A 39-year-old man with schizoaffective disorder has been maintained on risperidone long-acting injection 50mg fortnightly for 3 years. He attends his GP with concerns about sexual dysfunction including erectile dysfunction and loss of libido for 8 months. Blood tests show: prolactin 3200 mIU/L, testosterone 8.5 nmol/L (normal 10-30), thyroid function normal, glucose 5.4 mmol/L. He is otherwise stable mentally. Which management strategy addresses both his psychiatric stability and endocrine complications?
Q62
A 28-year-old woman with paranoid schizophrenia attends the community mental health team clinic. She has been on clozapine 350mg daily for 9 months with good symptom control. She reports a 6-week history of new-onset constipation with bowel movements every 4-5 days. Today she has abdominal pain and distension. Examination reveals absent bowel sounds and generalised abdominal tenderness. Temperature 37.8°C, pulse 110 bpm. What is the most appropriate immediate management?
Q63
A 35-year-old man with bipolar affective disorder type I is admitted with his fourth manic episode in 2 years despite apparent adherence to oral sodium valproate 1500mg daily. His valproate level is therapeutic at 85 mg/L. Previous episodes occurred on lithium (stopped due to tremor) and quetiapine (ineffective). He has no medical comorbidities. What is the most appropriate next step in long-term mood stabilisation?
Q64
A 46-year-old man with bipolar affective disorder type I has been maintained on lithium carbonate 1000mg daily for 8 years. He presents with a 3-month history of polyuria, polydipsia (drinking 6-7 litres daily), and nocturia 5 times per night. Blood tests show: sodium 148 mmol/L, lithium 0.85 mmol/L, glucose 5.2 mmol/L, calcium 2.4 mmol/L, serum osmolality 298 mOsm/kg. Urine osmolality is 180 mOsm/kg. What is the most likely diagnosis?
Q65
According to NICE guidelines for schizophrenia management, what is the recommended duration of antipsychotic continuation after a single episode of psychosis with full remission?
Q66
A 40-year-old man with a 15-year history of paranoid schizophrenia presents to A&E with sudden onset severe headache, fever of 39.1°C, and confusion. He was started on depot flupentixol 3 weeks ago after non-adherence to oral medication. On examination, he is sweating profusely, has generalised rigidity, and blood pressure of 165/95 mmHg. Blood tests show: CK 8500 U/L, WBC 15.2 × 10⁹/L, creatinine 165 μmol/L. What is the most likely diagnosis?
Q67
A 34-year-old woman with bipolar affective disorder type II presents to her psychiatrist requesting advice about pregnancy planning. She has been stable on lamotrigine 200mg daily for 3 years with no mood episodes. She previously failed trials of lithium and sodium valproate. She takes no other medications and has no medical comorbidities. What is the most appropriate advice regarding her medication during pregnancy?
Q68
A 37-year-old woman with bipolar affective disorder type I is admitted to the psychiatric unit with severe mania. She is aggressive, sexually disinhibited, and refusing all oral medication. She has a history of neuroleptic malignant syndrome following haloperidol use 3 years ago. Her family reports she stopped taking lithium 6 weeks ago. Physical examination reveals BP 145/90 mmHg, pulse 105 bpm, temperature 37.2°C. What is the most appropriate initial pharmacological management?
Q69
A 25-year-old man presents to the early intervention service with his first episode of psychosis. He describes a 6-month history of believing his neighbours can read his mind through the walls. He hears voices discussing his actions in the third person. His speech shows knight's move thinking. There is no substance misuse. Which symptom cluster represents first-rank symptoms of schizophrenia according to Schneider's criteria?
Q70
A 43-year-old woman with a 12-year history of bipolar affective disorder type I attends her GP. She has had four previous manic episodes requiring admission. She has been stable on lithium carbonate 800mg daily for 6 years. Recent blood tests show: lithium 0.9 mmol/L, sodium 141 mmol/L, potassium 4.2 mmol/L, creatinine 145 μmol/L (baseline 95 μmol/L), eGFR 38 ml/min (baseline 72 ml/min). Thyroid function is normal. What is the most appropriate management?
