be followed by depression.
  6. D Delirium
    In this clinical scenario, patient has fluctuating consciousness, impaired concentration and cognitive impairment that suggest that he has delirium. There is no evidence of psychotic symptoms or panic disorder. The overdose might have been precipitated by stress or an argument with the patient's girlfriend. An adjustment disorder is not associated with cognitive impairment.
  7. D Non-fluent expressive dysphasia
    The clinical features in this case scenario indicate that the patient has frontal lobe dementia. A lesion in the left frontal lobe can result in Broca's aphasia which is characterised by reduced frequency of speech and relatively preserved comprehension. Language is reduced to a few disjointed words and the failure to construct sentences. Left temporoparietal damage results in language that is fluent although the words themselves are incorrect. This is known as Wernicke's aphasia, receptive aphasia or posterior aphasia. Dysarthria simply means disordered articulation, i.e. slurred speech. Dyslexia describes a delayed and disorganised ability to read and write.
  8. E Vascular dementia
    Initially, the term ‘catastrophic reaction’ was applied to a patient's performance on neuropsychological assessment. A catastrophic reaction manifests as disruptive emotional behaviour when a patient is given a difficult task. It occurs especially when a patient is unable to solve a problem. The damage to the language areas plays an important part in its aetiology. It is commonly seen in Alzheimer's disease, vascular dementias and stroke.
  9. D The trail-making test
    Working memory and attention can be assessed by the trail-making test. This test includes 2 parts and involves accurately joining 25 dots as fast as possible. The behavioural inattention test (BIT) is a test for detecting and measuring the severity of visual neglect, primarily in stroke and head-injured patients. It consists of six conventional tests which include star cancellation and line cancellation. It also includes nine behavioural tests. The Hayling and Brixton tests assess aspects of frontal executive functions. The Hayling sentence completion test measures the ability to inhibit a habitual or prepotent response. The Brixton test measures the ability to detect rules in sequences of stimuli and concept formation. The token test helps to measure auditory comprehension in patients with aphasia due to stroke. The zoo map is a test of planning.
  10. D Matrix reasoning
    The Wechsler adult intelligence scale has both verbal and performance components. The verbal IQ is tested using subtests such as similarities, vocabulary, information, arithmetic, digit span and comprehension. The performance IQ is calculated based on picture completion, digit symbol coding, block design, matrix reasoning and picture arrangement. Symbol search, letter-number sequencing and object assembly are other subtests.
  11. D Remote
    In this case, the situation tests remote memory, which is recollection of past events. Working memory and immediate memory last for seconds. Recent memory is for a few hours at most. Procedural memory is more implicit, e.g. driving a car.26
  12. B 2
    The Glasgow coma scale is useful in assessing and monitoring a patient's level of consciousness. It is classified into best motor response, best verbal response and best eye-opening response. The eye-opening response is scored as follows: 1 = not opening the eyes, 2 = opening eyes to pain, 3 = opening the eyes to speech and 4 = spontaneously opening the eyes.
  13. D Raven's progressive matrices
    This consists of a series of visuospatial problem-solving tasks, which are thought to tap general intelligence, i.e. they are relatively independent of educational or cultural background. Test-re-test reliability is > 0.8 and internal reliability is > 0.7. It has a published normative rate-of-decay profile, which is defined as the normal pattern of failing more items as the test becomes progressively more difficult. This allows the detection of individuals who are faking poor performance, e.g. in compensation claims. The California verbal learning test is used to test verbal memory. The national adult reading test is used to test premorbid intelligence in English-speaking individuals with dementia. The Cambridge contextual reading test is used to measure premorbid intelligence in individuals with mild-to-moderate dementia. It has a higher predictive value than the national adult reading test. The WAIS is used to measure intelligence in adults and adolescents.
  14. E Vascular dementia
    NINDS-AIREN (NINDS-AIREN = Neuroepidemiology Branch of the National Institute of Neurological Disorders and Stroke-Association International pour la Recherche et l'Enseignement en Neurosciences) criteria are useful in the diagnosis of vascular dementia.
    NINCDS/ADRDA (NINCDS/ADRDA = National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer's Disease and Related Disorders Association) criteria are useful in the diagnosis of Alzheimer's dementia.
    The international consensus criteria for dementia with Lewy bodies are used for the diagnosis of Lewy body dementia.
    The Lund-Manchester criteria and NINDS criteria are useful for the diagnosis of frontotemporal dementia. Normal pressure hydrocephalus is characterised by a triad of symptoms: ataxia, dementia and urinary incontinence
  15. D Matrix reasoning
    The verbal IQ is calculated based on the sum of subtests: vocabulary, similarities, arithmetic, digit span, information and comprehension. Factor analysis has suggested that these subtests do not fall neatly into verbal and performance IQ; instead four factors emerge: verbal comprehension, perceptual organisation, working memory and processing speed. With the addition of three further subtests (symbol search, letter-number, sequencing and object assembly), it is also possible to calculate the scores on these four factors. The WAIS-III is a significant improvement on its predecessors in terms of better norms, improved artwork for visually presented items, and reliability coefficients for IQ scales and indices (0.88–0.97).
  16. D When light shone back to the left eye from the right, the pupil dilates
    Relative afferent pupillary defect (RAPD) occurs when there has been incomplete damage to the afferent pupillary pathway; this can occur with retrobulbar neuritis. Complete recovery may be apparent, but RAPD is still detected on routine examination. This deficit is detected using the 27swinging-flashlight test. In this case, when light is shone in the left affected eye, it causes both pupils to constrict. The light is swung to the right eye and both pupils constrict and then it is swung back to the left affected eye and the pupil dilates. This clinical observation indicates that there is incomplete damage in the afferent pupillary pathway.
  17. D Pure word deafness
    This is a syndrome of isolated loss of auditory comprehension and repetition, without any abnormality of speech, naming, reading, or writing. Auditory sound agnosia is a similar syndrome in which the individual is unable to hear nonverbal sounds, e.g. the sound of a bell ringing, despite having intact hearing.
  18. B Optic chiasma
    Bilateral defects are caused by lesions of the optic chiasma, and include pituitary neoplasms, meningiomas, craniopharyngiomas and secondary neoplasms. When one half of the field is affected, it is called hemianopia; when a quadrant is affected, it is called quadrantanopia. Visual field defects caused by lesions of each optic tract, optic radiation and cortex are called ‘homonymous’ to indicate the different, i.e. bilateral, origins of each unilateral pathway.
  19. D Toxoplasma encephalitis
    Patients who are HIV positive and have acquired immune deficiency syndrome are prone to opportunistic infections. Toxoplasmosis is the most common opportunistic infection in the brain in this group of patients. Toxoplasma gondii causes encephalitis and cerebral abscess, usually because of reactivation of previously acquired infection. It is treated with pyrimethamine combined with sulfadiazine and folinic acid.
