General practice psychiatry

September 2013

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Clinical challenge

Volume 42, No.9, September 2013 Pages 671-672

Melissa Tan

Questions for this month's clinical challenge are based on articles in this issue. The style and scope of questions is in keeping with the multiple choice questions of the RACGP Fellowship exam. The quiz is endorsed by the RACGP Quality Improvement and Continuing Professional Development Program and has been allocated 4 Category 2 points per issue. Answers to this clinical challenge are available immediately following successful completion online at Clinical challenge quizzes may be completed at any time throughout the 2011–13 triennium, therefore the previous months answers are not published.

Case 1 : Oliver Raven

Oliver, aged 44 years, presents with a relapse of obsessive-compulsive disorder (OCD) symptoms.

Question 1

Regarding OCD, which one of the following is CORRECT:

  1. Patients usually regard their obsessions as a logical thought process
  2. Patients with eating disorders are at higher risk of OCD
  3. Symptoms are rarely known to originate during childhood
  4. There is usually an identifiable cause for the relapse of symptoms
  5. Violent thoughts are inconsistent with a diagnosis of OCD.

Question 2

Regarding treatment of OCD, which one of the following is most accurate?

  1. Benzodiazepines are most useful in the presence of counting rituals
  2. Evidence of the need for cognitive-behavioural therapy (CBT) is equivocal for OCD
  3. Psychoanalytic psychotherapy has a strong evidence base for OCD
  4. Relaxation strategies are not recommended for OCD patients
  5. There is good evidence for monoamine oxidase inhibitors in OCD.

Question 3

Which one of the following is CORRECT regarding exposure and response prevention (ERP) therapy for OCD?

  1. High dropout rates of 50% have been noted in ERP, mainly due to anxiety
  2. ERP has a higher relapse rate than pharmacological interventions
  3. ERP is one of several psychological therapies with good evidence for OCD
  4. Evidence suggests 13 to 20 treatment sessions are optimal for OCD
  5. Research suggests an estimated response rate of 50–60% to ERP.

Question 4

Regarding the use of SSRIs in OCD, which one of the following is CORRECT?

  1. Adequate therapeutic trial of SSRIs in OCD requires at least 16 weeks
  2. Approximate response rate to SSRIs as first-line therapy is 60–80%
  3. Approximate response rate to SSRIs as add-on therapy to ERP is 60–80%
  4. If there is no response to SSRIs, benzodiazepines should be second-line treatment
  5. Most patients have an improvement in symptoms of approximately 20–40% with SSRIs.

Case 2: Esther Swaine

Esther, aged 37 years, has bipolar disorder.

Question 5

Using the probabilistic approach to bipolar disorder, which one of the following features is more common in bipolar depression compared with unipolar depression?

  1. Increased speed of physical activity
  2. Minimal prior depressive episodes
  3. Onset of first depression <25 years
  4. Reduced appetite
  5. Reduced sleep.

Question 6

Regarding treatment of bipolar disorder, which one of the following is most CORRECT?

  1. Antipsychotics are as effective as mood stabilisers in treating acute mania
  2. Atypical antipsychotics have not been demonstrated to prevent relapse
  3. Randomised controlled trials show poor efficacy of psychological therapies
  4. The efficacy of antidepressants in bipolar depression is well-established
  5. There is conflicting data regarding rates of antidepressant-induced mania.

Question 7

Regarding lithium treatment in bipolar disorder, which one of the following is most CORRECT?

  1. Lithium is associated with decreased parathyroid hormone levels
  2. Lithium is associated with hyperthyroidism
  3. Lithium is associated with reduced urine concentrating ability
  4. Lithium is efficacious in preventing manic and depressive relapses
  5. Recent studies found lithium to have significantly higher rates of teratogenesis.

Question 8

Which one of the following is most CORRECT about bipolar disorder?

  1. Bipolar disorder patients are as likely to attempt suicide as patients with major depression
  2. Bipolar disorder will usually first present with an episode of mania or hypomania
  3. In regards to bipolar disorder, most suicides occur during manic episodes
  4. Most patients with bipolar II disorder spend more time in elevated than depressed moods
  5. There is growing concern regarding the over-diagnosis of bipolar disorder.

