RANZCP MCQ Exam cheat sheet

First-rank symptoms (Schneider): audible thoughts, voices arguing/discussing, voices commenting on actions, thought insertion/withdrawal/broadcast, made feelings/impulses/acts, somatic passivity - historically suggestive of schizophrenia but not pathognomonic.

Schizophrenia diagnostic duration: ICD-11 requires ≥1 month of core symptoms; DSM-5-TR requires ≥6 months total with ≥1 month active symptoms plus functional decline.

Major depressive episode DSM-5-TR: ≥5 of 9 symptoms for ≥2 weeks, must include depressed mood or anhedonia; exclude mania/hypomania, substance, medical cause.

Manic episode: elevated/irritable mood plus increased energy for ≥1 week (or any duration if hospitalised), with ≥3 of 7 symptoms (4 if irritable); marked impairment, psychosis, or hospitalisation defines severity.

Hypomania: same symptom criteria as mania but ≥4 consecutive days, unequivocal change, no marked impairment or psychosis, not requiring hospitalisation.

Bipolar I requires ≥1 manic episode; bipolar II requires hypomania plus ≥1 major depressive episode and no lifetime mania.

Panic attack is a specifier across DSM-5-TR disorders (expected vs unexpected); panic disorder requires recurrent unexpected attacks plus ≥1 month of concern or maladaptive behaviour.

Serotonin syndrome: clonus (inducible/ocular/spontaneous), agitation, hyperreflexia, hyperthermia; Hunter criteria are more specific than Sternbach.

Neuroleptic malignant syndrome: lead-pipe rigidity, hyperthermia >38°C, autonomic instability, elevated CK, leukocytosis; onset over 1–3 days, distinct from serotonin syndrome's clonus.

Formal thought disorder descriptors: derailment (loosening of associations), tangentiality, circumstantiality (eventually reaches the goal), flight of ideas (manic), clanging, neologisms, word salad.

Delusion: fixed false belief held with conviction, not shared by the person's culture, resistant to contrary evidence; overvalued idea is less fixed and more understandable.

Hallucination is perception without an external stimulus; illusion is misperception of a real stimulus; pseudohallucination is perceived as internal/inner space.

Insight dimensions (David): awareness of illness, need for treatment, and attribution of symptoms - assess each separately rather than as a single yes/no.

Capacity (four abilities, Appelbaum & Grisso): communicate a choice, understand relevant information, appreciate the situation and consequences, reason about options.

MMSE maximum 30; MoCA maximum 30 and is more sensitive to mild cognitive impairment and executive dysfunction than the MMSE.

Clock-drawing test assesses visuospatial and executive function; it is a screening aid, not a diagnostic test for dementia.

Suicide risk assessment should document static factors (prior attempt, male sex, older age, family history) and dynamic factors (current intent, plan, access to means, hopelessness).

Beck Depression Inventory and PHQ-9 are self-report severity measures, not diagnostic instruments; PHQ-9 scores 5/10/15/20 mark mild/moderate/moderately severe/severe.

Clozapine is indicated in treatment-resistant schizophrenia (failure of ≥2 antipsychotics at adequate dose/duration); requires regular FBC monitoring for neutropenia and ECG/echocardiogram for myocarditis and cardiomyopathy.

Lithium monitoring: serum level 0.6–0.8 mmol/L for maintenance (0.8–1.0 in acute mania); check 12 hours post-dose; monitor renal function, thyroid, calcium, and ECG; toxicity risk rises with dehydration, NSAIDs, ACE inhibitors, thiazides.

SSRI/SNRI discontinuation syndrome: dizziness, paraesthesia, nausea, irritability, flu-like symptoms; shorter half-life agents (paroxetine, venlafaxine) are most implicated.

Antidepressant onset is typically 2–4 weeks; continue 6–12 months after remission for a first episode, and ≥2 years for recurrent or severe episodes.

MAOIs require tyramine-restricted diet and washout periods (typically 2 weeks; 5 weeks after fluoxetine) to avoid hypertensive crisis and serotonin syndrome.

QTc prolongation: haloperidol, ziprasidone, quetiapine, citalopram (dose-dependent) and methadone are notable offenders; correct potassium and magnesium before starting.

ECT: generalised seizure of adequate duration is required; cognitive effects are usually transient anterograde and retrograde amnesia; contraindications are raised intracranial pressure and recent myocardial infarction or stroke.

Tardive dyskinesia: orofacial choreoathetoid movements after prolonged dopamine blockade; risk increases with age, duration, and typical antipsychotics; VMAT2 inhibitors (valbenazine, deutetrabenazine) are evidence-based treatments.

Benzodiazepine withdrawal: rebound anxiety, insomnia, tremor, perceptual disturbances, and seizures; taper gradually (e.g., 5–10% reductions every 1–2 weeks) rather than abrupt cessation.

CBT model: thoughts, feelings, behaviours and physiology interact; treatment targets unhelpful cognitions and avoidance behaviours via behavioural experiments, cognitive restructuring, and exposure.

