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Atestace z Psychiatrie - independent subject foundations study materials
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Atestace z Psychiatrie - independent subject foundations practice questions

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Question 1Psychiatric assessment, descriptive psychopathology and formulation

Which statement best describes the relevance of NMDA receptor hypofunction to psychosis?

  1. NMDA receptor blockade selectively improves auditory hallucinations without affecting cognition.
  2. NMDA receptor antagonists can produce positive, negative and cognitive symptoms resembling aspects of schizophrenia. Correct answer.
  3. NMDA receptor hypofunction is a diagnostic biomarker that confirms schizophrenia in individual patients.
  4. NMDA receptor activity is unrelated to cortical interneuron function or glutamatergic signalling.

Explanation

NMDA receptor hypofunction is a prominent mechanistic model of schizophrenia because NMDA antagonists can induce psychosis-like positive symptoms as well as negative and cognitive features. It is not a diagnostic test.

Question 2Psychiatric assessment, descriptive psychopathology and formulation

A trainee says that fMRI directly measures neuronal firing and can diagnose schizophrenia. What is the best correction?

  1. fMRI measures cerebrospinal fluid dopamine concentration and is diagnostic when striatal dopamine is elevated.
  2. fMRI usually measures blood-oxygen-level-dependent signal as an indirect correlate of neural activity and is not a stand-alone diagnostic test for schizophrenia. Correct answer.
  3. fMRI measures cortical synapse number directly and is diagnostic when pruning is excessive.
  4. fMRI measures electrical spikes with millisecond precision and has replaced EEG for diagnosing psychosis.

Explanation

Most psychiatric fMRI uses BOLD contrast, an indirect haemodynamic signal related to neural activity. Neuroimaging findings in schizophrenia are valuable for research and differential diagnosis but are not diagnostic on their own.

Question 3Psychiatric assessment, descriptive psychopathology and formulation

Which structural neuroimaging finding is most consistently reported at group level in schizophrenia, while remaining non-specific for diagnosis in an individual patient?

  1. A pathognomonic enhancing lesion in the medial temporal lobe
  2. Complete absence of the corpus callosum in most patients
  3. Bilateral cerebellar infarction during the prodrome
  4. Enlarged lateral ventricles with subtle reductions in total and regional grey matter volume Correct answer.

Explanation

Group studies of schizophrenia commonly report ventricular enlargement and modest grey matter volume reductions, but these findings overlap with healthy and other clinical populations and are not diagnostic individually.

Question 4Psychiatric assessment, descriptive psychopathology and formulation

Which statement about the genetics of schizophrenia is most accurate?

  1. Risk is highly polygenic, with contributions from many common variants of small effect and some rare variants of larger effect. Correct answer.
  2. A single autosomal dominant mutation explains most cases across populations.
  3. Genetic risk is negligible because concordance is the same in monozygotic and dizygotic twins.
  4. A high polygenic risk score is sufficient by itself to diagnose schizophrenia.

Explanation

Schizophrenia has substantial heritability but is genetically complex. Common variants, rare copy number variants and environmental exposures all contribute; genetic findings are not currently diagnostic by themselves.

Question 5Psychiatric assessment, descriptive psychopathology and formulation

A copy number variant is found to substantially increase risk of psychosis but also increases risk of intellectual disability, autism spectrum disorder and epilepsy. What does this illustrate?

  1. Genetic determinism, where one variant inevitably causes one psychiatric disorder
  2. Assortative mating, where individuals with similar traits choose each other as partners
  3. Pleiotropy, where one genetic variant can influence risk for multiple phenotypes Correct answer.
  4. Mendelian anticipation, where symptoms always appear earlier in successive generations

Explanation

Pleiotropy describes a single genetic factor influencing multiple traits or disorders. Many neurodevelopmental risk variants are pleiotropic and do not map neatly onto one diagnostic category.

Question 6Psychiatric assessment, descriptive psychopathology and formulation

A four-year-old watches a toy being moved while another child is absent. The child predicts that the absent child will look for the toy where they last saw it, not where it is now. Which developmental capacity is being demonstrated?

  1. Object permanence
  2. Conservation of volume
  3. Theory of mind Correct answer.
  4. Separation-individuation

Explanation

False-belief tasks assess theory of mind: the capacity to represent another person's mental state as different from reality and from one's own knowledge.

Question 7Psychiatric assessment, descriptive psychopathology and formulation

During interview, a patient says, 'The neighbours watch me through the wall. Walls are like borders. Borders make passports. My passport is blue because the sea is honest.' Which term best describes this speech pattern?

  1. Circumstantiality
  2. Thought blocking
  3. Clang association
  4. Derailment or loosening of associations Correct answer.

Explanation

Derailment or loosening of associations involves shifts between ideas with weak or idiosyncratic connections. Circumstantiality eventually returns to the point; thought blocking is abrupt interruption; clang association is driven by sound rather than meaning.

Question 8Psychiatric assessment, descriptive psychopathology and formulation

A patient says, 'When I raise my arm, it is not me doing it. An outside force makes the movement happen.' Which psychopathological phenomenon is this?

  1. Compulsion
  2. Passivity experience Correct answer.
  3. Depersonalisation
  4. Overvalued idea

Explanation

A passivity experience is the belief that one's actions, impulses or bodily experiences are controlled by an external force. Compulsions are repetitive acts experienced as one's own, often resisted.

Question 9Psychiatric assessment, descriptive psychopathology and formulation

A patient looks at a red car passing the clinic and immediately knows it is a divine message that he has been chosen to save the city. The perception itself is ordinary, but the attached meaning is delusional. What is the best description?

