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MP 2016 Companion Guide PDF
MP 2016 Companion Guide PDF
Psychiatry:
A core textbook for undergraduates
Melvyn WB Zhang
Cyrus SH Ho
Roger CM Ho
MCQ exam (Paper 1)
Questions Answers
History, mental state exam and
psychopathology
1. A 40-year-old man admitted to the The answer is B.
medical ward for upper gastrointestinal
tract bleeding is a known patient Explanation: He exhibits denial and denies the
dependent on alcohol. His amylase level reality that he is dependent on alcohol and
is high. During the interview, he leading to medical complication.
mentions that, ‘I don’t have a problem
with alcohol.’ What is the defence
mechanism? Year: 2013.
A. Acting out
B. Denial
C. Projection
D. Rationalization
E. Reaction formation.
A. Ambivalence
B. Affective flattening Year: 2013
C. Alexithymia
D. Alogia
E. Anhedonia.
Year: 2013
1
Cognitive assessment
5. Which of the following is NOT a The answer is B.
prominent cognitive feature of cortical
dementia such as Alzheimer’s disease?
Explanation: Anhedonia (loss of interest) and
A. Amnesia depression are more common in subcortical
B. Anhedonia dementia. The other 4 As: amnesia, apathy,
C. Apathy agnosia and apraxia are common in cortical
D. Agnosia dementia.
E. Apraxia.
Year: 2013
A. Classical conditioning
B. Operant conditioning Year: 2013.
C. Free association
D. Reaction formation This is an advanced- level question.
E. Transference.
2
a. Death of a friend in the accident
b. Duration of medical leave
c. His age and gender Year: 2013.
d. History of panic disorder
e. History of substance abuse.
Year: 2013.
11. The MOST important predisposing The answer is D.
factor for Attention Deficit and
Hyperactivity Disorder (ADHD) is:
Explanation: Foetal alcohol syndrome and
antenatal exposure to nicotine is the most
A. Adverse social economic status
B. Development of autism before the important predisposing factor for ADHD.
onset of ADHD. Option A is non-specific. Male gender, rather
C. Female gender than female gender is more common for
D. Prenatal exposure to alcohol and ADHD. Option E is an important predisposing
nicotine by mother. factor for conduct disorder.
E. Presence of antisocial personality
disorder in father.
Year: 2013.
12. A 40-year-old widow, said the following, The answer is D.
‘I can’t stop thinking about my husband.
The pain is unbearable. It’s been eight Explanation: She suffers from intense grief
months and it’s like it happened which persists for longer than 6 months
yesterday. I still can’t believe it. I can’t after the loss, traumatic distress, sense of
look at his picture, it’s too painful. I feel disbelief, anger and bitterness, distressing,
numb. And my friends don’t
intrusive thoughts related to the death,
understand. They still have their
husbands. And, I want to kill his doctor. avoidance of reminders of deceased and
It’s his fault my husband died. My life is separation distress.
completely empty. It’s just not fair’.
Based on her description, what is the
MOST correct diagnosis? Year: 2013.
A. Adjustment disorder
B. Antisocial personality disorder
3
C. Delusional disorder
D. Intense grief reaction
E. Schizophrenia.
Year: 2013.
14. Which of the following is the MOST The answer is B.
important component of maintenance
treatment for schizophrenia? Explanation: Without maintenance
pharmacological treatment, 60-70% of
A. Cognitive behaviour therapy schizophrenia patients relapse within 1 year,
B. Monitored compliance in antipsychotic and almost 90% relapse in 2 years.
treatment Maintenance on antipsychotic therapy is the
C. Occupational rehabilitation single most important factor in preventing
D. Psychosocial rehabilitation rehospitalisation.
E. Family therapy.
Year: 2013.
4
17. Which of the following change is Answer is E.
LEAST likely to occur in anorexia
nervosa, binge-purging type? Explanation: It should be hypophosphatemia
a. Hypoestrogenemia and hypocalcaemia. As binge-puruging type is
b. Hypomagnesemia
associated with recurrent vomiting, it will lead
c. Hypokalaemia
d. Hyperamylasemia to hypokalaemia and inflammation in salivary
e. Hyperphosphatemia. gland, i.e. hyperamylasemia. Anorexia nervosa
in general is associated with hypoestrogenemia
and hypomagnesemia.
Year: 2013
5
21. Which of the following statements is The answer is E.
TRUE about a 76-year-old woman
suffering from an acute confusional state Explanation: In elderly, the mortality of
after a total hip replacement? delirium and acute confusional state is
between 6 to 18%. Generalized slowing is the
A. Anticholinergic drug is the treatment of most common finding on EEG. Her age is a risk
choice. factor.
B. Her age and gender are not a risk factor.
C. She should be allowed to leave the ward
against doctor advice should she wish to. Year: 2013
D. Fast, spike waves are often seen on the
EEG.
E. There is a mortality of up to 15%.
6
C. Prescribe small doses of
several different antipsychotics
rather than using one
antipsychotic.
D. Use a long-acting injectable
antipsychotic to aid adherence.
E. Use a rapid loading dose of
antipsychotic to speed up the
response.
Child and adolescent psychiatry
25. Which of the following is the MOST The answer is B.
COMMON disorder for children and
adolescents to be referred to see a child Explanation: Children with externalizing
and adolescent psychiatrist? disorders (e.g. conduct disorder) are more
likely to be referred and treated. 10% of
A. Child-onset schizophrenia children and adolescents seeing a psychiatrist
B. Conduct disorder have conduct problem. Separation anxiety
C. Down syndrome disorder and Down Syndrome may not need to
D. Separation anxiety disorder see a psychiatrist. 0.1% have psychotic disorder
E. Somatization disorder. and 1% have somatization disorder.
Year: 2013
26. An 8-year-old boy presents with The answer is A.
stereotypies, pronoun reversal, word
substitution, social problems, and Explanation: Repetitive movement,
echolalia, the most likely diagnosis is:
communication problem and social problems
indicate this boy suffers from autism.
A. Autism
B. Attention deficit and hyperactivity
disorder
Year: 2013.
C. Conduct disorder
D. Rett’s syndrome
E. Separation anxiety disorder.
7
D. Oppositional defiant disorder
E. Gender identity disorder of
childhood. Year: 2013.
Substance abuse
29. Based on clinical severity, men from The answer is C.
which of the following ethnicities are
MOST vulnerable to alcohol
Explanation: Indian men seem to be most
dependence in Singapore?
vulnerable to alcohol dependence in
A. Chinese Singapore. Malay men have the lowest risk.
B. Eurasian
C. Indian
D. Malay Year: 2013.
E. Other ethnic groups.
8
33. A 30-year-old man drinks alcohol and The answer is A.
develops flushing and tachycardia. He
took disulfiram 2 hours ago.
Explanation: The mechanism of actions of
Accumulation of which of the following
is accountable for the above disulfiram is to inhibit aldehyde dehydrogenase
phenomenon? and lead to acetaldehyde accumulation.
A. Acetaldehyde
B. Acetylcholine Year: 2013
C. Adrenaline
D. Alanine
E. Aspartic acid. This is an advanced-level question.
Psychopharmacology
34. Which of the following tricyclic The answer is B.
antidepressants is MOST effective in
the treatment of obsessive compulsive
Explanation: Among all TCAs, clomipramine is
disorder?
most potent is blocking 5HT reuptake.
A. Amitriptyline
B. Clomipramine
C. Desipramine Year: 2013
D. Doxepin
E. Imipramine.
9
D. Improving cognitive function Gastrointestinal side effects e.g. nausea,
significantly from baseline. vomiting and diarrhoea are the most
E. Stabilizing cognition, activities of daily common adverse effects.
living, and behavioural function.
Year: 2013.
38. Which of the following is FALSE The answer is D.
regarding the first generation
antipsychotics (FGAs)? Explanation: The second generation
antipsychotics have higher risk for metabolic
A. FGAs have high D2 receptor blocking syndrome as compared to the FGAs.
effects.
B. FGAs have increased risk of
extrapyramidal side effects as Year: 2013.
compared with the second generation
antipsychotics.
C. FGAs have increased risk of tardive
dyskinesia as compared with the
second generation antipsychotics.
D. FGAs have increased risk of causing
metabolic syndrome as compared with
the second generation antipsychotics.
E. FGAs have proven efficacy as
pharmacological treatment for
schizophrenia.
10
years in the past. Currently, she exhibits by lip smacking, chewing and fly catching
a non-rhythmical hyperkinetic movement tongue protrusion after long-term treatment of
disorder of the lips, jaw and tongue. The antipsychotics.
movement disorder MOST likely
consistent with this finding is:
Year: 2013.
A. Acute dystonia
B. Akathisia
C. Aphasia
D. Pseudoparkinsonism
E. Tardive dyskinesia.
A. Amitriptyline
B. Clonazepam
C. Paroxetine
D. Propranolol
E. Quetiapine.
Psychotherapy
43. A 66-year-old man who worked as an The answer is D.
executive accountant previously. He has
retired recently and presents with a Explanation: IPT and CBT are the evidence-
major depressive disorder. What is the based psychotherapy indicated for major
best choice of psychotherapy? depressive disorder. IPT can help him to work
on role transition, grief and loss.
A. Biofeedback
B. Eye movement desensitization and
reprocessing Year: 2013
C. Hypnosis
D. Interpersonal psychotherapy
E. Systemic desensitization.
11
are exposed to the feared stimuli and
A. Exposure and response prevention obsessions while rituals that typically serve to
B. Hypnotherapy reduce anxiety are prevented.
C. Interpersonal psychotherapy
D. Psychoanalysis
E. Supportive psychotherapy.
Year: 2013
45. Effective psychotherapy techniques The answer is D.
for Borderline Personality Disorder
include all of the following features Explanation: Distant therapist may have
EXCEPT: difficulty to establish trust and therapeutic
A. A treatment contract should be alliance with patient suffering from
established in the beginning borderline personality disorder.
phase of psychotherapy.
B. Adverse effects of self-
laceration are identified. Year: 2013.
C. Focus of treatment is to
establish connection between
actions and feelings.
D. Therapist is quiet, distant and
does not get too involved.
E. Therapist pays careful attention
to his or her own feelings in
order to manage
countertransference.
12
D. Financial difficulty
E. Hopelessness.
13
MCQ exam (Paper 2): Answer Key
Year: 2013.
2. A 30-year-old man firmly believes that the alien The answer is B.
has put an implant in his body and he feels there
is a pushing sensation on his aorta. Which types of Explanation: Cenesthetic
hallucinations BEST suited his description? hallucinations are unfounded
sensations of altered states in bodily
A. Auditory organs. Examples of cenesthetic
B. Cenesthetic hallucinations are a burning sensation
C. Gustatory in the brain, a pushing sensation in
D. Kinesthetic the blood vessels, and a cutting
E. Visual. sensation in the bone marrow. Bodily
distortion may also occur.
Year: 2013.
Year: 2013
Cognitive assessment
5. Which of the following statement is FALSE The answer is E.
about Mini-mental state examination (MMSE)?
Explanation: MMSE is a screening test
A. A total score of 5 indicates severe dementia.
B. Assessment of orientation to time and place is part and there is no gold standard to
of the MMSE. establish the diagnosis of dementia in
C. The MMSE can be administered in Chinese or clinical practice. Clinical assessment
English. by a psychiatrist or geriatrician is
D. The MMSE can be used to monitor treatment more important than MMSE in
progress after initiation of acetylcholinesterase
establishing diagnosis of dementia.
inhibitors (AChEIs).
E. The MMSE is the gold standard in establishing the
diagnosis of dementia.
Year: 2013
Psychiatric epidemiology
6. Which of the following settings have the HIGHEST The answer is D.
prevalence of delirium?
Explanation: General surgical patients:
A. Accident and emergency department 10-15%; Cardiac surgery patients:
B. Cardiac surgery ward 30%; Hip fractures: 50%; Age >65
C. General surgery ward admitted to ICU: 70%; Palliative
D. Hospice with palliative advanced cancer patients advanced cancer patients: 88%.
E. Nursing home looking after dementia patients.
Year: 2013.
7. The worldwide point prevalence of The answer is A.
schizophrenia is BEST estimated as:
Explanation: The worldwide point
A. 1% prevalence is 1% and Singapore is
B. 2.5% 0.6%.
C. 5%
D. 7.5%
E. 10%. Year: 2013
Psychiatric aetiology, diagnosis and classification
8. Advanced paternal age is a well- established The answer is E.
risk factor for which of the following psychiatry
illnesses?
Explanation: Advanced paternal age is
A. Alcoholism a risk factor for schizophrenia.
B. Major depressive disorder
C. Obsessive compulsive disorder
D. Generalized anxiety disorder Year: 2013.
E. Schizophrenia.
Year: 2013.
10. Individuals with which one of the following genes The answer is B.
have the HIGHEST risk of developing Alzheimer’s
disease? Explanation: Homozygous APO E4/E4
increases the risk of developing
A. Homozygous apolipoproteins (APO) E2/E2 Alzhimer’s disease by 8 times.
B. Homozygous APO E4/E4
C. Homozygous APO E6/E6
D. Heterozygous APO E2/E4
E. Heterozygous APO E2/E6. Year: 2013.
A. Cyclothymic disorder
B. Emotionally unstable personality disorder Year: 2013
C. Mixed affective disorder
D. Rapid cycling bipolar disorder
E. Schizoaffective disorder.
Year: 2013.
Year: 2013.
19. A 65-year-old man presents with memory The answer is C.
loss, which of the following is the LEAST important
indication for a computerized tomography (CT) Explanation: The other factors
scan for his brain: suggest an organic cause.
21. The MOST COMMON reason for children with The answer is A.
autism are brought to medical attention by their
parents is: Explanation: Language delay is the
most obvious sign and most disturbing
A. Language delays to parents when they discover their
B. Lack of toilet control children are lacking behind in
C. Odd play language development compared to
D. School difficulties other children.
E. Stereotyped behaviour.
Year: 2013.
22. Which of the following statements is FALSE The answer is B.
regarding separation anxiety disorder?
Explanation: Separation anxiety disorder
A. It involves recurrent distress when separate from
is more common in children and it can
attachment figures.
occur in adolescents.
B. Separation anxiety disorder does not occur in
adolescents.
C. Separation anxiety disorder is associated with school
refusal. Year: 2013.
D. The child has difficulty falling asleep at night.
E. The child may complain of somatic symptoms.
Year: 2013
24. A baby is born with low birth weight, microcephaly, The answer is A.
small eyes, upturned nose and a smooth, undeveloped
philtrum. He fails to thrive and develops seizures. Explanation: This is a classical
Which of the following was he MOST likely exposed
to during pregnancy? description of the facial features of
foetal alcohol syndrome
A. Alcohol
B. Cocaine
C. LSD Year: 2013.
D. Methamphetamine
E. Inhalants.
Substance abuse
25. The term which BEST describes an altered The answer is B.
physiological state and neuro- adaptation caused
by repeated administration of a drug is: Explanation: The term dependence
indicates physiological changes.
A. Addiction Misuse refers to use of any drug,
B. Dependence usually by self-administration, in a
C. Misuse manner that deviates from approved
D. Withdrawal social or medical patterns. Addiction is
E. Tolerance. non-specific and ignores the concept
of substance dependence is a medical
condition.
Year: 2013.