  20. A Abnormal synacthen test
    In this case, the patient has Addison's disease (primary hypoadrenalism), which is characterised by weight loss, anorexia, malaise, weakness, depression, nausea, vomiting, diarrhoea, myalgia and pigmentation (dust, slaty grey-brown). The short tetracosactide (synacthen) test is indicated for a diagnosis of Addison's disease and screening for adrenocorticotropic hormone (ACTH) deficiency should also be carried out. A patient with Addison's disease will show an impaired cortisol response to ACTH (normal response: 30-min cortisol >600 nmol/L). A patient with Addison's disease will have hypokalaemia. Acanthosis is a diffuse hyperplasia with thickening of the stratum spinosum. A low level of ceruloplasmin is seen in Wilson's disease.
  21. D Increased free serum copper
    The clinical presentation described is consistent with a diagnosis of Wilson's disease, also known as hepatolenticular degeneration. It is a rare autosomal recessive disorder due to a defect in the Wilson's disease gene (ATP7B) located on chromosome 13. It is characterised by deposition of copper in various parts of the body, including the liver, basal ganglia and cornea. In this disorder, free serum copper and 24-hour urinary copper are increased, whereas serum ceruloplasmin and total copper are decreased. A liver biopsy usually indicates increased copper deposition. Treatment includes long-term use of copper-chelating agents such as penicillamine or trientine, a low-copper diet and avoiding food with a high copper content such as chocolate and peanuts.28
  22. E Raised urinary catecholamine
    In this case signs and symptoms indicate that the patient suffers from a phaeochromocytoma. Phaeochromocytomas are tumours of the sympathetic nervous system. They are very rare, with fewer than 1 in 1000 cases of hypertension. Of these tumours 90% arise in the adrenal gland and 10% occur elsewhere in the sympathetic chain; 25% are multiple and 10% malignant. The clinical features are those of catecholamine excess and are frequently, but not necessarily, intermittent. The measurement of urinary metabolites (metanephrines and vanillylmandelic acid) is a useful screening test.
  23. A General health questionnaire
    Mental disorders in primary care settings pose a considerable burden, not only to the individual and their family but also to primary care services and, economically, to society. The general health questionnaire is designed for use as a screening instrument in primary care, general medical practice or community surveys. There is also a version with subscales for somatic symptoms, anxiety, insomnia, depression and social dysfunction. The other tests are not useful in assessing mood in the given case and presentation in primary care.
  24. E Mini-mental state examination
    There are numerous tests available to detect cognitive impairment. The MMSE remains a common screening tool for dementia. It is scored out of 30 points and assesses the areas of orientation, registration, recall, language, construction ability, attention and concentration. The clinical dementia rating scale gives an overall severity rating in dementia. The clock-drawing test helps to understand a patient's constructional abilities and, more importantly, his or her planning and organisational ability. Hachinski's ischaemia score helps to differentiate between vascular dementia and Alzheimer's disease.
  25. E Wisconsin card sorting test (WCST)
    This measures the ability to alter a cognitive set, show deficits in executive and conceptual functions, as well as initiate and monitor the patient's own actions. Some researchers have queried the task's sensitivity to frontal lobe pathology.
  26. D Ophthalmoplegia
    Wernicke's encephalopathy is classically characterised by the triad of ophthalmoplegia, ataxia and global confusion. Other features may include hypothermia, hypotension, coma, cardiovascular problems and peripheral neuropathies. There is a mortality rate of 10–20% despite adequate treatment.
  27. B Anterograde amnesia
    Korsakoff's syndrome is characterised by a severe memory defect, particularly for recent events and new information, and the patient compensates for this by confabulation. Polyneuropathy may be present and other associated symptoms may include delirium, confusion, disorientation in time and place, impaired attention and concentration, anxiety fear, depression and delusions. It is caused by thiamine deficiency.29
  28. B Calmly leave the interview room
    It is important to allow the patient, as far as possible, to describe his symptoms spontaneously. However, when the patient threatens violence it is difficult to follow the current plan of interviewing. It is safer to leave the interview room and obtain further assistance.
  29. E Overdose when alone in a hotel room
    Suicide increases as a function of age. It is rare in children aged < 12 years. It increases after puberty and the incidence continues to increase in the adolescent years. Adverse life events, especially interpersonal relationship difficulties, unemployment, socio-economic adversity, intention and careful planning are associated with a higher suicide risk.
  30. E Transketolase
    Transketolase deficiency affects carbohydrate metabolism in the brain and is believed to predispose to the occurrence of alcoholic organic brain complications. Guanylyl cyclase and phospholipase A2 are examples of effectors for neurotransmitter ligands acting through G-protein couple receptors. Conversion of ethanol to acetaldehyde requires the enzyme alcohol dehydrogenase. Acetaldehyde dehydrogenase deficiency affects alcohol metabolism, resulting in an accumulation of acetaldehyde. This can cause the alcohol flush reaction.
  31. E Poor parental supervision
    Causes of juvenile delinquency are complex and overlap with the causes of conduct disorder. They include social factors (e.g. low social class, poverty, poor housing and poor education), family factors (e.g. large family size, child-rearing practices including erratic discipline, harsh or neglecting care, martial disharmony, inconsistent and ineffective discipline, parental violence and aggression) and child factors (e.g. low IQ, educational and reading difficulties).
  32. C Functional abnormalities in the prefrontal area
    Attention deficit hyperactivity disorder is an aetiologically heterogeneous disorder, with genetic, neurochemical, affective-cognitive and social environment adversities contributing to the overall liability for the disorder. Genetic studies indicate heritability estimates of 70% or more. Neuroimaging studies show functional abnormalities in the prefrontal area, and other areas associated with executive function and the cerebellum.
  33. E Ventral tegmental area dopamine and enkephalin
    Availability of alcohol is a powerful determinant of the level of consumption. Culture and tradition are potent influences on the pattern of drinking. The start of drinking is influenced by the setting, the company and expectancies about the likely effects. A number of biological markers have been identified that may predict a vulnerability to developing alcohol abuse. They include reduced electroencephalography α activity and reduced P300 wave amplitude.
  34. B Antisocial behaviour
    Conduct disorders in childhood consist of temper tantrums, oppositional behaviour, irritability, aggression, stealing, lying, bullying and truancy. Continuation into adult life is common and over 50% of patients will have problems as adults.30
  35. A Being born in an urban area
    The risk factors for developing schizophrenia are family history, migrant or ethnic minority status, chronic cannabis or stimulant use, urban birth or residence, obstetric complications, maternal flu, malnutrition and winter birth. Genetic studies suggest that environmental factors contributing to the aetiology of schizophrenia are more likely to be unique or non-shared rather than familial.
  36. A Charles Bonnet syndrome
    The Charles Bonnet syndrome is a syndrome of visual hallucinations without any other psychotic symptoms or any evidence of mental illness. It consists of formed, complex, persistent, repetitive and stereotyped visual hallucinations. The patient recognises them as unreal, which may be enjoyable or distressing. This condition is associated with visual impairment.