Severe Mental Illness UK Medical PG Practice Questions and MCQs
Question 61: A 39-year-old man with schizoaffective disorder has been maintained on risperidone long-acting injection 50mg fortnightly for 3 years. He attends his GP with concerns about sexual dysfunction including erectile dysfunction and loss of libido for 8 months. Blood tests show: prolactin 3200 mIU/L, testosterone 8.5 nmol/L (normal 10-30), thyroid function normal, glucose 5.4 mmol/L. He is otherwise stable mentally. Which management strategy addresses both his psychiatric stability and endocrine complications?
A. Switch to paliperidone depot and add testosterone replacement
B. Continue risperidone depot and add cabergoline 0.5mg weekly
C. Switch to aripiprazole long-acting injection and monitor (Correct Answer)
D. Reduce risperidone depot to 37.5mg and add sildenafil
E. Switch to quetiapine immediate release and monitor prolactin
Explanation: ***Switch to aripiprazole long-acting injection and monitor***- **Aripiprazole** is a **partial dopamine D2 agonist**, which typically normalizes or significantly reduces **prolactin** levels while maintaining antipsychotic efficacy.- Moving to a **long-acting injection** (LAI) ensures continued **psychiatric stability** and adherence in a patient who has been stable on a depot for three years.*Switch to paliperidone depot and add testosterone replacement*- **Paliperidone** is the active metabolite of **risperidone** and is highly likely to continue causing significant **hyperprolactinaemia**.- Adding **testosterone** treats the symptom rather than the underlying cause and carries potential **cardiovascular risks** without resolving the high prolactin.*Continue risperidone depot and add cabergoline 0.5mg weekly*- **Cabergoline**, a dopamine agonist used to lower prolactin, carries a significant risk of **exacerbating psychosis** in patients with schizoaffective disorder.- It is generally preferred to switch the offending antipsychotic rather than adding a second medication to manage **iatrogenic side effects**.*Reduce risperidone depot to 37.5mg and add sildenafil*- A minor **dose reduction** is often insufficient to normalize such severely elevated **prolactin levels** (3200 mIU/L).- **Sildenafil** may help with erectile dysfunction but fails to address the underlying **hypogonadism** (low testosterone) and loss of libido caused by the medication.*Switch to quetiapine immediate release and monitor prolactin*- Switching from a long-acting injection to an **immediate-release oral medication** significantly increases the risk of **non-adherence** and relapse.- While **quetiapine** is prolactin-sparing, the loss of the **depot formulation** compromises the patient's long-term psychiatric stability.
Question 62: A 28-year-old woman with paranoid schizophrenia attends the community mental health team clinic. She has been on clozapine 350mg daily for 9 months with good symptom control. She reports a 6-week history of new-onset constipation with bowel movements every 4-5 days. Today she has abdominal pain and distension. Examination reveals absent bowel sounds and generalised abdominal tenderness. Temperature 37.8°C, pulse 110 bpm. What is the most appropriate immediate management?
A. Prescribe high-dose laxatives and review in 48 hours
B. Arrange urgent abdominal X-ray and surgical review (Correct Answer)
C. Reduce clozapine dose and commence regular laxatives
D. Continue clozapine and refer to gastroenterology outpatients
E. Stop clozapine immediately and observe for 24 hours
Explanation: ***Arrange urgent abdominal X-ray and surgical review***
- The patient's presentation with **abdominal pain**, **distension**, **absent bowel sounds**, **generalised abdominal tenderness**, **fever (37.8°C)**, and **tachycardia (110 bpm)** indicates a severe, acute abdomen, highly suggestive of **clozapine-induced paralytic ileus** or **bowel obstruction** which can progress to **toxic megacolon** or **perforation**.
- Urgent **abdominal imaging** (e.g., X-ray) and immediate **surgical consultation** are crucial to diagnose the extent of the pathology and intervene, as mortality from severe clozapine-induced gastrointestinal complications is high without prompt management.
*Prescribe high-dose laxatives and review in 48 hours*
- Administering **high-dose laxatives** is contraindicated in suspected **bowel obstruction** or **ileus** because it can exacerbate distension, potentially leading to **bowel perforation** or worsening the clinical picture.