26. While driving, a 40-year-old man with no previous The answer is A.
history refused to stop for the traffic police. He
was subsequently brought into the accident and Explanation: Auditory hallucinosis is
emergency department (AED) by them. You are usually composed of auditory
the resident working in the AED. When you assess hallucination. Sensorium is clear and it
him, he states that he was hearing voices in clear is different from delirium tremens.
consciousness. He admits to a history of alcohol There are not enough symptoms to
use. What is the most appropriate diagnosis? conclude that he suffers from
schizophrenia.
A. Alcoholic hallucinosis
B. Delirium tremens Year: 2013.
C. Korsakoff psychosis
D. Schizophrenia
E. Wernicke’s encephalopathy.
Year: 2013.
Psychopharmacology
30. Monoamine oxidase inhibitor (MAOI) is LEAST The answer is B.
useful in treating which of the following
disorders?
Explanation: MAOI is least useful to
A. Atypical depression treat OCD.
B. Obsessive compulsive disorder
C. Panic disorder
D. Severe depressive disorder not responding to Year: 2013.
selective serotonin reuptake inhibitor
E. Severe depressive disorder with hyponatraemia This is an advanced-level question.
31. Which of the following antidepressants is LEAST The answer is A.
likely to contribute to the development of
serotonin syndrome? Explanation: Bupoprion works on
dopamine and norepinephrine. As a
A. Bupropion result, it is least likely to cause
B. Fluoxetine serotonin syndrome.
C. Moclobemide
D. Paroxetine
E. Venlafaxine. Year: 2013.
Year: 2013.
33. Regarding lamotrigine, which of the following The answer is C.
statements is FALSE?
A. It acts at voltage-sensitive sodium channels. Explanation: Double-blind, placebo-
B. It inhibits the release of excitatory amino acid controlled trials have shown that it
neurotransmitters. has acute and prophylactic anti-
C. It is not effective in the treatment of bipolar depressant effects. It can lead to
depression. severe dermatological condition such
D. Its use can lead to toxic epidermal necrolysis. as Steven Johnson syndrome/ toxic
E. There is no need to monitor lamotrigine blood epidermal necrolysis. In Singapore,
levels during treatment. there is no blood test to check its
level.
Year: 2013
Year: 2013.
36. Which of the following psychotropic The answer is D.
medications is MOST EFFECTIVE in preventing
relapse in rapid cycling bipolar disorder?
Explanation: Lithium is less effective in
A. Haloperidol preventing relapse in rapid cycling
B. Lithium bipolar disorder. Valproate and
C. Olanzapine carbamazepine are preferred over
D. Valproate lithium.
E. Risperidone.
2013
Psychotherapy
37. In conducting psychotherapy with individuals who The answer is A.
have experienced a traumatic event and suffer
from post-traumatic stress disorder (PTSD), the Explanation: A is the answer. Affect or
following are all recommended techniques emotion should not be avoided in
EXCEPT: psychotherapy.
A. Benzodiazepine
B. Cognitive behaviour therapy Year: 2013.
C. Serotonin-noradrenaline reuptake inhibitor
D. Olanzapine
E. Psychodynamic psychotherapy.
Year: 2013.
40. A 23-year-old student is seen in the University The answer is D.
counselling centre because of relationship
problems. She has had one serious relationship Explanation: This patient
with her boyfriend that lasted about six months. demonstrates overgenearlization
She terminated the relationship because she because she believes in and follows a
discovered that her boyfriend was seeing general rule on the basis of limited
someone else. During psychotherapy, she examples.
mentions that ‘All men just can’t be trusted.’
Which of the following BEST describes this
thinking error? Year: 2013.
A. Arbitrary inference
B. Dichotomous thinking
C. Magnification
D. Overgeneralization
E. Selective abstraction.
Year: 2013
44. You are the resident working for the liver The answer is B.
transplant team. The MOST common psychiatric
disorder in patients with liver cancer in the week Explanation: Delirium is the most
before and after transplantation is: common disorder and it can be
caused by systemic infection, side
A. Adjustment disorder effect of immunosuppressant,
B. Delirium impairment of liver function, hepatic
C. Generalized anxiety disorder encephalopathy.
D. Major depressive disorder
E. Somatoform pain disorder.
Year: 2013.
45. You are the resident working in the obstetrics The answer is B.
department. Which of the following is the BEST
treatment strategies to treat hyperemesis during Explanation: Benzodiazepine may
pregnancy? cause cleft palate in the first
trimester. Psychoanalysis is not for
A. Benzodiazepines e.g. alprazolam symptomatic relief. SSRI like
B. Relaxation therapy fluvoxamine is associated with nausea
C. Psychoanalysis side effect. Hyperemesis is not
D. Selective serotonin reuptake inhibitor e.g. associated with stimulus. Relaxation
fluvoxamine therapy is the best treatment.
E. Stimulus deprivation.
Year: 2013.
MCQ exam (Paper 3)
A. Apathy
B. Blunted affect Year: 2013.
C. Euthymic affect
D. Labile affect
E. Flat affect.
Cognitive assessment
2. Which of the following is the presentation The answer is B.
of cortical dementia?
Explanation: Option B refers to frontal lobe
A. A 40-year-old man presents with memory loss
dementia which is cortical dementia.
and writhing movements. His father suffered
from the same condition.
Option A, C, D and E are considered to be
B. A 50-year-old man presents with change in
subcortical dementia.
personality, poor judgment, disinhibition and
perservation. He made a lot of mistakes in
Option A = Hungtington’s disease
Luria’s hand test.
Option C = Vascular dementia
C. A 60-year-old woman presents with memory
loss and depression after a cerebrovascular Option D = Parkinson’s disease
accident. Option E = Lewy body dementia
D. A 70-year-old man presents with memory loss,
rigidity, slowness of movement and difficulty
with walking and gait. Year: 2013.
E. A 75-year-old woman presents with visual
hallucination. The GP gave her haloperidol This is an advanced-level question.
and she develops severe extrapyramidal side
effects.
Psychiatric epidemiology
3. After the age of 65, the prevalence of The answer is A.
dementia increases by how many times
every 5 years?
A. 2 times
B. 4 times Year: 2013
C. 6 times
D. 8 times
E. 10 times.
Psychiatric aetiology, diagnosis and classification
4. An 18-year-old woman presents with The answer is E
questions about her risk of developing
schizophrenia. She is worried because her
Explanation: The risk of general population is
23-year-old brother has recently been
diagnosed with schizophrenia and required 1%. The risk of a sibling is 10%. Hence, the risk is
hospitalization for psychosis. There are no increased by 10 times.
other family members who have a history
of schizophrenia. Having a sibling with
schizophrenia increases her risk of
Year: 2013.
developing schizophrenia by?
A. 2 times
B. 4 times
C. 6 times
D. 8 times
E. 10 times.
Psychopathology
7. Agoraphobia without panic disorder can be Answer is A.
described as:
Explanation: A fear of enclosed space is one of
A. A fear of enclosed spaces the most common complaints among patients
B. A fear of speaking in public in Singapore (e.g. crowded MRT trains). Option
C. A fear of height B is social phobia.
D. Avoidance of authority figures
E. Worrying excessively about physical health.
Year: 2013.
Year: 2013
Year: 2013.
14. Which of the following is a poor prognostic The answer is E.
factor for schizophrenia? Explanation: Option E suggests that the aetiology of schizophrenia
is biological and resulted from a neurological lesion. Hence, the
A. Family history of mood disorder prognosis poor. Good prognostic and poor prognostic factors are
summarized as follows:
B. Female gender
C. Late onset Good Prognosis Poor Prognosis
Late onset Young onset
D. Precipitating factor Obvious precipitating factors No precipitating factors
E. Presence of neurological soft sign. Acute onset Insidious onset
Good premorbid function Poor premorbid function
Married Single, divorced, or widowed
Family history of mood disorders Family history of schizophrenia
Good support systems Poor support systems
Positive symptoms Negative symptoms
Year: 2013.
Year: 2013
Year: 2013
20. Late-onset psychotic disorder such as The answer is B.
schizophrenia or delusional disorder is
associated with:
Explanation: Late-onset psychotic disorder is
A. Less paranoia more likely to be associated with sensory
B. More likely to have sensory deficits deficit.
C. More loosening of associations
D. More thought disorders
E. More violent behaviour. Year: 2013.
21. Which of the following statements about The answer is D.
sleep disorders in old people is FALSE?
Explanation: Diazepam is long-acting and cause
A. Excessing napping is a common cause of
insomnia. oversedation or hang-over effect. This will
B. Insomnia is common in old people in increase fall risk among the elderly.
Singapore.
C. Insomnia is associated with increased irks of
depression. Year: 2013
D. If there is a need for benzodiazepine,
diazepam is the preferred sedative for old
people.
E. The first line treatment is sleep hygiene.
a. Alcohol
b. Cannabis
c. Cocaine
d. Mescaline
e. Heroin.
29. A 24-year-old man presents to the The answer is B.
Accident and Emergency Department
with fever, hypotension, agitation, Explanation: Disulfiram blocks this reaction at
tachycardia and odour of alcohol on the acetaldehyde dehydrogenase. After alcohol
his breath. His friend with him stated intake under the influence of disulfiram, the
that he was prescribed a medication by concentration of acetaldehyde in the blood may
a psychiatrist 4 weeks ago. The most be five to 10 times higher than that found
likely medication responsible is:
during metabolism of the same amount of
A. Diazepam alcohol alone. As acetaldehyde is one of the
B. Disulfiram major causes of the symptoms experienced by
C. Fluoxetine this man.
D. Haloperidol
E. Moclobemide.
Year: 2013.
30. A 40-year-old heroin addict reports The answer is C.
continued carving. He is on
methadone100mg daily. His methadone
Explanation: Methodone is associated with
dose is increased to 110mg daily. After one
week, he has a syncope and is taken to the prolonged QTc. This occurs after an increase in
Accident and Emergency Department. The the dose of methadone. This may lead to
most likely finding to explain his syncope cardiac arrhythmia and results in syncope.
is:
A. Electroencephalogram (EEG) shows evidence
of seizure activity. Year: 2013
B. Liver function tests reveal marked
transaminitis.
This is an advanced level question.
C. Prolonged QTc interval
D. Ultrasound Doppler shows deep vein
thrombosis.
E. Urine toxicology screen is positive for opioid.
A. Bupropion
B. Naltrexone Year: 2013.
C. Nicotine replacement treatment
D. Sertraline
E. Varenicline.
Psychopharmacology
32. The WEAKEST evidence for efficacy for The answer is B.
Post-traumatic Stress Disorder (PTSD) is
for which class of pharmacological
Explanation: Diazepam, a long term
agents?
a. Amitriptyline benzodiazepine may cause dependence and
b. Diazepam does not help to relieve anxiety symptoms in
c. Fluoxetine long run as it may cause withdrawal.
d. Fluvoxamine
e. Paroxetine.
Year: 2013.
Year: 2013
34. The MOST common side effect of selective The answer is C.
serotonin reuptake inhibitor (SSRI) is:
Explanation: GI disturbances such as nausea
A. Acne
B. Erectile dysfunction and vomiting are the most common side
C. Gastrointestinal disturbances effects.
D. Metabolic syndrome
E. Tinnitus.
Year: 2013.
35. Which of the following antipsychotic drugs The answer is A.
is MOST LIKELY to be associated with
adverse haematological side effects?
Explanation: Clozapine is the second generation
A. Clozapine antipsychotics which is most likely to be
B. Olanzapine associated with agranulocytosis.
C. Quetiapine
D. Risperidone
E. Ziprasidone. Year: 2013
36. Which of the following is the LEAST common The answer is E.
side effects of acetylcholinesterase
inhibitors? Explanation: The AChEI causes bradycardia as a
result of increased vagal tone.
A. Dizziness
B. Nausea
C. Nightmares Year: 2013.
D. Seizures
E. Tachycardia. This is an advanced-level question
Year: 2013
This is an advanced-level question.
Psychotherapy
39. At the one year follow-up of panic disorder, The answer is D.
which of the following treatments results
with the BEST outcome and the LEAST Explanation: CBT has better outcome than brief
functional impairment? dynamic psychotherapy and supportive
psychotherapy. Benzodiazepines and beta-
A. Benzodiazepines blockers only provide symptomatic relief.
B. Beta-blockers
C. Brief dynamic psychotherapy
D. Cognitive behaviour therapy Year: 2013.
E. Supportive psychotherapy.
Cognitive assessment
2. Which of the following cognitive tasks is NOT The answer is B.
an assessment of short term or long term
memory? Explanation: Option B refers to
verbal fluency which is part of the
A. Ask the patient to name the current Prime frontal lobe assessment. Option D
Minister of Singapore. refers to registration and it is an
B. Ask the patient to name as many animals as important component before
possible that can be found in the Singapore assessing the short-term recall
Zoo. (Option E). To be fair to the
C. Ask the patient to tell you his or her address patient, the patient should be given
and later, you check the answer with patient’s multiple attempts to register the 3
medical record. items before testing short-term
D. Inform the patient 3 objects (e.g. Apple, recall in Option E.
Newspaper and Train) and ask the patient to
name the 3 objects immediately. Year: 2013.
E. Inform the patient 3 objects (e.g. Apple,
Newspaper and Train) and ask the patient to
name the 3 objects after 5 minutes.
A. For severe depressive episode with psychotic There is not enough evidence to
features, psychotic symptoms usually occur suggest the diagnosis of
after manifestation of depressive symptoms. schizoaffective disorder because
B. Her psychotic symptoms are considered to be her symptoms do not suggest that
mood congruent. she suffers from schizophrenia.
C. Based on the case scenario, there is enough
evidence to suggest that she suffers from Year: 2013.
schizoaffective disorder.
D. The prescription of antipsychotic drug should
be considered.
E. Electroconvulsive therapy (ECT) is a
recognised treatment for his condition.
Year: 2013.
Psychopathology
8. Agoraphobia without panic attack is BEST The answer is D.
referred to:
Explanation: Patients suffering
A. Concern about physical appearance from agoraphobia has fear that
B. Constant worried about physical health they cannot escape from the
C. Fear of blood and needle enclosed space.
D. Fear of collapse in an enclosed space
E. Fear of authority figures. Year: 2013.
Year: 2013.
General adult psychiatry
10. Peter is 27-year-old and lives with his parents. The answer is A.
He has been employed as a delivery man for
most of the time since leaving school, but has Explanation: Peter develops
recently left his job as a salesman. He has grandiose delusion because he
never taken any illicit drugs. His parents state does not have the capacity to
that in the last three weeks, he has been make a machine to cure cancer
extremely active, requiring less sleep and not based on his background. The
appearing tired, being over-talkative and most appropriate diagnosis is
disinhibited and – on occasions – quite bipolar disorder with manic
irritable. He claimed to have invented a features.
machine for curing cancer and wished to go to
the U.S. to sell it. When stopped by his Year: 2013.
parents, he became violent, and they called
the police. Which of the following diagnosis is
MOST appropriate for this patient?
Year: 2013.
20. A 70-year-old woman with severe depressive The answer is B.
symptoms and strong suicidal ideation which
is not responded to amitriptyline 150mg daily Explanation: This elderly woman
and fluvoxamine 200mg daily. Each suffers from treatment resistant
medication was tried for 6 months with good depression and electroconvulsive
adherence. She has good past health. Her therapy is the treatment of choice
children consult you for further management. to treat suicidal ideation.
The MOST appropriate treatment which you
would recommend is: Old age is not a contraindication
for electroconvulsive therapy.
