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PGIM MD Psychiatry study materials
PGIM MD Psychiatry study resources

PGIM MD Psychiatry practice questions

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Question 1Medical expert

A 24-year-old man is brought to the emergency department with agitation, dilated pupils, sweating, and a heart rate of 128/min. He reports heavy alcohol use and his last drink was 14 hours ago. Which class of medication is first-line for managing his symptoms?

  1. Benzodiazepines Correct answer.
  2. Beta-blockers
  3. Opioid antagonists
  4. Antipsychotics

Explanation

Alcohol withdrawal syndrome is driven by loss of GABAergic and enhanced glutamatergic activity, so benzodiazepines are the first-line treatment because they restore GABA-A receptor activity and reduce the risk of seizures and delirium tremens. Antipsychotics and beta-blockers may control selected symptoms but do not treat the underlying withdrawal or prevent its complications.

Question 2Medical expert

Which clinical feature best distinguishes delirium tremens from uncomplicated alcohol withdrawal?

  1. Insomnia and irritability in the first 24 hours
  2. Autonomic hyperactivity with clouding of consciousness and disorientation Correct answer.
  3. Tremor of the outstretched hands
  4. A single generalized seizure at 12 hours

Explanation

Delirium tremens is defined by delirium, meaning impaired attention and awareness with disorientation, together with marked autonomic hyperactivity, and it typically emerges 48 to 96 hours after the last drink. Simple tremor, insomnia, and even an isolated withdrawal seizure can occur without delirium and therefore do not establish the diagnosis.

Question 3Medical expert

A patient with schizophrenia has taken clozapine for 6 weeks. He develops fever, confusion, muscle rigidity, and a creatine kinase of 2500 U/L. Which is the most likely diagnosis?

  1. Neuroleptic malignant syndrome Correct answer.
  2. Malignant hyperthermia
  3. Acute dystonic reaction
  4. Serotonin syndrome

Explanation

Neuroleptic malignant syndrome presents with the tetrad of fever, rigidity, autonomic instability, and altered mental status, with markedly raised creatine kinase, and clozapine is a recognized trigger. Serotonin syndrome instead produces hyperreflexia and clonus, while an acute dystonia causes sustained muscle spasm without fever or rhabdomyolysis.

Question 4Medical expert

Which electrocardiographic change is most associated with therapeutic use of clozapine and warrants monitoring?

  1. Prominent U waves
  2. ST-segment elevation
  3. Shortened PR interval
  4. QTc prolongation Correct answer.

Explanation

Clozapine can prolong the corrected QT interval and has been associated with myocarditis, so baseline and periodic ECG monitoring is recommended. ST elevation suggests acute myocardial injury, a shortened PR interval suggests pre-excitation, and prominent U waves suggest hypokalaemia, none of which are characteristic clozapine effects.

Question 5Medical expert

A 30-year-old woman with bipolar I disorder is 8 weeks pregnant and has had two manic episodes in the past. Which maintenance strategy is most appropriate?

  1. Stop all mood stabilisers until after delivery
  2. Continue lithium with close serum level and fetal monitoring Correct answer.
  3. Use carbamazepine as monotherapy
  4. Switch to valproate at a low dose

Explanation

Lithium remains a reasonable maintenance choice in pregnancy for patients with severe illness, provided levels are monitored closely because renal clearance changes and levels may fall, and fetal cardiac surveillance is arranged. Valproate and carbamazepine are both associated with teratogenicity, particularly neural tube defects, so they are avoided where possible.

Question 6Medical expert

Which finding is required for a diagnosis of schizophrenia under ICD-11?

  1. At least one core symptom such as persistent delusions, hallucinations, or thought disorder present for most of the time for at least one month Correct answer.
  2. Significant deterioration in work performance only
  3. Presence of at least two negative symptoms alone
  4. A continuous illness duration of at least six months

Explanation

ICD-11 requires at least one core symptom from the specified list, such as persistent delusions, persistent hallucinations, thought disorder, or experiences of influence, passivity, or control, present for most of the time for at least one month. The older six-month duration criterion belongs to DSM and is not an ICD-11 requirement.