- A review in 48 hours is dangerously delayed for a patient presenting with an **acute abdomen** and systemic signs of inflammation, which necessitates immediate assessment and intervention.
*Reduce clozapine dose and commence regular laxatives*
- While clozapine is the underlying cause, reducing the dose and commencing regular laxatives are appropriate for **mild to moderate constipation** but are wholly inadequate for an acute, life-threatening presentation like this.
- This approach fails to address the immediate surgical emergency suggested by the clinical signs and symptoms, potentially leading to severe adverse outcomes.
*Continue clozapine and refer to gastroenterology outpatients*
- Continuing **clozapine** would be extremely dangerous as its potent **anticholinergic effects** would further worsen the already compromised gastrointestinal motility, increasing the risk of **bowel perforation** and **sepsis**.
- Referral to **gastroenterology outpatients** is inappropriate for an acute abdomen with signs of systemic distress, which requires immediate emergency department evaluation and inpatient management.
*Stop clozapine immediately and observe for 24 hours*
- Although **stopping clozapine** is a necessary immediate step to prevent further gastrointestinal harm, simple observation for 24 hours is insufficient and highly risky given the severe clinical signs like **absent bowel sounds**, **fever**, and **tachycardia**.
- This approach delays critical **diagnostic imaging** and **surgical evaluation**, which are essential to manage conditions like **bowel obstruction** or **toxic megacolon** and prevent mortality.
Question 63: A 35-year-old man with bipolar affective disorder type I is admitted with his fourth manic episode in 2 years despite apparent adherence to oral sodium valproate 1500mg daily. His valproate level is therapeutic at 85 mg/L. Previous episodes occurred on lithium (stopped due to tremor) and quetiapine (ineffective). He has no medical comorbidities. What is the most appropriate next step in long-term mood stabilisation?
A. Add lithium to sodium valproate as combination therapy (Correct Answer)
B. Switch to depot antipsychotic monotherapy
C. Add lamotrigine to current sodium valproate
D. Increase sodium valproate dose to 2000mg daily
E. Add aripiprazole to current sodium valproate
Explanation: ***Add lithium to sodium valproate as combination therapy***
- Combining **lithium** with an **anticonvulsant** (like valproate) is a gold-standard step for patients who experience breakthrough episodes on monotherapy, especially in **rapid cycling** scenarios.
- While the patient previously had a **tremor**, this side effect is often **dose-dependent** and can be managed while providing the superior prophylactic benefits that dual-agent mood stabilization offers.
*Switch to depot antipsychotic monotherapy*
- **Depot antipsychotics** are primarily used to address **medication non-adherence**, which is not the primary issue here given the patient's **therapeutic valproate level**.
- Monotherapy is generally insufficient for a patient failing established treatments; **combination therapy** is preferred by guidelines like **NICE** for treatment-resistant bipolar disorder.
*Add lamotrigine to current sodium valproate*
- **Lamotrigine** is highly effective for preventing **bipolar depression**, but it has limited efficacy in preventing or treating **acute manic episodes**.
- There is an increased risk of **Stevens-Johnson Syndrome** when combining these drugs as valproate inhibits the metabolism of lamotrigine, doubling its plasma concentration.
*Increase sodium valproate dose to 2000mg daily*
- The patient's valproate level is already **85 mg/L**, which is within the established **therapeutic range** (50-100 mg/L or 125 mg/L depending on lab standards).
- Increasing the dose further is unlikely to provide significant additional control for breakthrough mania and significantly increases the risk of **hepatotoxicity** and **thrombocytopenia**.
*Add aripiprazole to current sodium valproate*
- While adding an **atypical antipsychotic** is an option, adding **lithium** is generally prioritized for long-term stabilization in patients failing monotherapy due to its unique **anti-suicidal properties**.
- The patient previously failed **quetiapine** (another atypical antipsychotic), making the addition of another agent from the same class a less robust strategic move than adding a second **mood stabilizer**.