A. Cognitive behaviour therapy
B. Electroconvulsive therapy Year: 2013.
C. Donepezil
D. Olanzapine
E. Repetitive transcranial magnetic stimulation.
A. Abstract thinking
B. Block design
C. Explain similarities
D. Oral presentation skills
E. Verbal concept formation
Substance abuse
25. Which of the following neuroanatomical The answer is C.
structures is MOST implicated in substance
misuse and dependence? Explanation: Substance abuse and
dependence produce additive
A. Amygdala effects on dopamine release in the
B. Basal nucleus of Meynert nucleus accumbens.
C. Nucleus accumbens
D. Hippocampus Year: 2013
E. Raphe nucleus.
Psychopharmacology
29. Which of the following antidepressants is The answer is C.
LEAST likely to have sexual side-effects?
Explanation: Mirtazapine and
A. Amitriptyline bupoprion have relatively low risk
B. Moclobemide of causing sexual side effects as
C. Mirtazapine compared to other
D. Fluoxetine antidepressants.
E. Venlafaxine.
Year: 2013
30. The benzodiazepine with the LONGEST half- The answer is B.
life is:
A. Clonazepam Explanation: Diazepam has the
B. Diazepam longest half life which lasts for
C. Flurazepam more than one day.
D. Lorazepam
E. Triazolam. Year: 2013
Year: 2013.
This is an advanced-level
question.
35. Which of the following drugs is LEAST likely The answer is D.
to increase lithium toxicity?
A. Angiotensin-converting enzyme (ACE) inhibitors Co-administration of valproate and
B. Calcium channel blockers lithium have no effect on the steady-
C. Non-steroidal anti-inflammatory drugs (NSAIDS) state kinetics of lithium.
D. Sodium valproate
E. Thiazide diuretics. Year: 2013
A. Continue fluoxetine 40mg every morning for It is dangerous to reduce the dose
five years. or stop antidepressant soon.
B. Continue fluoxetine 40 mg for six months and
then stop. Year: 2013
C. Provide intermittent maintenance
electroconvulsive therapy.
D. Stop fluoxetine and restart it at the first sign of
relapse.
E. Stop fluoxetine and start cognitive behaviour
therapy.
Psychotherapy
38. Which of the following treatment strategies The answer is B.
has the MOST evidence for treating obsessive
compulsive disorder? Explanation: Exposure and
A. Fluoxetine and brief dynamic response prevention is part of the
psychotherapy cognitive behaviour therapy and
B. Fluoxetine and exposure and response has the most evidence for treating
prevention obsessive compulsive disorder.
C. Fluoxetine and eye movement
desensitization and reprocessing Year: 2013
D. Fluoxetine and hypnotherapy
E. Fluoxetine and interpersonal
psychotherapy.
A. Catastrophic thinking
B. Magnification
C. Minimization
D. Personalization
E. Selective abstraction.
This is an advanced-level
question.
MCQ
Year:2014
3. A psychiatric patient suddenly realises that he is The answer is B.
an interpreter for deaf people and tries to
interpret others’ speech in sign language. He
Explanation: Mannerism is a goal –
demonstrates strange repetitive movements.
His signs appear to come in threes or fours, directed repetitive movement (e.g. a
occasionally swinging his shoulders, as if he is speaker tries to move his hands
conveying a message. Which of the following is repetitively to convey his messages).
the BEST term to describe his movements?
This man’s movements seemed to be
A. Ambitendency goal directed because he attempted
B. Mannerism to show sign language but not
C. Negativism understandable to deaf people.
D. Stereotypies
E. Waxy flexibility.
Year 2014
Cognitive assessment
4. A 33-year-old man with childhood developmental Answer: C
delay and epilepsy received special education
and now works as a cleaner. He has worked in a
Explanation: This case is more severe
tofu factory for three years. He can only perform
simple routine work in the factory. His than mild retardation which
supervisor reports his work performance is slow demonstrates more competency in
and poor. His family says he cannot live self-care and independence.
independently and demonstrated delay in People with severe or profound
achievement in self-care since young. How mental retardation are not able to
would you rate the level of mental retardation?
work in the factory.
A. Very mild mental retardation
B. Mild mental retardation
C. Moderate mental retardation Year 2014
D. Severe mental retardation
E. Profound mental retardation.
Psychiatric epidemiology
5. A 65-year-old retired teacher is concerned about The answer is D.
dementia and has assessed online resources for
information. She asks which type of dementia is
Explanation: Vascular dementia (VaD)
more common in Asians as compared to
Caucasians. Your answer is: is found to be more common than
Alzheimer’s disease (AD) in some
A. Alzheimer’s disease Asian countries. In a study conducted
B. Lewy body dementia by National Neuroscience Institute
C. Pseudodementia (Singapore), 53% suffered from VaD
D. Vascular dementia
versus 47% from AD. The ethnic
E. Fronto-temporal lobe dementia.
variation is due to genetic variation,
differences in vascular risk factors and
lifestyles.
Year: 2014
Psychiatric aetiology, diagnosis and classification
6. A 20-year-old national serviceman was The answer is B.
diagnosed to suffer from adjustment
disorder with depressed mood. He read the Explanation:
internet and found another disorder known Option A is correct and relevant for
as dysthymic disorder. He wants to know this case.
the differences between these two Option B is incorrect because
disorders. The following statements about dysthymic disorder is more likely
differences between adjustment disorder with to show a genetic pattern.
depressed mood and dysthymia are true Option C is true because
EXCEPT: adjustment disorder begins within
three months of a stressor, and
A. Adjustment disorder with depressed mood ends within six months of the
results from a known stressor, whereas stressor ending. Dysthymic
dysthymic disorder does not. disorder has a duration of two
B. Adjustment disorder with depressed mood years in adults and one year in
shows a genetic pattern, whereas children.
dysthymic disorder does not. Option D is correct
C. The duration of symptoms is shorter for Option E is correct.
adjustment disorder with depressed mood
than it is for dysthymic disorder. Year: 2014
D. The co-existence of a major depressive
disorder with dysthymic disorder is called
double depression. There is no term for a
major depressive disorder complicating
adjustment disorder with depressed mood.
E. Treatment is usually shorter and does not
require the use of medication for adjustment
disorder with depressed mood as compared
to dysthymic disorder.
7. You are a family doctor. A male and a female The correct answer is D.
schizophrenia patient who stay in the
community have decided to get married and Prevalence of Schizophrenia in
have a child. What is the risk for their child to Specific Populations
develop schizophrenia in the future?
Population Prevalence
A. 16% (%)
B. 26% General Population 1
C. 36% Non-twin sibling of a 9
D. 46% schizophrenic patient
E. 56%. Child with one 13
schizophrenic parent
Dizygotic twin of a 14
schizophrenic patient
Child of two 46
schizophrenic parents
Monozygotic twin of a 46
schizophrenic patient
Year: 2014
8. You are an oncology resident. A 60-year-old oncology The answer is B.
patient developed severe nausea as a side-effect during Explanation: This phenomenon is
chemotherapy. However, after completing treatment known as classical conditioning.
she continues to experience nausea whenever she Chemotherapy is an unconditional
returns to the hospital for follow-up. Which of the
stimulus (UCS) and the hospital
following psychological theories BEST describes her
experience?
building is conditional stimulus (CS).
The conditional (CR) and
A. Biofeedback unconditional response (UCR) include
B. Classical conditioning nausea. The pairing of CS and UCR will
C. Cognitive learning persist even UCS (i.e. chemotherapy)
D. Operant conditioning disappears.
E. Social learning.
Year: 2014
General adult psychiatry
9. A 25-year-old woman experiences episodes of The answer is C.
depersonalization, hyperventilation, dizziness,
and diaphoresis lasting for 15 minutes whenever
Explanation: the history and
she arrives at work. She has been overwhelmed
by work and conflicts with her supervisor for the symptoms suggest the diagnosis of
past 3 months. There are no such episodes at panic disorder because the anxiety
home or outside the office. What is the MOST symptoms are episodic with a clear
likely diagnosis? trigger.
Year: 2014.
12. You are a resident working in the Accident and The answer is E.
Emergency Department. A 39-year-old English man was
married to a Chinese Singaporean is brought to the Explanation: Hanging is considered to
Emergency Department after he attempted to hang be a dangerous suicide method and
himself. He is actively suicidal and has marital
this patient has high suicide risk. As
problems. He has not spoken to his wife for three days.
The hospital does not have a psychiatric ward nor a
he is not forthcoming and does not
stay-in psychiatric team. What is the MOST appropriate suffer from any medical or surgical
management plan? complication, sending him to IMH for
A. Admit Peter to the medical ward of your hospital. assessment under the Mental Health
B. Discharge Peter from Emergency Department with Act is the safest option.
follow-up in the polyclinic to reduce the stigma.
C. Discharge Peter from Emergency Department with Year: 2014
an early follow-up in the psychiatric department.
D. Refer the couple for marital counselling by on-call
medical social worker.
E. Transfer Peter to IMH for assessment and consider
admission under Mental Health (Care and
Treatment) Act.
13. A 40-year-old single man consulting you in a The answer is E.
general practice clinic reveals that since
adolescence he enjoys observing naked people
Explanation: Voyeurism refers to the
and those involved in sexual activities as it
helps him achieve sexual arousal. The presence of recurrent and intense
psychiatric condition associated with this sexual arousal from observing an
behaviour is: unsuspecting person who is naked, in
the process of disrobing or engaging
A. Exhibitionism in sexual activity over a total duration
B. Fetishism of 6 months.
C. Sadomasochism
D. Transvestism
E. Voyeurism. Year: 2014
14. A 65-year-old retired man consulting you in a The answer is E.
general practice clinic reveals that he has
marital problems. His wife complains that he is
Explanation: He exhibits narcissistic
very fuzzy about cooking. He does not eat
outside nowadays. If he goes to a high class personality trait. He demonstrates of
restaurant, he expects that the steak must be sense of entitlement and holds belief
properly done and he is entitled to change the that he is better than the others (e.g.
steak if it is poorly done. Now he finds most chef from all steak restaurants). He
steak restaurants in Singapore are not up to his preoccupies with unlimited success.
standard. He claims it is better to cook by
himself. If the food is not up to his standard, he
has no one to blame. He likes to go to high- Year: 2014
class club in town. He claims to be a special
member in the club due to his unlimited success
and donation. Which of the following
personality traits BEST describes this man?
A. Antisocial
B. Avoidant
C. Borderline
D. Histrionic
E. Narcissistic.
Year: 2014
18. You are a member of the Hospital Quality Improvement The answer is D.
Committee. The hospital wants to improve the
management of delirium. Which of the following Explanation: The typical course of
statements regarding delirium is FALSE? delirium last for 10-12 days. It is too early
to expect the majority of delirious
A. Around 30% of the elderly admitted to the medical ward patients recover by Day 3.
will develop delirium during hospitalisation.
B. Delirium is often missed or overlooked by health care Year: 2014
professionals in the elderly.
C. Delirium occurs in 10% of children undergoing day
surgery.
D. Delirium usually clears within 3 days of correcting
underlying medical cause.
E. The incidence of delirium increases with age.
20. You are a paediatric resident. You are concerned The answer is B.
about the mental health of a 50-year-old mother
whose 12-year-old daughter died of leukaemia. Explanation: Recurrent suicidal
You are not certain whether she suffers from thoughts are considered to be
normal grief or pathological grief. Normal grief is pathological grief.
NOT characterized by:
Year: 2014
A. Denial
B. Recurrent suicidal thoughts
C. Searching for the deceased
D. Sensations of seeing or hearing the deceased
E. Transient guilt.
Substance abuse
23. A 30-year-old man admitted to the medical ward The answer is E.
has no access to the substance which he used prior
to admission. He complains of nausea and muscle Explanation: Opiate withdrawal leads
pain. Physical examination reveals pupillary to mood changes, gastrointestinal
dilation. Which of the following substances is disturbances (e.g. nausea, vomiting),
MOST likely to cause the above withdrawal muscular aches, lacrimation and
symptoms? pupillary dilation.
Psychopharmacology
26. A 50-year-old man with a major depressive disorder did The answer is B.
not respond well to an adequate trial of sertraline
200mg (a selective serotonin reuptake inhibitor). Explanation: Option B may lead to
Neither did he fully respond to a subsequent 8-week serotonin syndrome.
trial of venlafaxine 150mg (serotonin noradrenaline
reuptake inhibitor). Which of the following is NOT
Year: 2014.
RECOMMENDED for this man?
The answer is B.
27. Bupoprion differs from SSRI in which of the
following ways? Explanation: Bupoprion has a lower
incidence of sexual side effects (not
A. Bupoprion has a higher incidence of sexual working on serotonin receptors) and a
side effects and a lower incidence of lower incidence of sedation and
sedation and weight gain. weight gain (as an energetic
B. Bupoprion has a lower incidence of sexual antidepressant).
side effects and a lower incidence of
sedation and weight gain.
Year: 2014.
C. Bupoprion has a lower incidence of sexual
side effects and higher incidence of
sedation and weight gain
D. Bupoprion has lower incidence of sexual
side effects and weight gain and a higher
incidence of sedation.
E. Bupoprion has a higher incidence of sexual
side effects and sedation and a lower
incidence of weight gain.
28. Besides treatment resistant schizophrenia, The answer is E.
another appropriate indication for clozapine is?
Explanation: Severe tardive dyskinesia
A. Severe agranulocytosis
B. Severe embolism is an indication for clozapine. Option
C. Severe hypersalivation A, B, C and D are side effects
D. Severe metabolic syndrome associated with clozapine.
E. Severe tardive dyskinesia.
. Year: 2014.
29. A 50-year-old cardiac patient suffers from The answer is C.
depression and the psychiatrist prescribed
fluoxetine. Which of the following statements Explanation: Fluoxetine has been
about fluoxetine is TRUE? reported to produce bleeding and
bruising in some individuals. SSRIs as
A. Fluoxetine decreases warfarin levels. a class are believed to inhibit platelet
B. Fluoxetine increases metabolism of warfarin. aggregation, which may underlie this
C. Fluoxetine increases bruising while patient is taking effect. The ability of SSRIs to reduce
warfarin. platelet aggregation may be an
D. He has no increased risk of gastrointestinal bleeding important intervention for patients
with fluoxetine. with occlusive coronary and
E. He should not change to paroxetine because cerebrovascular artery disease and
paroxetine decreases anticoagulant effect of deserves study.
warfarin.
In addition, warfarin is metabolized
via CYP 3A4 and fluoxetine inhibits
CYP 3A4 and increases the levels of
warfarin.
Year: 2014.
Year: 2014.
Psychotherapy
34. A 30-year-old woman suffers from obsessive The answer is B.
compulsive disorder and washes her hand 50
times a day. Which of the following techniques
Explanation: Exposure and response
is the MOST essential in the psychological
treatment of her compulsive hand washing prevention is most important
behaviour? behavioural treatment for OCD.
Systemic desensitization is indicated
A. Cognitive restructuring for phobia.
B. Exposure and response prevention
C. Social skill training
Year: 2014.
D. Systemic desensitization
E. Thought stopping.
Year: 2014.
Year: 2014.
Year: 2014.