Question 7Medical expert

A patient reports hearing two voices commenting on his actions and discussing him in the third person. Which term best describes this phenomenon?

  1. Pseudohallucinations
  2. Third-person auditory hallucinations Correct answer.
  3. Second-person auditory hallucinations
  4. Illusions

Explanation

Voices heard in the third person that comment on the patient's behaviour or discuss him among themselves are classically described as third-person auditory hallucinations and are strongly associated with schizophrenia. Second-person voices address the patient directly, pseudohallucinations are recognised as internally generated, and illusions are distortions of real external stimuli.

Question 8Medical expert

A 45-year-old man with depression develops confusion, hyperreflexia, and clonus 24 hours after starting a new antidepressant alongside a monoamine oxidase inhibitor. Which is the most likely cause?

  1. Serotonin syndrome Correct answer.
  2. Alcohol withdrawal
  3. Anticholinergic toxicity
  4. Neuroleptic malignant syndrome

Explanation

The combination of a serotonergic agent with a monoamine oxidase inhibitor can precipitate serotonin syndrome, which presents with altered mental status, autonomic instability, and neuromuscular hyperactivity such as clonus and hyperreflexia. Anticholinergic toxicity causes dry skin and flushing without clonus, and neuroleptic malignant syndrome causes rigidity with bradyreflexia.

Question 9Medical expert

Which statement about the mechanism of action of selective serotonin reuptake inhibitors is correct?

  1. They block dopamine D2 receptors
  2. They increase serotonergic neurotransmission by blocking the serotonin transporter Correct answer.
  3. They directly stimulate postsynaptic serotonin receptors
  4. They inhibit monoamine oxidase type A

Explanation

Selective serotonin reuptake inhibitors act by blocking the serotonin transporter, reducing reuptake and thereby increasing synaptic serotonin; clinical benefit follows downstream adaptive changes over weeks. They do not act as direct receptor agonists, do not inhibit monoamine oxidase, and lack clinically significant D2 blockade.

Question 10Medical expert

A 22-year-old woman has a body mass index of 15.5, intense fear of gaining weight, and amenorrhoea. Which electrolyte abnormality is most likely if she has been vomiting repeatedly?

  1. Hypocalcaemia with respiratory alkalosis
  2. Hypernatraemia with metabolic acidosis
  3. Hyperkalaemia with metabolic acidosis
  4. Hypokalaemia with metabolic alkalosis Correct answer.

Explanation

Repeated vomiting causes loss of gastric hydrochloric acid and potassium, producing a hypokalaemic, hypochloraemic metabolic alkalosis with a compensatory rise in bicarbonate. Hyperkalaemic acidosis and hypernatraemic acidosis are not typical consequences of vomiting.

Question 11Medical expert

Which feature most strongly suggests anorexia nervosa rather than bulimia nervosa?

  1. Significantly low body weight Correct answer.
  2. Preoccupation with body shape
  3. Self-induced vomiting
  4. Recurrent binge eating

Explanation

Anorexia nervosa is distinguished by significantly low body weight relative to the expected minimum, whereas bulimia nervosa typically occurs at normal or near-normal weight. Binge eating, self-induced vomiting, and shape preoccupation can occur in both disorders.

Question 12Medical expert

A 68-year-old woman has progressive memory loss, impaired word finding, and difficulty with visuospatial tasks, with preserved awareness of her deficits. Which is the most likely diagnosis?

  1. Frontotemporal dementia
  2. Delirium
  3. Alzheimer disease Correct answer.
  4. Normal ageing

Explanation

Progressive episodic memory impairment with language and visuospatial deficits in an older adult, with preserved awareness, is typical of Alzheimer disease. Delirium has an acute fluctuating onset, frontotemporal dementia presents with personality and language changes earlier, and normal ageing does not cause functional decline.

Question 13Medical expert

Which scale is specifically designed to assess delirium severity in hospitalised patients?