  37. B Delirium
    The cardinal feature of delirium is disturbed consciousness with disorientation in time and place, which typically fluctuates over the course of 24 hours with nocturnal deterioration. Two broad patterns of presentation are recognised. One pattern is where the patient is restless, irritable and over-sensitive to stimuli with psychotic symptoms and the other pattern is where there is psychomotor retardation and perseveration without psychotic symptoms.
  38. A Acute stress reaction
    In this case, signs and symptoms are suggestive of an acute stress reaction. It shares one of the two main criteria for post-traumatic stress disorder, which is the presence of a traumatic event. It starts within minutes of a traumatic event. The acute stress reaction resolves within hours in the absence of a stimulus and in 1–3 days in the presence of a stimulus. The resolution of symptoms starts in 8 hours in the absence of a stimulus and in 48 hours in the presence of a stimulus.
  39. E Post-traumatic stress disorder
    In this case, signs and symptoms are suggestive of post-traumatic stress disorder. After exposure to a traumatic event, this condition can occur within 6 months and, in certain instances, beyond this period. The symptoms include avoidance of the place of the incident, reliving the incident repeatedly, nightmares, irritability, hypervigilance and an exaggerated startled response. Patients can have an inability to recall certain parts of the incident.
  40. D Other neurotic disorders
    According to the ICD-10 classification system, neurasthenia is classified under other neurotic disorders. There are two main types of neurasthenia. In one of the types, affected individuals complain of increased tiredness after minimum mental effort and have disturbances in their concentration and thought processes. In the other type of neurasthenia, affected individuals present with physical symptoms such as weakness and tiredness. They complain of aches, pains and muscle weakness. In addition, neurasthenia can present with irritable mood, lack of interest and sleep disturbance.
  41. D More user friendly than the DSM-IV
    The ICD-10 classification system is clinically-oriented and less rigid in its definitions. It is less suitable for research purposes. Owing to its clinical orientation, the ICD-10 is more user-friendly 31than the DSM-IV. On the other hand, the DSM-IV is operational and has rigid definitions. It is suitable for research purposes. The ICD-10 is published by World Health Organization and is used widely in the UK and other parts of Europe. The DSM-IV is published by the American Psychiatric Association and is used widely in the USA.
  42. C Personality disorder is classified on a separate axis in the DSM-IV
    The DSM-IV and ICD-10 are two of the most widely used psychiatric classification systems. Personality disorder is classified separately on axis II in the DSM-IV, whereas in the ICD-10 it is classified along with current mental state diagnosis. The ICD-10 classification system does not distinguish between bipolar I and bipolar II since it was recognised after the ICD-10 was published in 1992. Recurrent brief depressive disorder is a new addition to the ICD-10. Schizotypal disorder is classified with schizophrenia in the ICD-10, whereas it is classified with personality disorder in DSM-IV. Borderline personality disorder, as found in the DSM-IV, is classified as an emotionally unstable personality disorder in the ICD-10.
  43. D The ICD-10 was developed by the World Health Organization whereas the DSM-IV was developed by the American Psychiatric Association
    The ICD-10 is available in all widely spoken languages. It has a single axis in chapter V. However, a separate, three-axis, multiaxial ICD-10 classification is available for use. The DSM-IV is available in English only and is a five-axis, multiaxial system. The ICD-10 has different versions for research, clinical work and primary care, whereas the DSM-IV has only one version. The ICD-10 does not include social consequences of clinical disorders, unlike the DSM-IV.
  44. B Global assessment of functioning
    The five-axis classification in the DSM-IV was designed to provide information on a patient's clinical disorder and level of functioning. The axes are as follows:
    Axis I: clinical disorders
    Axis II: personality disorders, mental retardation
    Axis III: general medical condition
    Axis IV: psychosocial and environmental problems
    Axis V: global assessment of functioning
  45. D There is 95% protein binding
    Benzodiazepines have a weak organic basis, so when they are subjected to physiological buffering they become lipid soluble to varying degrees – from moderate to high. Absorption from the gastrointestinal tract is complete and followed by first-pass metabolism. Diazepam and flurazepam are among the most rapidly absorbed compounds, with almost complete bioavailability after oral administration. Their kinetics conform to a two-compartment model, with the plasma concentration curve reflecting distribution and metabolism. Desmethyldiazepam is an active metabolite that undergoes slow oxidation before excretion, and therefore has a very long half-life of 30–100 hours. Food reduces the rate, but not the extent, of absorption of diazepam. Diazepam's elimination half-life in young adults and elderly people is 20 hours and 30–100 hours respectively.32
  46. C The dexamethasone suppression test is mostly unaffected
    Benzodiazepines have perhaps the highest therapeutic index of all psychotropic drugs and are extremely effective. It is therefore sometimes problematic to understand whether the ‘side effects’ represent adverse effects. The dexamethasone suppression test is largely unaffected in benzodiazepine use. However, in chronic high-dose therapy, benzodiazepines may interfere with the dexamethasone suppression test. In therapeutic doses, they have little effect on the cardiovascular and respiratory systems, although sometimes they can cause respiratory depression and reduce systolic blood pressure. Benzodiazepines inhibit the afferent pathways in the spinal cord, resulting in skeletal muscle relaxation. Neuroendrocrine systems are generally unchanged but occasionally plasma cortisol may be reduced.
  47. B The concentration of an intravenously administered drug declines exponentially
    The elimination of most drugs follows exponential or first-order kinetics, i.e. a constant fraction of the whole drug in the body is eliminated per unit of time. This corresponds to an exponential decline in concentration. The rate of absorption depends on the dose remaining to be absorbed. The rate of elimination depends directly on the amount of drug remaining in the body. The metabolism of alcohol in human beings follows zero-order kinetics. This means that the rate of absorption is independent of the concentration, i.e. the amount metabolised is fixed rather than the proportion of the drug. Bioavailability is the extent to which the drug reaches the systemic circulation when taken by a patient orally or parentally, compared with the same dose of drug given intravenously. Bioequivalence is dependent on efficacy, which in turn depends on plasma concentration.
  48. D Naproxen
    Fluvoxamine, when used with naproxen, increases the risk of bleeding. In addition, it should be used with caution when given together with lithium (or non-steroidal anti-inflammatory drugs [NSAIDs]), St John's wort, tryptophan or warfarin. Fluvoxamine inhibits the cytochrome P450 CYPIA2/2CG/3A4.
  49. D Neuroleptic malignant syndrome
    The patient has developed signs of the neuroleptic malignant syndrome. This is characterised by hyperthermia, rigidity, confusion and autonomic lability. It has a reported mortality rate of 20% and it can result in residual neurological deficits in survivors. The neuroleptic malignant syndrome usually resolves on discontinuation of the implicated antipsychotic and medical measures such as rehydration, correction of electrolytes and benzodiazepines if necessary. Dantrolene is another medication that can be used if necessary.
