Psychiatric Aspects of Terminal Illness — MCQs
A patient complains of sadness of mood, increased lethargy, early morning awakening, loss of interest and reports no will to live and hears voices asking her to kill self. What is the diagnosis?
Which of the following is NOT a characteristic feature of delirium tremens?
Elisabeth Kübler-Ross proposed five stages of:
Which of the following diseases has the maximum Disability-Adjusted Life Years (DALY) loss?
A 67-year-old lady is brought in by her six children, who say that she has become senile. Six months after her husband's death, she has become more religious and spiritual, and gives a lot of money in donation. She is occupied with too many activities and sleeps less. She now believes that she has a goal to change society. She does not like being brought to the hospital and is argumentative when questioned about her actions. The diagnosis is:
An elderly housewife lost her husband who died suddenly of Myocardial infarction. They had been staying alone for almost a decade with infrequent visits from her son and grandchildren. About a week after the death she heard his voice clearly talking to her as he would in a routine manner from the next room. She went to check but saw nothing. Subsequently she often heard his voice conversing with her and she would also discuss her daily matters with him. Over the past couple of years since his death, this has continued and provokes anxiety and sadness of mood when she is preoccupied with his thought. She should be treated with:
India is a country with different cultures and diverse languages. Which steps should a physician take to address the patient for better outcomes? 1. Insist on good communication 2. Insist on communication only via an interpreter 3. Treat them regardless of their cultural perceptions 4. The physician should consider the patient's religion and cultural perception Select the correct combination:
A 35 year old man feels that he is about to die because he is suffering from gastric cancer. All his radiological investigations prove the contrary. Which is the most probable diagnosis?
The 4AT is a screening tool for detection of delirium. Which THREE of the following parameters listed below are included in the 4AT tool? I. Alertness II. Apnoea III. Abbreviated Mental Test (AMT4) IV. Attention Select the correct answer using the code given below:
Which class of medications is known to worsen the symptoms of delirium in patients post-cardiac surgery?
Psychiatric Aspects of Terminal Illness Indian Medical PG Practice Questions and MCQs
Question 1: A patient complains of sadness of mood, increased lethargy, early morning awakening, loss of interest and reports no will to live and hears voices asking her to kill self. What is the diagnosis?
- A. Schizophrenia
- B. Major depressive disorder plus psychosis (Correct Answer)
- C. Schizoaffective disorder
- D. Schizotypal personality disorder
Explanation: ***Major depressive disorder plus psychosis*** - The patient presents with classic symptoms of **major depressive disorder**, including persistent sadness, **anhedonia (loss of interest)**, **lethargy**, and **early morning awakening**. - The presence of **auditory hallucinations** (hearing voices asking her to kill herself) indicates **psychotic features** accompanying the severe depression, leading to the diagnosis of major depressive disorder with psychotic features. *Schizophrenia* - While schizophrenia involves psychosis, the primary presentation here is a prominent **depressive syndrome** rather than the typical **positive symptoms (delusions, hallucinations)**, **negative symptoms (alogia, avolition)**, and **disorganized thought** processes characteristic of schizophrenia. - The depressive symptoms are too pervasive and central to the clinical picture to be solely schizophrenia. *Schizoaffective disorder* - This disorder requires a period of **at least two weeks of psychotic symptoms** (hallucinations or delusions) **without prominent mood symptoms**, which is not described. - In this case, the **psychotic symptoms are congruent with the depressed mood** (e.g., voices urging self-harm, reflecting hopelessness), rather than independent. *Schizotypal personality disorder* - This is a pervasive pattern of **social and interpersonal deficits** marked by acute discomfort with, and reduced capacity for, close relationships, as well as by **cognitive or perceptual distortions** and eccentricities of behavior. - It does not involve persistent, severe depressive episodes with overt psychotic symptoms as described, nor significant functional impairment to the extent seen here.
Question 2: Which of the following is NOT a characteristic feature of delirium tremens?
- A. Severe depression (Correct Answer)
- B. Extreme anxiety
- C. Delusion
- D. Hallucination
Explanation: ***Severe depression*** - While mood disturbances can occur with alcohol withdrawal, **severe depression** is not a hallmark or defining feature of **delirium tremens (DTs)** itself. - DTs primarily manifest as severe autonomic hyperactivity, altered mental status, and perceptual disturbances. *Hallucination* - **Hallucinations**, particularly **visual** (e.g., seeing insects or small animals), are a classic and common feature of delirium tremens. - These perceptual disturbances contribute significantly to the agitated and disoriented state of patients experiencing DTs. *Extreme anxiety* - **Extreme anxiety**, agitation, and fear are very common in delirium tremens due to the heightened state of arousal and terrifying hallucinations. - This **hyperarousal** is a direct result of the severe autonomic dysregulation. *Delusion* - **Delusions**, often **paranoid** or referring to being persecuted, are frequently observed in patients with delirium tremens. - These fixed, false beliefs contribute to the patient's confusion, fear, and sometimes aggressive behavior.