  1. Confusion Assessment Method for the ICU Correct answer.
  2. Positive and Negative Syndrome Scale
  3. Mini-Mental State Examination
  4. Hamilton Depression Rating Scale

Explanation

The Confusion Assessment Method for the ICU is a structured instrument for detecting and grading delirium, particularly in critical care settings. The Hamilton scale measures depression, the PANSS measures psychotic symptoms, and the MMSE screens cognition rather than delirium.

Question 14Medical expert

A 19-year-old student presents with 3 months of low mood, anhedonia, poor sleep, and passive thoughts that life is not worth living. He has no past psychiatric history. What is the most appropriate first step in management?

  1. Start lithium carbonate
  2. Prescribe a long-term benzodiazepine
  3. Arrange urgent electroconvulsive therapy
  4. Offer a structured psychological therapy such as cognitive behavioural therapy Correct answer.

Explanation

For a first episode of moderate depression without psychotic features, a structured psychological therapy such as cognitive behavioural therapy is an appropriate first-line treatment and is preferred where available. Lithium is used as an augmenting or mood-stabilising agent, ECT is reserved for severe or refractory illness, and benzodiazepines are not a treatment for depression.

Question 15Medical expert

A patient with schizophrenia has been adherent to risperidone for 3 months but has developed a prolactin level of 1200 mIU/L with galactorrhoea. Which change is most appropriate?

  1. Increase the risperidone dose
  2. Add a low-dose antipsychotic
  3. Add a dopamine agonist such as cabergoline
  4. Switch to a prolactin-sparing antipsychotic such as aripiprazole Correct answer.

Explanation

Risperidone commonly raises prolactin through strong D2 blockade in the tuberoinfundibular pathway, and switching to a prolactin-sparing agent such as aripiprazole or quetiapine is the preferred approach. Adding a dopamine agonist risks destabilising psychosis, and increasing the dose would worsen the hyperprolactinaemia.

Question 16Medical expert

Which statement about the pharmacokinetics of lithium is correct?

  1. It is highly protein bound in plasma
  2. It is metabolised extensively by hepatic cytochrome enzymes
  3. It has a short half-life of about 2 hours
  4. It is excreted unchanged by the kidney and its clearance falls with dehydration Correct answer.

Explanation

Lithium is a monovalent cation excreted unchanged by the kidney, so dehydration, sodium restriction, and NSAIDs can raise levels and cause toxicity. It is not hepatically metabolised, is not protein bound, and has a half-life of roughly 18 to 24 hours.

Question 17Medical expert

A patient on lithium presents with coarse tremor, vomiting, ataxia, and confusion. His lithium level is 2.8 mmol/L and creatinine is raised. Which is the most appropriate immediate management?

  1. Increase the lithium dose to stabilise mood
  2. Withhold lithium and give intravenous fluids only
  3. Withhold lithium and arrange haemodialysis Correct answer.
  4. Give a benzodiazepine and discharge home

Explanation

A lithium level above 2.0 mmol/L with neurological signs and renal impairment indicates severe toxicity, and haemodialysis is the definitive treatment because it removes lithium and corrects fluid and electrolyte disturbance. Simple fluid administration may be insufficient with renal impairment and significant neurological features.

Question 18Medical expert

Which is the strongest established risk factor for completed suicide in patients with a psychiatric disorder?

  1. Married status
  2. Young age under 25
  3. A previous suicide attempt Correct answer.
  4. Female sex

Explanation

A previous suicide attempt is the single strongest predictor of completed suicide and should always prompt a structured risk assessment and safety planning. Female sex, being married, and young age are associated with lower risk of completed suicide compared with the relevant contrasts.

Question 19Medical expert

Which finding is characteristic of delirium rather than dementia?

  1. Acute onset with fluctuating attention Correct answer.
  2. Progressive decline over years
  3. Preserved level of consciousness
  4. Insidious onset with preserved attention

Explanation

Delirium is distinguished by acute onset, fluctuating course, and impaired attention and awareness. Dementia typically has an insidious progressive course with attention relatively preserved until late stages, and consciousness is not impaired.

Question 20Medical expert

A 35-year-old man has recurrent, unexpected panic attacks and worries persistently about having another attack for 4 months. Which diagnosis best fits?