  50. C Nausea
    One of the common side effects of acamprosate is nausea. Other side effects include diarrhoea, abdominal pain, fluctuations in libido, pruritus and maculopapular rash. Acamprosate is a ʏ-aminobutyric acid agonist and glutamate antagonist. It is useful in maintaining abstinence in patients with strong cravings for alcohol. It should be started as soon as abstinence has been achieved, and continued for at least one year for optimum benefit.33
  51. D 5-HT2A receptors increase glutamate release
    5-Hydroxytryptamine (5-HT2A) receptors excite cortical pyramidal neurons, increase glutamate and decrease dopamine release. These receptors are involved in the mechanism of sleep and hallucinations. Blockade of 5-HT2A receptors leads to release of dopamine. 5-HT2A antagonism decreases extrapyramidal side effects.
  52. B α2
    All but one of the adrenergic receptors are postsynaptic. The only presynaptic adrenergic receptor is the α2- receptor. This is also known as apresynaptic autoreceptor. It is a G-protein couple receptor.
  53. Stimulation of α1- receptors leads to serotonin release
    Noradrenaline and serotonin neurons control each other in the central nervous system. Noradrenaline can control serotonin release both positively and negatively, i.e. stimulation of α1- receptor leads to release of serotonin, whereas stimulation of presynaptic α2- autoreceptors lead to inhibition of serotonin release (feedback inhibition). On the other hand, serotonin has only A negative feedback inhibitory role on noradrenaline release, through. stimulation of 5-HT2A- or 5-HT2C -receptors.
  54. D α2-Receptor antagonism
    Mirtazepine is classified as a noradrenergic and selective serotonergic antidepressant. It is an antagonist of presynaptic α2- adrenergic receptors, thus facilitating serotonin release. It acts as an antagonist of many other receptors including 5-HT2A and 5-HT2C.
  55. D Serotonin, noradrenaline and dopamine
    Venlafaxine has a unique mode of action. In low doses it acts on the serotonin system only. As the dose increases it acts on noradrenergic as well as serotonergic neurons. At higher does, i.e. 225 mg or above, it acts on all the three neurotransmitters, i.e. serotonin, noradrenaline and dopamine. In a nutshell, venlafaxine blocks the serotonin, noradrenaline and dopamine reuptake. In addition blocking noradrenaline reuptake in the frontal cortex could increase dopamine neurotransmission in this part of brain.
  56. B Buspirone
    Buspirone is an anxiolytic medication with 5-hydroxytryptamine (5-HT1A) partial agonist activity. It is a potent D2-receptor antagonist. It is mainly used for treatment of generalised anxiety disorder and other anxiety disorders. Even though it is an antianxiety medication, it is not related to benzodiazepines or barbiturates. It is not helpful for treating benzodiazepine withdrawal symptoms. These patients will need benzodiazepines to relieve their symptoms before starting buspirone.
  57. D Haloperidol
    High-potency neuroleptics such as haloperidol, pimozide and trifluoperazine have potent tic-suppressing effects. The usual dose of haloperidol is 1–8 mg. Newer antipsychotics such as risperidone and olanzapine have also been used for treatment of Gilles de la Tourette's syndrome with limited success. Risperidone is usually used in a dose range of 1–6 mg.34
  58. D Figure-ground differentiation
    Gestalt psychology is primarily concerned with perceptual processes. It maintains that aspects of perception reflect the brain's innate capacity to order simple sensations in characteristic ways. It holds that the whole or total quality of the image is perceived. According to gestalt psychology, the organisation of stimuli into the image is based on laws of perception, which include:
    • Similarity (similar images are grouped together even when separated physically)
    • Proximity (nearer images are grouped)
    • Closure (gaps are filled into complete a shape)
    • Good continuation (images that appear to continue in the same direction are grouped)
    • Common fate (images that are more together in a scene are grouped)
    • Reversible figures (such as the Necker cube)
    • Object constancy (despite expectations)
    • Perceptual set
  59. D Preoperational stage
    This description refers to the concept of egocentrism which is not merely selfishness. It is the restricted ability of a child to view the world from a single point of view which develops at age 2–7 years. This was demonstrated using the mountain task, in which a child would not be able to say what the other person could see from the other side of the desk when only one side of the mountain toy was shown to the child.
  60. B Formal operational stage
    Hypothetico-deductive reasoning develops in a proportion of children after the age of 12 years. It is characterised by manipulation of ideas and propositions and reasoning is based on construction of verbal arguments.
  61. B Circular reaction
    Circular reaction is seen during the sensorimotor stage of Piaget's stages of cognitive development; it develops at age 0–2 years. In this stage, infants develop an ability to recognise that they can make things happen. During the sensori motor stage, an infant's mental efforts are mainly focused on sensory experiences such as vision, hearing and touch. During this developmental stage, language starts to develop and thoughts start to dominate action.
  62. D Preconventional morality
    In this case, the 8-year-old boy is going through the preconventional morality stage of development.
    Kohlberg's theory of moral development is characterised by three levels and six stages, as follows:
    Level 1: It is preconventional morality that contains two stages:
    • Stage 1: Punishment and obedience orientation
    • Stage 2: Egotistical orientation
    Level 2: It is conventional morality that contains two stages
    • Stage 3: Maintaining good interpersonal relationship, being a good person
    • Stage 4: Maintaining social law and order
    Level 3: It is postconventional morality that contains two stages
    • Stage 5: Social contract or legalistic orientation
    • Stage 6: Universal principle of justice35
  63. A Conventional morality
    In this case, the 6-year-old boy is going through the conventional morality development stage. Kohlberg's theory of model development is characterised by three levels and six stages.
    Level 2 is conventional morality that contains two stages: maintaining good interpersonal relationships, being a good person and maintaining social law and order. They believe that what pleases others is right, so they try to avoid disapproval and to meet the expectations of others.
  64. C 12 months
    The child is able to say one word such as mummy, doggie. Hence, his age is likely to be 12 months. The following indicates speech development and corresponding age group:
    • 6 months (4–10 months): at this age child starts babbling
    • 9 months: child starts babbling repetitively
    • 12 months: child says words like mamma, papa. This is called the one-word stage
    • 24 months: child says ‘mamma come’. This is called the two-word stage
  65. A 3 years
    As a child grows, the fear of darkness develops at age 2–3 years, a fear of supernatural things at 5–8 years and a fear of bodily injury and disasters is seen from age 9–12 years. From age 0–6 months, a fear of falling and of loud noises is evident. Fear of strangers develops at the age of 1 year.
  66. E 9 months
    A child can hold his head up at age 3 months. He does oral exploration at age 5 months. At age 6 months, palmar grasp develops. By age 9 months the child can sit unsupported and pickup objects with a pincer grasp.
  67. C 3–5 years
    There are eight Erickson's stages of psychosocial development. In this example, the child is going through the initiative versus guilt stage which is seen between 3 years and 5 years.