Question 3: Elisabeth Kübler-Ross proposed five stages of:
- A. Grief (Correct Answer)
- B. Delusion
- C. Schizophrenia
- D. None of the options
Explanation: ***Grief*** - Elisabeth Kübler-Ross is renowned for her work on the **five stages of grief**, a model describing emotional responses to terminal illness or significant loss. - These stages are **denial, anger, bargaining, depression, and acceptance**, which individuals may experience when facing their own death or the death of a loved one. - This model was introduced in her seminal 1969 book **"On Death and Dying"**. *Delusion* - Delusions are **fixed, false beliefs** that are not in keeping with the individual's cultural background, often seen in psychotic disorders like schizophrenia. - Kübler-Ross's work does not focus on specific cognitive distortions like delusions. *Schizophrenia* - Schizophrenia is a severe psychiatric disorder characterized by **distortions of thought, perception, emotions, language, sense of self, and behavior**. - While schizophrenia can involve significant psychological distress, it is a **distinct clinical entity** not directly related to Kübler-Ross's stages of grief. *None of the options* - This option is incorrect because the work of Elisabeth Kübler-Ross is directly associated with the **five stages of grief**, which describe the emotional process individuals experience when facing terminal illness or loss.
Question 4: Which of the following diseases has the maximum Disability-Adjusted Life Years (DALY) loss?
- A. Schizophrenia (Mental Disorder)
- B. Bipolar depression (Bipolar Disorder)
- C. Mania (Bipolar Disorder Episode)
- D. Unipolar depression (Major Depressive Disorder) (Correct Answer)
Explanation: ***Unipolar depression (Major Depressive Disorder)*** - **Major Depressive Disorder (MDD)** is considered a leading cause of **disability worldwide**, contributing significantly to DALYs due to its high prevalence, chronicity, and disabling nature. - The long-term impact on daily functioning, productivity, and overall quality of life makes it the mental disorder with the largest burden of disease. *Schizophrenia (Mental Disorder)* - While **schizophrenia** causes severe disability and is highly impactful on individuals and society, its prevalence is lower than that of unipolar depression. - The DALY burden for schizophrenia is substantial, but **unipolar depression** affects a much larger proportion of the global population. *Bipolar depression (Bipolar Disorder)* - **Bipolar disorder (depressive episodes)** also contributes significantly to disability, but it is less prevalent than unipolar depression. - Although the depressive phases are often more severe than unipolar depression, the overall DALYs are lower due to its **comparatively lower incidence**. *Mania (Bipolar Disorder Episode)* - **Mania**, a component of bipolar disorder, can cause significant impairment during an episode but is typically **episodic** and less frequent than depressive states in bipolar disorder. - The DALYs attributed to manic episodes alone are generally lower than the overall burden of persistent depressive states found in unipolar depression.
Question 5: A 67-year-old lady is brought in by her six children, who say that she has become senile. Six months after her husband's death, she has become more religious and spiritual, and gives a lot of money in donation. She is occupied with too many activities and sleeps less. She now believes that she has a goal to change society. She does not like being brought to the hospital and is argumentative when questioned about her actions. The diagnosis is:
- A. Depression
- B. Impulse control disorder
- C. Mania (Correct Answer)
- D. Schizophrenia
Explanation: ***Mania*** - The patient exhibits classic symptoms of **mania**: increased religiosity, excessive donations, overactivity, reduced sleep, and a **grandiose belief** ("goal to change society"). - Her **argumentativeness** and resistance to evaluation are consistent with the **lack of insight** often seen in manic episodes. *Depression* - While the death of her husband could trigger depression, her symptoms of **increased energy**, reduced sleep, and grandiosity are **contrary to typical depression** (low mood, anhedonia, fatigue). - Depression usually involves feelings of **worthlessness and guilt**, not an inflated sense of self-importance or mission. *Impulse control disorder* - This category usually involves specific problematic behaviors (e.g., gambling, kleptomania) driven by an **irresistible urge**, often preceded by tension and followed by relief. - The patient's broader constellation of symptoms, including grandiosity and reduced sleep, points to a more pervasive mood disturbance rather than a single maladaptive impulse. *Schizophrenia* - Schizophrenia is characterized by **psychosis**, including prominent hallucinations, delusions (often bizarre), disorganization in thought and speech, and negative symptoms. - While she has a **grandiose delusion**, the overall clinical picture, especially the prominent mood and energy changes, is much more indicative of a **manic episode**.
