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EBEP - 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 28-year-old doctor is brought to hospital after 6 days of sleeping 2 hours nightly, speaking rapidly, spending thousands of euros on unrealistic business plans, and claiming special political influence. He is irritable when challenged and requires admission because of unsafe behaviour. There is no intoxication or medical cause. Which diagnosis is most appropriate?

  1. Borderline personality disorder
  2. Cyclothymic disorder
  3. Adjustment disorder with mixed disturbance of emotions and conduct
  4. Bipolar I disorder, current manic episode Correct answer.

Explanation

A manic episode involves abnormally elevated or irritable mood with increased energy and marked impairment, psychosis, or hospitalization. Hospitalization means the episode need not last a full week to qualify; a manic episode establishes bipolar I disorder.

Question 20Mood syndromes, longitudinal diagnosis and recovery planning

A 41-year-old reports feeling low most days for 3 years, with low energy, poor concentration, pessimism, and low self-esteem. She has never had mania or hypomania and has not been symptom-free for more than a few weeks. Her symptoms are distressing but have not met criteria for repeated discrete severe depressive episodes. Which diagnosis best fits?

  1. Cyclothymic disorder
  2. Bipolar II disorder
  3. Persistent depressive disorder (dysthymia) Correct answer.
  4. Brief depressive episode

Explanation

Persistent depressive disorder describes chronic depressive symptoms lasting at least 2 years in adults, without extended symptom-free intervals. Cyclothymia requires chronic fluctuating hypomanic and depressive symptoms.

Question 21Mood syndromes, longitudinal diagnosis and recovery planning

Eight days after giving birth, a 31-year-old has almost no sleep, fluctuating confusion, pressured speech, and a belief that her baby has been replaced by an evil double. She hears a voice telling her not to feed the baby. What is the most appropriate response?

  1. Reassure the family that intrusive thoughts are normal and arrange routine review in 6 weeks
  2. Same-day urgent psychiatric assessment with infant safeguarding and likely mother-baby inpatient care Correct answer.
  3. Prescribe a hypnotic by telephone and avoid further assessment
  4. Start exposure therapy to the baby as the sole intervention

Explanation

Postpartum psychosis is a psychiatric emergency because of risks to mother and infant. Urgent specialist assessment, risk management, and usually inpatient care in a mother-baby unit are indicated where available.

Question 22Mood syndromes, longitudinal diagnosis and recovery planning

Five days after giving birth, a 32-year-old woman is sleepless, elated and says the baby has a divine mission. She is pacing and intermittently frightened that staff will steal the baby. What is the best management?

  1. Reassure the family that this is normal baby blues
  2. Arrange urgent psychiatric assessment and consider admission to a specialist mother-baby unit if available Correct answer.
  3. Wait until the 6-week postnatal check because postpartum disorders usually settle
  4. Offer only parenting classes because medication is always contraindicated postpartum

Explanation

Postpartum psychosis is a psychiatric emergency, often beginning within days of birth, and requires urgent specialist assessment to protect mother and infant while supporting attachment.

Question 23Psychosis, differential diagnosis and ongoing care

Which feature most strongly supports a diagnosis of primary negative symptoms rather than secondary negative symptoms in schizophrenia?

  1. Reduced facial expression that begins immediately after a large increase in dopamine-blocking medication
  2. Social withdrawal occurring only during persecutory delusions about neighbours
  3. Loss of motivation that fully remits when a major depressive episode is treated
  4. Persistent avolition and blunted affect after depression, positive symptoms, substance use and antipsychotic parkinsonism have been addressed Correct answer.

Explanation

Primary negative symptoms are intrinsic to schizophrenia and persist after common secondary causes have been considered. Depression, positive symptoms, sedation, extrapyramidal effects and substance use can all mimic or worsen negative symptoms.

Question 24Psychosis, differential diagnosis and ongoing care

Which factor is most consistently associated with poorer outcome in first-episode psychosis and is a key target for early intervention services?