    Erikson's stages of psychosocial development:
    1. Trust versus basic mistrust: birth to 18 months
    2. Autonomy versus shame: 18 months to 3 years
    3. Initiative versus guilt: 3–5 years
    4. Industry versus inferiority: 6–12 years
    5. Identity versus role confusion: adolescence
    6. Intimacy versus isolation: young adulthood
    7. Generativity versus stagnation: middle adulthood
    8. Ego integrity versus despair: late adulthood
  68. B Anxious avoidant
    This is an example of anxious avoidant attachment pattern. Mary Ainsworth has described four main types of attachment on the basis of a strange situation procedure. A secure type of attachment is seen in 65% of infants. In this case, the infant uses the caregiver as a secure base, explores freely, may or may not be distressed at separation, but greets positively on reunion, seeks comfort, settles down and returns to exploration. Anxious avoidant attachment is seen in 20% of infants. In this case the infant appears normally interested in the caregiver, explores busily, minimal distress at separation, and ignores or avoids caregiver on reunion. Resistant/Ambivalent attachment is seen in 10% of infants. In this case there is minimal exploration, and 36the infant stays closer to the carer, and both seeks and resists contact on reunion. Disorganised attachment is seen in 15% of infants. In this case the infant is disorganised and presents with disoriented behaviour, such as freezing or odd postures, in the presence of the caregiver.
  69. B Oral phase
    The oral phase of Freud's psychosexual development is seen between 0 and 18 months. Object constancy is Margaret Mahler's sixth subphase and lasts from 2 years to 5 years. Stranger anxiety occurs from 7 months till the end of the first year. Separation anxiety develops at age < 1 year. It peaks between 9 and 18 months and diminishes by about 2.5 years of age. Piaget's sensori motor stage is from 0 years to 2 years. The conventional morality stage of Kohlberg is between 7 and 12 years.
    Mahler's developmental phases are:
    • Normal autism (0–2 months)
    • Symbiosis (2–5 months)
    • Differentiation (5–10 months)
    • Practising (10–18 months)
    • Rapprochement (18–24 months)
    • Object constancy (2–5 years)
  70. D Temperament
    Thomas and Chess conceptualised temperament as representing the behavioural style in children. In the 30-year-long New York Longitudinal Study nine categories of dimensions were observed (e.g. activity level, adaptability, mood) and temperament was categorised into three main types:
    1. Easy temperament: 40%
    2. Difficult temperament: 10%
    3. Slow to warm up: 15%
    Rest ungrouped: 35%
    Attachment: John Bowlby; object constancy: Margaret Mahler; and imprinting: Lorenz
  71. C Egocentric thinking
    A characteristic feature of the sensorimotor stage (before 2 years) is a lack of object permanence. This is similar to the situation of ‘out of sight out of mind’. Other stages include primary, secondary and tertiary circular reactions. Animistic thinking (inanimate objects seen as being alive) and egocentric thinking (being unable to consider the world from any viewpoint other than their own) are a part of the preoperational stage. Conservation and transitive inference are mastered in the concrete operational stage. Conservation means an understanding that the quantity or amount of a substance or group of objects remains unchanged when nothing has been added or taken away from it.
  72. A Each stage is a prerequisite for the next stage of development
    Each stage is a prerequisite for one of the four stages of cognitive development described by Jean Piaget (sensorimotor, preoperational, concrete operations and formal operations). These stages lead to capacity for an adult's thought. Each stage is a prerequisite for the next one.37
  73. D Social learning incorporates both classic and operant models
    There are three types of learning: classic, operant or instrumental, and social learning which incorporates classic and operant conditioning. Classic conditioning is a result of environmental events whereas operant learning is thought to result from the consequences of a person's actions. Learning is defined as the change in behaviour resulting from repeated practice; both the environment and the behaviour interact to produce the learned change.
  74. B Classic conditioning is the association of a neutral stimulus with a conditioned stimulus which brings a response originally elicited by an unconditioned stimulus
    In classic conditioning, there is pairing of a conditioned or neutral stimulus with an unconditioned stimulus (response), such that the neutral stimulus eventually evokes an unconditioned stimulus. In habituation, response to repeated stimuli decreases and eventually disappears over time. Instrumental and operant learning are one and the same. Social learning occurs by observations, identification and role modelling.
  75. B Changing cognitions involved in the dissonant relationship
    Cognitive dissonance refers to the discomfort produced by inconsistent cognitions. It is therefore an unpleasant feeling caused by having simultaneous conflicting ideas. Cognitive consistency can be achieved by changing attitudes, beliefs and actions. The way in which a person thinks is called cognition and cognition affects a person's behaviour. Cognitive dissonance occurs when a person holds simultaneous conflicting ideas, e.g. if a person fails an exam, he says that even the better candidates didn't pass; by doing this he reduces their dissonance. In the classic example of The Fox and the Grapes by Aesop, the fox sees grapes hanging up high and has a strong desire to eat them. However, the fox is unable to reach them and so thinks that the grapes are not worth eating as they must be unripe or sour. The fox reduces his dissonance by denigrating the value of the grapes (this is where the expression ‘sour grapes’ comes from).
  76. D It leads to the same mean score in different response patterns
    The Likert scale is a five-point scale indicating the level of agreement with presented statements. It has several advantages including its increased sensitivity compared with the dichotomous Thurstone scale. It is more easily administered. A disadvantage is that the response patterns may result in the same mean score.
  77. C Osgood and Tannenbaum's congruity theory
    Osgood and Tannenbaum's congruity theory suggests that, when two beliefs are mutually inconsistent, the one that is less firm will change. It is oriented to communication and persuasion. Festinger's cognitive dissonance theory suggests that, when an individual's behaviour is inconsistent with his or her attitude, it leads to dissonance, which in turn leads to change of attitude so that it is consistent with the behaviour. Fritz Heider's balance theory is that individuals seek harmony of attitudes and beliefs and they evaluate related things in a similar manner. Self-evaluation maintenance theory suggests that the skills or interests that define us can cause dissonance when they appear to be superior in others close to us. Postdecision dissonance is where one justifies an unalterable decision as the right one.38
  78. E Social exchange theory
    Social exchange theory suggests that people prefer relationships that appear to offer an optimum cost-benefit attraction. It also involves comparison of various attractive options. This theory is influenced by other disciplines such as economics, sociology and psychology. According to equity theory, the cost-benefit of a relationship for each person is approximately equal in a preferred relationship. Reciprocal reinforcement explains the attraction that occurs with rewards in both directions. Proxemics relate to the interpersonal space body buffer zone.
  79. D Is useful in detecting frontal lobe lesions
    The WCST is used to test set-shifting ability, which is thought to be a function of the frontal lobe. It consists of a pack of cards, each of which has a number of coloured shapes. There are three possible shapes, three possible colours, and one, two or three exemplars of the shape that could appear on each card. The patient has to sort the pack of cards into three piles, but is given no instructions as to the sorting principle.
  80. B Death of a spouse/partner
    Life events have emerged as risk factors for the onset of major depression, suicide and other psychiatric morbidity. They are given weighting that relates to the closeness of the lost relative and the impact on the individual patient. Their impact depends on the individual's personality and genetic endowment.