Question 6: An elderly housewife lost her husband who died suddenly of Myocardial infarction. They had been staying alone for almost a decade with infrequent visits from her son and grandchildren. About a week after the death she heard his voice clearly talking to her as he would in a routine manner from the next room. She went to check but saw nothing. Subsequently she often heard his voice conversing with her and she would also discuss her daily matters with him. Over the past couple of years since his death, this has continued and provokes anxiety and sadness of mood when she is preoccupied with his thought. She should be treated with:
- A. Benztropine
- B. Risperidone
- C. Sertraline (Correct Answer)
- D. Lorazepam
Explanation: ***Sertraline*** - The patient exhibits symptoms consistent with **prolonged grief disorder**, characterized by persistent longing for the deceased, intense emotional pain, and clinically significant distress or functional impairment following bereavement. Sertraline, an **SSRI antidepressant**, is effective in treating symptoms of grief, anxiety, and depression. - The auditory hallucinations of her deceased husband's voice, while concerning, are described as routine and conversational, suggesting a **psychotic feature secondary to severe depression or complicated grief**, rather than a primary psychotic disorder. Treating the underlying mood and anxiety component with an antidepressant is the priority. *Benztropine* - **Benztropine is an anticholinergic medication** primarily used to treat **extrapyramidal symptoms** (EPS) associated with antipsychotic use or Parkinson's disease. - There is no indication of EPS or Parkinson's disease in this patient, making benztropine an inappropriate choice for her symptoms of grief, anxiety, and auditory phenomena. *Risperidone* - **Risperidone is an atypical antipsychotic** primarily used to treat schizophrenia, bipolar disorder, and agitation. While it can address psychotic symptoms, the auditory hallucinations described here ("heard his voice clearly talking to her as he would in a routine manner") are likely **grief-related pseudohallucinations** or a reflection of the intense emotional bond, rather than frank psychosis requiring antipsychotic medication. - Administering an antipsychotic without first addressing the underlying grief and mood disorder could result in unnecessary side effects and may not effectively resolve her primary distress. The anxiety and sadness following preoccupation with his thought suggest a **depressive component** rather than a primary thought disorder. *Lorazepam* - **Lorazepam is a benzodiazepine** used for short-term management of anxiety, insomnia, and seizures. - While the patient experiences anxiety, lorazepam would only provide **symptomatic relief** for acute anxiety and does not address the underlying prolonged grief, sadness, or the grief-related auditory experiences. Long-term use of benzodiazepines can lead to dependence and withdrawal issues.
Question 7: India is a country with different cultures and diverse languages. Which steps should a physician take to address the patient for better outcomes? 1. Insist on good communication 2. Insist on communication only via an interpreter 3. Treat them regardless of their cultural perceptions 4. The physician should consider the patient's religion and cultural perception Select the correct combination:
- A. 1,4 (Correct Answer)
- B. 1,2
- C. 2,3
- D. 3,4
Explanation: ***1,4*** - **Good communication** is paramount in healthcare, especially in a diverse country like India, to ensure **patient understanding**, **adherence** to treatment plans, and overall patient satisfaction. - Considering a patient's **religion and cultural perceptions** allows the physician to tailor treatment and communication in a sensitive and **respectful manner**, fostering trust and better **health outcomes**. *1,2* - While good communication (1) is vital, **insisting solely on an interpreter** (2) may not always be feasible or necessary, particularly if the physician and patient share a common language or if the patient prefers direct communication. This can also disrupt the flow of rapport building. - **Over-reliance on interpreters** can sometimes lead to misinterpretations or loss of non-verbal cues if the interpreter is not trained in medical interpretation. *2,3* - **Insisting only on an interpreter** (2) can be restrictive and may compromise direct patient-physician rapport, as discussed above. - **Treating patients regardless of their cultural perceptions** (3) is an ethnocentric approach that can lead to mistrust, non-adherence, and ultimately **poor health outcomes** as it disregards the patient's beliefs and values regarding health and illness. *3,4* - **Treating patients regardless of their cultural perceptions** (3) can result in a lack of understanding and non-adherence if the treatment conflicts with the patient's deeply held beliefs. - While considering religion and cultural perception (4) is crucial, this option includes an incorrect approach (3) that can undermine patient care.
Question 8: A 35 year old man feels that he is about to die because he is suffering from gastric cancer. All his radiological investigations prove the contrary. Which is the most probable diagnosis?