A. Autonomy
B. Beneficence
C. Confidentiality
D. Non-maleficence
E. Justice.
A. Catatonia
B. Meningitis
C. Neuroleptic malignant syndrome
D. Serotonin syndrome
E. Status epilepticus.
Psychopathology
1. A 50-year-old woman claims that unfamiliar The answer is D.
people whom she met on the street were her
husband. She believes that her husband put Explanation: Fregoli syndrome is a
on a disguise. What is the diagnosis? delusional mis-indentification syndrome
when unfamiliar people are identified as
A. Capgras syndrome a familiar person.
B. Charles de Bonnet syndrome
C. DeClerambault’s syndrome Year: 2014
D. Fregoli syndrome
E. Ganser syndrome.
Year: 2014.
4. A 50-year-old Singaporean Chinese man The answer is E.
firmly believes that he needs to flee from
Singapore to Russia for his personal safety. Explanation: This man firmly believes
He has developed this belief after reading a that the newspaper article referred to him
newspaper article about Edward Snowden and this is impossible because the
who released national security materials of person involved is a Caucasian with US
the United States (US). This man firmly citizenship. This is known as delusion of
believes that the newspaper mentions his reference.
name and describes about his role in the leak
of US national secrets. Which of the following Year: 2014.
terms BEST describe his experience?
A. Delusion of erotomania
B. Delusion of grandiosity
C. Delusion of guilt
D. Delusion of jealousy
E. Delusion of reference.
Cognitive assessment
5. You are administering the Mini-Mental State The answer is B.
Examination (MMSE) to a 70-year-old woman
who did not receive any formal education. She Explanation: Option B is the most useful
has difficulty to complete the full version of task to assess her attention because she
MMSE. Which of the following tasks is MOST may not be able to perform serial 7 due
useful to assess her attention? to low level of education. Option A
assesses constructional apraxia. Option
C assesses orientation. Option D
A. Constructing a double pentagon assesses registration and short term
B. Naming the months from December in backward memory. Option E assess working
direction memory.
C. Orientation to time and place
D. Three-item registration and recall Year: 2014.
E. Three-stage command.
13. You are a medical officer working in the Army The answer is D.
Camp. A 19-year-old man is recently enlisted
for National Service and his parents inform Explanation: Stimulant treatment (e.g.
you that he walks around his flat during sleep. modanfinil) is used to treat narcolepsy
Which of the following recommendations is but not sleep-walking.
LEAST appropriate?
Year: 2014
A. Safety measures
B. Sleep hygiene
C. Stay out of camp at night
D. Stimulant
E. Supportive psychotherapy.
14. A 25-year-old man believes that he suffers The answer is B.
from adult ADHD. Which of the following
criteria is compulsory to establish such Explanation: History of ADHD symptoms
diagnosis? in childhood is a compulsory diagnostic
criteria for diagnosing adult ADHD
A. Absence of inattention symptoms in adulthood symptoms.
B. History of ADHD symptoms before the age of 12
C. History of conduct disorder Year: 2014
D. Presence of hyperactivity symptoms in adulthood
E. History of substance abuse.
Substance abuse
22. You are a resident working at the Accident The answer is D.
and Emergency Department. A 21-year-old
man is brought in by police and he is Explanation: Ketamine-induced
disorientated to time, place and person. He ulcerative cystitis which includes urge
needs to urinate very often and seems to have incontinence, decreased bladder
urinary incontinence. A package of capsules compliance, decreased bladder volume,
is found in his pocket and suspected to be detrusor overactivity, and painful
illicit drugs. Which of the following drugs is haematuria.
MOST likely to cause the above symptoms?
Year: 2014.
A. Amphetamine
B. Cannabis
C. Cocaine
D. Ketamine
E. Phencyclidine.
Year: 2014.
Year: 2014.
Psychopharmacology
26. A 30-year-old man suffers from autism and The answer is A.
epilepsy. He has been very aggressive. The
psychiatrist prescribes sodium valproate Explanation: The patient is on a relatively
1300mg nocte to control his aggression and high dose of sodium valproate. The first
epilepsy. His mother concludes the sodium step should check serum level of sodium
valproate is not effective. The first step of valproate because patient may not non-
management should be: compliant to the medication.
Year: 2014.
33. Which of the following medications is MOST The answer is C
likely to exacerbate psoriasis?
Explanation: Lithium has higher risk to
A. Amitriptyline worsen psoriasis as compared to other
B. Haloperidol psychotropic medications.
C. Lithium
D. Risperidone
E. Sodium valproate. Year: 2014.
A. Amitriptyline
B. Reboxetine Year: 2014.
C. Mirtazapine
D. Duloxetine
E. Venlafaxine.
37.Agomelatine, a new antidepressant is BEST The answer is D.
given in which of the following parts of the day?
Explanation: Early evening is the best
A. Early morning time for circadian rhythms
B. Late morning resynchonizing (1-2h before dark phase).
C. Early afternoon
D. Early evening
E. Past mid-night.
Year: 2014.
Psychotherapy
38. A 24-year-old depressed woman said, “People The answer is C.
in my office try to make my life difficult and
then deem themselves as ultimate smart to Explanation: Interpersonal therapy (IPT)
know about me. I have resigned as I am is indicated for depressive disorder. It
uncomfortable with the office settings. I am helps the patient to understand the
aware that I am getting verbally aggressive communication difficulties (verbal
towards other people whenever they provoke aggression). Psychotherapist can
me. I want to see a psychotherapist because I perform role-play to help patient to
want to deal with these people before I lose my improve communcation. IPT also helps
self-identity.” Which of the following patient to deal with the loss associated
psychotherapies is MOST appropriate? with her self-identity and resignation.
A. Autonomy
B. Capacity
C. Confidentiality
D. Non-maleficence
E. Justice.
43. A 25-year-old man was arrested for murder. The answer is C.
According to the police, he shows no remorse
towards his act. He firmly believes that killing
Explanation: In forensic psychiatry,
one person will not lead to death sentence. He
needs to kill several people to get death psychopath represents the most severe
sentence. He always carries a chopper and form of antisocial personality disorder.
wants to attack innocent people. If he is People with psychopathy demonstrate
released from the prison, he will kill more extremely low level of empathy and
people, including his parents. Which of the remorse. They have high chance of
following diagnoses is MOST appropriate?
recidivism.
A. Biopathy
B. Egopathy Year: 2014.
C. Psychopathy
D. Sociopathy
E. Superegopathy.
Consultation liaison psychiatry
44. You are a resident working in the Children The answer is D.
Emergency Department. A 5-year-old boy is
presented for recurrent urinary tract infection
Explanation: Münchausen syndrome by
and confirmed by raised white blood cell
proxy occurs when an individual (the
counts in urine. According to his mother, the
mother) must have presented another
boy likes to insert foreign body into his penis
individual (the boy) to others (AED
via the urethra meatus. After taking a
doctor) as medically ill (recurrent urinary
thorough history and conducting physical
tract infection) without the intention of
examination, you cannot gather any evidence
obvious external rewards but invasive
the boy could insert foreign body into his
investigation or hospitalizations.
penis. It is not anatomically and
Münchausen syndrome by proxy is
physiologically feasible for the boy to do so.
considered to be a form of child abuse.
You cannot exclude the possibility that it
She is displacing her anger (husband
could have been done by his mother. History
visiting commercial sex workers) towards
also reveals that the parents have marital
her son.
problems and his father is suspected to visit
commercial sex workers frequently. She is
very keen to admit her son for further invasive Year: 2014.
investigations. What is the MOST likely
diagnosis?
Year: 2014.
46. You are a resident working in the Accident The answer is A.
and Emergency Department (AED). A 26-year-
old woman gave birth one month ago. She is a
Explanation: In this situation, both
single mother and broke up with her
boyfriend. She has poor social support and mother and baby should be admitted to
no one helps her to look after the baby. She the hospital because no one looks after
has been depressed for 1 month and wanted the baby at home. IMH does not have
to jump down from her flat two weeks ago. facility to look after her baby.
She was referred to the woman’s mental
health service. She was referred to a case The psychiatrist in the hospital should
manager but no medication was prescribed.
consider starting antidepressant because
She breastfeeds her baby. Today, she wants
to jump again. The mother and her baby are she is highly suicidal and SSRI like
bought to the AED by the case manager. sertraline is safe for breastfeeding.
Which of the following is the BEST
management? Year: 2014.
A. Admit the mother and her baby to the hospital.
The mother will go to the psychiatric ward and the
baby will go to paediatric ward. She will benefit
from antidepressant and psychological
intervention.
B. Admit the mother and her baby to the hospital.
The mother will go to the psychiatric ward and the
baby will go to paediatric ward. She should
receive psychological intervention only because
antidepressants are dangerous for breastfeeding.
C. Discharge the mother and her baby from the AED
because she suffers from adjustment disorder.
Her risk is low.
D. Discharge the mother and her baby from the AED
because she receives good care from case
manager.
E. Send both mother and her baby to the Institute of
Mental Health for compulsory admission.
47. What of the following psychiatric side effects The answer is D.
is MOST common in Hepatitis C patients
receiving interferon treatment? Explanation: Interferon treatment is
well known to be associated with
A. Anxiety
depression.
B. Cognitive impairment
C. Confusion
D. Depression Year: 2014.
E. Hallucination.
Options:
A. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy
B. Korsakoff syndrome
C. Dissociative fugue
D. Vascular dementia
E. Lewy body dementia
Lead-in: Match the appropriate diagnosis to each of the following clinical scenarios.
51. A 60-year-old woman is brought in by the police for psychiatric assessment as she was found
missing for a few days. She is unable to provide any personal details about herself and appears to be in
a daze. She cannot recall where she has been in the past 3 days. Her son, with whom she is very close,
died in a road traffic accident few days ago. She appears to be tidy and well-groomed. All
investigations done for her are normal. (Choose 1 option)
52. A 65-year-old man presents with fluctuating memory loss with mood swings. He has slurred speech
and left-sided muscle weakness. He has multiple medical comorbidities, including poorly controlled
hypertension and diabetes. (Choose 1 option)
53. A 60-year-old man is brought in by the police to the hospital for assessment as he was found
wandering the streets. When the doctor speaks to him, he says that he is here to meet a friend who was
hospitalized and that he has seen the doctor before. Medical records show that he has been a chronic
alcohol drinker. (Choose 1 option)
Answers:
51: C
52: D
53: B
Question 54-55
Options:
A. 5-HT2 antagonist
B. Buytrylcholinesterase inhibitor
D. GABAA agonist
Answers:
54: D
55: C
Question 56-57:
Options:
A. Action
B. Contemplation
C. Pre-contemplation
D. Maintenance
E. Relapse
Lead-in: identify the stages of behaviour change based on the model established by Prochaska and
DiClemente.
56. Begins to realize that his/her behaviour has both advantages and disadvantages and start to feel
57. Makes an initial attempt to rectify the problematic behaviour. (Choose 1 option)
Answers:
56: B
57: A
Question 58-60
B. Conduct disorder
C. Enuresis
E. Separation anxiety
58. A 8 year-old boy regularly wets his bed at night ever since his parents were divorced. He has also
been noted by his teacher to be more quiet and irritable than usual since the parents’ separation.
(Choose 1 option)
59. A 15-year-old boy regularly bullies and gets into fights with fellow students in school. He has on
several occasions set fire to the grocery shops and vehicles. He also has a history of stealing from
60. A 8-year-old boy is frequently rude and argumentative towards his teachers. He gets irritated
easily
by others and would often disobey the school rules. Nevertheless, he is not aggressive towards
others and has no forensic history. He does not appear to have any problems at home.
(Choose 1 option)
Answers:
58: C
59: B
60: D
MCQs
A. Capgras’ syndrome
B. Charles de Bonnet’s syndrome
C. De Clérambault's syndrome
D. Ganser’s syndrome
E. Othello’s syndrome
1
Cognitive assessment
4 Which of the following is NOT a prominent cognitive The answer is A.
feature of cortical dementia?
Explanation: Articulation
A. Problems with articulation
B. Problems with calculation difficulty is associated with
C. Problems with drawing a clock face subcortical dementia which is
D. Problems with expression of emotion characterised by neurological
E. Problems with recognition sign.
Year: 2014
Year: 2014
Psychiatric epidemiology
6 By 2020, which of the following illnesses is The answer is D.
predicted to have higher global disease burden
than depressive disorder? Explanation: Based on the
prediction of WHO, ischaemic
A. Anxiety disorder heart disease will rank No.1
B. Dementia while depressive disorder will
C. Diabetes rank No.2 in global disease
D. Ischaemic heart disease
burden.
E. Schizophrenia.
Year: 2014
2
Year: 2014
3
General adult psychiatry
12 You are a general practitioner. A 22-year-old The answer is A.
patient comes to consult you because she is
stressed. Her father boarded an aeroplane Explanation: As the plane has
which was found missing and probably has crashed, the chance of survival
crashed. She is not certain about the status of for her father is low. She will
her father and he is not contactable. At this experience anticipatory grief
moment, she is MOST likely to develop which during the period of
of the following psychiatric conditions? uncertainty.
Year: 2014
A. Anticipatory grief
B. Compensation neurosis
C. Dissociative state
D. Psychosis
E. Hypochondriasis.
Year: 2014
14 Which of the following statements concerning generalized The answer is C.
anxiety disorder is FALSE?
Explanation: Option C refers to
A. Alcohol misuse is a common comorbidity. panic disorder.
B. Cognitive behaviour therapy is generally helpful.
C. Excessive worries and anxiety symptoms are episodic. Year: 2014
D. Short-term benzodiazepines can be an effective treatment
E. There is a 2 to 1 ratio of women to men suffering from this
disorder.
4
occur.
Year: 2014.
16 A 45-year-old man consults you because he is stressed The answer is A.
over his daughter’s eating disorder. His daughter suffers
from anorexia nervosa. He is very concerned about her
Explanation: Based on eating
condition. He wants to seek your reassurance. Which of
the following indicates a GOOD prognostic factor for his disorder research, early age of
daughter? onset indicates good
prognostic factor. The other
A. Early age of onset factors are poor prognostic
B. Past hospitalisation factors.
C. Frequent self-induced vomiting rather than food restriction
D. Very low BMI
E. Perfectionistic personality. Year: 2014.
Year: 2013.
Old age psychiatry
19 Which of the following statements about depressive The answer is D.
disorder in old people is TRUE?
Explanation: Depression in
A. Depressive disorder in elderly is accompanied by a much
lower suicide risk than in younger adults. elderly is accompanied by
B. Depressive disorder in elderly is less likely to be associated higher suicide risk and more
with paranoia as compared to younger adults. paranoia. Elderly takes longer
C. Elderly suffering from depressive disorder takes shorter time time to respond as they cannot
to respond as compared to younger adults tolerate medications as good as
D. Mild depressive disorder is more prevalent in elderly women
young adults. Prevalence of
than men.
E. Prevalence of depressive disorder rises sharply with age in depression in elderly is around
the community. 3% (10-15% if depressive
symptoms are included). Only
10% of depression emerges in
5
elderly and there is no sharp
rise in prevalence.
Year: 2014.
Year: 2014
21 What is the MOST likely diagnosis in a 75- year-old man The answer is B.
with declining cognition, visual hallucinations, and
parkinsonism symptoms? Explanation: The classical triad
of dementia with Lewy Bodies is
A. Alzheimer’s disease memory loss, visual
B. Dementia with Lewy Bodies hallucination and parkinsonism.
C. Late-onset schizophrenia
D. Fronto-temporal lobe dementia Year: 2014
E. Vascular dementia.
6
Year: 2014
Year: 2014
A. Action
B. Contemplation
C. Denial
D. Precontemplation
E. Maintenance.
Psychopharmacology
27 Which of the following neurochemicals is metabolized by The answer is E.
monoamine oxidase?