  81. A Non-target stimuli are represented among a series of random stimuli on a computer screen
    Selective attention, i.e. focused attention, involves a mechanism by which certain information is registered and other information rejected, whether or not the latter enters conscious awareness. The cocktail party phenomenon is an example in which we manage to select one or two voices to listen to from the hubbub of conversation taking place in the same room. In the Stroop colour word test, the patient is asked to name the colour in which the words are written; if the words are unrelated to colour, the colour of the print is compatible with meaning. Thus, in the Stroop test, there is competition between the automatic and the controlled processing systems.
  82. B The test correlates well with other established tests of cognitive function
    Construct validity refers to whether a test measures a specified and well-defined construct, e.g. if a test measures cognitive function there should not be clusters of items from other aspects of the mental state.
  83. A Consists of 21 items
    Beck's depression inventory (BDI) is a 21-question, self-rating inventory. It is sensitive to change, but is biased towards cognitive items. It can be used in children aged > 13 years and adults. The BDI has a copyright and requires permission from the authors for its use.39
  84. D Events
    Cognitive therapy emphasises how the patient comes to think about him or herself, the future and the world. The cognitive view assumes that one assigns meaning and value to one's perceptions and experiences. Cognitive schemata are organised representations of prior experiences that help a person to screen, encode and categorise perceptions. Cognitive therapy is primarily concerned with cognitive events.
  85. C Dichotomous reasoning
    Cognitive therapy is more than the routine application of a series of techniques. The focus is on the cognitive factors that maintain emotional disturbance and maladaptive behaviour. Dichotomous reasoning means that the person sees things in black and white. Arbitrary inference means that the person jumps to conclusions despite contradictory or insubstantial evidence. Overgeneralisation refers to when a single incident is accepted as an invariable rule or consequence. Selective abstraction means that the person takes a detail out of context and misses the significance of the whole situation.
  86. 86. E It was influenced by the work of Albert Ellis
    Cognitive-behavioural therapy refers to a method of therapy based on a theory of emotional disorders. Theoretically, the emphasis is on information processing, i.e. individuals react, feel and behave according to how they process the information contained in the environment. Albert Ellis had named it in rational-emotive therapy.
  87. B Crowds
    Agoraphobia is anxiety associated with places or situations either from which escape may be difficult or in which help may not be available in the event of a panic attack. It means literally fear of the crowded place. It is strongly associated with panic.
  88. D Preparedness
    Behavioural therapy assumes that a person's behaviour is a way of adapting to the environment, and not necessarily a reflection of some kind of underlying psychopathology. Preparedness is an inherited biological trait. It means that things feared may be or have been potentially dangerous to the human race.
  89. 89. B The benefits of reducing the DUP appear to be long-lasting
    Evidence suggestes that treatment of the first episode of psychosis with an aim of a shorter duration of untreated psychosis (DUP) results in improved positive and negative symptoms of psychosis. In addition, treatment with an emphasis on a shorter DUP is associated with significantly improved social functioning compared with a longer DUP. Early intervention in psychosis is based on multimodal treatment, such as antipsychotic medications, psychology and social aspects of care. As per the available evidence, the advantages seem to be permanent rather than temporary.40
  90. D Onset of a first episode of psychosis is delayed
    A randomised controlled trial, conducted at the personal assessment and crisis evaluation clinic (PACE clinic) in Melbourne, concluded that cognitive therapy alone or in combination with a low-dose antipsychotic can delay the onset and reduce the severity of the first episode of psychosis in patients with sub-threshold symptoms. In addition to reducing the severity of psychotic symptoms, there is a reduction in non-psychotic symptoms and distress following treatment. However, monotherapy with an antipsychotic was not as efficacious as cognitive therapy alone or in combination. The transition to the first episode of psychosis is strongly associated with the presence of positive symptoms.
  91. D Sodium valproate
    Of the given options, sodium valproate is effective in the prophylaxis of bipolar affective disorder. The National Institute for Health and Care Excellence (NICE) recommends sodium valproate as a first-line option for the treatment of acute manic episodes, in combination with an antidepressant for the treatment of depressive episodes and for prophylaxis. Lithium is a effective medication in treating acute manic episode and also effective in the prophylaxis of bipolar affective disorder. Most of the side effects are dose related. Common side effects are nausea, vomiting, gastrointestinal upset and tremors. It can cause a person to drink more and pass more urine. It can also reduce the capacity of the kidneys to concentrate urine: it reduces the glomerular filtration rate. Lithium can cause interstitial nephritis in a small number of patients. The risk of relapse may be reduced by decreasing the dose gradually over a period of at least a month and avoiding incremental serum reductions of >0.2 mmol/L.
  92. B She has a five-fold risk of relapse
    It is now well established that stopping antidepressants soon after treatment is associated with a high risk of relapse. Controlled studies involving patients with recurrent depression have shown that maintenance treatment with antidepressants can substantially reduce relapse rate.
  93. B Emotional incontinence
    In this case, after a stroke the patient has developed emotional incontinence. It is a neurological sign when an affected individual is unable to control laughter and/or crying. It is characterised by sudden onset of laughter or crying episodes which last for a few seconds to minutes, and can occur several times a day. It is an extreme form of labile affect. It is also known as a pseudo-bulbar affect. This sign is observed in patients with brain injury, frontal lobe damange, stroke, multiple sclerosis and other neurological illnesses. In this case, there are no signs and symptoms to suggest depression and bipolar disorder.
  94. D Nihilistic delusions
    This case description is an example of Cotard's syndrome in which the patient presents with nihilistic delusions that she is dead and her internal organs are degenerating or have stopped working. This condition is found in patients with psychotic depression and schizophrenia. In grandiose delusions patients believe beyond doubt that they possess special powers and abilities. In delusions of guilt, patients have inappropriate and extreme feelings of guilt which are not based in reality. In persecutory delusions, the most common delusions, patients believe that they are being followed, persecuted or spied upon. In delusions of infidelity, also known as morbid jealousy, patients are convinced that their partner has been unfaithful contrary to evidence suggesting otherwise.41
  95. 95. A Ambitendence
    In this scenario, the patient has ambitendence which is characterised by a state of cooperation and opposition (take the offered hand and withdraw), leading to incompletion of the task (hand shake). It is one of the catatonic signs observed in schizophrenia. Another catatonic sign is negativism, in which a patient will resist or oppose all passive movements. Stereotypy is an extensive repetition of movement, speech pattern, ideas or posture, which could be simple or complex in nature. Chorea is the abnormal and involuntary movements seen in neurological disorders such as Huntington's disease, Sydenham's chorea and Wilson's disease. Ambivalence is a state in which an individual experiences both positive and negative feelings towards a person or thing.
  96. D Selective mutism
    Elective mutism was a term used in the DSM-III to describe refusal to speak in all social situations despite a normal ability to interact. However, this was redefined in the DSM-IV as a refusal to speak in specific situations despite normal ability and termed ‘selective mutism’. This form of mutism is seen in children with emotional or psychiatric disorder. It is also seen in adults with hysteria, depression, schizophrenia or organic disorders. Akinetic mutism is usually seen in frontal lobe injury, when a person refuses to move and speak. Poverty speech is an inability to initiate or participate in a conversation, and speech usually lacks content that is not prompted. In stammering, the normal flow of speech is interrupted.
