Emergency Psychiatry — MCQs

Emergency Psychiatry Indian Medical PG Practice Questions and MCQs

Question 11: A psychiatrist receives a call from a patient who expresses thoughts of harming his ex-girlfriend. The patient describes a detailed plan to attack her at her workplace. Which of the following represents the psychiatrist's most appropriate legal obligation?

A. Warn the ex-girlfriend and notify law enforcement (Correct Answer)
B. Only notify the patient's family
C. Warn only law enforcement
D. Maintain patient confidentiality

Explanation: ***Warn the ex-girlfriend and notify law enforcement*** - This scenario directly triggers the **"duty to warn"** and **"duty to protect"** principles, primarily stemming from the **Tarasoff v. Regents of the University of California** case. - The psychiatrist has a legal obligation to take reasonable steps to protect the identifiable victim, which includes directly warning the intended victim and informing law enforcement. *Only notify the patient's family* - Notifying the patient's family alone does not fulfill the **legal obligation to protect** an identifiable third party from a serious threat of harm. - While family involvement might be part of a comprehensive safety plan, it is insufficient as the sole action in this critical situation. *Warn only law enforcement* - While notifying law enforcement is a crucial step, the **Tarasoff duty** specifically mandates warning the **intended victim** directly (or those who can reasonably be expected to notify the victim). - Relying solely on law enforcement might not ensure the immediate safety of the ex-girlfriend, especially if there's a delay in their response or ability to locate her. *Maintain patient confidentiality* - Patient confidentiality is a cornerstone of psychiatric practice, but it is **not absolute** when there is a serious and imminent threat of harm to an identifiable individual. - The **duty to protect** a potential victim *outweighs* the duty to maintain confidentiality in such extreme circumstances.

Question 12: Management of a violent patient in psychiatry includes all except:

A. CBT (Correct Answer)
B. Haloperidol
C. ECT
D. BZD

Explanation: ***CBT*** - **Cognitive Behavioral Therapy (CBT)** is a long-term psychological intervention aimed at changing maladaptive thought patterns and behaviors. It is **not suitable for immediate management** of an acutely violent patient. - While CBT can be beneficial for aggression management in a stable patient, it requires patient cooperation, cognitive engagement, and time, which are not available during a **violent psychiatric emergency**. *Haloperidol* - **Haloperidol** is a potent typical antipsychotic frequently used in acute settings for rapid tranquilization of violent or severely agitated patients. - It is effective in reducing **psychosis-related agitation** and can be administered **intramuscularly** for quick onset of action. - Often used in combination with benzodiazepines for optimal control of acute violence. *ECT* - **Electroconvulsive Therapy (ECT)** may be considered in **severe, treatment-resistant cases** of violence associated with conditions like uncontrolled mania, catatonic excitement, or psychotic depression when pharmacological interventions have failed. - While not used for immediate acute management due to logistical requirements (consent, anesthesia, specialized setup), it can be an effective option for severe psychiatric conditions with persistent violence. - It works by inducing a brief controlled seizure, which can rapidly alleviate severe symptoms. *BZD* - **Benzodiazepines (BZDs)** like lorazepam or diazepam are **first-line agents** in the acute management of violent or agitated patients due to their rapid anxiolytic, sedative, and muscle relaxant properties. - They are particularly useful for **calming acute agitation** and are often combined with antipsychotics for rapid tranquilization. - Can be administered intramuscularly or intravenously for quick action in psychiatric emergencies.