7
A. Acetylcholine Explanation: This refers to
B. Brain-derived neutrophic factor pharmacodynamic action of
C. Histamine MAOI.
D. Glutamate
E. Serotonin. Year: 2014
Year: 2014
8
D. Mannan-binding lectin gene – M*1502 carbamazepine. Those who are
E. Serotonin transporter gene – S*1502. positive for this genotype may
have high risk of developing
Steven Johnson syndrome.
Year: 2014
Psychotherapy
36 A 30-year-old woman with panic disorder does not The answer is B.
respond to an initial treatment with a selective serotonin
reuptake inhibitor (SSRI). Which of the following
Explanation: The effect of CBT is
treatment is considered the best approach?
as efficacious as SSRI.
A. Benzodiazepine
B. Cognitive behaviour therapy
C. Hypnotherapy Year: 2014.
D. Olanzapine
E. Psychodynamic psychotherapy.
9
37 You are a medical officer working in the army. A 22-year- The answer is C
old national serviceman comes to see you because he is
very angry with his male supervisor and wants to see a
Explanation: Psychodynamic
psychologist. He also informs you that he is very angry
with his own father. He passed you an emotional 500- psychotherapy is most
word open letter posted on his Facebook account. In his appropriate in this case because
letter, the patient mentions that his father has been this patient needs to analyse the
abusive towards him. He finds his male supervisor is as pattern of history repeating
abusive as his father and the pattern keeps repeating itself. He may learn not to
itself. Which of the following psychotherapy is MOST
project his father onto the male
appropriate in this case?
supervisor.
A. Cognitive behaviour therapy
B. Problem solving therapy Year: 2014.
C. Psychodynamic psychotherapy
D. Reminiscence therapy
E. Validation therapy.
38 A 20-year-old woman suffers from borderline The answer is E.
personality disorder. She works as a clerk. During
psychotherapy session, she discloses that she really Explanation: The patient
hates the psychologist and has thoughts of killing the exhibits intense negative
transference towards the
psychologist. Her conviction to kill the psychologist is
psychologist. She does not have
1 out of 10 (1 =very unlikely, 10 = very likely).
the real intention to kill the
Furthermore, she does not have a plan or not sure psychologist but she mentions
when to kill the psychologist. She has no forensic this due to intense negative
history and no history of violence. She admits the transference.
idea of killing the psychologist is her own thought.
She has no command hallucination. Which of the Year: 2014.
following BEST describes this phenomenon?
A. Denial
B. Displacement Year: 2014
C. Projection
D. Projective identification
E. Undoing
10
secretary complains of low mood, poor appetite, poor
sleep and suicidal thought. She is very depressed over Explanation: Most depressed
the death of her son who passed away 26 hours after
patients have the capacity to
birth. She has history of depression without any
psychotic feature. She underwent a traumatic delivery give consent. Based on the
because an obstetrician in private practice performed history, there is no evidence to
amniocentesis, induction of labour and administered suggest that she lacks the
syntocinon 3 weeks before the expected date of capacity to make decision (e.g.
delivery. The patient later found out that the obstetrician no psychotic features, working
induced labour because the doctor planned to go for a
as a secretary). The obstetrician
holiday. Patient did not fully understand about the
procedure and did not agree with induction of labour did not respect patient’s
which resulted in premature birth of her son. The autonomy before carrying out
obstetrician claims that she does not have capacity to aminocentesis, induction of
make decision due to history of depression. She felt that labour and administering
the doctor performed the procedure against her will and syntocinon.
the death of her son was avoidable. Which ethical
principle was violated by the obstetrician? Year: 2014.
A. Autonomy
B. Beneficence
C. Confidentiality
D. Involuntary treatment
E. Justice.
A. Actus reus
B. Jealousy
C. Automatism
D. Diminished responsibility
E. Mens rea.
Liaison Psychiatry
42 A 20-year-old man was given a high dose of The answer is C.
intravenous haloperidol. He develops high fever
and you suspect that he may develop neuroleptic Explanation: Patients
malignant syndrome (NMS). All of the following suffering from NMS usually
clinical features suggest NMS EXCEPT: present with elevated CK,
ALT, AST, LDH in the serum
11
A. Autonomic instability and high levels of myoglobin
B. Diaphoresis and protein in the urine
C. Decreased catecholamines in urine
D. Myoglobinuria Year: 2014.
E. Rigidity.
Year: 2014.
46 You are a medical resident. A 40-year-old man is The answer is A.
admitted to the medical ward due to altered mental state
and requires further medical investigations. Past records Explanation: The patient suffers
show a history of substance abuse. He sleeps poorly and from delirium tremens, resulted
paces around the unit, restless and grumpy on the next from alcohol withdrawal.
day. He appears to be confused and exhibits tachycardia
12
at 106 beats per minutes. His palms and forehead are Year: 2014.
sweaty and his tongue is showing a course tremor. When
asked, the patient says he feels anxious. Which of the
following is the CORRECT diagnosis?
A. Alcohol withdrawal
B. Amphetamine withdrawal
C. Cannabis withdrawal
D. Nicotine withdrawal
E. Opioid withdrawal.
Question 51 – 53
Options:
A. Acting out
B. Splitting
C. Projection
D. Rationalization
13
E. Regression
Lead-in: A 23-year-old woman with a psychiatric diagnosis of borderline personality disorder is admitted
to the ward for deliberate self-harm. She has a past history of physical abuse by her parents when she was
young.
Select the most appropriate defense mechanism for each of the following situations.
51. A staff nurse asks her to change out of her own clothing and wear hospital attire. She
becomes
upset and refuses to follow the instruction of the nurse. She purposely tries to upset the nurse
and tests
her reactions. During a psychotherapy session, she finds the nurse is as hostile and abusive as
her
mother. (C)
52. She says that she cut herself on the arm with a penknife to externalize her pain and ease
her stress
in life. She feels that self-cutting is an acceptable way of coping and that it has benefits in
making her
mind clearer and stabilizing her emotions. (D)
53. She is noted to be lying flat on the floor, clutching a teddy bear and crying loudly. When
the nurse
asks what happened, she replies, in a child-like manner, that the other patients bullied her.
(E)
Question 54 – 56
Options:
A. Confabulation
B. Déjà vu
C. Jamais vu
D. Delusional memory
E. Factitious disorder
14
Lead-in: Select the most appropriate item from above that fits the following clinical description.
54. A 45-year-old man with temporal lobe epilepsy returns home after being hospitalized for 4 days
due to breakthrough seizure. He says that his house appears to be unfamiliar as if it is a stranger’s
55. A 32-year-old woman with schizophrenia suddenly breaks into tears during the ward round and
shouts that alien performed an operation to insert a device in her abdomen when she was young.
Corroborative history from her mother reveals that she had an appendectomy at the Singapore
56. A 28-year-old man presents to the hospital with abdominal pain and bilateral upper limb numbness.
He demands to be admitted and thoroughly investigated for his symptoms. On checking of his medical
records, it is revealed that this is his 25th visit to the hospital complaining of unusual presentation of
symptoms for which extensive investigations were done each time, all results being unremarkable. He
always requests for admission and feels very happy to stay in the ward as a patient. (E)
Question 57 – 58
Options:
A. Concentration
B. Constructional praxis
C. Delayed recall
D. Language – naming
E. Luria’s test
15
Lead-in: Match the above with the following:
Question 59 – 60
Options:
A. Delusion of control
B. Delusion of reference
D. Nihilistic delusion
E. Persecutory delusion
Lead-in: The following scenarios refer to a patient with delusional ideas. Select the most appropriate item
from above that best match the type of delusion described below.
59. A 64-year-old woman believes that her life and the world are coming to the end after her son
passed away from cancer. She has stopped eating and bathing for the past 4 days, as she believes firmly
60. A 21-year-old man feels that his feelings and actions are no longer his own. He firmly believes that
someone has planted a device in his brain to make him think and react strangely as if he is a robot. (A)
16
MCQ
Cognitive assessment
3. A 30-year-old woman has received 6 sessions of The answer is B.
electroconvulsive therapy (ECT). After the ECT,
she complains of cognitive impairment and Explanation: Young patients
attributes the following symptoms as side effects usually develop retrograde
of ECT. Which of the following is most likely amnesia of recent events but not
caused by ECT? anterograde amnesia (option A)
or life events (option C). ECT
A. Cannot follow the instructions given by her does not affect multi-tasking and
1
supervisor after she returns to work calculation.
B. Cannot recall the password of her email account
C. Cannot remember details of her ex-marriage Year: 2015.
D. Difficulty to perform two tasks at one time
E. Unable to calculate.
Year: 2014
7. Which of the following is least likely to be a risk The answer is A.
factor for delusional disorder?
Explanation: Having a religion is
A. Having a religion not a risk factor for developing
B. Increased age delusional disorder. The risk of
C. Immigration delusional disorder increases
D. Sensory impairment with age. Hearing loss is a risk
E. Social isolation. factor. Low socioeconomic status
and severe stress are also risk
2
factors.
Year: 2014
A. Alpha1-adrenergic
B. Dopaminergic
C. Histaminergic
D. Muscurinic cholinergic
E. Nicotinic cholinergic.
General adult psychiatry
10. A 30-year-old man suffers from schizophrenia. The answer is C.
He first exhibited first rank symptoms at the age
of 16 and the onset was insidious. He exhibits Explanation: Poor prognostic
anhedonia although his hallucinations are under factors include young onset, no
control by antipsychotic drug. His uncle suffers precipitating factors, insidious
from depressive disorder. All of the following are onset, poor premorbid
poor prognostic factors except? functioning, family history of
schizophrenia, negative
A. Anhedonia symptoms, poor support,
B. Exhibition of first rank symptoms at the age of 16 neurological symptoms and poor
C. Family history of depressive disorder compliance.
D. Male gender
E. Insidious onset. Year: 2014
11. You are the resident working in the Accident and The answer is B.
Emergency Department. A schizophrenia patient
informs you that he has homicidal thought. Which Explanation: Delusion of
of the following sign or symptom is least reference is not directly related
important in predicting homicide? to violence and carries lower risk
of homicide as compared to
A. Command hallucinations other signs and symptoms.
B. Delusion of reference
C. History of previous violence Year: 2014
3
D. Irresistible urge to attack
E. Need to defend oneself as are result of
persecutory delusion.
The answer is C.
12. All of the following are poor prognostic signs for
obsessive compulsive disorder except: Explanation:
Poor prognosis:
A. Bizarre compulsions 1. yielding to compulsions
B. Childhood onset (not resisting)
C. Episodic course 2. childhood onset
D. Comorbid major depression 3. bizarre compulsions
E. Succumbing to obsessions and compulsions. 4. need for hospitalization
5. presence of overvalued
ideas (i.e. acceptance)
6. personality disorders
(especially schizotypal)
7. co-existing delusional
beliefs
8. co-existent major
depressive disorder
Year: 2014
13. You are a general practitioner. A 35-year-old The answer is E.
hotel butler came to see you because his lawyer
wants him to be seen by a psychiatrist. He was Explanation: Voyeurism is
recently arrested for installing pinhole camera in defined as recurrent and intense
the hotel guestrooms. He secretly filmed couples sexual arousal from observing
having sex in the hotel guestrooms. He has other people being naked or
filmed more than 100 videos and enjoyed engaging sexual activity.
watching them over and over again. He claims
that he has the compulsion to collect those Year: 2014
videos and he feels relieved after the arrest.
Which of the following is the most likely
diagnosis?
A. Erotomania
B. Kleptomania
C. Obsessive compulsive disorder
D. Sadomasochism
E. Voyeurism.
4
personality best describes this patient? of new interpersonal situations
(e.g. meeting new colleagues)
A. Avoidant personality disorder and belief of socially inept.
B. Borderline personality disorder
C. Histrionic personality disorder
D. Paranoid personality disorder Year: 2014
E. Schizoid personality disorder
15. Which of the following is not a common feature of Answer: D
serotonin syndrome?
Explanation: Serotonin syndrome
A. Acidosis actually causes fever. Metabolic
B. Diaphoresis acidosis in seen in 9% of
C. Hyperreflexia patients.
D. Hypothermia
E. Myoclonus. Year: 2014
5
For metabolism, all psychotropic
medications metabolized in the
liver have their elimination half-
life increased two or three-fold in
the elderly.
Year: 2014
6
20. Which of the following is most important risk The answer is C.
factor for vascular dementia?
Explanation: Among all the
A. History of depression options, hypertension is the most
B. History of poor academic performance significant risk factor for vascular
C. History of hypertension dementia.
D. High level of physical activity
E. High level of high density lipoproteins. Year: 2014
21. You are the visiting physician of a nursing home. The answer is A.
The nursing home staffs feel very helpless when
handling aggression in dementia patients and Explanation: Antipsychotic drug
they need to seek your advice. Which of the (e.g. risperidone) has the most
following psychotropic medication have the most evidence in improving
evidence in managing aggression in patients aggression in dementia patients
suffering from dementia? among all options.
7
A. Boys aged two to four are not significantly have no evidence base. For
affected. option C, most children take 3-5
B. Children do best if they have no contact with the years to recover. Socio-
father for two years. economic status affects the
C. Most children have no significant problems after outcome.
three to six months.
D. Socio-economic status is not associated with the Year: 2014
degree of impairment.
E. To evaluate the impact, one must take into
consideration the age and the developmental
level of the child.
8
E. He suffers from stimulant intoxication.
28. The most important objective of The answer is D.
psychological intervention in treating people
suffering from alcohol misuse is: Explanation: Achieving
abstinence or reduction of
A. To conduct in a group therapy format alcohol use is most important
B. To apply cognitive behaviour therapy (CBT) as psychotherapeutic objective.
the first approach
C. To combine psychological intervention and Year: 2014.
pharmacotherapy (e.g. disulfiram)
D. To focus on achieving and maintaining
abstinence or reducing alcohol use
E. Explore unresolved psychodynamic conflicts.
Psychopharmacology
29. Which of the following medications is not The answer is E.
associated with weight gain?
Explanation: Topiramate is
A. Clozapine associated with weight loss and
B. Mirtazapine not weight gain.
C. Olanzapine
D. Sodium valproate Year: 2014
E. Topiramate.
9
nervosa. because of the risk of seizure.
D. It is an antidepressant used for depressed
patients with cardiovascular disease and habit of Year: 2014
smoking.
E. It does not cause weight gain.
34. Which of the following side effects is least likely The answer is D.
to occur in patients taking quetiapine?
Explanation: Quetiapine is
A. Antihistamine effects associated with antihistamine
B. Orthostatic hypotension effects, orthostatic hypotension,
C. Increase in liver transaminase increase in liver transaminase
D. Increase in prolactin and weight gain.
E. Weight gain.
Year: 2014
35. Which of the following is the best treatment Answer is E.
option for severe depressive episode with
psychotic features? Explanation: ECT has the most
evidence in treating psychotic
A. Amitriptyline depression as compared to other
B. Cognitive behaviour therapy treatment options.
C. Lamotrigine
D. Methylphenidate Year: 2014
E. Electroconvulsive therapy.
10
pressure is 180/90. Which of the following associated with dose-dependent
medications should be stopped? hypertension.
