SMLE Psychiatry 4 — Questions and Answers
Question 1: A 32-year-old woman has a pervasive pattern of instability in interpersonal relationships, marked impulsivity, recurrent self-harm, chronic feelings of emptiness, and frantic efforts to avoid abandonment. What personality disorder is most likely?
- Histrionic personality disorder
- Borderline personality disorder (Correct answer)
- Narcissistic personality disorder
- Dependent personality disorder
Correct answer: Borderline personality disorder
Borderline personality disorder (BPD) is characterised by instability in relationships, self-image, and affects, marked impulsivity, self-harm, chronic emptiness, and desperate avoidance of abandonment. Dialectical behaviour therapy (DBT) is the evidence-based treatment.
Question 2: A patient on an SSRI starts taking tramadol and develops agitation, myoclonus, hyperreflexia, diaphoresis, and diarrhoea. What is the most likely diagnosis?
- Neuroleptic malignant syndrome
- Serotonin syndrome (Correct answer)
- Anticholinergic toxicity
- Malignant hyperthermia
Correct answer: Serotonin syndrome
Serotonin syndrome results from excessive serotonergic activity, often from combining serotonergic drugs (SSRI + tramadol). The triad includes altered mental status, autonomic instability, and neuromuscular hyperactivity (myoclonus, hyperreflexia). Treatment involves stopping offending agents and cyproheptadine.
Question 3: A mother brings her 3-year-old child who does not speak, avoids eye contact, engages in repetitive hand flapping, and lines up toys in a specific order. What is the most likely diagnosis?
- ADHD
- Autism spectrum disorder (Correct answer)
- Intellectual disability
- Selective mutism
Correct answer: Autism spectrum disorder
Autism spectrum disorder (ASD) is characterised by persistent deficits in social communication and interaction (poor eye contact, lack of speech) and restricted, repetitive patterns of behaviour (hand flapping, lining up objects). Diagnosis is typically made by age 2-3.
Question 4: A 55-year-old man with chronic alcoholism is found confused with confabulation, anterograde amnesia, and ataxia. Thiamine was not administered during his recent hospital admission. What is the diagnosis?
- Wernicke encephalopathy
- Korsakoff syndrome (Correct answer)
- Hepatic encephalopathy
- Alcohol withdrawal delirium
Correct answer: Korsakoff syndrome
Korsakoff syndrome is characterised by severe anterograde amnesia and confabulation (fabrication of memories to fill gaps) following Wernicke encephalopathy due to thiamine (B1) deficiency. It represents the chronic, irreversible phase of Wernicke-Korsakoff syndrome.
Question 5: What is the first-line medication for obsessive-compulsive disorder (OCD)?
- Benzodiazepines
- SSRIs at high doses (Correct answer)
- Typical antipsychotics
- Lithium
Correct answer: SSRIs at high doses
SSRIs at higher doses than used for depression (e.g., fluoxetine 40-80 mg, fluvoxamine 200-300 mg) are first-line pharmacotherapy for OCD. Clomipramine (a tricyclic with strong serotonergic activity) is an alternative. CBT with exposure and response prevention is the first-line psychological treatment.
Question 6: A patient presents after ingesting a large number of paracetamol tablets 4 hours ago. He is asymptomatic. What is the most important immediate management step?
- Wait for symptoms to develop
- Check serum paracetamol level and plot on treatment nomogram (Correct answer)
- Administer activated charcoal
- Start N-acetylcysteine empirically
Correct answer: Check serum paracetamol level and plot on treatment nomogram
At 4 hours post-ingestion, a serum paracetamol level should be checked and plotted on the Rumack-Matthew nomogram to determine if N-acetylcysteine (NAC) treatment is indicated. Patients may be asymptomatic initially despite potentially hepatotoxic levels.
SMLE Psychiatry 4
A 32-year-old woman has a pervasive pattern of instability in interpersonal relationships, marked impulsivity, recurrent self-harm, chronic feelings of emptiness, and frantic efforts to avoid abandonment.
What personality disorder is most likely?