  1. Illusion
  2. Delusional perception Correct answer.
  3. Auditory hallucination
  4. Obsessive rumination

Explanation

Delusional perception occurs when a normal perception is given a new, false and personally significant delusional meaning. An illusion is a misperception of a real external stimulus.

Question 10Psychiatric assessment, descriptive psychopathology and formulation

A person hears two voices commenting on their actions while alone in a quiet room. They believe the voices come from outside their head. Which term best describes this experience?

  1. Auditory hallucination Correct answer.
  2. Illusion
  3. Intrusive thought
  4. Flight of ideas

Explanation

A hallucination is a perception-like experience without an external stimulus. Voices commenting on actions are auditory hallucinations and are clinically important in psychosis assessment.

Question 11Psychiatric assessment, descriptive psychopathology and formulation

Which statement best reflects good diagnostic practice when using classification systems for psychotic disorders?

  1. A single bizarre delusion is sufficient to diagnose schizophrenia in every classification system regardless of duration or context.
  2. Psychotic symptoms caused by delirium should be classified as schizophrenia if hallucinations are prominent.
  3. Classifications should be applied after assessing symptom type, duration, functional impact, mood symptoms, substance use, medical causes and cultural context. Correct answer.
  4. Cultural and religious context is irrelevant once a belief appears unusual to the examiner.

Explanation

Diagnosis of psychotic disorders requires more than naming symptoms. Duration, impairment, mood episodes, substances, medical or neurological causes and cultural context all influence classification and management.

Question 12Psychiatric assessment, descriptive psychopathology and formulation

A 19-year-old reports occasional suspicious ideas and brief perceptual disturbances with recent functional decline, but no sustained frank psychosis. Which instrument is specifically designed to help assess clinical high risk for psychosis?

  1. Hamilton Rating Scale for Depression
  2. Alcohol Use Disorders Identification Test
  3. Comprehensive Assessment of At-Risk Mental States (CAARMS) Correct answer.
  4. Mini-Mental State Examination

Explanation

CAARMS is used to assess attenuated psychotic symptoms and other clinical high-risk states. It supports structured risk assessment but does not by itself establish a diagnosis of schizophrenia.

Question 13Psychiatric assessment, descriptive psychopathology and formulation

Which scale is most appropriate for quantifying positive symptoms, negative symptoms and general psychopathology in schizophrenia research or specialist clinical monitoring?

  1. Positive and Negative Syndrome Scale (PANSS) Correct answer.
  2. Yale-Brown Obsessive Compulsive Scale
  3. Clinical Institute Withdrawal Assessment for Alcohol
  4. Epworth Sleepiness Scale

Explanation

PANSS is a structured rating scale for schizophrenia symptom domains, including positive, negative and general psychopathology items. It is not a screening test for unrelated syndromes.

Question 14Psychiatric assessment, descriptive psychopathology and formulation

A 46-year-old has a first episode of visual hallucinations, fluctuating attention and new disorientation after starting several medicines. What is the most appropriate initial diagnostic approach?

  1. Diagnose schizophrenia because hallucinations are present and begin long-term antipsychotic treatment without further assessment.
  2. Diagnose delusional disorder because visual hallucinations are more specific than auditory hallucinations.
  3. Delay all medical assessment until the psychotic symptoms have persisted for six months.
  4. Assess urgently for delirium, medication effects, substance use and medical or neurological causes before diagnosing a primary psychotic disorder. Correct answer.

Explanation

Late or atypical first psychosis, visual hallucinations, fluctuating attention and disorientation should prompt urgent assessment for delirium, medication effects, substances and medical or neurological causes.

Question 15Psychiatric assessment, descriptive psychopathology and formulation

A 32-year-old has a long history of assaults, repeated lying for profit, reckless disregard for safety, failure to honour financial obligations, and lack of remorse. School records describe truancy, cruelty to peers, and arrests before age 15. Which personality disorder is most likely?

  1. Schizoid personality disorder
  2. Antisocial personality disorder Correct answer.
  3. Avoidant personality disorder
  4. Dependent personality disorder

Explanation

Antisocial personality disorder requires a pervasive adult pattern of disregard for and violation of others' rights, with evidence of conduct disorder before age 15. The developmental history is essential to the diagnosis.

Question 16Psychiatric assessment, descriptive psychopathology and formulation

A 29-year-old has recurrent sudden aggressive outbursts in which he punches walls or threatens others after minor frustrations. The outbursts are grossly disproportionate, unplanned, and followed by remorse. They do not occur only during mania, intoxication, psychosis, or antisocial offending for gain. Which diagnosis is most likely?

  1. Pyromania
  2. Intermittent explosive disorder Correct answer.
  3. Kleptomania
  4. Conduct disorder

Explanation

Intermittent explosive disorder consists of recurrent impulsive aggressive outbursts that are disproportionate to provocation and not better explained by another disorder, substances, or deliberate instrumental aggression.

Question 17Psychiatric assessment, descriptive psychopathology and formulation

A trial reports that a relapse-prevention intervention reduces 1-year relapse from 2% to 1%. The abstract emphasizes a 50% relative risk reduction. What is the most accurate interpretation for clinical decision-making?

  1. The intervention prevents relapse in half of all treated patients
  2. The result proves the intervention is clinically large regardless of baseline risk
  3. The number needed to treat is 2 because the relative risk reduction is 50%
  4. The absolute risk reduction is 1%, so about 100 patients need treatment to prevent one relapse Correct answer.

Explanation

Relative effects can look impressive when baseline risk is low. Absolute risk reduction is 2% minus 1% = 1%, giving an NNT of 100 over the stated time horizon.