Question 13: Visual hallucinations are most commonly seen in:

A. OCD
B. Delusional syndrome
C. Delirium (Correct Answer)
D. Mania

Explanation: ***Delirium*** - **Visual hallucinations** are a hallmark symptom of **delirium**, often described as vivid and fluctuating. - Delirium presents with acute onset of **waxing and waning consciousness**, attention deficits, and cognitive impairment. *OCD* - **Obsessive-compulsive disorder** (OCD) is characterized by recurrent, intrusive thoughts (**obsessions**) and repetitive behaviors (**compulsions**). - It does not typically involve hallucinations; rather, individuals are usually aware of the irrationality of their obsessions and compulsions. *Delusional syndrome* - **Delusional disorders** primarily involve fixed, false beliefs (**delusions**) that are not bizarre and are not accompanied by prominent hallucinations. - While hallucinations can occur, they are generally not the most prominent or characteristic feature, unlike in delirium or psychotic disorders. *Mania* - **Mania**, a mood disorder, is characterized by an elevated, expansive, or irritable mood, increased activity, racing thoughts, and decreased need for sleep. - While psychotic features such as delusions (often grandiose) can occur in severe mania, **visual hallucinations** are less common than in delirium and audio hallucinations are more likely if present.

Question 14: What is the correct sequence of disorientation experienced by a person after a traumatic head injury?

A. First place, then time, followed by person.
B. First person, then time, followed by place.
C. First time, then person, followed by place.
D. First time, then place, followed by person. (Correct Answer)

Explanation: ***Correct: First time, then place, followed by person.*** - Disorientation to **time** is typically the first sign because it requires continuous updating of transient information, making it the most vulnerable to brain injury. - Disorientation to **place** usually follows, indicating difficulty in processing and remembering current environmental context. - Disorientation to **person** (self) is generally the last to occur, as personal identity is the most deeply ingrained and stable aspect of orientation. - This sequence (Time → Place → Person) is the classic pattern in traumatic head injury and cognitive impairment. *Incorrect: First place, then time, followed by person.* - Disorientation to **place** typically comes after disorientation to time, as spatial awareness is generally more stable than temporal awareness. - This sequence is not the commonly observed pattern in traumatic head injury where **time** is usually lost first. *Incorrect: First person, then time, followed by place.* - Disorientation to **person** (self) is generally the last to occur, not the first, as personal identity is the most deeply ingrained and stable aspect of orientation. - This sequence incorrectly places **person** at the beginning of the progression. *Incorrect: First time, then person, followed by place.* - While disorientation to **time** is correctly identified as first, disorientation to **person** typically occurs much later than disorientation to **place**. - This sequence does not align with the typical progression: Time → Place → Person.

Question 15: Delirium is defined as?

A. Acute onset of disturbed consciousness (Correct Answer)
B. Chronic onset of disturbed consciousness
C. Progressive generalized impairment of intellectual functions and memory without impairment of consciousness
D. Disorientation without clouding of consciousness

Explanation: ***Acute onset of disturbed consciousness*** - **Delirium** is characterized by an **acute or subacute onset** of fluctuating attention and cognition, indicating a rapid change from baseline mental status. - The core feature is a **disturbance in attention** and **awareness (consciousness)**, which can manifest as reduced clarity, disorientation, or an inability to focus. *Chronic onset of disturbed consciousness* - **Delirium** is by definition an **acute condition**, not chronic. Chronic conditions affecting consciousness tend to be more stable or progressively worsening over a longer period. - **Chronic disturbances** in consciousness are more indicative of conditions like persistent vegetative state or severe dementia, which have different diagnostic criteria than delirium. *Progressive generalized impairment of intellectual functions and memory without impairment of consciousness* - This description is characteristic of **dementia**, where there is a **gradual decline** in cognitive function (memory, intellect) without the primary disturbance of consciousness seen in delirium. - In **dementia**, alertness is generally preserved, while **delirium** involves a direct impairment of the ability to focus, sustain, or shift attention. *Disorientation without clouding of consciousness* - While **disorientation** can be a feature of delirium, it is not the sole defining characteristic and often occurs in conjunction with **clouding of consciousness** (impaired awareness and attention). - Isolated disorientation without other signs of disturbed consciousness might be seen in other conditions but is not sufficient for a diagnosis of **delirium**.

Question 16: The Confusion Assessment Method (CAM) is used for which of the following?

