Psychiatry Question Bank

Sample

1. A 74-year-old widowed woman who lives alone and has severe bilateral hearing loss reports that her neighbours drill holes in her walls to spy on her and talk about her at night. Her MoCA is 28/30. There is no fluctuation, parkinsonism, visual hallucinations or depressed mood, and MRI brain and blood tests are unremarkable. Which is the most likely diagnosis?

Very-late-onset schizophrenia-like psychosis (onset after age 60) typically affects women and is associated with sensory impairment (especially hearing loss), social isolation and premorbid paranoid or schizoid traits. It features persecutory 'partition' delusions about neighbours and auditory hallucinations, with negative symptoms and formal thought disorder usually absent. Organic causes should be excluded. Dementia with Lewy bodies would involve fluctuating cognition, recurrent visual hallucinations and parkinsonism. Delirium involves inattention and fluctuating consciousness. Psychotic depression requires a prominent depressive syndrome. Pearl: correcting sensory deficits (hearing aids) and low-dose antipsychotics, which older adults tolerate at much lower doses, form the basis of treatment.

Sample

2. In a person physically dependent on heroin, when do acute withdrawal symptoms typically reach their peak after the last dose?

Heroin is a short-acting opioid (rapidly converted to 6-monoacetylmorphine and morphine). Withdrawal typically starts 6–12 hours after the last dose, peaks at about 36–72 hours, and the acute phase subsides over 5–10 days, although insomnia, dysphoria and craving can persist for weeks. With methadone, onset is delayed to 24–48 hours, the peak occurs later, and the syndrome is milder but more prolonged, lasting 2–3 weeks or more. A peak at 4–6 hours is too early for heroin. A peak at 7–10 days or 2–3 weeks confuses peak timing with the protracted phase. Pearl: timing guides buprenorphine induction.

Sample

3. A 29-year-old woman reports marked irritability, mood swings, tearfulness, bloating and feeling overwhelmed during the 7–10 days before menses, resolving within a few days of bleeding. Prospective daily symptom ratings across 2 cycles confirm the pattern and a symptom-free follicular phase. Symptoms impair her work. Thyroid function is normal and she does not wish to conceive. Which is the most appropriate first-line pharmacological treatment?

Confirmed PMDD, with at least five symptoms in the final week before menses that improve after onset and are minimal post-menses, confirmed by 2 cycles of prospective ratings, is treated first-line with SSRIs (ACOG, RCOG). SSRIs work within days in PMDD, so they can be given continuously, in the luteal phase only, or from symptom onset. A drospirenone-containing combined oral contraceptive is an alternative. Progesterone has not shown benefit over placebo in randomised trials. GnRH agonists with add-back therapy are effective but are reserved for refractory cases because of cost and adverse effects. Benzodiazepines such as alprazolam have limited evidence and carry dependence risk, so they are not first-line. Pearl: rule out premenstrual exacerbation of an underlying disorder.

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4. What property of lisdexamfetamine underlies its lower abuse potential compared with immediate-release dexamfetamine?

Lisdexamfetamine is dexamfetamine covalently linked to L-lysine. The conjugate is inactive and is converted to active dexamfetamine by enzymatic hydrolysis, mainly in red blood cells, which gives a gradual onset and long duration (about 13 hours) and blunts the euphoric 'rush' when snorted or injected, reducing misuse potential. Selective noradrenaline reuptake inhibition describes atomoxetine; alpha-2A agonism describes guanfacine and clonidine. The OROS osmotic-release system is used by Concerta (methylphenidate). Pearl: NICE NG87 recommends lisdexamfetamine as second-line after methylphenidate in children, but first-line (alongside methylphenidate) in adults.

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5. Which pharmacological property of buprenorphine most accounts for its lower risk of fatal respiratory depression compared with methadone when taken alone?

Buprenorphine is a partial mu-opioid agonist, so as the dose increases its respiratory depressant effect plateaus (ceiling effect), whereas full agonists such as methadone and heroin produce dose-dependent respiratory depression. This gives buprenorphine a wider safety margin in overdose when taken alone. The safety margin is substantially reduced when combined with benzodiazepines, alcohol, gabapentinoids or other depressants. Its half-life is long (about 24–42 hours), allowing daily or alternate-day dosing. It is a kappa antagonist, not an agonist. It has very high, not low, mu-receptor affinity, which explains precipitated withdrawal and blockade of other opioids. Pearl: high affinity makes naloxone reversal of buprenorphine require higher doses.