A. Carbamazepine
B. Lamotrigine
C. Lithium
D. Sodium valproate
E. Topiramate
Psychotherapy and defence mechanisms
39. A 28-year-old woman comes to consult you The answer is C.
because she is very upset after being scolded by
her manager. The chief executive officer (CEO) Explanation: The manager
of her company has raised the standard for transferred his anger to his
annual performance. Her manager is very upset subordinate which carries less
this arrangement and scolds her for no reason. emotional risk as compared to the
Which of the following is the defence mechanism CEO. This is known as displacement.
exhibits by the manager?
A. Couple therapy
B. Dialectical behaviour therapy
11
C. Problem solving psychotherapy
D. Supportive psychotherapy
E. Family therapy.
A. Affirmation
B. Clarification
C. Empathic validation
D. Observation
E. Interpretation.
A. Altruism
B. Denial
C. Displacement
D. Repression
E. Reaction formation.
43. Which of the following is the most effective The answer is C.
approach for a 30-year-old woman with
obsession about contamination and washes her Explanation: Option C is known
hands every time she touches something which as exposure and response
she considers dirty? prevention (ERP) and is the most
12
effective approach among all
A. Having the patient place her hands in a container options. Option D is not good
of worms to create extreme phobia and ability to enough because the
overcome obsession psychologist should guide the
B. Having the patient snap her wrist with a rubber patient to further challenge the
band when she thinks about contamination and obsessions rather than just
about to wash her hands highlighting the obsessions.
C. Having the patient touch a dirty object, then not Option B is thought stopped and
allowing her to wash her hands for several hours is not as effective as ERP.
D. Highlighting to the patient that her obsession is a
cognitive error. Year: 2014
E. Providing the patient with message cards to
remind herself that the hand washing is
unnecessary.
44. A 30-year-old army officer presents for treatment The answer is C.
of post-traumatic stress disorder after surviving
an accident which his tank fell into the river from Explanation: The psychologist is
a bridge. He was driving a tank on a bridge when providing in-vivo exposure by
it suddenly collapsed. Several army officers were imaging the accident scene to
seriously injured in this accident. As part of the overcome fear and anxiety
treatment, the psychologist asks the patient to associated with flashback.
imagine that he is safely driving his tank over a
bridge. Which of the following best describes this Year: 2014
therapeutic intervention?
A. Aversion therapy
B. Cognitive therapy
C. Exposure therapy
D. Interpersonal therapy
E. Supportive therapy.
13
assessment
E. Discuss with the consultant-in-charge and the
social worker on the next day.
14
construction worker had a fall, fractured his spine
and injured the brain. He develops pain in Explanation: Duloxetine is an
multiple sites. He has one episode of epilepsy antidepressant indicated for both
after the injury. He is depressed but does not depression and pain. Bupropion,
have suicidal thought. Electrocardiogram is amitriptyline and chlorpromazine
normal. Which of the following medication is most increases the risk of seizure.
helpful in this situation? There is no indication to
prescribe moclobemide in this
A. Amitriptyline case.
B. Bupropion
C. Chlorpromazine Year: 2014
D. Duloxetine
D. Moclobemide
EMI
15
Question 51 – 53
Options:
A. Abstinent
B. Action
C. Contemplation
D. Pre-contemplation
E. Preparation
Lead-in: Choose the most appropriate stage based on Prochaska and DiClemente’s stages of change
model.
51. A 35-year-old man with cannabis misuse ignores the advice of family and friends, and
continues using the drug and causing amotivational syndrome.
Answer: D
52. A 40-year-old woman has been attending Narcotics Anonymous meetings and cessation to
use pain killer has been integrated into her life.
Answer: B
53. A 40-year-old man recognises the problem of alcohol misuse and is considering the pros and
cons of treatment.
Answer: C
Question 54 – 57
Options:
16
A. Deficiency of thiamine
Lead-in: Select the most appropriate item from the above that is most likely seen in the following
clinical scenario.
54. An 80-year-old man presents with increased forgetfulness and memory problems over the last 2
years. He often misplaces his things and unable to find his own way home when he goes out of the
house.
Answer: C
55. A 50-year-old man with long standing alcohol dependence presents with acute onset of confusion
Answer: A
56: A 22-year-old female presents with syncope and dizziness. She believes that she is overweight
and has been restricting her diet. Her BMI is17 and she has not had her menstruation for the past 3
months.
Answer: E
Question 58 – 59
Options:
17
A. Alcohol intoxication
B. Cannabis intoxication
D. Manic episode
E. Pseudobulbar palsy
Lead-in: Select the most appropriate diagnosis from the above for the following clinical scenario.
57. A 54-year-old man is admitted following a stroke. He is noted to be crying and laughing in the
ward at time. His speech has become nasal “like a duck” and his tongue is spastic and stiff.
His score for Mini Mental State Examination is 28/30.
Answer: E
58. A 45-year-old man presents to the Emergency Department in a disinhibited manner. He tries to
hit the nurses when they attempt to draw blood from him and he shouts loudly on how badly
treated he is by his wife. However he soon becomes apologetic and tearful. He is unsteady in
his gait and speech is slurred. He subsequently falls asleep soundly in the cubicle while
waiting for the doctor.
Answer: A
Question 59 - 60
Options:
18
C. Dopamine D2 receptor antagonist
Lead-in Select the most likely mechanism of drug action from above.
59. Disulfiram
Answer: A
60. Haloperidol
Answer: C
19
MCQ exam 11 (2015 Rotation 1)
Author: Roger Ho
Year: 2015
2. Which of the following is an example of Answer is D
obsession?
Explanation: Option A refers to
A. A man has a false belief which is non-bizarre in delusion (e.g. morbid jealousy which
content and the patient tries to convince others to can be non-bizarre in content). Option
believe it. B is not a psychopathology. Option C
B. A woman cannot get her ex-boyfriend out of her refers to binge eating. Option E refers
mind and feels compelled to know his to distortion of body image.
whereabouts.
C. A woman compulsively eats everything in front of Author: Roger Ho
her and feels guilty afterwards. Year: 2015
D. A man recognises the irrationality to open an
envelope multiple times to ensure no vulgarity was
written on the letter.
E. A woman has a distorted belief of being too fat and
counting calorie intake not to exceed 1000 per day.
Author: Roger Ho
Year: 2015.
Cognitive assessment
6. A 70-year-old man is receiving inpatient The answer is E.
treatment at the National University Hospital.
Which of the following is the BEST way to Explanation: The best way to assess
assess “the orientation to place” during the Mini location should be least controversial
Mental State Examination? among healthy subjects. Answer A will
create a lot of inconsistency because
A. Name of Hospital and Name of Street, Name of every person has a different home
Home Address, The distance between home and address. Direction is another
hospital, Name of Country controversial answer. Some healthy
B. Name of Hospital, Name of City, Name of subjects would say NUH is at the south
Country, Name of nearby country, Name of of Singapore. Some would argue it is
Continent. southwest and makes it hard to decide
C. Name of Hospital, Road, District, Direction on the score. Option B asks about
(North/South/East/West), Name of country location outside of Singapore and this
D. Ward Number, Floor, Name of Hospital, Direction is less relevant to the orientation to
(North/South/East/West), Name of country current place. Option E is the best way
E. Ward Number, Floor, Name of Hospital, Nearest to assess the orientation to place during
MRT station and Name of country. the MMSE and the subject will get 5
points if all answers are correct.
Author: Roger Ho
Year: 2015
Psychiatric epidemiology
7. A 30-year-old woman suffering from The answer is B.
schizophrenia is married to a 35-year-old man
without history of psychiatric illness. Her Explanation: If one parent suffers from
husband is concerned that their child will schizophrenia and the other parent does
develop schizophrenia. If the prevalence of not have mental illness, 13% of the
schizophrenia in the general population is 1%, children will develop schizophrenia. As
what is the risk of their child developing 1% of the general population suffering
schizophrenia as compared to the general from schizophrenia, the risk is 13
population? times.
Author: Roger Ho
Year: 2015
A. Borderline personality
B. Histrionic personality
C. Narcissistic personality
D. Obsessive compulsive personality
E. Paranoid personality
18. A 30-year-old woman suffers from The answer is A.
depression due to marital problems.
Further inquiry reveals that she encounters Explanation: The stop-start
psychosexual problems in her marriage. technique is used in the treatment of
Her husband has premature ejaculation but premature ejaculation. The woman
refuses to see a doctor. Which of the uses her hands to stimulate the man
following is most appropriate advice? to erection. Then she stops the
stimulation. After he loses his
A. Advise her to apply the stop –start technique. erection, she can resume stimulation
B. Advise her to apply the suction device on her and then stop again. This will
husband. prolong the time before ejaculation.
C. Adviser her to change the method of
contraception. Author: Roger Ho
D. Advise her to consider psychodynamic Year: 2015
psychotherapy.
E. Advise her to persuade her husband to consider
sildenafil.
Author: Roger Ho
Year: 2015.
Old age psychiatry
24. The following are features of pseudo- The answer is C.
dementia with the exception of:
Explanation: The onset of pseudo-
a. Usually acute in onset dementia is usually acute. There is
b. Presence of lack of motivation and does not attempt the presence of the lack of
to answer the questions motivation and attempt to answer
c. Memory deficits are often reported by family questions. Individuals usually give
members the answer „I don‟t know‟ to the
d. Intact arithmetic skills questions. Memory deficits are
e. Intact visual-spatial organisation. usually reported by the patients
themselves, instead of their relatives
and friends. As compared to
dementia, there are intact arithmetic
skills, paired associate learning and
visual-spatial organization.
Author: Roger Ho
Year: 2015.
26. Which of the following is the best initial treatment The answer is E.
for agitation in dementia?
A. Antipsychotic drug
Explanation: Behavioural therapy
B. Antidepressant (e.g. relaxation training, rewarding
C. Aversion therapy calm behaviour and modulating
D. Benzodiazepine environment) is the best initial
E. Behavioural strategies treatment for dementia.
Author: Roger Ho
Year: 2015
Author: Roger Ho
Year: 2015.
Substance abuse
32. A 24-year-old man has been using an illicit The answer is E.
drug on a regular basis. He presents with
urinary problems. In the past, he could Explanation: Regular use of
drink two cans of soft drink (250ml per can) ketamine will lead to the epithelial
without the need to rush to toilet. inflammation in urinary tract and
Nowadays, he needs to rush to toilet after cause urinary incontinence. As a
drinking a small bottle of Yakult (100 ml). result, his urinary retention capacity
Which of the following drugs is most likely has reduced significantly to one-
to be associated with the above fifth of his original capacity.
phenomenon?
Author: Roger Ho
A. 3-4 methylenedioxymethamphetamine Year: 2015.
B. Buprenorphine
C. Cocaine
D. Heroin
E. Ketamine
A. Amphetamine
B. Clozapine
C. Fluoxetine
D. Lorazepam
E. Haloperidol
40. A patient complains of nausea after taking The answer is D
escitalopram. Which of the following
antidepressants is least likely to cause Explanation: Mirtazapine works on the
nausea as compared to escitalopram? 5-HT3 receptors and avoid nausea.
Psychotherapy
44. The psychiatrist has ordered intramuscular The answer is B.
haloperidol instead of intramuscular lorazepam.
The patient developed acute dystonia. He is very Explanation: This patient transfers
angry at the psychiatrist. The patient does not his emotional response (i.e. anger)
express the anger towards the psychiatrist, but to a particular person (i.e. healthcare
became verbally abusive towards the ward assistant) who was not involved in
attendant and healthcare assistants. This patient the medication error and carries less
exhibited which of the following defence emotional risk (i.e. affecting his
mechanisms? discharge plan made by the
doctors).
A. Denial
B. Displacement Author: Roger Ho
C. Projection Year: 2015
D. Reaction formation
E. Sublimation
A. Anterograde amnesia
B. Dissociative amnesia
C. Misidentification syndrome
D. Retrograde amnesia
E. Selective amnesia
49. Which one of the following statements about Answer: E The patient believes that
somatisation disorder is false? he suffers from a terminal illness.
Author: Roger Ho
Year: 2015
Extended matching items
Question 51 – 54
Options:
Lead-in: Select the most appropriate diagnosis from the above for the following clinical
scenario.
51. Tiffany is a ten-year-old girl brought to the clinic for an assessment. The mother
describes her having facial tics and muscle spasms in various parts of her body,
especially of her fingers and toes, eyes, excessive blinking and twitching around her
mouth. The muscle spasms affect her writing. She has been punished in school for
shouting vulgarities. (Answer: E)
52. Tim is a ten-year-old boy brought to the clinic for an assessment. The mother
describes him as an argumentative person. He is also spiteful and blames others for
his troubles. Following an argument with his father, his family called a church
counsellor for advice. Tim told the counsellor that he could scold his father as he has
the freedom to express himself. (Answer: C)
53. Tina is a ten-year old girl with difficulties attending school. She complains of gastric
discomfort in the mornings and she has persistent fears that her parents might have an
accident or be kidnapped on their way to work. Tina does not sleep well at night.
(Answer: D)
54. Tom is a ten-year-old boy brought to the clinic for an assessment. On entering the
examination room, Tom was so disruptive that the doctor and nurses could not handle
him. The mother described a 4-year history of aggressive and destructive behavior at
home and in school. He has been suspended by the school on a yearly basis since
Primary 1 due to fighting. He is often uncontrollable at home and has broken dishes
and furniture. Last year, Tom was playing with the gas stove and started a small fire
in the HDB flat after an argument with his father. Tom frequently pulls the family dog
around by its tail. (Answer: B)
Author: Roger Ho
Question 55 – 57
Options:
A. Agranulocytosis
B. Irritable bowel syndrome
C. Neuroleptic malignant syndrome
D. Psychogenic polydispsia
E. Pseudoseizure
Lead-in: Select the most appropriate diagnosis from the above for the following clinical
scenario.
55. A 25-year-old man who suffers from schizophrenia, has a tonic – clonic
seizure as a result of hyponatraemia. He believes that he must drink water
constantly to purify himself of all sin. (Answer: D)
56. A 30-year-old woman who suffers from schizophrenia is stressed about her
new job as a receptionist. She complains of bloating, abdominal distension,
diarrhoea and frequent abdominal pain that is relieved by defecation. (Answer:
B)
57. A 35-year-old man with acute psychosis develops high fever, difficulty in
swallowing and labile blood pressure 3 days after commencing intramuscular
haloperidol. (Answer: C)
Author: Roger Ho
Question 58 – 60
Options:
A. Adherence therapy
B. Cognitive remediation
C. Graded exposure and desenitisation
D. Grief therapy
E. Psychoeducation
Lead-in: Select the most appropriate psychological treatment from the above for the
following clinical scenario.