  1. Agoraphobia without panic
  2. Panic disorder Correct answer.
  3. Social anxiety disorder
  4. Generalised anxiety disorder

Explanation

Panic disorder requires recurrent unexpected panic attacks followed by at least one month of persistent concern about further attacks or their consequences, or maladaptive behavioural change. Generalised anxiety disorder involves chronic worry across multiple domains, social anxiety is triggered by social scrutiny, and agoraphobia concerns avoidance of situations due to fear of escape difficulty.

Question 21Medical expert

Which neurotransmitter abnormality is most consistently implicated in the positive symptoms of schizophrenia?

  1. Increased GABA activity
  2. Increased subcortical dopamine activity Correct answer.
  3. Reduced serotonin activity
  4. Reduced acetylcholine activity

Explanation

The dopamine hypothesis holds that positive symptoms arise from increased subcortical dopamine transmission in the mesolimbic pathway, supported by the efficacy of D2-blocking drugs and dopamine-releasing agents. Serotonin, GABA, and acetylcholine are involved in other aspects of the illness but are not the principal explanation for positive symptoms.

Question 22Medical expert

A 28-year-old woman has a history of unstable relationships, fear of abandonment, recurrent self-harm, and marked identity disturbance. Which psychological therapy has the strongest evidence base?

  1. Psychoanalysis
  2. Systematic desensitisation
  3. Dialectical behaviour therapy Correct answer.
  4. Cognitive remediation therapy

Explanation

Dialectical behaviour therapy is the best-supported psychological treatment for borderline personality disorder, combining skills training in emotion regulation and distress tolerance with validation strategies. Psychoanalysis lacks strong trial evidence, systematic desensitisation targets phobias, and cognitive remediation targets cognitive deficits in psychosis.

Question 23Medical expert

A 40-year-old man with alcohol dependence abruptly stops drinking and has a generalised seizure 18 hours later. Which medication is most appropriate to prevent further seizures and withdrawal progression?

  1. Propranolol
  2. Chlordiazepoxide Correct answer.
  3. Haloperidol
  4. Disulfiram

Explanation

Benzodiazepines such as chlordiazepoxide are the treatment of choice for alcohol withdrawal because they reduce the risk of seizures and delirium tremens through GABA-A potentiation. Haloperidol does not prevent withdrawal seizures, propranolol masks symptoms, and disulfiram is an aversive maintenance agent started after detoxification.

Question 24Medical expert

Which statement about the Mental State Examination finding of 'flight of ideas' is correct?

  1. It is a disorder of thought content involving fixed false beliefs
  2. It is an inability to register new information
  3. It is a false perception in the absence of a stimulus
  4. It is a disorder of thought form in which speech jumps rapidly between loosely connected ideas Correct answer.

Explanation

Flight of ideas is a disorder of the stream and form of thought in which speech moves rapidly between ideas connected by rhymes, puns, or superficial associations, classically seen in mania. Fixed false beliefs describe delusions, inability to register information describes amnesia, and false perception without a stimulus describes hallucination.

Question 25Medical expert

A patient with obsessive-compulsive disorder has intrusive thoughts of harming others and washes his hands for 2 hours each day. Which treatment approach has the strongest evidence base?

  1. Long-term benzodiazepines
  2. Cognitive behavioural therapy with exposure and response prevention Correct answer.
  3. Psychodynamic psychotherapy
  4. Antipsychotic monotherapy

Explanation

Exposure and response prevention within cognitive behavioural therapy is the psychological treatment with the strongest evidence for obsessive-compulsive disorder and is first-line alongside an SSRI. Benzodiazepines are not recommended for maintenance, antipsychotic monotherapy is not effective, and psychodynamic therapy lacks strong trial support.

Question 26Medical expert

A 26-year-old woman is brought to the emergency department with 4 days of insomnia, pressured speech, and grandiosity after starting a course of high-dose corticosteroids for an autoimmune flare. She has no prior psychiatric history and no family history of bipolar disorder. Which feature most strongly supports a diagnosis of substance/medication-induced bipolar and related disorder rather than bipolar I disorder?