Question 18Psychiatric assessment, descriptive psychopathology and formulation

Which historical contribution is most closely associated with Emil Kraepelin's influence on psychiatric classification?

  1. Describing moral treatment as liberation from chains in asylums
  2. Introducing the term schizophrenia to replace dementia praecox
  3. Developing the first selective serotonin reuptake inhibitor
  4. Distinguishing dementia praecox from manic-depressive illness by longitudinal course and outcome Correct answer.

Explanation

Kraepelin emphasised longitudinal course and outcome, including the distinction between dementia praecox and manic-depressive illness. Bleuler later introduced the term schizophrenia.

Question 19Mood syndromes, longitudinal diagnosis and recovery planning

A 31-year-old male with a history of recurrent major depressive episodes is brought to the emergency department in an exhilarated, irritable state lasting 10 days. He has spent his entire savings on luxury sports cars, has not slept for 4 consecutive nights while claiming boundless energy, and exhibits pressured speech, grandiose plans of buying nuclear power plants, and flight of ideas. Toxicological screening is negative. What is the diagnosis?

  1. Bipolar affective disorder, current episode manic without psychotic symptoms (F31.1) Correct answer.
  2. Recurrent depressive disorder, currently in remission (F33.4)
  3. Obsessive-compulsive disorder (F42)
  4. Generalized anxiety disorder (F41.1)

Explanation

This patient meets full ICD-10 criteria for Bipolar affective disorder, current episode manic (F31.1): elevated/irritable mood, increased energy/activity, decreased need for sleep, pressured speech, flight of ideas, spending sprees/disinhibition, and grandiosity lasting more than 1 week with marked functional disruption, occurring in a patient with past depressive episodes. In ICD-10, the occurrence of a single manic episode in someone with prior depression establishes the diagnosis of bipolar affective disorder.

Question 20Mood syndromes, longitudinal diagnosis and recovery planning

A 29-year-old woman with Bipolar I disorder experiences 6 distinct affective episodes within a single 12-month period (3 manic episodes and 3 major depressive episodes), separated by short partial remissions. What clinical subtype is diagnosed, and what is the relationship between this pattern and antidepressant monotherapy?

  1. Rapid cycling bipolar disorder (defined by at least 4 affective episodes within 12 months); antidepressant monotherapy is contraindicated as it frequently triggers or destabilizes rapid cycling Correct answer.
  2. Schizotypal disorder; antidepressants are curative
  3. Cyclothymia; requires high-dose tricyclic antidepressants
  4. Persistent depressive disorder; indicates psychotherapy resistance

Explanation

Rapid cycling is defined under ICD-10/ICD-11 and DSM-5-TR by the occurrence of at least 4 mood episodes (depressive, manic, hypomanic, or mixed) within a 12-month period. It occurs in 10–20% of bipolar patients and is more prevalent in women. Antidepressant monotherapy is recognized as a major precipitating and destabilizing factor that can induce cycle acceleration and switch to mixed or manic states; guidelines recommend withdrawing antidepressants and optimizing mood stabilizers (e.g., lithium, valproate, quetiapine).

Question 21Mood syndromes, longitudinal diagnosis and recovery planning

A 26-year-old woman presents with persistent low mood. Unlike classical melancholia, she experiences marked mood reactivity (her mood brightens significantly in response to actual or potential positive events), long-standing interpersonal rejection sensitivity that impairs her relationships, severe hypersomnia (sleeping 12 hours per night), hyperphagia with intense carbohydrate cravings, and a heavy, weighted feeling in her limbs ('leaden paralysis'). What is the clinical subtype?

  1. Atypical depression Correct answer.
  2. Cotard syndrome
  3. Capgras delusion
  4. Catatonic stupor

Explanation

This patient exemplifies the classic features of Atypical Depression (F32.8 or DSM-5 atypical features specifier): mood reactivity (the mandatory core feature), accompanied by at least two vegetative/physical signs: leaden paralysis (heavy sensation in arms/legs), hypersomnia, hyperphagia/weight gain, and enduring interpersonal rejection sensitivity. Historically, atypical depression demonstrated preferential response to monoamine oxidase inhibitors (MAOIs), and in modern practice responds well to SSRIs and SNRIs.

Question 22Psychosis, differential diagnosis and ongoing care

A 30-year-old man with chronic schizophrenia exhibits profound affective flattening, avolition, alogia, and severe anhedonia, without active positive delusions or hallucinations. These negative symptoms have persisted unchanged for over 2 years and cause massive occupational impairment. What distinguishes primary negative symptoms from secondary negative symptoms?

  1. Primary negative symptoms are intrinsic core manifestations of the schizophrenia disease process, whereas secondary negative symptoms are caused by depression, parkinsonian side effects, social deprivation, or positive symptoms Correct answer.
  2. Primary negative symptoms only occur during childhood, while secondary negative symptoms occur in geriatric patients
  3. Primary negative symptoms respond rapidly to selective serotonin reuptake inhibitors, whereas secondary negative symptoms do not
  4. Primary negative symptoms are defined solely by the presence of prominent visual hallucinations

Explanation

In schizophrenia psychopathology, primary negative symptoms (the 'deficit syndrome') are enduring, intrinsic features of the core neurodevelopmental disease pathophysiology. In contrast, secondary negative symptoms arise as consequences of other factors: extrapyramidal hypokinesia (neuroleptic-induced parkinsonism), comorbid major depressive episodes, institutionalization/environmental understimulation, or social withdrawal driven by active paranoid delusions. Identifying and treating secondary causes is critical before concluding that deficit symptoms are refractory.