Behavioural activation for depression targets withdrawal and inactivity; activity scheduling and graded task assignment increase contact with reinforcing contingencies.

Exposure therapy requires graded, repeated, prolonged exposure without safety behaviours until habituation; escape or avoidance maintains anxiety.

Psychodynamic concepts: transference (patient's feelings toward therapist), countertransference (therapist's reactions), resistance, defence mechanisms, and repetition compulsion.

DBT (Linehan) four modules: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness; targets parasuicidal behaviour and therapy-interfering behaviour first.

Mentalization-based treatment (Bateman & Fonagy) for borderline personality disorder: aims to restore capacity to understand behaviour in terms of mental states; typically 12–18 months.

Motivational interviewing (Miller & Rollnick): collaborative, evocative, and autonomy-supportive; uses OARS (open questions, affirmations, reflections, summaries) and explores ambivalence rather than confronting.

Systemic/family therapy: circular causality, genograms, boundaries, triangulation, and identified patient; structural therapy (Minuchin) targets enmeshment and disengagement.

Therapeutic alliance is a consistent predictor of outcome across modalities; rupture-and-repair processes are clinically important.

ADHD DSM-5-TR: ≥6 inattentive and/or ≥6 hyperactive-impulsive symptoms (≥5 for age ≥17), present before age 12, in ≥2 settings, causing impairment; not better explained by another disorder.

Autism spectrum disorder: persistent deficits in social communication plus restricted/repetitive behaviours, present in early development; specify intellectual and language impairment and severity levels.

Tourette disorder: multiple motor and ≥1 vocal tic for >1 year, onset before age 18; coprolalia occurs in a minority (~10%).

Separation anxiety disorder is the most common childhood anxiety disorder; school refusal is a behaviour, not a diagnosis.

Conduct disorder: persistent violation of rights of others or major age-appropriate norms; callous-unemotional traits are a specifier and predict poorer response to standard parenting interventions.

First-line medication for ADHD is a stimulant (methylphenidate or amphetamine); monitor height, weight, blood pressure, and sleep; atomoxetine is a non-stimulant alternative.

Depression in adolescents: fluoxetine has the strongest evidence base; SSRIs carry a boxed warning for increased suicidality in patients under 25, requiring close monitoring.

Eating disorders: anorexia nervosa has the highest mortality of psychiatric disorders; refeeding syndrome risk requires cautious caloric advancement and electrolyte monitoring (especially phosphate).

Child protection: mandatory reporting duties apply to reasonable suspicion of abuse or neglect; assessment should avoid repeated interviewing that contaminates evidence.

Delirium: acute onset, fluctuating course, inattention, and altered consciousness; use the 4AT or CAM; common precipitants are infection, drugs, pain, constipation, retention, and metabolic derangement.

Dementia subtypes: Alzheimer's (hippocampal/medial temporal atrophy, insidious amnesia), vascular (stepwise, vascular risk factors), Lewy body (fluctuating cognition, visual hallucinations, parkinsonism, REM sleep behaviour disorder), frontotemporal (personality/language change).

Lewy body dementia: severe neuroleptic sensitivity - avoid typical antipsychotics; cholinesterase inhibitors may help cognition and hallucinations.

Acetylcholinesterase inhibitors (donepezil, rivastigmine, galantamine) are indicated for mild-to-moderate Alzheimer's; memantine (NMDA antagonist) for moderate-to-severe disease.

Depression in older adults frequently presents with somatic complaints and cognitive impairment; pseudodementia improves with treatment of depression.

Late-onset schizophrenia is more common in women, has less family history, and relatively preserved affect; onset after 60 is uncommon.

Benzodiazepines increase falls, fractures, and confusion in older adults; Beers criteria advise avoidance where possible.

Capacity and driving: dementia does not automatically preclude driving, but fitness must be assessed and relevant licensing authorities notified where required.

Elder abuse includes physical, psychological, financial, sexual abuse and neglect; ask directly and document safeguarding actions.

Delirium is the most common psychiatric presentation in general hospitals; non-pharmacological measures (orientation, sleep hygiene, early mobilisation) are first-line; antipsychotics are used for severe distress or risk.

Agitated delirium: avoid benzodiazepines in older adults and in hepatic/renal impairment where possible; use low-dose haloperidol or atypical antipsychotics, monitoring QTc.

Serotonin syndrome vs NMS vs anticholinergic toxicity: clonus/hyperreflexia (serotonin), rigidity/hyperthermia/high CK (NMS), dry skin/mydriasis/urinary retention (anticholinergic).

Alcohol withdrawal: CIWA-Ar guides symptom-triggered benzodiazepine dosing; thiamine (parenteral) before glucose to prevent Wernicke encephalopathy; monitor for delirium tremens (onset typically 48–96 hours).

