Free UKMLA mental health questions with explanations

E. Clozapine

Clozapine is the treatment of choice for treatment-resistant schizophrenia, defined as failure to respond to adequate trials of at least two antipsychotics, one being a non-clozapine second-generation agent. It is the only antipsychotic with proven superior efficacy in this group and requires registration with a monitoring service for FBC monitoring, weekly for the first 18 weeks and less frequently thereafter, because of agranulocytosis risk, with troponin and CRP surveillance for myocarditis during titration.

A. Flight of ideas

Flight of ideas is the thought-form abnormality of mania: thinking is accelerated, ideas follow one another rapidly and the patient jumps from topic to topic, but the links between successive ideas are still discernible and are often superficial, such as a shared word, a rhyme (clang association) or something in the environment. It is usually accompanied by pressure of speech, as here, and sleeplessness with elevated or irritable mood makes a manic episode the likely context. The distinction from loosening of associations (derailment), the thought disorder of schizophrenia, is that in derailment the connections between ideas are absent or incomprehensible, so speech becomes progressively harder to follow, whereas in flight of ideas the listener can usually retrace the path. Tangential speech drifts away from the point without returning, circumstantial speech reaches the point only after excessive detail, and perseveration is the inappropriate repetition of a previous response.

A. Delusions or hallucinations persisting during periods of normal mood

The defining feature of schizoaffective disorder is that psychotic symptoms are not confined to mood episodes: schizophrenic symptoms and a mood syndrome coexist in the same episode, and psychosis is also present when mood is normal. In depression with psychotic symptoms the delusions and hallucinations arise within the depressive episode and resolve as it lifts. Mood-incongruent content and the type of hallucination do not separate the two diagnoses, because both can occur in either condition.

D. Bipolar affective disorder

Postpartum psychosis affects roughly one to two in every thousand births overall, but around one in five women with bipolar disorder (one in two if a mother or sister has had it), and about half of those who have had a previous episode of postpartum psychosis; a family history of the condition also raises risk. It is a psychiatric emergency that usually begins in the first two weeks after birth, so a woman with bipolar disorder should be referred at booking to the specialist perinatal mental health team for a written pre-birth plan. Previous postnatal depression makes recurrent depression more likely but only modestly increases the risk of psychosis.

D. Increase the sertraline dose and continue for at least 12 weeks

SSRIs act more slowly in OCD than in depression and usually need doses at the upper end of the range, so an adequate trial is at least 12 weeks at the maximum tolerated dose. Four weeks at a starting dose is not a failed trial; the correct move is to titrate the dose upwards and persist. Switching to clomipramine, another SSRI, or adding an antipsychotic are all steps for OCD that has genuinely failed an adequate SSRI trial, and each carries more adverse effects than simply optimising the current drug. Stopping medication would remove a treatment that has not yet had a fair chance to work.

B. Low-intensity CBT including exposure and response prevention

This is obsessive-compulsive disorder with mild functional impairment: the rituals occupy around an hour a day and she is still attending lectures and socialising. For mild impairment the first step is a brief, low-intensity psychological treatment built around exposure and response prevention (ERP), delivered as guided self-help, brief individual CBT or group CBT. Medication is reserved for moderate or severe impairment, or for mild cases that do not respond to or decline psychological treatment. Applied relaxation is a treatment for generalised anxiety disorder rather than OCD, and psychodynamic therapy has no evidence base for obsessional symptoms.

C. Fluoxetine

Fluoxetine, licensed at 60 mg daily for bulimia nervosa, is the antidepressant with the strongest evidence for reducing binge-purge frequency, and the effect is independent of any action on mood. No drug is recommended for bulimia: bulimia-nervosa-focused guided self-help is offered first, then individual CBT-ED, and medication should not be offered as the sole treatment. Any drug is therefore an adjunct to psychological therapy rather than a replacement for it.

A. Respiratory alkalosis reducing ionised calcium

Hyperventilation blows off carbon dioxide and produces an acute respiratory alkalosis. As hydrogen ion concentration falls, albumin releases protons and binds more calcium, so the ionised fraction of calcium drops even though total calcium is unchanged. Low ionised calcium lowers the threshold for nerve depolarisation, producing perioral and digital paraesthesia and the carpopedal spasm seen here. The symptoms resolve as breathing slows and CO2 normalises; the treatment is calm, slowed breathing rather than any electrolyte replacement, and rebreathing into a bag is no longer advised because of the risk of hypoxia.

D. Naltrexone

Naltrexone, an opioid receptor antagonist, dampens the dopaminergic reward signal in the mesolimbic pathway that gambling activates, and randomised trials show it reduces gambling urges and behaviour. It is the medication with the best evidence and is considered as an adjunct when psychological treatment has not been enough; use is unlicensed, so this must be explained, liver function should be checked, and it must not be given to anyone using opioids because it precipitates withdrawal. Antidepressants and antipsychotics have not shown consistent benefit for gambling in the absence of a co-existing mood or psychotic disorder, and bupropion and lithium have been studied without evidence to recommend them.

A. Regular scheduled appointments with one named GP

Persistent physical symptoms without an identified disease are best managed through continuity: one clinician, regular booked reviews that are not driven by symptom escalation, a positive explanation of how the symptoms arise, and agreed limits on further investigation. Once a thorough work-up is normal, repeated referral and testing rarely find new disease, carry iatrogenic harm and reinforce the belief that something has been missed. Symptom-contingent access rewards escalation, whereas fixed appointments decouple contact from symptoms and reduce overall attendance. Reassurance without an explanation of the symptoms tends to be short-lived, and discharge removes the relationship that helps most.