Question 23Psychosis, differential diagnosis and ongoing care

A 19-year-old male is admitted after developing abrupt-onset persecutory delusions, visual illusions, and emotional lability 3 days after failing his final high school examinations. The total duration of symptoms has been 5 days. Somatic and toxicological screenings are completely negative. By day 8 of hospitalization, his symptoms remit completely without residual deficits. Under ICD-10, which diagnostic entity best captures this clinical course?

  1. Acute and transient psychotic disorder (F23) Correct answer.
  2. Hebephrenic schizophrenia (F20.1)
  3. Delusional disorder (F22.0)
  4. Residual schizophrenia (F20.5)

Explanation

Under ICD-10 (F23), Acute and transient psychotic disorders are defined by an acute onset (change from non-psychotic to clearly psychotic state within 2 weeks, often within 48 hours), polymorphic or typical psychotic features, associated acute stress, and complete recovery within 1 to 3 months (frequently within days to weeks). If symptoms were to persist continuously beyond 1 month, the diagnosis would require re-evaluation toward schizophrenia.

Question 24Psychosis, differential diagnosis and ongoing care

A 54-year-old accountant has been convinced for the past 6 months that his next-door neighbor is orchestrating a secret legal conspiracy to forfeit his apartment lease. He has drafted dozens of coherent legal petitions to the municipal court. Beyond this isolated, encapsulated persecutory belief, his affect is intact, his speech is organized, and he continues to perform complex accounting tasks without cognitive impairment. He denies auditory or somatic hallucinations. What is the diagnosis?

  1. Delusional disorder (F22.0) Correct answer.
  2. Catatonic schizophrenia (F20.2)
  3. Vascular dementia (F01)
  4. Schizotypal disorder (F21)

Explanation

Under ICD-10 (F22.0), Delusional disorder is characterized by the development of a single delusion or a series of related delusions that are usually persistent and sometimes lifelong, typically persecutory, querulant, jealous, grandiose, or hypochondriacal. The delusion is systematized, hallucinations are absent or transient, and the personality, intellect, and daily functioning outside the immediate sphere of the delusion are remarkably preserved.

Question 25Psychosis, differential diagnosis and ongoing care

A 36-year-old woman with chronic schizophrenia who recently recovered from an acute psychotic exacerbation presents with profound sadness, feelings of guilt, anhedonia, tearfulness, and active suicidal ideation, despite the complete resolution of her hallucinations and persecutory delusions. Which diagnostic category under ICD-10 specifically addresses this clinical syndrome?

  1. Post-schizophrenic depression (F20.4) Correct answer.
  2. Simple schizophrenia (F20.6)
  3. Bipolar I disorder, most recent episode hypomanic (F31.0)
  4. Hypochondriacal disorder (F45.2)

Explanation

Post-schizophrenic depression (F20.4 in ICD-10) is diagnosed when a patient has had a definite schizophrenic illness within the past 12 months, some schizophrenic symptoms (positive or negative) may still be present but no longer dominate the clinical picture, and depressive symptoms fulfilling criteria for at least a mild depressive episode predominate, carrying high suicide risk. Antidepressant augmentation while maintaining antipsychotic stability is the standard evidence-based management.

Question 26Anxiety, obsessive-compulsive and trauma-related formulations

A 30-year-old male spends 4 hours every day repeatedly checking door locks, gas knobs, and electrical outlets because of intrusive doubts that his negligence will cause a catastrophic fire. He recognizes that his fears are excessive and irrational (ego-dystonic). What is the gold-standard, first-line evidence-based psychotherapeutic intervention for Obsessive-Compulsive Disorder (OCD)?

  1. Exposure and Response Prevention (ERP / KBT - expozice se zábranou rituálu) Correct answer.
  2. Unstructured supportive counseling with reassurance and family accommodation
  3. Classic Jungian dream analysis
  4. Direct confrontation with physical electroshocks delivered whenever an obsession occurs

Explanation

Exposure and Response Prevention (ERP; in Czech: expozice se zábranou rituálu), a specialized form of Cognitive Behavioral Therapy (CBT), is the psychological treatment of choice for OCD with the strongest empirical support. The patient is systematically exposed in vivo or imaginally to fear-provoking triggers (e.g., locking the door once) while strictly refraining from engaging in the compulsive neutralizing ritual (checking). This promotes inhibitory learning, cognitive reappraisal of threat, and natural habituation of anxiety.

Question 27Anxiety, obsessive-compulsive and trauma-related formulations

A 40-year-old bus driver survived a catastrophic traffic collision 12 hours ago involving multiple fatalities. He presents with an initial 'dazed' state, narrowed attention, disorientation, autonomic hyperarousal, and emotional detachment. Somatic and neurological evaluations show no head injury. According to ICD-10 criteria (F43.0), what is the diagnosis and recommended clinical approach?

  1. Acute stress reaction (F43.0); provide psychological first aid (safety, warmth, practical assistance, active listening without forcing emotional exposure), as symptoms typically diminish within hours or 2 to 3 days Correct answer.
  2. Schizophrenia, catatonic type; immediate involuntary admission for ECT
  3. Mandatory single-session Critical Incident Stress Debriefing (CISD) with forced re-exposure to all trauma details
  4. Permanent disability retirement and high-dose clozapine therapy

Explanation

Acute Stress Reaction (ICD-10 F43.0) is a transient psychiatric disturbance of exceptional severity that develops in response to overwhelming physical or psychological trauma within minutes, showing polymorphic symptoms (daze, dissociation, anxiety, autonomic hyperactivity), which typically begin to subside within hours and resolve within 2 to 3 days. Recommended management is Psychological First Aid (ensuring safety, physical comfort, supportive presence). Research shows that mandatory single-session forced debriefing (CISD) can be harmful and increase PTSD rates.

