A 24-year-old student is brought to A&E by police after being found naked in the street, shouting that he is 'the chosen one' who will save humanity. His friends report he has not slept for 5 days, has been spending excessive amounts of money, and initiated multiple sexual relationships. He has no past psychiatric history but his mother has bipolar disorder. Mental state examination reveals pressured speech, flight of ideas, and grandiose delusions. What is the most appropriate initial pharmacological management?
Q162
A 42-year-old man with bipolar affective disorder type I presents to his psychiatrist for routine follow-up. He has been taking lithium carbonate for 18 months with good mood stability. Recent blood tests show: lithium level 0.9 mmol/L, creatinine 145 μmol/L (baseline 95 μmol/L), eGFR 52 ml/min/1.73m² (previously 78), and TSH 6.2 mU/L (normal range 0.5-5.0). Which parameter represents the most concerning long-term complication requiring immediate action?
Q163
A 35-year-old woman with established schizophrenia has been taking haloperidol 10mg daily for 6 months. She attends her GP reporting involuntary writhing movements of her tongue and grimacing that started 2 weeks ago. These movements persist throughout the day and are causing significant distress. Her psychotic symptoms remain well-controlled. Examination confirms oro-buccal dyskinesia. What is the most appropriate immediate management?
Q164
A 28-year-old man presents to A&E with a 3-week history of hearing voices commenting on his actions and believing that his thoughts are being broadcast on the radio. He has become socially withdrawn and neglects his personal hygiene. His family reports no previous psychiatric history. On examination, he appears dishevelled and displays blunted affect. Urine drug screen is negative. Which first-rank symptom of schizophrenia is he demonstrating?
Severe Mental Illness UK Medical PG Practice Questions and MCQs
Question 161: A 24-year-old student is brought to A&E by police after being found naked in the street, shouting that he is 'the chosen one' who will save humanity. His friends report he has not slept for 5 days, has been spending excessive amounts of money, and initiated multiple sexual relationships. He has no past psychiatric history but his mother has bipolar disorder. Mental state examination reveals pressured speech, flight of ideas, and grandiose delusions. What is the most appropriate initial pharmacological management?
A. Oral olanzapine and lorazepam (Correct Answer)
B. Oral sodium valproate and risperidone
C. Oral lithium carbonate as monotherapy
D. Intramuscular haloperidol and oral lithium
E. Intramuscular lorazepam and oral lamotrigine
Explanation: ***Oral olanzapine and lorazepam***
- This patient is presenting with **acute mania with psychotic features**; NICE guidelines recommend **atypical antipsychotics** (like olanzapine, risperidone, or quetiapine) as first-line treatment for rapid symptom control.
- The addition of a **benzodiazepine** such as **lorazepam** is appropriate for managing acute agitation, behavioral disturbance, and severe insomnia associated with the manic episode.
*Oral sodium valproate and risperidone*
- While risperidone is a first-line agent, **sodium valproate** is generally considered a second-line option for acute mania if antipsychotics are ineffective or not tolerated.
- Combination therapy with a mood stabilizer and an antipsychotic is usually reserved for cases that fail to respond to monotherapy, rather than as the **initial pharmacological management**.
*Oral lithium carbonate as monotherapy*
- **Lithium** has a **slow onset of action** (typically 5-7 days for full effect), making it unsuitable as a sole agent for acute, severe mania where rapid tranquilization is required.
- It is highly effective for long-term prophylaxis but requires titration and **blood level monitoring**, making it secondary to antipsychotics in an emergency setting.
*Intramuscular haloperidol and oral lithium*
- **Intramuscular (IM)** administration should be reserved for patients who refuse oral medication or pose an immediate danger, which is not clearly indicated before attempting oral route first.
- Starting **lithium** during an acute psychotic manic episode without a sedative or faster-acting antipsychotic does not address the patient's immediate safety and behavioral needs.