Question 64: A 46-year-old man with bipolar affective disorder type I has been maintained on lithium carbonate 1000mg daily for 8 years. He presents with a 3-month history of polyuria, polydipsia (drinking 6-7 litres daily), and nocturia 5 times per night. Blood tests show: sodium 148 mmol/L, lithium 0.85 mmol/L, glucose 5.2 mmol/L, calcium 2.4 mmol/L, serum osmolality 298 mOsm/kg. Urine osmolality is 180 mOsm/kg. What is the most likely diagnosis?
A. Diabetes insipidus secondary to lithium (Correct Answer)
B. Diabetes mellitus type 2
C. Primary polydipsia
D. Hypercalcaemia causing polyuria
E. Syndrome of inappropriate ADH secretion
Explanation: ***Diabetes insipidus secondary to lithium***- Long-term **lithium therapy** is a common cause of **nephrogenic diabetes insipidus**, as it interferes with the action of **ADH** on the collecting ducts of the kidney.- The diagnostic profile includes **high serum osmolality** (298 mOsm/kg) and **hypernatremia** (148 mmol/L) with inappropriately **low urine osmolality** (180 mOsm/kg), matching this patient's presentation.*Diabetes mellitus type 2*- This is excluded by a **normal glucose level** of 5.2 mmol/L; hyperglycemia would be the hallmark for polyuria/polydipsia in diabetes mellitus.- While it causes similar symptoms, the underlying mechanism involves osmotic diuresis due to glucose, which is not supported by lab tests here.*Primary polydipsia*- In **primary polydipsia**, excessive water intake would lead to **low serum osmolality** and **hyponatremia**, which contradicts the patient's hypernatremia and elevated serum osmolality.- This condition involves a psychological drive for water intake, not a defect in renal concentrating ability.*Hypercalcaemia causing polyuria*- While **hypercalcaemia** can induce nephrogenic diabetes insipidus-like symptoms by impairing renal ADH response, the patient's **calcium level** of 2.4 mmol/L is within the normal range.- Therefore, hypercalcaemia is not the cause of the polyuria in this specific case.*Syndrome of inappropriate ADH secretion*- **SIADH** presents with the opposite biochemical profile: **hyponatraemia** (low serum sodium) and inappropriately **high urine osmolality** (concentrated urine).- The patient exhibits hypernatremia and dilute urine, which rules out SIADH.
Question 65: According to NICE guidelines for schizophrenia management, what is the recommended duration of antipsychotic continuation after a single episode of psychosis with full remission?
A. 6-12 months after symptom remission
B. 1-2 years after symptom remission (Correct Answer)
C. 3-5 years after symptom remission
D. Lifelong treatment is recommended
E. Antipsychotics can be discontinued immediately after remission
Explanation: ***1-2 years after symptom remission***- According to **NICE guidelines**, patients who experience a first episode of psychosis and achieve full remission should continue **antipsychotic medication** for at least 1-2 years.- This duration is specified to significantly reduce the high **risk of relapse** seen when treatment is discontinued prematurely while balancing potential **side-effect burdens**.*6-12 months after symptom remission*- While some general medical conditions require 6 months of treatment, this is considered **insufficient duration** for schizophrenia spectrum disorders.- Discontinuing treatment before the **1-year mark** is clinically associated with a much higher rate of **acute psychotic relapse**.*3-5 years after symptom remission*- This duration is typically reserved for patients who have suffered **multiple relapses** or have a history of **severe risk** to themselves or others.- For a **single episode** with full remission, extending the primary maintenance phase to 5 years is not the standard **initial guideline** recommendation.*Lifelong treatment is recommended*- Lifelong medication is primarily indicated for patients with **recurrent episodes** or chronic, treatment-resistant symptoms.- It is not routinely mandated for a **first episode** of psychosis if the patient remains stable and symptom-free during the **maintenance phase**.*Antipsychotics can be discontinued immediately after remission*- Immediate discontinuation leads to a nearly universal and **rapid relapse** of psychotic symptoms due to the underlying pathophysiology.- NICE guidelines emphasize a **gradual dose reduction** and close monitoring rather than abrupt cessation, even after the maintenance period is over.