Cancer and depression: distinguish from fatigue, pain, and steroid effects; antidepressants are effective, and psychostimulants are sometimes used for rapid effect in terminal illness.

HIV psychiatry: screen for depression and cognitive impairment; efavirenz and some antiretrovirals interact with psychotropics via CYP pathways.

Steroid-induced psychosis: typically affective/mixed features, dose-related, usually within days to weeks; management is dose reduction plus antipsychotic if needed.

Medically unexplained symptoms: assess for depression, anxiety, and physical disease; avoid premature reassurance and repeated unnecessary investigations.

Post-stroke depression is common, associated with poorer rehabilitation outcomes; SSRIs are first-line, with caution regarding bleeding risk.

Fitness to stand trial (Presser criteria): ability to understand the charges and proceedings, instruct counsel, follow evidence, and appreciate the significance of proceedings.

Not guilty by reason of insanity (M'Naghten): at the time of the act, a defect of reason from disease of the mind meant the person did not know the nature and quality of the act or did not know it was wrong.

Risk assessment tools: HCR-20 (historical, clinical, risk management), PCL-R (psychopathy, score ≥30), VRAG and Static-99R (sexual offending); actuarial tools estimate group risk, not individual certainty.

Civil detention criteria generally require mental disorder plus risk to self or others (or grave deterioration); detention must be the least restrictive option.

Fitness to stand trial and criminal responsibility are distinct questions; a person may be unfit yet not insane.

Malingering differs from factitious disorder: malingering is motivated by external gain (avoiding prosecution, financial compensation), whereas factitious disorder is motivated by the sick role.

Duty to warn/protect (Tarasoff principle) may permit or require breach of confidentiality when a patient poses a serious identifiable threat to a specific person.

Capacity to consent to treatment is decision-specific; a refusal of treatment by a capable patient must be respected even if the outcome may be harmful.

Automatism (sane or insane) requires involuntary behaviour; intoxication is generally not a defence to mens rea except in specific statutory circumstances.

DSM-5-TR substance use disorder: ≥2 of 11 criteria in 12 months; severity is mild (2–3), moderate (4–5), severe (≥6); tolerance and withdrawal count as criteria.

Alcohol withdrawal timeline: tremor and anxiety from ~6–12 hours, hallucinations 12–24 hours, seizures 12–48 hours, delirium tremens 48–96 hours.

Wernicke encephalopathy triad: ophthalmoplegia, ataxia, confusion; treat with parenteral thiamine promptly; untreated it progresses to Korsakoff syndrome.

Alcohol biomarkers: GGT, MCV, AST:ALT ratio >1.5, and carbohydrate-deficient transferrin; none is diagnostic in isolation.

Opioid substitution: methadone is a full agonist with QT and respiratory depression risk; buprenorphine is a partial agonist with a ceiling effect and lower overdose risk; naltrexone blocks opioid effects.

Naltrexone and acamprosate reduce alcohol relapse; disulfiram is a deterrent requiring adherence and abstinence and is contraindicated in cardiac disease and pregnancy.

Tobacco: varenicline is among the most effective single agents; combination NRT is more effective than a single form; behavioural support improves all pharmacotherapy outcomes.

Stimulant use disorder has no approved pharmacotherapy; contingency management is the best-supported psychosocial intervention.

Neonatal abstinence syndrome follows in-utero opioid exposure; Finnegan scoring guides treatment, and breastfeeding may be considered depending on maternal substance and dose.

Dopamine pathways: mesolimbic (reward/psychosis), mesocortical (cognition/negative symptoms), nigrostriatal (motor - extrapyramidal effects), tuberoinfundibular (prolactin inhibition).

Serotonin: 5-HT1A (anxiolytic/antidepressant), 5-HT2A (atypical antipsychotic target), 5-HT3 (antiemetic), and the serotonin transporter (SSRI target).

HPA axis: hypothalamic CRH → pituitary ACTH → adrenal cortisol; dexamethasone suppression test abnormality in melancholic depression reflects impaired negative feedback.

Frontal lobe lesions cause disinhibition, apathy, perseveration, and poor planning; parietal lesions cause neglect and apraxia; occipital lesions cause visual field defects.

Wernicke's area (dominant posterior superior temporal) - receptive aphasia; Broca's area (dominant inferior frontal) - expressive aphasia with preserved comprehension.

Korsakoff syndrome: anterograde amnesia with confabulation from mammillary body and thalamic damage; typically follows untreated Wernicke encephalopathy.

Huntington disease: autosomal dominant CAG repeat expansion (≥36 pathogenic); presents with chorea, cognitive decline, and psychiatric symptoms; anticipatory (genetic) testing requires counselling.

Wilson disease: copper deposition with hepatic and neuropsychiatric features, Kayser-Fleischer rings, low ceruloplasmin; treatable, so screen in young-onset psychosis with movement disorder.

Hyponatraemia with SSRIs and carbamazepine: SIADH is a recognised cause; correct sodium slowly to avoid osmotic demyelination.