  1. High educational achievement before onset
  2. Longer duration of untreated psychosis Correct answer.
  3. Rapid engagement with family psychoeducation
  4. Early treatment of comorbid substance misuse

Explanation

A longer duration of untreated psychosis is associated with poorer symptomatic and functional outcomes. Early intervention services aim to reduce delays, improve engagement and address family, social and substance-related factors.

Question 25Psychosis, differential diagnosis and ongoing care

Under the Chinese Classification of Mental Disorders (CCMD-3) and ICD-11, what is the minimum duration requirement for active characteristic psychotic symptoms (e.g., persecutory delusions, auditory hallucinations) to establish a diagnosis of Schizophrenia (精神分裂症)?

  1. At least 48 hours
  2. At least 1 month Correct answer.
  3. At least 6 months continuous active psychosis
  4. At least 2 years

Explanation

Under CCMD-3 and ICD-10/ICD-11, the diagnosis of Schizophrenia (精神分裂症) requires the presence of characteristic psychotic symptoms (delusions, hallucinations, formal thought disorder, or catatonic/negative symptoms) for a minimum duration of at least 1 month during the active phase. (Note: DSM-5 requires 1 month of active symptoms within an overall 6-month continuous disturbance).

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

A 30-year-old has recurrent abrupt episodes of intense fear with palpitations, trembling, shortness of breath, and fear of dying. ECG, thyroid tests, and substance screen are normal. For 4 months she has worried about further attacks and avoids exercise because bodily sensations may trigger panic. Which treatment directly targets the maintaining mechanism?

  1. CBT with interoceptive exposure and cognitive restructuring Correct answer.
  2. Mandatory long-term benzodiazepine monotherapy
  3. Avoidance of all situations that can cause autonomic arousal
  4. Antipsychotic depot medication

Explanation

Panic disorder is maintained by catastrophic misinterpretation and avoidance of bodily sensations. CBT, including interoceptive exposure, helps patients learn that these sensations are tolerable and not dangerous.

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

A 22-year-old student avoids seminars because she fears blushing, shaking, and saying something foolish while others watch. She knows the fear is excessive, has no unexpected panic attacks, and is comfortable studying alone. Which diagnosis is most likely?

  1. Agoraphobia
  2. Generalized anxiety disorder
  3. Avoidant personality disorder
  4. Social anxiety disorder Correct answer.

Explanation

Social anxiety disorder is marked by fear of negative evaluation in social or performance situations, leading to avoidance or endurance with intense anxiety. The feared outcome is scrutiny or humiliation, not being unable to escape as in agoraphobia.

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

A 46-year-old has excessive worry about finances, health, work, and his children on most days for 8 months. He finds the worry difficult to control and has muscle tension, restlessness, irritability, and insomnia. There are no obsessions, panic attacks, or substance use. Which diagnosis best accounts for the presentation?

  1. Illness anxiety disorder
  2. Generalized anxiety disorder Correct answer.
  3. Obsessive-compulsive disorder
  4. Acute stress reaction

Explanation

Generalized anxiety disorder involves persistent, excessive, hard-to-control worry across multiple domains with associated somatic or cognitive symptoms. The breadth of worries distinguishes it from illness anxiety focused mainly on health.

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

A 27-year-old has intrusive thoughts that her hands are contaminated after touching door handles. She recognises the thoughts as unreasonable but washes for several hours daily until her skin cracks. Which psychological treatment is most specific for this disorder?

  1. Supportive therapy focused on reassurance after each washing ritual
  2. Exposure and response prevention Correct answer.
  3. Dream interpretation to uncover the symbolic meaning of contamination
  4. Social skills training

Explanation

OCD is treated with CBT that includes exposure to feared cues and prevention of compulsive rituals. Reassurance and accommodation usually perpetuate the obsession-compulsion cycle.

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

A 58-year-old cannot discard newspapers, broken appliances, and receipts because he feels he may need them someday. Rooms are unusable because of clutter, and attempts by relatives to remove items cause marked distress. There is no manic episode, dementia, or delusional belief about the objects. Which diagnosis is most likely?