  1. Presence of grandiose delusions during the episode
  2. Elevated energy and reduced need for sleep lasting at least 4 days
  3. Temporal onset closely following steroid exposure with full remission after the drug is withdrawn Correct answer.
  4. Marked impairment in social and occupational functioning

Explanation

The distinguishing feature of a medication-induced bipolar picture is a close temporal relationship to the offending agent, with symptoms resolving once the drug is stopped or dose reduced. Grandiosity, functional impairment, and a 4-day duration of elevated mood with reduced sleep are simply descriptive criteria for a manic episode and do not identify the cause.

Question 27Medical expert

Which statement best describes the mechanism by which clozapine reduces the risk of recurrent suicidal behaviour in people with schizophrenia?

  1. It reduces suicide risk primarily by its potent anticholinergic action on central muscarinic receptors
  2. It lowers suicide risk chiefly through its strong D2 receptor blockade in the mesolimbic pathway
  3. It reduces suicide risk through effects including serotonin 5-HT2A antagonism, noradrenergic activity and clozapine/norclozapine plasma levels Correct answer.
  4. It prevents suicide mainly by inducing agranulocytosis and thereby increasing clinical monitoring contact

Explanation

Clozapine is the only antipsychotic with an established anti-suicidal effect in schizophrenia, and the mechanism is multifactorial, involving 5-HT2A antagonism, noradrenergic and possibly glutamatergic effects, and plasma clozapine/norclozapine concentrations. Its D2 occupancy is comparatively low and loose, so D2 blockade does not explain the effect.

Question 28Medical expert

A 31-year-old man with treatment-resistant schizophrenia has been stable on clozapine for 2 years. He now develops fever, sore throat, and malaise. Which immediate action is most appropriate?

  1. Reassure him that this is a common benign reaction and continue routine monitoring
  2. Reduce the clozapine dose by half and review in one week
  3. Arrange an urgent full blood count and withhold clozapine until the result is known Correct answer.
  4. Add a broad-spectrum antibiotic and continue clozapine unchanged

Explanation

Fever and sore throat in a patient taking clozapine must be treated as possible neutropenia or agranulocytosis until excluded. The drug should be withheld and an urgent full blood count obtained, with management guided by the neutrophil count and local protocols.

Question 29Medical expert

Which feature is most characteristic of a psychogenic (non-epileptic) seizure compared with a generalised tonic-clonic epileptic seizure?

  1. A stereotyped sequence of tonic stiffening followed by rhythmic clonic jerking
  2. Prolonged duration with asynchronous, out-of-phase limb movements and closed eyes resisting passive opening Correct answer.
  3. A postictal period of confusion and drowsiness lasting several minutes
  4. Tongue biting with a lateral laceration and urinary incontinence

Explanation

Psychogenic non-epileptic seizures typically show asynchronous, out-of-phase movements, fluctuating course, closed eyes that resist passive opening, and absence of a clear postictal confusional state. Generalised tonic-clonic seizures have a stereotyped tonic-clonic sequence, lateral tongue biting, incontinence, and postictal confusion.

Question 30Communicator

A 34-year-old man is brought to the emergency department after a first episode of psychosis. He speaks only Mandarin and no interpreter is immediately available. According to good psychiatric communication practice, what is the most appropriate immediate step?

  1. Ask a bilingual security guard to interpret the interview
  2. Proceed with the interview using gestures and simple English because treatment cannot be delayed
  3. Postpone all assessment and any necessary sedation until a family member arrives
  4. Arrange a trained telephone or video interpreter before conducting the diagnostic interview Correct answer.

Explanation

Assessment of psychosis requires accurate language for delusions, hallucinations, and risk. Using an untrained ad hoc interpreter, especially a family member or security staff, risks errors, breaches confidentiality, and distorts the mental state examination. A trained professional interpreter, in person or by telephone/video, should be arranged promptly while urgent safety measures proceed in parallel.

Question 31Communicator

During a mental state examination, a patient says: 'The radio has been broadcasting my private thoughts to the whole street.' Which term best describes this phenomenon?