Question 66: A 40-year-old man with a 15-year history of paranoid schizophrenia presents to A&E with sudden onset severe headache, fever of 39.1°C, and confusion. He was started on depot flupentixol 3 weeks ago after non-adherence to oral medication. On examination, he is sweating profusely, has generalised rigidity, and blood pressure of 165/95 mmHg. Blood tests show: CK 8500 U/L, WBC 15.2 × 10⁹/L, creatinine 165 μmol/L. What is the most likely diagnosis?
A. Neuroleptic malignant syndrome (Correct Answer)
B. Serotonin syndrome
C. Acute bacterial meningitis
D. Malignant catatonia
E. Encephalitis
Explanation: ***Neuroleptic malignant syndrome*** - This diagnosis is strongly supported by the classic tetrad of **fever**, **rigidity**, **altered mental status (confusion)**, and **autonomic dysfunction (sweating, hypertension)**, all present in a patient recently started on a **depot antipsychotic (flupentixol)**. - The elevated **creatine kinase (CK)** indicates **rhabdomyolysis**, and the elevated **creatinine** suggests **acute kidney injury**, both common and severe complications of NMS. *Serotonin syndrome* - Typically results from **excess serotonergic activity**, often due to interactions between antidepressant medications or illicit drugs, which is not the context with flupentixol. - Key features often include **hyperreflexia**, **myoclonus**, **tremor**, and gastrointestinal symptoms like diarrhea, which are not predominant here. *Acute bacterial meningitis* - While presenting with **fever**, **headache**, and **confusion**, it would typically show **nuchal rigidity** and possibly focal neurological signs. - It does not explain the profound **generalised muscular rigidity** or the significantly elevated **CK levels** seen in this patient. *Malignant catatonia* - Can present with **fever**, **rigidity**, and autonomic instability, mimicking NMS, but typically arises in the context of severe psychiatric illness or withdrawal states, rather than directly post-initiation of an antipsychotic. - While it shares features, the explicit link to recent **antipsychotic initiation** and the severe rhabdomyolysis with very high CK are more characteristic of NMS. *Encephalitis* - Presents with **fever**, **headache**, **confusion**, and can cause seizures or focal neurological deficits. - It does not typically cause the severe, generalized **muscular rigidity** or the dramatic elevation in **CK** indicative of muscle breakdown seen in this case.
Question 67: A 34-year-old woman with bipolar affective disorder type II presents to her psychiatrist requesting advice about pregnancy planning. She has been stable on lamotrigine 200mg daily for 3 years with no mood episodes. She previously failed trials of lithium and sodium valproate. She takes no other medications and has no medical comorbidities. What is the most appropriate advice regarding her medication during pregnancy?
A. Continue lamotrigine at current dose throughout pregnancy
B. Switch to lithium in first trimester then continue throughout pregnancy
C. Discontinue lamotrigine and remain medication-free during pregnancy
D. Continue lamotrigine with dose adjustment based on therapeutic monitoring (Correct Answer)
E. Switch to olanzapine before conception and continue throughout pregnancy
Explanation: ***Continue lamotrigine with dose adjustment based on therapeutic monitoring***
- **Lamotrigine clearance** increases significantly (up to 50-65%) during pregnancy due to the induction of **glucuronidation** by estrogen, leading to subtherapeutic levels and high risk of relapse.
- Monitoring **serum levels** and adjusting the dose proportionately is necessary to maintain clinical stability while minimizing **teratogenic risk**, which is relatively low for lamotrigine.
*Continue lamotrigine at current dose throughout pregnancy*
- Maintaining a static dose is likely to result in **subtherapeutic plasma concentrations** as the pregnancy progresses, increasing the risk of a **bipolar mood episode**.
- Dose adjustments are standard clinical practice for **antiepileptic drugs** used in pregnancy to compensate for altered **pharmacokinetics**.
*Switch to lithium in first trimester then continue throughout pregnancy*
- **Lithium** is associated with a specific risk of **Ebstein’s anomaly** (a cardiac defect) if used during the first trimester, making it a second-line choice compared to stable lamotrigine therapy.