Question 28Anxiety, obsessive-compulsive and trauma-related formulations

A 32-year-old female presents 4 months after surviving an armed robbery. She experiences persistent intrusive flashbacks, intense nightmares where she relives the assault, severe physiological distress upon encountering men resembling the perpetrator, avoidance of the entire neighborhood where the incident occurred, hypervigilance, and an exaggerated startle response. What is the diagnosis under ICD-10?

  1. Post-traumatic stress disorder (PTSD, F43.1) Correct answer.
  2. Bipolar II disorder, hypomanic episode (F31.0)
  3. Factitious disorder (F68.1)
  4. Anorexia nervosa (F50.0)

Explanation

Under ICD-10 (F43.1), Post-Traumatic Stress Disorder (PTSD) arises as a delayed or protracted response to a stressful event or situation of exceptionally threatening or catastrophic nature. Core diagnostic criteria comprise: (1) persistent re-experiencing/intrusions (flashbacks, vivid memories, recurring distressing nightmares); (2) persistent avoidance of stimuli associated with the trauma; and (3) persistent symptoms of psychological and autonomic hyperarousal (hypervigilance, heightened startle response, insomnia).

Question 29Anxiety, obsessive-compulsive and trauma-related formulations

According to international clinical practice guidelines (WHO, NICE, APA) and the Czech Psychiatric Society (ČPS ČLS JEP), which two evidence-based psychotherapeutic modalities are considered first-line treatments for Post-Traumatic Stress Disorder (PTSD)?

  1. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and Eye Movement Desensitization and Reprocessing (EMDR) Correct answer.
  2. Unrestricted psychoanalytic free association and electroconvulsive therapy
  3. Autogenic training and primal scream therapy
  4. Neurolinguistic programming (NLP) and craniosacral osteopathy

Explanation

Both Trauma-Focused Cognitive Behavioral Therapy (TF-CBT, incorporating prolonged imaginal exposure, cognitive restructuring, and narrative processing) and Eye Movement Desensitization and Reprocessing (EMDR, utilizing bilateral sensory stimulation while processing traumatic memories) are designated as the gold-standard, first-line psychotherapies for PTSD by the WHO, NICE, and ČPS ČLS JEP guidelines with the highest level of empirical evidence (Level 1A).

Question 30Anxiety, obsessive-compulsive and trauma-related formulations

In the World Health Organization's ICD-11 classification, how is Complex Post-Traumatic Stress Disorder (CPTSD, code 6B41) formally distinguished from classic Post-Traumatic Stress Disorder (PTSD, code 6B40)?

  1. CPTSD requires meeting all core diagnostic criteria of classic PTSD (re-experiencing, avoidance, persistent threat sense) plus three additional persistent domains of 'disturbances in self-organization' (DSO): severe affect dysregulation, persistent negative self-concept (feelings of worthlessness/shame), and persistent difficulties in sustaining interpersonal relationships, typically following prolonged or repeated interpersonal trauma Correct answer.
  2. CPTSD is diagnosed only in children under 5 years of age
  3. CPTSD requires the complete absence of any traumatic event
  4. CPTSD is defined solely by the presence of prominent auditory musical hallucinations

Explanation

ICD-11 introduced Complex PTSD (CPTSD, 6B41) as a distinct diagnostic entity that typically develops following exposure to prolonged, repeated, or multiple traumatic stressors from which escape is difficult or impossible (e.g., childhood abuse, prolonged domestic violence, torture). Diagnosis requires fulfilling the 3 core PTSD symptom clusters (re-experiencing in the here-and-now, avoidance, hypervigilance) PLUS the 3 'Disturbances in Self-Organization' (DSO) clusters: (1) severe emotional/affective dysregulation, (2) persistent negative self-concept of shame and failure, and (3) pervasive difficulties in interpersonal relationships.

Question 31Anxiety, obsessive-compulsive and trauma-related formulations

A 42-year-old executive is terminated from his job during corporate restructuring. Over the subsequent 3 weeks, he develops anxious distress, feelings of helplessness, mild sleep disturbance, and impaired concentration at home, causing subjective suffering but not meeting the symptom threshold for a major depressive episode or generalized anxiety disorder. What is the diagnosis under ICD-10?

  1. Adjustment disorder (F43.2) Correct answer.
  2. Hebephrenic schizophrenia (F20.1)
  3. Delirium tremens (F10.4)
  4. Autism spectrum disorder (F84.0)

Explanation

Adjustment disorder (ICD-10 F43.2) is a state of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or stressful life event (e.g., job loss, divorce, serious illness). Symptoms must manifest within 1 month of the stressor and typically resolve within 6 months unless the stressor persists. It does not fulfill criteria for a specific depressive or anxiety disorder.

Question 32Substance-related, cognitive and liaison assessment

How does disulfiram (Antabuse) function biochemically to deter alcohol consumption in relapse prevention therapy, and what toxic intermediate accumulates upon ethanol ingestion?

  1. Irreversible inhibition of aldehyde dehydrogenase (ALDH), leading to massive accumulation of acetaldehyde causing facial flushing, throbbing headache, nausea, vomiting, tachycardia, and hypotension Correct answer.
  2. Stimulation of gastric alcohol dehydrogenase, accelerating ethanol absorption by 500%
  3. Blockade of central dopamine D2 receptors, inducing immediate acute muscular dystonia
  4. Direct covalent binding to hemoglobin, preventing oxygen delivery to the lungs

Explanation

Disulfiram functions as an aversive deterrent by irreversibly inhibiting the liver enzyme aldehyde dehydrogenase (ALDH). Under normal ethanol metabolism, alcohol dehydrogenase (ADH) oxidizes ethanol to acetaldehyde, which ALDH promptly oxidizes to harmless acetate. When a patient on disulfiram ingests alcohol, acetaldehyde accumulates to 5- to 10-fold toxic concentrations, producing the severe, unpleasant disulfiram-ethanol reaction (facial flushing, diaphoresis, throbbing headache, nausea, severe vomiting, chest tightness, palpitations, and hypotension).