*Intramuscular lorazepam and oral lamotrigine*
- **Lamotrigine** is effective for **bipolar depression** and maintenance therapy but has no clinical efficacy in the treatment of **acute mania**.
- Use of **intramuscular lorazepam** is unnecessary if the patient is willing and able to take medications orally, as oral routes are preferred for initial stabilization.
Question 162: A 42-year-old man with bipolar affective disorder type I presents to his psychiatrist for routine follow-up. He has been taking lithium carbonate for 18 months with good mood stability. Recent blood tests show: lithium level 0.9 mmol/L, creatinine 145 μmol/L (baseline 95 μmol/L), eGFR 52 ml/min/1.73m² (previously 78), and TSH 6.2 mU/L (normal range 0.5-5.0). Which parameter represents the most concerning long-term complication requiring immediate action?
A. The lithium level indicating potential toxicity
B. The elevated TSH suggesting hypothyroidism
C. The significantly reduced eGFR indicating chronic kidney disease (Correct Answer)
D. The combination of elevated creatinine and reduced eGFR
E. The duration of lithium therapy exceeding 12 months
Explanation: ***The significantly reduced eGFR indicating chronic kidney disease***
- The patient's **eGFR has significantly dropped** from 78 to 52 ml/min/1.73m², indicating a progression to **Stage 3a Chronic Kidney Disease (CKD)**.
- This substantial decline in kidney function due to chronic lithium use (known to cause **chronic tubulointerstitial nephritis**) is a **major long-term complication** requiring urgent assessment and potential adjustment of lithium therapy to prevent irreversible damage.
*The lithium level indicating potential toxicity*
- A lithium level of **0.9 mmol/L** is within the generally accepted **therapeutic range** for maintenance therapy (0.6–1.0 mmol/L).
- This level does not indicate **acute lithium toxicity**, which typically occurs at levels >1.5 mmol/L, and the patient is reported to have good mood stability, suggesting no acute toxic symptoms.
*The elevated TSH suggesting hypothyroidism*
- An elevated TSH (6.2 mU/L) is indicative of **lithium-induced hypothyroidism**, a common side effect of long-term lithium therapy.
- While it requires management, usually with **levothyroxine**, it is generally **less acutely life-threatening** or organ-damaging compared to a significant decline in renal function.
*The combination of elevated creatinine and reduced eGFR*
- While both an **elevated creatinine (145 µmol/L from 95 µmol/L)** and **reduced eGFR** are concerning indicators of renal impairment, the eGFR provides a more standardized measure of **kidney function stage**.
- The specific *reduction* in eGFR from baseline (78 to 52 ml/min/1.73m²) represents the direct evidence of **progressive chronic kidney disease**, making it the most precise and alarming parameter for long-term complications requiring action.
*The duration of lithium therapy exceeding 12 months*
- The **duration of lithium therapy (18 months)** itself is not a complication, but rather a risk factor for developing long-term side effects like renal and thyroid dysfunction.
- Many patients safely take lithium for **decades**, but regular monitoring is crucial; the actual *physiological changes* (like declining eGFR) are the concerning complications, not the time on medication.
Question 163: A 35-year-old woman with established schizophrenia has been taking haloperidol 10mg daily for 6 months. She attends her GP reporting involuntary writhing movements of her tongue and grimacing that started 2 weeks ago. These movements persist throughout the day and are causing significant distress. Her psychotic symptoms remain well-controlled. Examination confirms oro-buccal dyskinesia. What is the most appropriate immediate management?
A. Stop haloperidol and switch to clozapine
B. Add procyclidine to counteract the extrapyramidal side effects
C. Stop haloperidol and switch to an atypical antipsychotic such as olanzapine (Correct Answer)
D. Continue haloperidol and reassure that symptoms will resolve
E. Reduce haloperidol dose by 50% and review in 2 weeks
Explanation: ***Stop haloperidol and switch to an atypical antipsychotic such as olanzapine***
- The patient's involuntary writhing movements of the tongue and grimacing, after 6 months of haloperidol, are characteristic of **tardive dyskinesia (TD)**, a late-onset extrapyramidal side effect.