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6. A 35-year-old woman reports hearing her late mother's voice comforting her. She explains that the voice is heard 'inside my head, not through my ears', that it lacks the vividness of real speech, and that she knows it is not really her mother. There is no other evidence of psychosis. Which phenomenon is being described?

In the Jaspers-Kandinsky sense, a pseudohallucination is a perception-like experience located in inner subjective space rather than external objective space and lacking the full substantiality of a true percept; insight into its unreality is usually preserved. It occurs in bereavement, personality disorders, dissociation and stress, and is not in itself indicative of psychosis. A functional hallucination is triggered by a real stimulus in the same modality and heard alongside it. An extracampine hallucination is perceived outside the limits of the sensory field, such as a voice from another city. An auditory illusion is a misperception of a real external sound. Pearl: true hallucinations are experienced in external space with the vividness of real perception.

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7. A 45-year-old man with schizophrenia and alcohol dependence has been homeless for 3 years and has been repeatedly excluded from hostels because he is not abstinent. Which intervention has the best evidence for achieving stable housing for him?

Housing First, developed by Pathways to Housing in New York, gives immediate access to independent, permanent housing with flexible, voluntary support from ACT or intensive case management. Housing is not conditional on psychiatric treatment or abstinence. Trials such as At Home/Chez Soi in Canada show large improvements in housing stability and some gains in quality of life. The 'staircase' or treatment-first model requires people to move through stages and meet conditions before being housed, and many drop out. Severe mental illness, substance misuse and tuberculosis are all overrepresented among homeless people.

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8. Which statement about very early-onset (childhood-onset) schizophrenia, with onset before 13 years, is most accurate?

Childhood-onset schizophrenia (onset before 13 years) affects roughly 1 in 10,000–40,000 children, is more common in boys, typically has an insidious onset with premorbid developmental, language and social abnormalities, and has a poorer prognosis than adult-onset illness. DSM-5-TR applies the same diagnostic criteria as in adults, although failure to reach expected developmental levels may replace functional decline. Auditory hallucinations remain most common; prominent visual hallucinations should prompt a search for organic causes. Pearl: in young children, differentiate from imaginative play, autism and trauma-related perceptual experiences; clozapine is effective in treatment-resistant cases.

Sample

9. A 26-year-old woman married 6 months ago has been unable to have vaginal intercourse because of intense fear of pain and involuntary tightening of her pelvic floor muscles whenever penetration is attempted; she cannot use tampons. Gynaecological examination under relaxed conditions shows no structural abnormality. The couple are distressed. Which is the most appropriate management?

This is genito-pelvic pain/penetration disorder (formerly vaginismus and dyspareunia), a common cause of unconsummated marriage. DSM-5-TR criteria include persistent difficulty with penetration, vulvovaginal or pelvic pain, fear or anxiety about pain, and marked tightening of pelvic floor muscles for at least 6 months. Management combines psychoeducation, cognitive-behavioural psychosexual therapy with graded self-insertion of vaginal dilators (a form of systematic desensitisation) and pelvic floor physiotherapy, with high success rates; the partner is involved. Surgical hymenectomy is inappropriate without structural pathology. Sertraline alone does not address conditioned muscle spasm and fear. Sildenafil treats male erectile dysfunction, which is not the problem. Pearl: botulinum toxin injection is reserved for refractory cases.

Sample

10. A 28-year-old woman has recurrent episodes of severe abdominal pain with a normal CT abdomen, together with anxiety, agitation, visual hallucinations and proximal limb weakness. The latest episode began after a period of fasting. Serum sodium is 124 mmol/L and the urine darkens on standing. Which investigation is most appropriate during the episode?

Acute intermittent porphyria is an autosomal dominant deficiency of porphobilinogen deaminase (hydroxymethylbilane synthase) presenting, usually in women aged 20 to 40, with attacks of severe neurovisceral abdominal pain, autonomic features, motor neuropathy, hyponatraemia (often due to SIADH) and psychiatric symptoms such as anxiety, depression, psychosis and confusion. Attacks are precipitated by fasting, alcohol, the menstrual cycle and porphyrinogenic drugs such as barbiturates and carbamazepine. A markedly raised urine porphobilinogen during an attack confirms the diagnosis. Serum ceruloplasmin is incorrect because it tests for Wilson's disease. Serum calcium is relevant to hyperparathyroidism, which lacks neuropathy and dark urine. Serum cortisol assesses adrenal failure. Pearl: there are no skin lesions in acute intermittent porphyria.