Question 33Substance-related, cognitive and liaison assessment

A 71-year-old retired schoolteacher presents with an insidious, progressive 2-year decline in short-term episodic memory, word-finding difficulties, spatial disorientation in unfamiliar neighborhoods, and difficulty managing complex financial transactions. Neurological exam is non-focal. MRI of the brain demonstrates bilateral hippocampal and medial temporal lobe atrophy without significant ischemic lesions. Which CSF biomarker profile is characteristic of Alzheimer's disease (F00)?

  1. Normal Abeta42, absent total tau, and presence of oligoclonal IgG bands exclusively
  2. Decreased amyloid-beta 1-42 (Abeta42) or reduced Abeta42/Abeta40 ratio, combined with elevated total tau (t-tau) and elevated phosphorylated tau (p-tau181) Correct answer.
  3. Marked elevation of 14-3-3 protein with normal amyloid and normal tau
  4. Profoundly elevated glucose, high neutrophils, and low chloride

Explanation

The core cerebrospinal fluid (CSF) biomarker signature of Alzheimer's disease pathophysiology reflects cortical amyloid deposition and neurofibrillary tangle pathology. It consists of reduced CSF amyloid-beta 42 (Abeta42, or a decreased Abeta42/Abeta40 ratio, due to sequestration into parenchymal amyloid plaques), accompanied by elevated CSF total tau (t-tau, reflecting cortical axonal neurodegeneration) and elevated phosphorylated tau (p-tau181 or p-tau217, reflecting hyperphosphorylated neurofibrillary tangle formation).

Question 34Substance-related, cognitive and liaison assessment

A 74-year-old man has fluctuating confusion, recurrent detailed visual hallucinations and new parkinsonism. His wife reports that a previous small dose of haloperidol caused marked rigidity and sedation. Which diagnosis best explains this pattern?

  1. Behavioural variant frontotemporal dementia
  2. Late-onset schizophrenia
  3. Dementia with Lewy bodies Correct answer.
  4. Vascular dementia

Explanation

Dementia with Lewy bodies is suggested by cognitive fluctuations, recurrent visual hallucinations, parkinsonism and antipsychotic sensitivity.

Question 35Substance-related, cognitive and liaison assessment

An 82-year-old woman is withdrawn and inattentive two days after hip surgery. She is drowsy by day, disoriented at night and has fluctuating alertness. Her family asks whether she has become depressed. What is the most likely diagnosis?

  1. Hypoactive delirium Correct answer.
  2. Major depressive disorder
  3. Normal ageing
  4. Persistent complex bereavement disorder

Explanation

Acute onset, fluctuation, impaired attention and altered arousal after surgery strongly suggest delirium, including the often-missed hypoactive subtype.

Question 36Substance-related, cognitive and liaison assessment

A 70-year-old inpatient with pneumonia becomes agitated at night, pulls out intravenous lines and is misidentifying staff. Oxygen saturation is low and he is constipated. What is the priority management plan?

  1. Diagnose late-onset bipolar disorder and start lithium
  2. Give regular high-dose benzodiazepines until he sleeps through the night
  3. Treat likely delirium by correcting medical precipitants, providing orientation and using medication only if needed for immediate safety Correct answer.
  4. Delay assessment until he is calm because agitation prevents diagnosis

Explanation

Delirium management focuses on identifying and treating precipitants, environmental and orientation measures, and cautious short-term medication only for severe distress or safety risks.

Question 37Substance-related, cognitive and liaison assessment

A 58-year-old man with metastatic colorectal cancer says he wants to stop chemotherapy and asks whether life is still worth living. He is in pain and has insomnia but can discuss his prognosis coherently. What is the best psychiatric contribution?

  1. Assume he is suicidal and request involuntary admission
  2. Tell the oncology team that treatment refusal is a symptom of depression
  3. Assess depression, demoralisation, pain, capacity, values and supports in collaboration with oncology and palliative care Correct answer.
  4. Avoid asking about suicidal thoughts because it may increase risk

Explanation

In serious illness, wishes to stop treatment require careful assessment of mood, suffering, capacity and goals of care; asking about suicide is appropriate and does not by itself increase risk.

Question 38Substance-related, cognitive and liaison assessment

An 82-year-old postoperative patient becomes acutely confused, fluctuates during the day, misidentifies staff, and has visual hallucinations. Which consultation-liaison recommendation is best?

  1. Diagnose schizophrenia and start lifelong antipsychotic treatment without medical review
  2. Ignore the symptoms because hallucinations are normal after surgery
  3. Assess and treat underlying causes, optimise pain, hydration and sleep-wake cues, use reorientation, and reserve short-term antipsychotic medication for severe distress or risk Correct answer.
  4. Use benzodiazepines as first-line treatment for all delirium regardless of cause

Explanation

The picture is delirium. Management prioritises identifying reversible medical causes and non-pharmacological measures; medication is short term and targeted when distress or risk is significant.

Question 39Psychotherapy models, learning processes and therapeutic communication

A 24-year-old has repeated self-cutting after feared rejection, rapidly shifting views of partners from idealised to hateful, chronic emptiness, intense anger, and impulsive spending. Which management plan is most appropriate as a core treatment?