Case 3 : Ned Tully

Ned, aged 17 years, is a high school student. His mother Emily is concerned about his odd behaviour and habit of locking himself in his room.

Question 9

Regarding presentation of emerging psychosis in adolescents, which one of the following is CORRECT?

  1. Prodromes preceding definitive psychotic illness can only be identified retrospectively
  2. Psychosis most commonly presents with discrete, isolated symptoms in adolescents
  3. Recurrent hallucinatory phenomena in adolescents are indicative of underlying illness
  4. Symptoms such as hallucinations and delusions are diagnostic of psychosis
  5. Transient hallucinatory phenomena are not common in adolescents.

Question 10

Regarding prognosis of emerging psychosis in adolescents, which one of the following is CORRECT?

  1. Certain patterns of symptoms in early phases can reliably predict psychotic illness
  2. Risk of psychotic illness is generally not associated with substance abuse
  3. The majority of patients with emerging psychosis progress to psychotic illness
  4. Patients prone to drug-induced psychoses have no higher risk of psychiatric illness
  5. Some individuals have a genetic predisposition to drug-induced psychosis.

Question 11

After an acute deterioration, Ned is commenced on olanzapine.

When monitoring adolescents on antipsychotics, which one of the following should be performed within the stated time intervals?

  1. Abdominal circumference every 12 months
  2. Blood glucose every 6 months
  3. Full blood count every 6 months
  4. Liver function every 6 months
  5. Prolactin measured every month for the first 3 months.

Question 12

Emily sustained some bruising during Ned’s deterioration. Two weeks later, she has ongoing sleeping difficulties. You consider psychological first aid.

Which one of the following is NOT a component of psychological first aid?

  1. Addressing basic needs such as providing emotional support
  2. Encouraging engagement with social supports
  3. Promoting adaptive coping such as problem-solving
  4. Recounting details of the traumatic event
  5. Reducing initial distress.

Case 4 : Clementine Morgan

Clementine, aged 16 years, presents with depressive symptoms, and asks about antidepressants.

Question 13

Which one of the following is CORRECT, regarding antidepressants in adolescents?

  1. Adolescents taking SSRIs are at small, but increased risk of suicidal ideation
  2. Serotonin syndrome is less severe, but more common, than in adults taking SSRIs
  3. Side effects of SSRIs in adolescents are similar to those in adults
  4. There is substantial research regarding side effects of SSRIs in adolescents
  5. Tricyclic antidepressants are effective in adolescent depression.

Question 14

Regarding physical side effects of SSRIs in adolescents, which one of the following is CORRECT?

  1. Psychiatric side effects of SSRIs are more common than physical side effects
  2. Research found self-reported physical symptoms declined over 3 months
  3. Sexual side effects in adolescents taking SSRIs are well documented
  4. SSRIs in adolescents is strongly associated with reduction in expected growth
  5. Studies found low rates of adolescents reporting physical side effects to SSRIs.

Question 15

Regarding psychiatric side effects of SSRIs in adolescents, which one of the following is CORRECT?

  1. Manic spectrum psychiatric side effects of antidepressants are common
  2. Manic switching involves a single switch from hypomania into mania
  3. Patients with psychotic depression do not have an increased risk of manic switching
  4. Rapid cycling involves three or more manic swings over a six month period
  5. The rate of antidepressant-related manic switching in adolescents is approximately 12–15%.

Question 16

Regarding cessation of SSRIs in adolescents, which one of the following is most CORRECT?

  1. Adolescents can be warned that withdrawal symptoms may include gait disturbance
  2. Serotonin discontinuation syndrome has not been described in adolescent populations
  3. Weaning of SSRIs in adolescents is recommended over weeks to months
  4. Withdrawal reactions upon cessation of SSRIs often last 10–14 days in adolescents
  5. Withdrawal symptoms may include autonomic instability for a period of 1–3 days.


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Clinical challenge