  1. Ideas of reference
  2. Thought broadcasting Correct answer.
  3. Auditory hallucination
  4. Thought insertion

Explanation

Thought broadcasting is the delusional belief that one's thoughts are accessible to others, here via the radio. It is a passivity phenomenon often grouped with first-rank symptoms. It differs from thought insertion, where alien thoughts are placed into the mind, and from ideas of reference, where neutral events are misread as personally meaningful.

Question 32Communicator

A patient with schizophrenia repeatedly says 'telephone, telephone, television, television' and jumps between loosely connected ideas. Which descriptive term should be recorded in the mental state examination?

  1. Clang association
  2. Derailment with perseveration Correct answer.
  3. Circumstantiality
  4. Flight of ideas

Explanation

Derailment (loosening of associations) describes speech that slips between ideas without logical connection, while perseveration is repetition of the same word or phrase. Together they describe this sample accurately. Circumstantiality and flight of ideas have different defining features and should not be used interchangeably.

Question 33Communicator

In a capacity assessment, a patient can state the risks and benefits of refusing surgery but cannot explain how those facts apply to his own situation. Which element of decision-making capacity is most clearly impaired?

  1. Retention of information
  2. Expression of choice
  3. Appreciation Correct answer.
  4. Understanding

Explanation

Appreciation is the ability to apply understood information to one's own circumstances and recognise its personal relevance. Understanding concerns comprehending the facts, expression concerns communicating a choice, and retention concerns holding information long enough to decide. This patient demonstrates a specific deficit in appreciation.

Question 34Communicator

A trainee is about to interview a patient who has just disclosed sexual abuse. Which opening approach best demonstrates active listening?

  1. 'Let us move on to your sleep pattern first.'
  2. 'I am sure you will feel better once you talk about it.'
  3. 'Why do you think this happened to you?'
  4. 'You mentioned something difficult happened. Take your time and tell me as much or as little as you wish.' Correct answer.

Explanation

Active listening involves giving permission, allowing the patient to control the pace, and avoiding premature interpretation or reassurance. An open, permissive invitation reduces distress and supports disclosure. 'Why' questions can imply blame, reassurance can minimise, and changing topic can signal avoidance.

Question 35Communicator

Which statement best describes the purpose of summarising during a psychiatric interview?

  1. It allows the clinician to demonstrate diagnostic expertise to the patient
  2. It checks shared understanding and gives the patient a chance to correct the clinician's formulation Correct answer.
  3. It fills silence when the clinician has run out of questions
  4. It replaces the need for a collateral history from relatives

Explanation

Summarising is a core communication skill that verifies the clinician's understanding and invites correction, strengthening the therapeutic alliance. It is not a filler for silence or a display of expertise. Collateral history remains necessary where consent and confidentiality permit.

Question 36Communicator

A patient lacks capacity to consent to a depot antipsychotic and has an advance decision refusing all intramuscular injections. What is the most appropriate professional response?

  1. Respect the advance decision unless the specific legal criteria for overriding it are met Correct answer.
  2. Proceed with the injection because treatment is clinically indicated
  3. Ignore the advance decision because the patient now lacks capacity
  4. Ask a relative to sign the consent form on the patient's behalf

Explanation

A valid and applicable advance decision refusing specified treatment carries legal weight even after capacity is lost, and clinicians must follow it unless the applicable legal framework permits and justifies overriding it. Relatives cannot consent on behalf of an adult lacking capacity, and clinical indication alone does not override a valid refusal.

Question 37Communicator

Which behaviour by a psychiatrist best demonstrates the principle of maintaining professional boundaries?

  1. Accepting a small gift without discussing it with the team
  2. Sharing personal social media details so the patient feels understood
  3. Declining a patient's invitation to attend her birthday party and discussing the therapeutic reasons for this Correct answer.
  4. Attending the party discreetly to support the patient's recovery

Explanation

Boundary maintenance protects the therapeutic relationship and the patient's vulnerability. Declining social invitations and explaining the rationale preserves trust and avoids role confusion. Attending, sharing personal contact details, or accepting gifts without discussion risk blurring boundaries.