  1. Structured psychotherapy such as dialectical behaviour therapy, with a collaborative crisis plan Correct answer.
  2. Indefinite high-dose benzodiazepines as the main intervention
  3. No treatment because personality disorders are untreatable
  4. Antipsychotic depot medication for all symptoms regardless of target symptoms

Explanation

Borderline personality disorder is treated primarily with structured psychological therapies such as DBT, mentalization-based therapy, or related approaches. Medication may target comorbidity or specific symptoms but is not the core treatment.

Question 40Psychotherapy models, learning processes and therapeutic communication

A patient with alcohol use disorder says, "I know drinking is damaging my liver, but it is the only way I sleep." Which response best reflects motivational interviewing?

  1. "You must stop drinking immediately or treatment will not continue."
  2. "It sounds as if alcohol feels useful in the short term, while another part of you is worried about the harm it is causing." Correct answer.
  3. "Your insomnia is irrelevant until you accept that you are addicted."
  4. "I will arrange admission today because ambivalence means you lack capacity."

Explanation

Motivational interviewing uses empathy, reflective listening, autonomy support, and exploration of ambivalence. It avoids confrontation, coercion, and premature advice-giving.

Question 41Psychotherapy models, learning processes and therapeutic communication

A man with schizophrenia hears a voice saying he is worthless. In CBT for psychosis, which therapist intervention is most consistent with the model?

  1. Tell him the voice is definitely unreal and ask him not to mention it again
  2. Explore triggers, meanings, evidence, coping responses, and alternative explanations collaboratively Correct answer.
  3. Interpret the voice as proof of unconscious sexual conflict before discussing coping
  4. Avoid discussing voices because attention to psychotic symptoms inevitably worsens them

Explanation

CBT for psychosis works collaboratively on appraisals, distress, coping, safety behaviours, and alternative explanations. It does not rely on blunt contradiction or avoidance of symptoms.

Question 42Psychotherapy models, learning processes and therapeutic communication

A 23-year-old woman with borderline personality disorder has recurrent self-harm after interpersonal crises. In dialectical behaviour therapy, what is usually the highest priority treatment target?

  1. Detailed exploration of childhood memories before any current risk work
  2. Medication adherence, because DBT is primarily a pharmacological adherence programme
  3. Avoiding discussion of self-harm to prevent reinforcement
  4. Life-threatening behaviours, analysed with chain analysis and linked to skills practice Correct answer.

Explanation

DBT prioritises life-threatening behaviours, then therapy-interfering behaviours and quality-of-life targets. Chain analysis and skills training connect triggers, vulnerabilities, behaviours, and alternatives.

Question 43Psychotherapy models, learning processes and therapeutic communication

In psychotherapy, a patient becomes intensely angry when the therapist is two minutes late and says, "You are just like my father, always abandoning me." What concept best describes this phenomenon?

  1. Thought blocking
  2. Negative reinforcement
  3. Akathisia
  4. Transference Correct answer.

Explanation

Transference refers to feelings, expectations, and relational patterns from earlier relationships being experienced in the therapeutic relationship. It can be clinically useful when handled thoughtfully.

Question 44Treatment principles, adverse effects and medication monitoring

A 29-year-old woman with paranoid schizophrenia has failed two sequential, adequate 6-week monotherapy trials of atypical antipsychotics (risperidone 6 mg/day and olanzapine 20 mg/day) with verified treatment adherence. She remains tormented by continuous imperative auditory hallucinations and persecutory delusions. What is the evidence-based next step in management according to Czech and international consensus?

  1. Add a third-generation partial agonist (aripiprazole) to olanzapine
  2. Switch to high-potency first-generation depot fluphenazine
  3. Initiate clozapine monotherapy with mandatory hematological monitoring Correct answer.
  4. Refer immediately for bilateral prefrontal stereotactic leucotomy

Explanation

This patient meets the validated consensus criteria for treatment-resistant schizophrenia (TRS): lack of satisfactory clinical response despite two adequate trials of different antipsychotics at therapeutic doses for at least 4 to 6 weeks with confirmed adherence. Under ČPS ČLS JEP and international guidelines, clozapine is the gold-standard, evidence-based medication for TRS and should be initiated promptly rather than delaying with sequential ineffective trials. Mandatory absolute neutrophil count (ANC) monitoring is required to detect life-threatening agranulocytosis.

Question 45Treatment principles, adverse effects and medication monitoring

A 25-year-old woman taking risperidone 4 mg daily presents with amenorrhea for 5 months, bilateral non-puerperal galactorrhea, and reduced bone mineral density. Serum prolactin is 115 ng/mL (normal: <25 ng/mL). Pregnancy test is negative and pituitary MRI shows no adenoma. What is the molecular mechanism responsible for this adverse event?

  1. Potent antagonism of dopamine D2 receptors in the tuberoinfundibular dopamine pathway Correct answer.
  2. Stimulation of anterior pituitary growth hormone-releasing factor
  3. Inhibition of central serotonin reuptake in the dorsal raphe nucleus
  4. Blockade of histaminergic H1 receptors in the tuberomammillary nucleus

Explanation

Dopamine released from the arcuate nucleus of the hypothalamus acts tonic-inhibitorily on anterior pituitary lactotroph D2 receptors via the tuberoinfundibular pathway. Antipsychotics with high affinity D2 antagonism that cross the blood-brain barrier readily (or lack p-glycoprotein efflux exclusion from the pituitary, such as risperidone, paliperidone, and amisulpride) block these D2 receptors, removing the tonic inhibitory brake on prolactin secretion and producing hyperprolactinemia, galactorrhea, amenorrhea, and long-term osteopenia.