- The most appropriate immediate management is to discontinue the offending typical antipsychotic (**haloperidol**) and switch to a **second-generation (atypical) antipsychotic** like olanzapine, which has a lower risk of TD.
*Stop haloperidol and switch to clozapine*
- While **clozapine** has the lowest risk of extrapyramidal symptoms, it is typically reserved for **treatment-resistant schizophrenia** due to its significant side effect profile and need for intensive monitoring.
- It is not usually the first-line switch for TD when other safer atypical antipsychotics have not been tried.
*Add procyclidine to counteract the extrapyramidal side effects*
- **Anticholinergic medications** like procyclidine are effective for **acute dystonia** and **parkinsonism**, but they are **contraindicated** in tardive dyskinesia.
- These drugs can paradoxically worsen TD by further disturbing the dopamine-acetylcholine balance in the basal ganglia.
*Continue haloperidol and reassure that symptoms will resolve*
- **Tardive dyskinesia** is often irreversible, and continuing the causative drug (haloperidol) significantly increases the risk of permanent symptoms.
- Reassurance alone is inappropriate and can lead to chronic, debilitating movements.
*Reduce haloperidol dose by 50% and review in 2 weeks*
- While dose reduction can be a strategy for some side effects, TD typically requires **complete cessation of the typical antipsychotic** to prevent further progression and potentially allow some resolution.
- A 50% reduction may not be sufficient to halt the underlying neurological changes causing these involuntary movements.
Question 164: A 28-year-old man presents to A&E with a 3-week history of hearing voices commenting on his actions and believing that his thoughts are being broadcast on the radio. He has become socially withdrawn and neglects his personal hygiene. His family reports no previous psychiatric history. On examination, he appears dishevelled and displays blunted affect. Urine drug screen is negative. Which first-rank symptom of schizophrenia is he demonstrating?
A. Thought broadcast and third-person auditory hallucinations (Correct Answer)
B. Thought insertion and second-person auditory hallucinations
C. Delusional perception and thought withdrawal
D. Passivity phenomena and thought echo
E. Somatic passivity and running commentary
Explanation: ***Thought broadcast and third-person auditory hallucinations***
- The patient's belief that his thoughts are being transmitted via the radio is a classic example of **thought broadcast**, a core first-rank symptom of schizophrenia.
- Hearing voices **commenting on his actions** directly points to **third-person auditory hallucinations**, where voices discuss the patient or his actions.
*Thought insertion and second-person auditory hallucinations*
- **Thought insertion** is the belief that external thoughts are being *put into* one's mind, which is not described in the patient's symptoms.
- **Second-person auditory hallucinations** involve voices talking *directly to* the patient, whereas the patient hears voices *commenting on* his actions (third-person).
*Delusional perception and thought withdrawal*
- **Delusional perception** occurs when a normal perception is given a sudden, abnormal, delusional meaning, a feature not present in this scenario.
- **Thought withdrawal** refers to the belief that thoughts are being *removed* from one's mind by an external force, which is distinct from thoughts being broadcast.
*Passivity phenomena and thought echo*
- **Passivity phenomena** involve the belief that one's actions, feelings, or impulses are *controlled* by an external agency, which is not the primary symptom described.
- **Thought echo** is the experience of hearing one's own thoughts spoken aloud immediately after they occur, not voices commenting on actions.
*Somatic passivity and running commentary*
- **Somatic passivity** involves the belief that bodily sensations are being *imposed* by an external agency, a symptom not evidenced in this patient's presentation.
- While **running commentary** (voices commenting on actions) is a first-rank symptom described, the presence of **somatic passivity** in this option makes it incorrect for the overall clinical picture.