- This patient has already **failed a trial of lithium**, so switching back to it would be clinically inappropriate and risk destabilizing her condition.
*Discontinue lamotrigine and remain medication-free during pregnancy*
- **Bipolar affective disorder** carries a very high risk of **postpartum psychosis** and relapse during pregnancy; medication-free periods are generally discouraged for patients with severe mental illness.
- Abruptly stopping medication after being stable for three years poses a significant threat to both **maternal well-being** and the safety of the pregnancy.
*Switch to olanzapine before conception and continue throughout pregnancy*
- While **olanzapine** is an option in bipolar disorder, switching a patient who is already stable on an effective, relatively safe medication increases the risk of **relapse**.
- Antipsychotics like olanzapine are associated with **metabolic side effects** such as weight gain and **gestational diabetes**, which require additional monitoring.
Question 68: A 37-year-old woman with bipolar affective disorder type I is admitted to the psychiatric unit with severe mania. She is aggressive, sexually disinhibited, and refusing all oral medication. She has a history of neuroleptic malignant syndrome following haloperidol use 3 years ago. Her family reports she stopped taking lithium 6 weeks ago. Physical examination reveals BP 145/90 mmHg, pulse 105 bpm, temperature 37.2°C. What is the most appropriate initial pharmacological management?
A. Intramuscular aripiprazole and oral lorazepam
B. Intramuscular olanzapine and restart lithium (Correct Answer)
C. Oral sodium valproate and intramuscular lorazepam
D. Intramuscular haloperidol and oral promethazine
E. Electroconvulsive therapy as first-line treatment
Explanation: ***Intramuscular olanzapine and restart lithium***
- **Intramuscular (IM) olanzapine** is effective for rapid control of **acute agitation** and aggression in severe mania, especially when the patient is refusing oral medication.
- **Restarting lithium** is crucial because the patient had a documented response to it previously, and its abrupt discontinuation is a common cause of **manic relapse**.
*Intramuscular aripiprazole and oral lorazepam*
- While **IM aripiprazole** can be used for acute agitation, **olanzapine** often has a faster onset and more robust evidence for severe manic agitation.
- **Oral lorazepam** is unsuitable as the patient is actively **refusing all oral medications**, necessitating a parenteral approach for all initial treatments.
*Oral sodium valproate and intramuscular lorazepam*
- **Oral sodium valproate** cannot be administered given the patient's refusal of all oral medications, making it an inappropriate initial choice for rapid stabilization.
- Although **IM lorazepam** helps with sedation and anxiety, it does not directly address the underlying **psychotic features** and severe mania as effectively as an antipsychotic.
*Intramuscular haloperidol and oral promethazine*
- **Intramuscular haloperidol** is absolutely contraindicated due to the patient's history of **Neuroleptic Malignant Syndrome (NMS)** following its use.
- Administering a **first-generation antipsychotic** like haloperidol in this scenario carries a significant and life-threatening risk of **NMS recurrence**.
*Electroconvulsive therapy as first-line treatment*
- **Electroconvulsive therapy (ECT)** is highly effective for severe mania but is typically reserved for **treatment-resistant cases**, catatonia, or when rapid response is critical due to severe medical compromise.
- It is not considered the **first-line pharmacological management** for initial stabilization before attempting rapid tranquilization with antipsychotics.
Question 69: A 25-year-old man presents to the early intervention service with his first episode of psychosis. He describes a 6-month history of believing his neighbours can read his mind through the walls. He hears voices discussing his actions in the third person. His speech shows knight's move thinking. There is no substance misuse. Which symptom cluster represents first-rank symptoms of schizophrenia according to Schneider's criteria?