Question 46Treatment principles, adverse effects and medication monitoring

Which second- or third-generation antipsychotic agent functions pharmacodynamically as a partial agonist at dopamine D2 and D3 receptors and serotonin 5-HT1A receptors, while acting as an antagonist at serotonin 5-HT2A receptors, resulting in low prolactin elevation and minimal sedation?

  1. Aripiprazole Correct answer.
  2. Haloperidol
  3. Amisulpride
  4. Chlorpromazine

Explanation

Aripiprazole (along with cariprazine and brexpiprazole) is categorized as a third-generation dopamine partial agonist. It acts as a high-affinity partial agonist at dopamine D2 and D3 receptors, modulating dopaminergic neurotransmission dynamically: functioning as a functional antagonist in hyperdopaminergic mesolimbic states (reducing positive symptoms) and as a functional agonist in hypodopaminergic mesocortical and tuberoinfundibular pathways, which prevents hyperprolactinemia.

Question 47Treatment principles, adverse effects and medication monitoring

A 35-year-old male with chronic schizophrenia develops severe, life-threatening constipation leading to paralytic ileus, requiring surgical decompression. Which antipsychotic agent possesses the most potent anticholinergic and antiserotonergic gut hypomotility effects, making gastrointestinal hypomotility a recognized major cause of fatal toxicity?

  1. Clozapine Correct answer.
  2. Aripiprazole
  3. Amisulpride
  4. Haloperidol

Explanation

Clozapine exhibits potent antimuscarinic (M1, M3), antiserotonergic (5-HT3), and antihistaminergic properties that significantly impair gastrointestinal peristalsis. Clozapine-induced gastrointestinal hypomotility (CIGH) occurs in up to 30–50% of patients and can progress silently to severe constipation, fecal impaction, paralytic ileus, bowel necrosis, and septic shock, with a mortality rate rivaling or exceeding that of clozapine-induced agranulocytosis.

Question 48Treatment principles, adverse effects and medication monitoring

A 23-year-old male with treatment-resistant schizophrenia is treated with clozapine 350 mg daily. In week 3 of treatment, he develops low-grade fever (38.1°C), sinus tachycardia (resting HR 128 bpm), chest pain, dyspnea, and peripheral eosinophilia. Troponin I is elevated at 0.45 µg/L and C-reactive protein is 78 mg/L. Echocardiogram reveals new left ventricular wall motion hypokinesia. What is the diagnosis and immediate action?

  1. Clozapine-induced myocarditis; stop clozapine immediately, arrange urgent cardiology-led hospital care, and consider any later rechallenge only exceptionally after recovery with multidisciplinary risk assessment and intensive monitoring Correct answer.
  2. Typical viral pharyngitis; administer paracetamol and double the clozapine dose
  3. Acute panic attack; administer oral lorazepam and continue routine titration
  4. Neuroleptic malignant syndrome; administer high-dose intravenous haloperidol

Explanation

Clozapine-induced myocarditis is a life-threatening adverse reaction concentrated in the first weeks after initiation. Fever, disproportionate tachycardia, chest symptoms, raised CRP and troponin, and new ventricular dysfunction require immediate clozapine cessation and urgent cardiology-led assessment and treatment. Rechallenge is not routine, but 'never rechallenge' is too absolute: selected patients have been rechallenged after full recovery under specialist multidisciplinary oversight, slow retitration, and intensive biomarker monitoring.

Question 49Treatment principles, adverse effects and medication monitoring

A 68-year-old female is admitted with severe psychotic depression (melancholic features, Cotard delusion of internal organ destruction, refusal to eat and drink with rapid dehydration). Her medical status is deteriorating acutely. According to Czech and international psychiatric consensus, what is the treatment of choice with the fastest response rate and highest clinical efficacy?

  1. Electroconvulsive therapy (ECT) Correct answer.
  2. Long-term exploratory psychodynamic psychotherapy
  3. Oral St. John's Wort (Hypericum perforatum) monotherapy
  4. Outpatient light therapy with a 10,000-lux lamp

Explanation

Electroconvulsive therapy (ECT) is the definitive first-line, life-saving treatment for severe depression with psychotic features, melancholia, severe inanition/dehydration, or acute lethal suicidality. Response rates in psychotic depression exceed 80–90%, and ECT achieves symptomatic improvement substantially faster than pharmacotherapy. In the Czech Republic, ECT is performed under general anesthesia (propofol, etomidate) and muscle relaxation (succinylcholine) under strict safety protocols.

Question 50Treatment principles, adverse effects and medication monitoring

A 28-year-old male with acute euphoric mania is admitted to the psychiatric department. Blood tests, ECG, and physical exam are normal. According to Czech psychiatric guidelines (ČPS ČLS JEP) and CANMAT/CINP algorithms, which pharmacological class represents the first-line evidence-based monotherapy for acute mania?

  1. Tricyclic antidepressants (e.g., amitriptyline 150 mg daily)
  2. A mood stabilizer (lithium or valproate) or a second-generation antipsychotic (e.g., olanzapine, quetiapine, risperidone, or aripiprazole) Correct answer.
  3. High-dose buspirone monotherapy
  4. Psychostimulants (e.g., methylphenidate 60 mg daily)

Explanation

First-line pharmacological treatment of acute mania according to ČPS ČLS JEP, CANMAT, and WFSBP guidelines consists of monotherapy with a proven mood stabilizer (lithium or sodium valproate) or an atypical antipsychotic (quetiapine, olanzapine, risperidone, aripiprazole, or asenapine). In cases of severe manic agitation or psychotic features, combination therapy (a mood stabilizer plus an atypical antipsychotic) provides superior and faster antimanic control.