58. A 20-year-old nursing student has been diagnosed with social phobia. She is
currently on medical leave but needs to prepare to return to her studies. She
says that she does not know how to overcome anxiety when she performs a
procedure in front of her tutors and classmates. (Answer: C)
59. A 23-year-old woman newly diagnosed with a first manic episode and is
currently an inpatient. She insists on writing a will, marrying a taxi driver and
booking a hotel to view fireworks during the National Day. She says that she
does not understand why she has so many new ideas racing through her
mind. (Answer: E)
60. A 40-year-old woman lost her daughter who committed suicide 6 months ago.
She feels very guilty and finds it difficult to move on. She is bargaining with
God to let her daughter be alive again. (Answer: D)
MCQ exam 12
A. Approximate answer
B. Circumstantiality
C. Flights of ideas
D. Lossening of associations
E. Tangentiality.
Author: Roger Ho
Year: 2015
Author: Roger Ho
Year: 2015
Author: Roger Ho
Year: 2015
Author: Roger Ho
Year: 2015
18. A 40-year-old woman suffes from depression The answer is D.
and insomnia. She worries that she does not
get enough rapid eye movement (REM) sleep at
Explanation: The REM sleep is more
night. She has read about REM sleep and wants
to discuss with you. Which of the following frequent towards the second half of
statements is CORRECT about the REM sleep? sleep. Each episode of the REM sleep
lasts for 90 minutes. The complexity of
A. Each episode of the REM sleep lasts for 3-4 hours. dream and sympathetic activity increase
B. Reduction of the REM sleep will lead to increased during the REM sleep. There is an
complexity of dream.
increase in vaginal blood flow during the
C. Reduction of the REM sleep will increase
sympathetic activity throughout her sleep. REM sleep.
D. She wakes up at 2 am and maintains light sleep
from 2am onwards. As a result, there is more Author: Roger Ho
interruption to the REM sleep. Year: 2015
E. There is reduction in vaginal blood flow during the
REM sleep.
23. All the following clinical features are more The answer is D.
common in late onset depression as compared to
early onset depression EXCEPT: Answer: Late onset depressive disorder is
associated with absence of family history
A. Cognitive impairment of depressive disorder. The following
B. High suicide risk features are more common in late onset
C. Paranoia depressive disorder: psychomotor
D. Presence of family history of depressive disorder retardation/agitation, complaints of
E. White matter changes loneliness, depressive pseudodementia
(cognitive impairment), paranoia, anxiety,
high suicide risk, somatic complaints,
white matter changes due to
microvascular infarcts.
Author: Roger Ho
Year: 2015
Author: Roger Ho
Year: 2015
The answer is B.
28. Peter is a 11-year-old boy and his mother
brought him to see you because she does Explanation: The most appropriate
not have the energy to deal with Peter. Hediagnosis is conduct disorder. In order to
lives with his mother and three siblings. fulfil the diagnostic criteria of conduct
His father left them when he was 7-year- disorder, here must be repetitive and
old. He is aggressive towards his sibling persistent pattern of behaviour in which
and classmates. He has difficulty keeping either the basic rights of others or major
up with school work and has been age appropriate societal rules are
transferred to 3 different schools in the violated. The duration of the symptoms
past 3 years. He has always been known to must have lasted for at least a minimum
be a bully in school. He has destroyed of 6 months. Other symptoms might
properties in school and wanted to join include setting fire and stealing objects of
gangs. Which of the following is the MOST value within the house and also outside
appropriate diagnosis? of the house.
Substance abuse
29. A 20-year-old schizophrenia patient receives The answer is C.
olanzapine 20 mg per day. He has been
compliant to olanzapine. He started smoking
Explanation: Nicotine increases the
for the past one month. After he started
smoking, he experiences more psychotic metabolism of olanzapine and smokers
symptoms. Which of the following is the MOST requires higher dose of olanzapine in
likely explanation? order to be effective.
The answer is D.
32. A 30-year-old man has been drinking 8
cups of coffee per day. Which of the Explanation: Excessive caffeine intake
following is NOT a side effect of excessive is associated with relaxation of lower
caffeine intake? oesophageal sphincter which is
associated with reflux.
A. Agitation
B. Diuretic effect Author: Roger Ho
C. Migraine Year: 2015
D. Tightened lower oesophageal sphincter
E. Sinus tachycardia.
Psychopharmacology
33. Which of the following medications has The answer is B.
recently obtained the FDA approval to treat low
sexual desire in women? Explanation: Filbanserin is a
norepinephrine-dopamine disinhibitor
A. Dapoxetine approved for the treatment of pre-
B. Flibanserin menopausal women with hypoactive
C. Sildenafil sexual desire disorder.
D. Tadalafil
E. Uprima
Author: Roger Ho
Year: 2015
Author: Roger Ho
Year: 2015
Psychotherapy
41. A 40-year-old man who is admitted to the The answer is E.
medical ward for upper gastrointestinal tract
bleeding, is known to be patient dependent on Explanation: This patient expresses his
alcohol. His gamma-glutamyl transferase (GGT) views to ban alcohol and claims that he
level is raised. During the interview, he hates drinking which is opposite to his
mentions that, ‘I hate drinking and alcohol. The unacceptable internal impulses to drink.
government should ban alcohol.’ What is his He drank prior to admission as evidenced
defence mechanism? by the raised GGT.
A. Actus reus
B. Jealousy
C. Automatism
D. Diminished responsibility
E. Mens rea.
44. A 21-year-old male patient suffered from The answer is D.
psychosis and his mother worried that his
condition would deteriorate. She brought him
Explanation: Non-maleficience refers to
to see a general practitioner. The doctor told
them that he had high toxin level in his body the obligation to avoid harm. In this case,
without performing any biological investigation. the general practitioner did not refer to
The doctor suggested magnetic field therapy the patient to see a psychiatrist or start
(MFT) to help him to detoxify. The doctor with an antipsychotic drug. He applied
charged $5000 for the MFT. His parents agreed magnetic field therapy (MFT) which has
for the treatment and borrowed money to pay
no evidence in treating psychosis. As a
for the treatment. After the MFT, his psychosis
got worse. Which of the following ethical result, the condition of patient got worse
principles did the general practitioner violate? and caused harm to patient.
A. Conduct disorder
B. Exhibitionism
C. Kleptomania
D. Psychopathy
E. Malignant narcissism
A. Kosakoff’s syndrome
B. Postnatal depression
C. Postpartum psychosis
D. Schizoaffective disorder
E. Wernicke’s encephalopathy
Author: Roger Ho
Year: 2014.
49. A 60-year-old man develops abnormal The answer is B.
movements including paralysis and gait
disturbances. He was stressed after moving Explanation: He suffers from
into a new HDB flat. His daughter is very conversion disorder due to stress
concerned. The neurologist has assessed him associated with moving house.
but cannot identify any underlying organic Conversion disorder usually involves
cause for his abnormal movements. His motor or sensory functions.
abnormal movements are controlled by
alprazolam. What is the MOST appropriate Author: Roger Ho
Year: 2014.
psychiatric diagnosis?
A. Conversion disorder
B. Dissociative fugue
C. Ganser syndrome
D. Munchausen syndrome
E. Somatisation disorder
Extended matching items
Question 51 – 54
Options:
A. Command hallucination
B. Pareidolia
C. Hypnagogic hallucination
D. Synaesthesia
E. Tactile hallucination
Lead-in: Select the most appropriate psychopathology from the above for the following
clinical scenario.
51. A 10-year-old girl saw a vivid image of Santa Claus on the cloud without conscious
effort. (Choose 1 option)
(Answer: B)
52. A 20-year-old woman complains of hearing colour after taking hallucinogen. (Choose
1 option)
(Answer: D)
53. A 30-year-old man is disoriented and says there are insects crawling under his skin.
(Choose 1 option)
(Answer: E)
54. A 70-year-old man complains of hearing a female voice from the toilet when he is
falling asleep. (Choose 1 option)
(Answer: C)
Question 55 – 57
Options:
A. Agranulocytosis
B. Myocarditis
C. Neuroleptic malignant syndrome
D. Psychogenic polydipsia
E. Syndrome of inappropriate anti-diuretic hormone secretion (SIADH)
Lead-in: Select the most appropriate diagnosis from the above for the following clinical
scenario.
55. A 40-year-old man is admitted due to seizure and hyponatraemia. He suffers from
chronic schizophrenia and believes that he must drink water constantly to purify
himself of all sin. (Choose 1 option)
(Answer: D)
56. A 45-year-old woman is admitted due to depression, low back pain and
hyponatraemia. She has history of lung cancer and the cancer has spread to the bone.
(Choose 1 option)
(Answer: E)
57. A 50-year-old man is admitted due to chest pain and dizziness after commencing
clozapine 5 weeks ago. (Choose 1 option)
(Answer: B)
Question 58 – 60
Options:
A. Agomelatine
B. Carbamazepine
C. Lithium carbonate
D. Risperidone
E. Vortioxetine
Lead-in: Select the most appropriate psychotropic medication from the above for the
following clinical scenario.
(Answer: D)
(Answer: A)
60. A 40-year-old woman develops toxicity commencing thiazide and another medication
together. (Choose 1 option)
(Answer: C)
MCQ exam 13
Author: Roger Ho
Year: 2015
3. A 30-year-old man suffers from brain tumour and The answer is C.
develops catatonia. Which of the following is NOT
a classical sign of catatonia?
Explanation: Lip smacking is a
A. Ambitendency classical feature of tardive dyskinesia
B. Echolalia but not catatonia. Option A, B, D and
C. Lip smacking E are classical features of catatonia.
D. Mutism
E. Waxy flexibility Author: Roger Ho
Year: 2015
4. A 65-year-old depressed man has been refusing The answer is C.
his meals. He believes there is no point eating
since he is dying. When the doctor reviews him in
Explanation: This patient exhibits
the evening, he says “I was dead in the morning
till afternoon”. Which of the following terms BEST most severe form of delusion of
describe his psychopathology? nihilism and believed that he was
dead. Delusion of nihilism is
A. Delusion of hypochondriasis associated with depression.
B. Delusion of identity
C. Delusion of nihilism
1
D. Delusion of persecution Author: Roger Ho
E. Delusion of reference Year: 2015
Cognitive assessment
5. Which of the following cognitive impairments are The answer is D.
MOST likely to be associated with subcortical
dementia? Explanation: Parietal lobe is
responsible for calculation and
A. Impairment in calculation and mood disorder occipital lobe is responsible
B. Impairment in calculation and visuospatial abilities visuospatial abilities. Temporal lobe
C. Impairment in visuospatial abilities and memory loss is responsible for memory and
D. Difficulty in articulation and mood disorder Broca’s area on the frontal lobe is
E. Memory loss and language problem responsible for language. Dysarthria
and depression are most likely to be
associated with subcortical dementia.
Author: Roger Ho
Year: 2015
Psychiatric epidemiology
6. The percentage of children with autistic disorder The answer is E.
also suffering from mental retardation is?
Explanation: Previous
epidemiological study has shown
A. 10% that 70% of children with autism
B. 20% have mental retardation.
C. 30% Approximately 30% has mild to
D. 50% moderate mental retardation, and
E. 70%. around 40% have severe to profound
mental retardation.
Author: Roger Ho
Year: 2015
Psychiatric aetiology and pathology
7. A 30-year-old schizophrenia patient is interested The answer is D.
in Indian dance. She needs to imagine and act for
different characters (e.g. princess, animal etc)
Explanation: This patient exhibits
during the performance. She has difficulty putting
herself in those imagined situations. Damages in difficulty in abstract thinking as a
which of the following neuroanatomical areas is result of damage in the pre-frontal
MOST likely to cause her difficulty? cortex which is a common pathology
found in schizophrenia.
A. Basal ganglia
B. Occipital lobe Author: Roger Ho
C. Parietal lobe
D. Frontal lobe Year: 2015
E. Temporal lobe.
2
D. Operant conditioning
E. Secondary gain. Author: Roger Ho
Year: 2015
9. Which of the following neuroanatomical areas is The answer is C.
LEAST likely to be affected in Alzheimer's
disease? Explanation: Nucleus accumbens
is associated with addiction and
A. Basal nucleus of Meynert
least likely to be affected in
B. Hippocampus
C. Nucleus accumbens Alzheimer’s disease compared to
D. Parietal lobe other structures. Basal nucleus of
E. Temporal lobe Meynert produces acetylcholine.
Hippocampus is affected due to
memory impairment in
Alzheimer’s disease.
Hippocampus is found in the
medial temporal lobe. Parietal
lobe is affected and resulted in
constructional apraxia.
Author: Roger Ho
Year: 2015.
10. Based on previous research evidence, which of the The answer is A.
following personality disorders is MOST commonly
seen in an individual who has past psychiatric Explanation: Previous research has
history of conduct disorder? demonstrated that around 40% of
young people with conduct disorder
A. Antisocial personality disorder go on and develop antisocial
B. Borderline personality disorder personality disorder in adulthood.
C. Histrionic personality disorder
D. Narcissistic personality disorder Author: Roger Ho
E. Passive aggressive personality disorder. Year: 2015.
3
factor for PTSD symptoms. and maintains PTSD symptoms. It is
B. Dissociation is not seen in patients suffering from important to assess the legal status,
PTSD. especially in PTSD related to road
C. Eye movement desensitization reprocessing (EMDR) traffic accident.
shows the most effective results.
D. The duration of PTSD can be as short as 48 hours Author: Roger Ho
after a traumatic event. Year: 2015
E. PTSD has unique clinical features and patients
cannot suffer from comorbid anxiety or depression.
Author: Roger Ho
Year: 2015
14. Which of the following conditions is least likely to The answer is C.
be a co-morbidity of OCD?
Explanation:
A. Anankastic (Obessive compulsive) personality trait Among all the options, pathological
B. Paediatric autoimmune neuropsychiatric disorder gambling is least likey to be a
associated with Streptococcus comorbidity of obsessive compulsive
C. Pathological gambling disorder (OCD). PANDAS is one of the
D. Pathological hoarding causes of paediatric OCD. Tourette’s
E. Tourette’s syndrome syndrome is common in young
people with OCD (incidence: 5 to 7%;
20-30% have history of tics).
Pathological hoarding is part the
OCD spectrum disorder. Some of the
OCD patients have obsessive
compulsive personality trait.
Author: Roger Ho
Year: 2015
4
borderline personality disorder is FALSE?
Explanation: Impulsivity in borderline
A. Dialectical behaviour therapy and mentalisation- personality disorder improves
based therapy are evidence-based psychotherapy. significantly over time while affective
B. Environmental factors play more important role than symptoms have the least
genetic factors. improvement.
C. Impulsivity worsens when the patients get older.
D. Projective identification is a common defence Author: Roger Ho
mechanism. Year: 2015
E. The majority of patients are women.
Author: Roger Ho
Year: 2015
17. A 30-year-old woman suffers from depression The answer is B.
due to infertility. Further inquiry reveals that she
suffers from spastic contraction of her vagina
Explanation: This woman suffers
during sexual intercourse. Which of the following
is MOST appropriate management? from vaginismus. It is not uncommon
that woman suffering from
A. Apply dynamic psychotherapy and explore vaginismus is mistaken as a
unconscious conflicts depressed or anxious patient and
B. Apply behaviour therapy and gradual approach of being offered with psychiatric
using dilator of increasing size.
treatments without treating the
C. Prescribe muscle relaxant such as bromazepam.
underlying condition. The most
D. Prescribe selective serotonin reuptake inhibitor such
as fluvoxamine. evidenced treatment is applying
E. Prescribe as norepinephrine-dopamine disinhibitor dilator in a gradual approach as part
such as filbanserin. of the behaviour therapy.
Author: Roger Ho
Year: 2015
5
D. Orientation
E. Visual-spatial organization. Author: Roger Ho
Year:2015
6
Child and adolescent psychiatry
23. Which of the following childhood psychiatric The answer is E.
disorders has the LOWEST heritability?