  97. D Incongruent affect
    Affect is a pattern of observable behaviour, that is an expression of feelings or emotions. It is variable over time and changes in response to changing emotional state. In this case description, the observed affect (laughs and jokes) is different to subjective affect (sadness); it is termed ‘inappropriate affect’. Maintenance of an affective state is termed ‘stability of affect’. Labile affect in the absence of such stability can be seen as a sudden unprovoked change in affect in which patients can cry or laugh excessively for no apparent reason. The inability to express emotions is termed ‘flat affect’, whereas restricted ability to express emotions is termed ‘blunt affect’. Alexithymia is an inability to recognise and use words to describe emotions and feelings.
  98. B Tangentiality
    A formal thought disorder is considered to be a schizophrenic language disorder characterised by disordered speech, and results from disorganised thoughts. It is often a symptom of schizophrenia, mania, severe depression with psychosis and other psychotic disorders. Tangentiality is a formal thought disorder in which there is tangential association of ideas leading to disruption in the smooth continuity of speech. Knight's move thinking, drivelling, omission, derailment and circumstantiality are other examples of formal thought disorders. Thought insertion, thought broadcasting, thought withdrawal and thought block are Schneider's first rank symptoms. Delusion of presecution is a fixed belief in which patients believe that they are being followed, persecuted and spied on, and that the perceived persecutor will cause them harm.
  99. A Compulsions
    Obsessions are repetitive, senseless, intrusive thoughts that are recognised as irrational thoughts by the sufferer. Several unsuccessful attempts have been made to resist these thoughts. The content of the thought can be related to aggression, dirt, contamination, fear of causing harm, and religious or sexual thoughts. In order to reduce the associated anxiety symptoms patients carry out repetitive acts such as counting, cleaning repeatedly, or touching or arranging things in symmetry; these acts are termed ‘compulsions’.42
  100. E Somatic hallucinations
    Perceptual disturbance such as hallucinations are false sensory perception in the absence of external stimulus. Hallucinations can be mood congruent or mood incongruent. These can be auditory, visual, gustatory, olfactory and somatic in nature. Somatic hallucinations can be tactile or haptic which involves either superficial sensations or sensations just under the skin in the absence of real stimulus.
  101. C Thought broadcasting
    Thought insertion, thought withdrawal; thought broadcasting and thought echo are Schneider's first rank symptoms of schizophrenia. In addition, delusion of perception, delusion of control and 3rd person auditory hallucinations is other first rank symptoms (though not Schneiderian). In thought broadcasting, the patient believes that their thoughts are being broadcasted and people are aware of what they are thinking.
  102. D De Clerambault's delusion
    Another term for De Clerambault's syndrome is erotomania. In this condition, the patient believes that an exalted or well-known person is in love with him or her. In Cotard's syndrome, the person believes that he or she is dead or some part of his or her body is rotten or doesn't exist. Couvade's syndrome is an abnormality of experience of self, in which a spouse/partner complains of obstetric symptoms during his partner's pregnancy. In Capgras' syndrome, the patient believes that someone close has been replaced by an exact double. Othello's syndrome, also known as morbid jealousy – a condition in which an individual believes that his or her spouse or partner is unfaithful.
  103. A Delusional memory
    Delusional mood, delusional perception, delusional memory and sudden delusional ideas constitute primary delusions. Delusional memory is a condition in which, even though in reality something has never happened, the individual believes and reports an irrational or false event as if it had occurred in the past. In delusional mood, a person senses that there is a change in the environment but is unable to make sense of this change, resulting in being perplexed. In delusional perception, a patient gives new meaning to normally perceived objects.
  104. B Delusional mood
    Delusional mood, delusional perception, delusional memory and sudden delusional ideas constitute primary delusions. In delusional mood a person thinks that there is something wrong around him but he doesn't know what is wrong. Positive symptoms of schizophrenia comprise delusions and hallucinations, whereas negative symptoms of schizophrenia consist of apathy, poverty of speech, and blunted and incongruent affect.
  105. E Othello's syndrome
    Othello's syndrome is also known as morbid jealousy. In this condition, an individual believes that his or her spouse or partner is unfaithful. De Clerambault's syndrome, also known as erotomania, is a condition in which that patient believes that an exalted or well-known person is in love with him or her. In Cotard's syndrome, the person believes that he or she is dead or some part of his or her body is rotten or doesn't exist. Couvade's syndrome is an abnormality of experience of self, in which a male spouse also complains of obstetric symptoms during his female partner's pregnancy. In Capgras' syndrome, the patient believes that a person who is close has been replaced by an exact double.43
  106. E Ekbom's syndrome
    Delusional parasitosis, aslo known as Ekbom's syndrome is a condition in which an individual develops a delusion, a false belief, that he or she is infested by parasites. Individuals with this condition usually present to specialists such as dermatologists and pest control experts rather than a psychiatrist. Individuals can bring scrapings of their skin or related samples to prove that there are parasites crawling under or on their skin. Delusory cleoparasitosis is a related condition in which the individual believes that the house is infested by parasites rather than the body.
  107. B Completion illusion
    Hallucinations and illusions are perceptual abnormalities. In an illusion, a stimulus is present but a different object or image is perceived. In a hallucination, the perception occurs in the absence of a stimulus. In a completion illusion, a stimulus that doesn't form a complete object may be perceived as complete. It occurs due to inattention and disappears when an individual concentrates on the object. In this example, because of inattention, the student read Holland as Poland.
  108. A Affect illusion
    In illusions, a stimulus is present but a different object or image is perceived. In hallucinations, perception occurs in the absence of a stimulus. In completion illusion, a stimulus that doesn't form a complete object may be perceived as complete. Affect illusion arises in the context of a particular mood state. As in this example, due to fear of the dark, the woman sees the figure of a ghost in a tree on a dark night. This disappears on additional concentration.
  109. E Pareidolic illusion
    In this example, the individual has a pareidolic illusion. In this illusion, which is often playful, the object is formed from ambiguous stimuli and intensifies on additional attention. One such example is seeing figures of cars or human faces when looking into the clouds.
  110. C Functional hallucination
    In functional hallucinations, an external stimulus provokes the hallucination but the stimulus and hallucination are in same modality as in this case; it is a sound that is perceived individually. Elementary hallucinations are not fully formed. They could be in the form of noises.
  111. D Reflex hallucination
    Elementary hallucinations are not fully formed. They could be in the form of noises. In functional hallucinations an external stimulus provokes the hallucination but the stimulus and hallucination are in the same modality; in this case it is a sound that is perceived individually. In extracampine hallucinations, the patient has hallucinations that are well beyond the limits of his sensory fields. In reflex hallucination, a person experiences the stimulus in one modality but perceives it in a different modality. In this case the patient sees colours whenever he hears the sound of running water.