A. Knight's move thinking, third-person auditory hallucinations, and paranoid delusions
B. Thought broadcasting, third-person auditory hallucinations, and passivity phenomena (Correct Answer)
C. Social withdrawal, affective flattening, and thought disorder
D. Grandiose delusions, pressure of speech, and decreased need for sleep
E. Paranoid delusions, formal thought disorder, and negative symptoms
Explanation: ***Thought broadcasting, third-person auditory hallucinations, and passivity phenomena***- These are classic **Schneider's first-rank symptoms**, which include thought interference (insertion, withdrawal, broadcasting), specific auditory hallucinations, and **passivity phenomena** (of affect, impulse, or volition).- The patient's belief that his neighbors can read his mind is a form of **thought broadcasting**, and hearing voices discussing his actions in the third person is a definitive **third-person auditory hallucination**.*Knight's move thinking, third-person auditory hallucinations, and paranoid delusions*- **Knight's move thinking** (derailment) is a formal thought disorder but is not considered a Schneiderian first-rank symptom.- **Paranoid delusions** are common in schizophrenia but are only first-rank if they specifically involve **delusional perception** or other specific experiences of influence.*Social withdrawal, affective flattening, and thought disorder*- These are categorized as **negative symptoms** of schizophrenia and general formal thought disorder, rather than first-rank symptoms.- Schneider's criteria focus primarily on specific **positive symptoms** and experiences of alien control or thought interference.*Grandiose delusions, pressure of speech, and decreased need for sleep*- This cluster is characteristic of a **manic episode** in bipolar disorder, not the core diagnostic criteria for schizophrenia.- **Pressure of speech** and **decreased need for sleep** are objective signs of increased psychomotor activity, whereas first-rank symptoms focus on the subjective experience of disturbed thought and perception.*Paranoid delusions, formal thought disorder, and negative symptoms*- While these are frequently present in a schizophrenia diagnosis, they do not belong to the specific list of **Schneider's first-rank symptoms**.- **First-rank symptoms** are prioritized due to their high specificity for schizophrenia in the absence of organic brain disease, rather than general symptoms.
Question 70: A 43-year-old woman with a 12-year history of bipolar affective disorder type I attends her GP. She has had four previous manic episodes requiring admission. She has been stable on lithium carbonate 800mg daily for 6 years. Recent blood tests show: lithium 0.9 mmol/L, sodium 141 mmol/L, potassium 4.2 mmol/L, creatinine 145 μmol/L (baseline 95 μmol/L), eGFR 38 ml/min (baseline 72 ml/min). Thyroid function is normal. What is the most appropriate management?
A. Continue lithium and repeat renal function in 3 months
B. Reduce lithium dose and recheck levels in 1 week
C. Switch to sodium valproate and monitor renal function (Correct Answer)
D. Stop lithium immediately and commence olanzapine
E. Refer to nephrology and maintain lithium pending review
Explanation: ***Switch to sodium valproate and monitor renal function***
- The patient exhibits **chronic kidney disease (CKD)** progression with an **eGFR falling below 45 ml/min** and a creatinine increase of >50 μmol/L, which necessitates discontinuing lithium according to **NICE guidelines**.
- **Sodium valproate** is a recommended alternative for **bipolar disorder prophylaxis** that does not carry the same risk of nephrotoxicity as lithium.
*Continue lithium and repeat renal function in 3 months*
- Continuing lithium despite a significant decline in **eGFR** and rising **creatinine** risks irreversible **nephrogenic diabetes insipidus** or end-stage renal failure.
- Standard monitoring intervals are inappropriate when current results show **stage 3B CKD**, requiring immediate clinical intervention.
*Reduce lithium dose and recheck levels in 1 week*
- While lower doses of lithium reduce the risk of acute toxicity, they do not halt the **chronic interstitial nephritis** associated with long-term use.
- Because lithium is **renally excreted**, any reduction in kidney function leads to higher serum levels, making dose adjustment insufficient for long-term safety in this patient.
*Stop lithium immediately and commence olanzapine*
- Immediate cessation of lithium without a gradual taper or transition to another mood stabilizer is associated with a high risk of **rapid relapse** into mania.
- While **olanzapine** is effective for acute episodes, **sodium valproate** or **quetiapine** are preferred transitions for long-term prophylaxis in this clinical scenario.
*Refer to nephrology and maintain lithium pending review*
- While a **nephrology referral** is indicated for declining renal function, the GP must act promptly to remove the offending **nephrotoxic agent**.
- Maintaining lithium while waiting for a specialist review allows for further **renal deterioration** and potential lithium toxicity.