  1. Obsessive-compulsive personality disorder
  2. Kleptomania
  3. Major neurocognitive disorder
  4. Hoarding disorder Correct answer.

Explanation

Hoarding disorder is defined by persistent difficulty discarding possessions, perceived need to save them, distress with discarding, and clutter that compromises living areas. It is not simply perfectionism or theft.

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

A 25-year-old spends 4 hours daily checking mirrors and comparing photographs because he believes his nose is grotesquely asymmetric. Others see no noticeable defect. He has stopped dating and repeatedly seeks cosmetic surgery. What is the most appropriate clinical approach?

  1. Assess risk and offer CBT tailored to body dysmorphic disorder, with an SSRI considered when indicated Correct answer.
  2. Refer directly for cosmetic surgery because insight is poor
  3. Diagnose delusional disorder and avoid psychological treatment
  4. Reassure him once that his nose is normal and discharge

Explanation

Body dysmorphic disorder involves preoccupation with perceived appearance defects plus repetitive checking or camouflaging. CBT adapted for BDD and serotonergic medication can help; cosmetic procedures usually do not treat the underlying disorder.

Question 32Anxiety, obsessive-compulsive and trauma-related formulations

Four months after a motorway crash, a 39-year-old has intrusive sensory memories, nightmares, avoidance of driving, persistent guilt that she should have prevented the crash, hypervigilance, and exaggerated startle. Which first-line psychological treatment should be offered?

  1. Single-session compulsory psychological debriefing
  2. Long-term benzodiazepines to suppress recall
  3. Individual trauma-focused CBT or EMDR Correct answer.
  4. Supportive therapy that avoids any discussion of the trauma

Explanation

PTSD persisting beyond the early post-trauma period is treated with trauma-focused psychological therapies such as trauma-focused CBT or EMDR. Routine single-session debriefing and long-term benzodiazepines are not recommended treatments.

Question 33Anxiety, obsessive-compulsive and trauma-related formulations

A refugee who survived years of captivity has recurrent re-experiencing of torture, avoidance of reminders, and persistent threat arousal. He also has severe affect dysregulation, pervasive shame and worthlessness, and inability to sustain close relationships. Which ICD-11 diagnosis best captures this combination?

  1. Simple phobia
  2. Acute stress reaction
  3. Complex post-traumatic stress disorder Correct answer.
  4. Dissociative amnesia only

Explanation

ICD-11 complex PTSD includes the core PTSD triad plus disturbances in self-organization: affect dysregulation, negative self-concept, and relational disturbance, often after prolonged or repeated trauma.

Question 34Anxiety, obsessive-compulsive and trauma-related formulations

A 49-year-old manager is chronically preoccupied with rules, lists, and exact procedures. He misses deadlines because work is never perfect enough, refuses to delegate unless others follow his method precisely, and sees his standards as correct rather than intrusive. Which diagnosis is most likely?

  1. Obsessive-compulsive disorder
  2. Dependent personality disorder
  3. Hypomania
  4. Obsessive-compulsive personality disorder Correct answer.

Explanation

Obsessive-compulsive personality disorder is an ego-syntonic pattern of perfectionism, orderliness, and control at the expense of flexibility and efficiency. OCD involves intrusive obsessions and compulsions that are usually experienced as unwanted.

Question 35Anxiety, obsessive-compulsive and trauma-related formulations

A 17-year-old with anorexia nervosa has a BMI of 14.5 kg/m2, pulse 38/min, postural dizziness, recent fainting, and potassium 2.8 mmol/L after vomiting. What is the safest next step?

  1. Begin outpatient fluoxetine as the sole treatment
  2. Reassure that normal menstruation would exclude serious risk
  3. Arrange urgent medical assessment and likely admission for monitored stabilisation and refeeding Correct answer.
  4. Delay intervention until she requests weight restoration

Explanation

Severe underweight, bradycardia, syncope, postural symptoms, and hypokalaemia indicate acute medical risk in anorexia nervosa. Stabilisation and refeeding require careful monitoring for arrhythmia and refeeding complications.