A. Schizophrenia
B. Delirium (Correct Answer)
C. Dementia
D. Depression

Explanation: ***Delirium*** - The Confusion Assessment Method (CAM) is a widely used and highly sensitive and specific tool for the rapid identification of **delirium**. - It assesses for acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness. *Schizophrenia* - Schizophrenia is a chronic mental health disorder primarily characterized by **psychosis**, including hallucinations, delusions, and disorganized thought. - While patients with schizophrenia can experience cognitive difficulties, specialized scales like the Positive and Negative Syndrome Scale (PANSS) are used, not the CAM. *Dementia* - Dementia is a gradual and progressive decline in cognitive function, including memory, thinking, and reasoning, severe enough to interfere with daily life. - Tools like the mini-mental state examination (MMSE) or Montreal Cognitive Assessment (MoCA) are used for screening and assessing dementia, not the CAM. *Depression* - Depression is a mood disorder characterized by persistent sadness, loss of interest, and other emotional and physical symptoms. - Assessment tools like the Hamilton Depression Rating Scale (HDRS) or Patient Health Questionnaire-9 (PHQ-9) are used for depression.

Question 17: Which of the following can cause delirium?

A. Hypoxia
B. Barbiturates
C. Alcohol withdrawal
D. All of the options (Correct Answer)

Explanation: ***All of the options*** - **Delirium** is an acute, fluctuating disturbance in attention and cognition, often with altered consciousness, and can be caused by a wide range of factors. - **Hypoxia**, **barbiturate** use, and **alcohol withdrawal** are all well-established causes of delirium. *Hypoxia* - **Cerebral hypoxia**, or insufficient oxygen supply to the brain, directly impairs neuronal function, leading to acute confusion and altered mental status characteristic of delirium. - Conditions like severe respiratory failure, heart failure, or anemia can precipitate hypoxia and subsequent delirium. *Barbiturates* - **Barbiturates** are central nervous system depressants that can cause sedation, confusion, and cognitive impairment, especially in overdose or in susceptible individuals. - While they typically induce sedation, paradoxical excitement or severe cognitive dysfunction consistent with delirium can occur. *Alcohol withdrawal* - **Alcohol withdrawal** can lead to a severe form of delirium known as *delirium tremens*, characterized by extreme confusion, hallucinations, tremors, and autonomic instability. - The rapid cessation of chronic alcohol intake disrupts neurochemical balance, leading to hyperexcitability and delirium.

Question 18: In which of the following psychiatric conditions is floccillation seen?

A. Mania
B. Depression
C. Anxiety disorders
D. Delirium (Correct Answer)

Explanation: ***Delirium*** - **Floccillation**, or carphologia, is specifically characterized by **purposeless plucking at bedclothes or imaginary objects**, indicative of severe agitation and altered consciousness. - It is a classic sign of **severe delirium**, often seen in critically ill, elderly, or demented patients. *Mania* - Mania presents with elevated mood, increased energy, and racing thoughts, but typically does not involve the disoriented, purposeless movements characteristic of floccillation. - While extreme agitation can occur in mania, it is usually goal-directed or related to the patient's grandiosity or irritability. *Depression* - Depression is characterized by low mood, anhedonia, and psychomotor retardation or agitation, but not by picking at bedclothes. - Psychomotor agitation in depression usually involves pacing or restless movements associated with distress, rather than the disoriented floccillation. *Anxiety disorders* - Anxiety disorders involve excessive worry and fear, with symptoms like restlessness, tension, and hypervigilance. - While patients can be agitated, they generally maintain awareness of their surroundings and typically do not exhibit meaningless motor behaviors like floccillation.

Practice by Chapter

Suicide Risk Assessment and Management

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Violence Risk Assessment

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Agitation and Aggression Management

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Acute Psychosis

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Neuroleptic Malignant Syndrome

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Serotonin Syndrome

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Psychiatric Emergencies in Children

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Civil Commitment Process

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Crisis Intervention

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Disaster Psychiatry

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