Question 38Communicator

During a risk assessment, a patient says he has thoughts of ending his life but will not elaborate. Which response is most likely to improve disclosure?

  1. 'Many people feel like that; it usually passes.'
  2. 'If you do not tell me everything, I cannot help you.'
  3. 'Thank you for telling me. I would like to understand what has been happening for you, at your pace.' Correct answer.
  4. 'You must promise me you will not do anything until we meet again.'

Explanation

Acknowledging disclosure, expressing gratitude, and inviting elaboration at the patient's pace supports engagement and reduces shame. Demanding promises, normalising dismissively, or issuing ultimatums tends to close down communication and may increase risk.

Question 39Communicator

A 28-year-old woman with emotionally unstable personality disorder repeatedly calls the crisis line and then disconnects. Which team approach best reflects good communication practice?

  1. Rotate staff so that each caller speaks to a different clinician each time
  2. Arrange for calls to be answered by an answerphone to reduce staff burden
  3. Restrict all crisis line access to teach her to manage alone
  4. Agree a consistent crisis plan with clear contact arrangements and share it across the team Correct answer.

Explanation

Consistency, predictability, and a shared crisis plan reduce escalation and support containment for people with recurrent crisis presentations. Blanket restriction, deliberate inconsistency, or automated answering risks abandonment and increased risk. The plan should be co-produced and documented.

Question 40Communicator

A patient from a culture where eye contact with doctors is considered disrespectful avoids looking at the interviewer. What is the most appropriate interpretation?

  1. Interpret it as a sign of depression with psychomotor retardation
  2. Confront the patient about being evasive
  3. Record it as evidence of persecutory ideation
  4. Consider the behaviour as culturally normative before inferring poor rapport or suspiciousness Correct answer.

Explanation

Cultural norms shape non-verbal communication, and reduced eye contact may reflect respect rather than psychopathology or poor engagement. Clinicians should interpret behaviour in cultural context before drawing diagnostic conclusions. Confrontation risks damaging the alliance and is unjustified.

Question 41Communicator

A 70-year-old man with mild cognitive impairment is accompanied by his daughter, who answers most questions for him. What is the best communication strategy?

  1. Direct all questions to the daughter because she knows him best
  2. Address the patient directly first and involve the daughter as an additional informant with his agreement Correct answer.
  3. Speak more loudly and use simplified speech throughout
  4. Ask the daughter to leave so the patient cannot be influenced

Explanation

Good practice is to address the patient directly, preserving autonomy, and to involve the carer as an informant with the patient's agreement. Excluding the carer or bypassing the patient undermines person-centred care. Simplifying or shouting is not indicated for mild cognitive impairment.

Question 42Communicator

A patient with schizophrenia describes hearing voices commenting on his actions. Which question best explores this experience without leading him?

  1. 'Are the voices a symptom of your illness?'
  2. 'Do the voices ever tell you to harm yourself?'
  3. 'Can you tell me more about the voices you hear?' Correct answer.
  4. 'You hear voices commenting on what you do, don't you?'

Explanation

Open questions allow the patient to describe the experience in his own words, reducing suggestibility and preserving the validity of the mental state examination. Leading questions can implant detail, and closed risk questions, while important, do not explore phenomenology. Framing the experience as a symptom may be premature.

Question 43Communicator

A patient requests that her diagnosis not be shared with her employer but agrees that her occupational health doctor may be informed. What is the correct communication approach?

  1. Share the full record with the occupational health doctor as implied consent
  2. Refuse to contact the occupational health doctor to avoid any disclosure
  3. Inform the employer because employment affects treatment planning
  4. Share only the agreed information with the occupational health doctor and record the consent Correct answer.

Explanation

Confidentiality permits disclosure with valid consent, limited to the information the patient has agreed to share. Consent should be documented and its scope respected. Informing the employer without consent, refusing all contact, or over-sharing beyond consent are all inappropriate.

Question 44Communicator

A junior doctor is shouted at by a distressed patient who accuses the team of poisoning him. Which response best reflects de-escalation communication?