- A. Somatic symptom disorder
- B. Conversion disorder
- C. Delusional disorder
- D. Illness anxiety disorder (Correct Answer)
Explanation: ***Illness anxiety disorder*** - This patient exhibits a **preoccupation with having a serious illness** (gastric cancer) despite evidence to the contrary (negative radiological investigations). - The fear of illness is **persistent** and **causes significant distress**, leading to the belief that he is "about to die." - In illness anxiety disorder, patients may have **intense health anxiety** but typically retain some capacity for at least temporary reassurance with negative test results, even if the anxiety returns. - The presentation focuses on **fear and preoccupation** rather than an absolutely fixed, unshakeable delusional belief. *Somatic symptom disorder* - Characterized by **one or more significant physical symptoms** that cause significant distress or functional impairment, along with excessive thoughts, feelings, or behaviors related to these symptoms. - In this case, the primary concern is the *fear* of having a serious illness, rather than significant physical symptoms themselves. - The emphasis is on the **belief about having cancer** rather than distressing somatic symptoms. *Conversion disorder* - Involves **neurological symptoms** (e.g., altered motor or sensory function, weakness, paralysis, seizures) that are incompatible with recognized neurological or medical conditions. - The patient's presentation does not involve neurological deficits, and the primary concern is fear of a specific disease (gastric cancer) rather than unexplained neurological symptoms. *Delusional disorder* - Characterized by one or more **fixed, unshakeable, nonbizarre delusions** that persist for at least one month. - In **delusional disorder, somatic type**, the patient would have an absolutely fixed belief about having a disease with **no insight** and **no response to reassurance** despite clear contrary evidence. - While this patient has a strong belief about having cancer, the clinical presentation described (preoccupation with health concerns in the context of negative investigations) aligns more specifically with **illness anxiety disorder**, which is the more common diagnosis in this scenario per standard medical teaching.
Question 9: The 4AT is a screening tool for detection of delirium. Which THREE of the following parameters listed below are included in the 4AT tool? I. Alertness II. Apnoea III. Abbreviated Mental Test (AMT4) IV. Attention Select the correct answer using the code given below:
- A. I, III and IV (Correct Answer)
- B. I, II and IV
- C. I, II and III
- D. II, III and IV
Explanation: ***I, III and IV*** - The 4AT screening tool specifically includes **Alertness**, **AMT4 (Abbreviated Mental Test)**, and **Attention** as key parameters for detecting delirium. - The **AMT4** component assesses **cognitive function**, while **Alertness** and **Attention** evaluate the patient's state of consciousness and focus. *I, II and IV* - This option incorrectly includes **Apnoea**. While apnoea is a significant medical condition, it is not a direct parameter in the **4AT delirium screening tool**. - The 4AT focuses on cognitive and neurological signs of delirium, not respiratory patterns. *I, II and III* - This option also incorrectly includes **Apnoea** as one of the parameters in the 4AT tool. - The 4AT is designed to assess **delirium**, which primarily manifests through altered mental status, rather than respiratory issues. *II, III and IV* - This option is incorrect as it includes **Apnoea** and omits **Alertness**, which is a fundamental component of the **4AT delirium screening tool**. - **Alertness** is crucial for evaluating the patient's level of consciousness, a primary sign of delirium.
Question 10: Which class of medications is known to worsen the symptoms of delirium in patients post-cardiac surgery?
- A. Antipsychotics
- B. Anticholinergics (Correct Answer)
- C. Benzodiazepines (BZD)
- D. Antihistamines
Explanation: **Explanation:** **1. Why Anticholinergics are the Correct Answer:** Delirium is fundamentally characterized by a neurochemical imbalance, most notably a **cholinergic deficiency** and a dopaminergic excess. Medications with anticholinergic properties (e.g., atropine, scopolamine, or certain tricyclic antidepressants) block acetylcholine receptors in the brain, directly precipitating or severely worsening the symptoms of delirium (confusion, disorientation, and cognitive impairment). In post-cardiac surgery patients, the brain is already vulnerable due to systemic inflammation and micro-emboli; adding an anticholinergic agent further destabilizes the neurotransmitter balance. **2. Analysis of Incorrect Options:** * **A. Antipsychotics:** These are actually the **treatment of choice** for the agitation associated with delirium. Low-dose Haloperidol is frequently used because it antagonizes dopamine, helping to restore the neurochemical balance. * **C. Benzodiazepines (BZD):** While BZDs can worsen delirium in the elderly or cause "paradoxical agitation," they are not the primary pharmacological *cause* of the underlying cholinergic deficit. They are generally avoided in delirium **unless** the delirium is caused by Alcohol Withdrawal or BZD withdrawal. * **D. Antihistamines:** While first-generation antihistamines (like diphenhydramine) have anticholinergic side effects and can cause delirium, "Anticholinergics" as a class is the more specific and direct answer regarding the underlying pathophysiology. **3. High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice for Delirium:** Haloperidol (IV/IM/Oral). * **Delirium vs. Dementia:** Delirium is acute, reversible, and characterized by **fluctuating levels of consciousness** and impaired attention. * **The "BZD Exception":** Use Benzodiazepines for delirium *only* if the etiology is Alcohol or Sedative-Hypnotic withdrawal. * **Post-Op Risk:** Post-cardiac surgery delirium is common (up to 30-50%) and is associated with increased mortality and longer ICU stays.
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