Question 36Anxiety, obsessive-compulsive and trauma-related formulations

A 26-year-old with normal BMI describes recurrent episodes of eating very large amounts with loss of control, followed by self-induced vomiting and laxative misuse. She has dental enamel erosion and shame about body shape. What is the most appropriate initial management principle?

  1. Offer bulimia-nervosa-focused guided self-help or CBT-ED and assess physical risk including electrolytes Correct answer.
  2. Prescribe antipsychotic medication as the mandatory first-line treatment
  3. Recommend cosmetic dental treatment only
  4. Avoid psychological treatment until BMI is below the anorexia nervosa range

Explanation

Bulimia nervosa involves binge eating with compensatory behaviours. Treatment includes eating-disorder-focused psychological therapy, often guided self-help or CBT-ED, while monitoring medical complications such as electrolyte disturbance.

Question 37Anxiety, obsessive-compulsive and trauma-related formulations

A 38-year-old has weekly episodes of eating much more than others would in similar circumstances, with loss of control, rapid eating, eating alone from embarrassment, and intense guilt afterwards. She does not vomit, misuse laxatives, fast, or exercise compulsively. Which diagnosis is most likely?

  1. Bulimia nervosa
  2. Anorexia nervosa, binge-eating/purging type
  3. Avoidant/restrictive food intake disorder
  4. Binge-eating disorder Correct answer.

Explanation

Binge-eating disorder features recurrent binge episodes with distress and no regular compensatory behaviours. The absence of purging or other compensation distinguishes it from bulimia nervosa.

Question 38Anxiety, obsessive-compulsive and trauma-related formulations

A 36-year-old teacher develops intermittent leg weakness after a minor accident. Neurological examination shows internal inconsistency, and investigations do not suggest multiple sclerosis or stroke. Which explanation is most helpful?

  1. The weakness is real and common in functional neurological disorder, where nervous-system functioning is disrupted rather than structurally damaged Correct answer.
  2. Your tests are normal, so this is stress and not a neurological problem
  3. You are unconsciously producing symptoms to gain care, so psychotherapy is the only treatment
  4. The symptoms prove an early degenerative neurological disease that tests cannot yet detect

Explanation

Functional neurological disorder should be explained as a real, potentially reversible disorder of function, using positive clinical signs and avoiding dismissive reassurance.

Question 39Anxiety, obsessive-compulsive and trauma-related formulations

A 13-year-old is distressed by intrusive thoughts that she might contaminate her baby brother. She repeatedly washes and asks her mother for reassurance. She recognises the thoughts as unwanted. What is the most likely diagnosis?

  1. Conduct disorder
  2. Early-onset dementia
  3. Obsessive-compulsive disorder Correct answer.
  4. Dissocial personality disorder

Explanation

Ego-dystonic intrusive thoughts and repetitive washing or reassurance-seeking are typical of obsessive-compulsive disorder in young people.

Question 40Substance-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 41Substance-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 42Substance-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 43Substance-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 44Substance-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 45Psychotherapy 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 46Psychotherapy 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 47Psychotherapy 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 48Psychotherapy 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 49Psychotherapy 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 50Treatment principles, adverse effects and medication monitoring

A 24-year-old develops acute neck spasm and upward eye deviation two days after starting a high-potency antipsychotic. Which neurobiological mechanism best explains this adverse effect?

  1. Serotonin 5-HT1A partial agonism in the raphe nuclei
  2. Muscarinic M1 receptor stimulation in the hippocampus
  3. Noradrenaline transporter blockade in the locus coeruleus
  4. Dopamine D2 receptor blockade in the nigrostriatal pathway Correct answer.

Explanation

Acute dystonia is an extrapyramidal symptom caused by dopamine D2 blockade in nigrostriatal pathways, producing relative cholinergic overactivity in basal ganglia motor circuits.