  1. Match his volume so that he knows he is being heard
  2. Speak calmly and slowly, acknowledge his fear, and offer a safe space to talk Correct answer.
  3. Tell him he is being unreasonable and must calm down
  4. Leave without explanation and cancel all further contact

Explanation

De-escalation relies on calm, non-confrontational communication, acknowledging the patient's emotional experience without colluding with the delusion. Reducing stimulation and offering space supports containment. Matching volume, criticising, or abandoning the patient escalate risk.

Question 45Communicator

A 16-year-old requests confidential contraception advice and asks that her parents not be told. She is assessed as competent to consent. What is the most appropriate response?

  1. Respect confidentiality within the agreed limits, explaining when disclosure might be necessary Correct answer.
  2. Inform her parents immediately because she is a minor
  3. Tell her everything will be shared with her parents as routine practice
  4. Refuse to discuss contraception without parental consent

Explanation

Where a minor is assessed as competent, confidentiality can be maintained within clearly explained limits, such as serious risk. Routine parental disclosure, automatic refusal, or blanket promises of secrecy are all inappropriate. Limits should be discussed prospectively.

Question 46Communicator

During a home visit, a patient's partner answers every question and states that the patient is 'fine'. The patient looks frightened and silent. What is the most appropriate next step?

  1. Confront the partner about being controlling in front of the patient
  2. Accept the partner's account because it is corroborated in the home
  3. Discharge the patient because no problems are reported
  4. Arrange to see the patient alone at a later point and follow local safeguarding procedures Correct answer.

Explanation

Silence and fear with a dominant partner raise concern about coercion or domestic abuse. Creating an opportunity to speak with the patient alone and following safeguarding procedures protects her safety. Accepting the account, confronting the partner, or discharging prematurely may increase danger.

Question 47Communicator

A patient with delirium becomes agitated during an interview. Which communication adjustment is most appropriate?

  1. Increase the pace of questioning to complete the assessment quickly
  2. Ask complex hypothetical questions to test reasoning
  3. Shorten sentences, orient the patient frequently, and reduce background noise Correct answer.
  4. Conduct the interview in a busy corridor to reduce waiting

Explanation

Delirium impairs attention and orientation, so communication should be brief, concrete, and orienting, with reduced environmental stimulation. Rapid or complex questioning worsens confusion. A busy corridor increases distraction and distress.

Question 48Communicator

A patient repeatedly asks whether he will recover. The clinician is uncertain. Which response best reflects honest communication?

  1. 'It is best not to think about the future.'
  2. 'I cannot discuss prognosis with you.'
  3. 'I don't know exactly how things will go, but here is what we can do together to improve your chances.' Correct answer.
  4. 'You will definitely be fully recovered within six months.'

Explanation

Honest communication acknowledges uncertainty while offering realistic hope and a collaborative plan. False certainty, refusal to discuss, or discouraging discussion of the future all undermine trust. Shared decision-making depends on transparent discussion of uncertainty.

Question 49Communicator

A patient with somatic symptom disorder brings a folder of investigations and demands more tests. Which communication approach is most appropriate?

  1. Refer him to multiple specialties to ensure nothing is missed
  2. Acknowledge the reality of his distress, agree a single named clinician, and schedule regular planned reviews Correct answer.
  3. Tell him the symptoms are imaginary
  4. Order the requested tests to maintain the alliance

Explanation

Effective communication validates distress without reinforcing repeated investigation. A consistent clinician and planned, regular contact reduce help-seeking escalation. Colluding with unnecessary tests, dismissing symptoms as imaginary, or multiple referrals perpetuate the cycle.

Question 50Communicator

Which written entry in the psychiatric record best meets professional documentation standards?

  1. 'States voices say 'kill yourself' nightly for 2 weeks; denies intent; risk plan agreed with patient and team.' Correct answer.
  2. 'Probably personality disorder; nothing much to add.'
  3. 'Patient seems a bit odd today; will review.'
  4. 'Discussed at length; see notes elsewhere.'

Explanation

Good documentation is specific, quotes key content, records risk and the resulting plan, and is contemporaneous. Vague impressions, stigmatising shorthand, and cross-references to unspecified notes fail these standards and impede safe handover.