  112. B Extracampine hallucination
    In functional hallucinations, an external stimulus provokes a hallucination but the stimulus and hallucination are in same modality; in this case it is a sound that is perceived individually. In extracampine hallucinations, the patient has hallucinations that are well beyond the limits of his sensory fields. In this case, patient hears the voice of his dead sister far away from his sensory field.44
  113. A Displacement
    Anna Freud described 10 defence mechanisms in her work. Reaction formation, projection and regression are three of them. In displacement, emotions or wishes are transferred from the original object or person to a more suitable substitute.
    Reaction formation is seen in patients with obsessive-compulsive disorder. Here the attitude is opposed to the oppressed wish and constitutes the opposite reaction.
    Projection: unacceptable thoughts, emotions and feelings are projected on to some other person.
    Regression: at the time of stress or threat a person returns to an earlier stage of maturational functioning.
    Identification: a person takes the attributes of others to him- or herself.
  114. D Regression
    Regression is the defence that refers to the reversion to the early stage of ego functioning. Each and every person has defences to deal with stress. Some of them are mature defences such as altruism, sublimation, suppression and humour. Some are immature and neurotic defences such as displacement, isolation regression and projection.
    Isolation: thoughts, emotions or behaviour is isolated to break the link with other thoughts or memories.
  115. C Sublimation
    This is the transformation of our instinctual energy to a more socially acceptable one. So, in this case, rather than shouting back at the consultant, the trainee went to the gym and transformed his anger and frustration into exercising. This is a mature defence mechanism.
  116. C Passive aggression
    Regression is the defence that refers to the reversion to the early stage of ego functioning, or at the time of stress or threat a person returns to an earlier stage of maturational functioning.
    Repression is a type of basic defence in which unacceptable or uncomfortable ideas, thoughts or emotions are pushed away into unconsciousness.
    Passive aggression is characterised by non-cooperation with no display of anger.
  117. C 1856
    Sigmund Freud was born on 6 May 1856. He was born in a town called Moravia, which is now part of the Czech Republic. His father was a wool merchant. He specialised in neurology. When he was in France, he trained in hypnosis. He also worked with hysterical patients, and while working with these patients he developed psychoanalysis.
  118. C Czech Republic
    Sigmund Freud was born on 6 May 1856. He was born in a town called Moravia, which is now part of the Czech Republic. His father was a wool merchant. He specialised in neurology. When he was in France, he trained in hypnosis. He also worked with hysterical patients, and while working with these patients, he developed psychoanalysis.45
  119. B Investigation of a serious crime
    Although priests and lawyers enjoy their relationships with their clients who preserve the hermetically sealed notion of confidentiality, doctors do not. An unwelcome consequence of the Tarasoff case is to extend the psychiatrist's role as an agent of social control and to give clinicians barriers to predicting dangerousness that they simply do not possess. Respecting confidentiality is only one among an ever-growing list of duties that the doctor must balance against each other.
  120. E Participants can withdraw consent to all data collected at any time during the study
    The law with regard to consent to medical treatment makes it clear that any unconsented touching of patients by a doctor may be both a civil wrong (tort) and a criminal act (battery). Whether implicit or explicit, the patient's consent will not be valid unless he is informed, capable and free from duress. The doctor is required to impart sufficient, understandable and relevant information to the patient to enable a choice based on the patient's own judgement of the alternatives.
  121. D Kurt Schneider
    Schneider proposed first rank symptoms of schizophrenia. These are neither diagnostic nor prognostic but indicate schizophrenia. The first rank symptoms are thought insertion, thought withdrawal, thought broadcasting, delusions of perception, passivity phenomena, third person auditory hallucinations and running commentary. The term ‘schizophrenia’ was coined by Eugene Bleuler in 1911. Carl Schneider described different forms of formal thought disorders.
  122. C Ewald Hecker
    Hebephrenic schizophrenia is a type of schizophrenia in which affective changes are prominent. The mood is shallow and inappropriate, and thoughts are disorganised. The onset is usually in adolescence. Hecker described hebephrenic schizophrenia. Bleuler coined the term. William Tuke promoted moral treatment for psychiatric patients.
  123. D Théodule-Armand Ribot
    Anhedonia is lack of pleasure in doing activities that were previously enjoyable. Ribot coined the term ‘anhedonia’. Sifneos coined the term ‘alexithymia’, which is difficulty in verbalising emotions. Moreno is considered to be the father of psychodrama. Kahlbaum described cyclothymia, which is persistent instability of mood, involving periods of depression and mild elation; none of these periods is severe or prolonged enough to fulfil the diagnosis of bipolar affective disorder.
  124. E Peter Sifneos
    Sifneos coined the term ‘alexithymia’, which is difficulty in verbalising emotions. It is also described as an inability or difficulty in describing or being aware of one's emotions or mood. It is seen in conditions such as depression, substance misuse or post-traumatic stress disorder.
  125. A It is a dissociative state
    Latah is a dissociative state triggered by a sudden shock or fright. The patient goes into repetitive speech (echolalia) or movements (echopraxia). This syndrome is most prevalent among middle-aged Malaysian women.46
  126. E Symptoms are similar to those of cardiac dysfunction
    The World Health Organization, in the ICD-10, classifies this condition as a psychosomatic disorder (f 45.30). Also known as ‘soldier's heart’ it was described by Jacob Mendes Da Costa during the American civil war.
  127. A It is a depressive state
    Susto is a cultural syndrome condition common to Latin America; it occurs after a sudden traumatic and shocking life event. It is believed that the soul is lost from the body after a traumatic emotional or physical life event, which leads to sadness, sickness and misery. It can be a life-threatening illness and presents with symptoms of lethargy, lack of motivation, insomnia and diarrhoea.
  128. D Susto
    Espanto is the more severe form of the condition susto (the soul leaves the body due to the individual being frightened by a ghost). The only treatment of susto/espanto is via spiritual means, which includes ritual cleansings, herbs by a curandero, a spiritual healer (or curandera if female). Women seem to be affected more than men. It is associated with a higher mortality rate compared with the general population.
  129. B It is a compulsive desire to become a cannibal
    Windigo is a culture-bound syndrome found in Algonquian, which is a Native American tribe. The person has an intense craving for human flesh and there is a compulsive desire to become a cannibal. The person is very scared that he may become a cannibal (windigo monster). It usually occurs during the winter and when food is scarce. It rarely responds to any medication, and is not included in the DSM-IV.
  130. A It causes the patient to have difficulty in remembering and concentrating
    The origin of this condition is West Africa. Brain fag is usually seen in high school/university students when they are stressed by challenges at university or school. Students will often mention that their brains are ‘fatigued’ and they cannot concentrate or remember, and have difficulty thinking. Somatic symptoms are centred on the head and neck: pain, pressure, blurring of vision and feelings of heat and burning due to ‘too much thinking’. It can resemble certain anxiety, somatoform and depressive disorders.