Explanation: Genetic factors are
A. Asperger’s syndrome implicated in all of the above
B. Attention deficit and hyperactivity disorder conditions with the exception of
C. Autism school refusal. For ADHD, first-
D. Enuresis degree relatives are at high risk of
E. School refusal. developing ADHD. For autism,
evidence suggests that two regions
on chromosome 2 and 7 contain
genes related to autism. Similarly,
70% of children with enuresis have a
first degree relative who suffered
from enuresis.
Author: Roger Ho
Year: 2015
24. Which one of the following medications is MOST The answer is A.
indicated for a child diagnosed with attention
deficit and hyperactivity disorder (ADHD) but has a Explanation: Atomoxetine is
previous history of Tourette’s syndrome? indicated for treatment of a child
diagnosed with ADHD and with a
A. Atomoxetine previous history of Tourette’s
B. Fluoxetine syndrome. The indications for the
C. Methylphenidate usage of non-stimulants include
D. Risperidone inability to tolerate the side effects
E. Omega-3 fatty acids. associated with stimulants,
unsatisfactory response to
stimulants and history of substance
misuse.
Author: Roger Ho
Year: 2015
25. Which of the following symptoms ONLY occurs in The answer is D.
children with conduct disorder but not oppositional
defiant disorder? Explanation: Children suffering from
oppositional defiant disorder tend to
A. Annoy other people and like to argue have temper tantrums, being angry
B. Being spiteful and defy rules and spiteful, argue with adults, defy
C. Blame others for their own mistakes and refuse to rules and blame others for their
take responsibility mistakes. Children suffering from
D. Damage property and threaten the basic rights of oppositional defiant disorder do not
other people damage properties and threaten the
E. Refuse to go to school and have poor academic basic rights of other people.
performance.
Author: Roger Ho
Year: 2015
Substance abuse
26. A 30-year-old man was admitted to the The answer is C.
medical ward due to epilepsy. Currently, he
7
does not have access to the drug which he Explanation: Midazolam is a
often used prior to admission. He complains benzodiazepine and it is one of the
of insomnia, anxiety and shakiness. He is not benzodiazepine most commonly
depressed. Which of the following being misused by patients due to its
substances is MOST likely to cause the rapid onset of action. The
above symptoms? withdrawal symptoms include
insomnia, anxiety, shakiness and
A. Cocaine withdrawal fit. Withdrawal from
B. Methylphenidate
cocaine will lead to crash or
C. Midazolam
D. Nicotine depression.
E. Quetiapine
Author: Roger Ho
Year: 2015
27. Which of the medication is LEAST likely to be The answer is C.
used to treat patients suffering from substance
abuse in Singapore?
Explanation: Buprenorphine
A. Acamprosate for alcohol dependence and (Subutex) is banned in Singapore
mefenamic acid for opioid withdrawal. after widespread diversion between
B. Bupropion for nicotine dependence and methadone 2004 to 2006. Disulfiram is not used
for opioid dependence worldwide because of potential
C. Buprenorphine for opioid dependence and disulfiram serious cardiovascular complications
for alcohol dependence when mixed with alcohol.
D. Diazepam for benzodiazepine withdrawal and
vareniciline for nicotine dependence
E. Hydroxyzine for opioid withdrawal and naltrexone for Author: Roger Ho
pathological gambling. Year: 2015
Author: Roger Ho
Year: 2015
Psychopharmacology
29. Regarding bupropion, which of the following The answer is B.
statements is FALSE?
Explanation: Bupropion is less likely
A. A common side effect is weight loss. to cause sexual dysfunction as
B. It leads to the same degree of sexual dysfunction as compared to other selective
fluoxetine. serotonin reuptake inhibitors.
8
C. It blocks dopamine reuptake.
D. It is contraindicated for patients with history of Author: Roger Ho
epilepsy. Year: 2015
E. It is used in the treatment of attention deficit and
hyperactivity disorder
Author: Roger Ho
Year: 2015
32. Regarding lamotrigine, which of the following The answer is B.
statements is CORRECT?
Explanation: Besides option B, the
A. During the first week of initiation, there should be other options are incorrect. During
rapid increase in dose after initiation to achieve rapid the first week of initiations, slow
control of mood symptoms. introduction of the drug, with gradual
B. Lamotrigine has acute and prophylactic weekly increases in dose will reduce
antidepressant effects in bipolar depression. the risk of rash. Although H.S.A. does
C. The risk of serious rashes appears to be much lower not require genetic test HLA B*1502
in Singaporean patients as compared to other test before initiation for lamotrigine,
countries. this does not mean lamotrigine does
D. The serum levels of lamotrigine are needed to be not cause Steven Johnson
monitored for treatment. Syndrome. Quite a number of local
E. There is no need to conduct genetic test before Singaporean patients develop Steven
starting lamotrigine because Stevens-Johnson Johnson Syndrome after taking
syndrome is not known to occur. lamotrigine.
Author: Roger Ho
Year: 2015
33. Which of the following is the MOST The answer is C.
APPROPRIATE indication for prescribing
clozapine? Explanation: Clozapine may cause
9
agranulocytosis and requires
A. Failed trial of chlorpromazine and sodium valproate frequent full blood count monitoring.
with adequate dose and duration of treatment. A psychiatrist only prescribes
B. Failed trail of fluanxol, a long-acting depot clozapine if a patient fails to respond
antipsychotic drug with adequate dose and duration. to a first generation and second
C. Failed trial of haloperidol and olanzapine with generation antipsychotic drug with
adequate dose and duration of treatment. adequate dosage and duration of
D. Failed trial of risperidone and quetiapine with treatment.
adequate dose and duration of treatment.
E. Recurrent schizoaffective symptoms and suicidal Author: Roger Ho
ideation and does not respond to quetiapine and Year: 2015
fluoxetine
10
and his family doctor has started a medication to
treat his symptoms. He develops jaundice and Explanation: This patient develops
dark urine after taking the medication. Which of
idiopathic fatal hepatotoxicity after
taking sodium valproate.
the following medications is MOST LIKELY to be
responsible? Author: Roger Ho
Year: 2015
A. Haloperidol
B. Lamotrigine
C. Lithium
D. Sodium valproate
E. Sulpiride.
Psychotherapy
38. A 40-year-old man is admitted to the medical The answer is D.
ward because of upper gastrointestinal tract
bleeding. He has 30-year history of alcohol Explanation: This man tries to justify
dependence. His amylase level is high. During the
interview, he mentions that, „Compared to people
his alcohol dependence with a
who died of famine and war, I am very lucky plausible explanation rather than
indeed. There is no big deal about drinking examining the real cause of upper
alcohol. We should fulfil our dream when we are gastrointestinal bleeding.
alive. I prefer to drink and will continue to drink.‟
What is his defence mechanism? Author: Roger Ho
Year: 2015
A. Acting out
B. Denial
C. Projection
D. Rationalization
E. Reaction formation.
11
E. Selective abstraction
The answer is B.
42. Which one of the following is the BEST predictor of
future violent behaviour? Explanation: A history of past
violence is the best predictor of
A. History of conduct disorder future violence among the 5 options.
B. History of past violence
C. History of substance abuse Author: Roger Ho
D. Low intelligence. Year: 2015
E. Presence of first rank symptoms
43. You are a General Practitioner. You have been The answer is D.
managing a 40-year-old businessman who suffers
from depression and he is undergoing a divorce.
Explanation: Based on the scenario,
His wife, who is not staying with him, calls your
clinic and requests a medical report on behalf of this man is 40-year-old, working as a
her husband. She is very upset that he has businessman and suffering from
prepared a will and decided to give his properties depression, he has capacity to make
to his parents. His wife claims that her lawyer decision. His wife may have hidden
requests for a medical report to certify her agenda for the arrangement of
husband suffers from depression and lacks the
properties. Based on the PDPA, you
capacity to write a will. His wife believes that he
is suicidal but does not want the property to be cannot issue medical report without
transferred to his parents if he would commit her husband’s consent even it is
suicide. She does not communicate with her requested by her lawyer.
husband. Which of the following actions is MOST
appropriate? Author: Roger Ho
Year: 2015
A. Call the patient immediately and sends him to the
nearest Accident and Emergency Department for
assessment.
B. Issue the medical report to his wife and keep the
discussion with his wife confidential.
C. Issue the medical report to his wife because the
medical report is requested by her lawyer.
D. Refuse to issue the medical report and inform his
12
wife that his medical information is protected by the
Personal Data Protection Act.
E. Refuse to issue the medical report and inform his
wife that her husband is protected by the Mental
Capacity Act.
13
people are around and there is
gradual onset. In addition, there is
the presence of wide range of
atypical presentation such as pelvic
thrusting, lack of tonic and clonic
movements, one-sided
somatosensory symptom and
reactive papillary light reflex.
Author: Roger Ho
Year: 2015
47. Which of the following psychiatric conditions is The answer is B.
most prevalent after a head injury?
Explanation: The most common
A. Anorexia, motor retardation and terminal insomnia psychiatric condition after a head
B. Anxiety, irritability and sensitive to noises injury is post-concussion syndrome
C. Depression, simple auditory hallucination and with a prevalence rate of 50% after 2
paranoia months and 12% after 1 year.
D. Panic attack, phobia and interpersonal rejection Anxiety, irritability and sensitive to
sensitivity noises are symptoms of post-
E. Reactive mood, change in appetite and leaden concussion syndrome. Option A
paralysis suggests melancholia. Option E
suggests atypical depression.
Author: Roger Ho
Year: 2015
48. A 60-year-old woman presents with uncontrollable The answer is C.
episodes of laughing or crying. Which of the
following conditions is LEAST likely to cause such Explanation: This woman suffers
phenomenon? from pathological crying. Common
causes include dementia, multiple
A. Bipolar disorder sclerosis, stroke and severe head
B. Cerebrovascular accident injury. Lability associated with
C. Chronic schizophrenia bipolar disorder may present with
D. Dementia uncontrollable episodes of laughing
E. Multiple sclerosis and crying. Chronic schizophrenia is
least likely to cause this
phenomenon and associated with
blunted affect.
Author: Roger Ho
Year: 2015
14
A. Agomelatine Year: 2015
B. Carbamazepine
C. Enalapril This is an advanced level question.
D. Fluoxetine
E. Thiazide
50. A 30-year-old woman came to see you because she The answer is A.
worries that her nose is too large and crooked since
the age of 15 years. She is increasingly worried Explanation: This woman suffers
about her nose deformity despite assurance from from body dysmorphic disorder.
various doctors. Which of the following is the first- Patients with this disorder have
line medication for her condition? preoccupation with perceived
defects or flaws in physical
A. Fluoxetine appearance that are not observable
B. Lithium to others. They perform repetitive
C. Lorazepam behaviours or mental acts (e.g.
D. Risperidone comparing their appearance with
E. Valproate that of others) in response to their
appearance concerns. Selective
serotonin re-uptake inhibitors (SSRIs)
antidepressants are first-line
treatment. About 50% of patients
respond to SSRIs but if the response
is poor, augmentation with a second-
generation antipsychotic is
recommended.
Author: Roger Ho
Year: 2015
EMI Paper 13
Question 51 – 53
15
Options:
A. Alzheimer's dementia
B. Antisocial personality disorder
C. Acute manic episode
D. Exhibitionism
E. Schizophrenia
Lead-in: Select the most appropriate diagnosis from the above for the following clinical
scenario.
51. A 32-year-old Chinese man is arrested after lurking in the sand dunes, exposing his
flaccid penis to sunbathing females in the Sentosa beach. (Choose 1 option) D
52. A 40-year-old Malay man is arrested after running naked down the Orchard Road
shouting that he is the God of Love. (Choose 1 option) C
53. A 65-year-old Indian man is arrested after exposing himself at a local park. His family
reported to the police that he went missing. He could not find his way home and slept in the
local park. (Choose 1 option) A
Question 54 – 57
Options:
A. Catatonia
B. Conversion disorder
C. Elective mutism
D. Psychomotor retardation
E. Thought blocking
Lead-in: Select the most appropriate diagnosis from the above for the following clinical
scenario.
54. A 10-year-old boy is brought by his mother for not speaking to her for the past four
months, following the arrival of a stepfather in his house. He has a history of multiple
parental separations. He studies at a neigbourhood primary school and the school report
shows good academic performance in all subjects. (Choose 1 option) C
55. A 20-year-old lady took some unknown medication to lose weight. She has lost 20 kg
over 3 months but she develops mutism, rigidity, echopraxia and negativism. (Choose 1
option) A
16
56. The speech of a 30-year-old man is so delayed that he begins to reply only when the
interviewer asks the next question. He makes no eye contact and has lost considerable weight.
(Choose 1 option) D
57. A 40-year-old woman suddenly develops an inability to see during a bitter family
argument over her late father's will and properties. Her family bring her to the family doctor.
She herself does not seem distressed and able to find her way out of the clinic. (Choose 1
option) B
Question 58 – 60
Options:
A. Diminished responsibility
B. Fitness to plead
C. Informed consent
D. Lasting power of attorney
E. Torasoff’s rule: Duty to warn
Lead-in: Select the most appropriate concept from the above for the following clinical
scenario.
58. A 20-year-old man tells his therapist that he and her girlfriend are "fated to be together".
He is very upset with her for breaking off with him and plans to stab her. (Choose 1 option)
E
59. A 40-year-old woman assaulted a delivery man whom she believed he was sent by Satan.
The man suffered from mild injury and she was arrested by police. After starting clozapine
during her hospitalisation at the Institute of Mental Health, the patient no longer believes the
victim was sent by Satan. The Court asks if the case can proceed. (Choose 1 option)
B
60. A 60-year-old woman agrees to appoint her son and daughter to be the donees and make
decision for her when she develops dementia. (Choose 1 option)
D
17
MCQ exam 14
A. Conversion disorder
B. Early onset Alzheimer’s disease
C. Fronto-temporal lobe dementia
D. Dissociative amnesia
E. Schizotypal personality disorder.
Author: Roger Ho
Year: 2015
3. A 40-year-old German woman residing in The answer is B.
Singapore reported hearing her neighbour
talking about her for the past two weeks. She Explanation: She suffers from acute
claims two male voices getting angry and psychosis due to stress. She reports
making racist remarks about her and saying pseudohallucinations. As a result,
that she should leave Singapore, while the she has good prognosis and benefit
female voice took her side and defended her. from short course oral antipsychotic
She can hear their voices inside her head and regular follow-up.
everywhere in her house at any time of the
day. She does not have any suicidal or Author: Roger Ho
homicidal ideation. Her other struggles at Year: 2015
this time included stress of taking care of two
children when her husband went overseas.
Which of the following statements is correct?
A. She exhibits negative symptoms of schizophrenia.
B. She has good prognosis.
C. She has poor prognosis.
D. She requires depot antipsychotic treatment.
E. She suffers from paranoid personality disorder.
4. Which of the following subtypes of delusion is the The answer is D.
LEAST frequent?
Explanation: Shared delusion or folie
A. Grandiose a deux is rare because it requires
B. Jealous two persons to become patients.
C. Persecutory
D. Shared Explanation: Roger Ho
E. Somatic. Year: 2015
Cognitive assessment
The answer is C.
5. Which of the following features is more
suggestive of dementia rather than pseudo- Explanation: In genuine dementia
dementia? like Alzheimer’s disease, memory is
worse for recent events. Option A, B,
A. Abrupt onset of cognitive impairment D and E are more suggestive of
B. Depressed mood before onset of cognitive pseudodementia.
impairment
C. Memory worse for recent events as compared to Author: Roger Ho
remote events Year: 2015
D. No confabulation
E. Fluctuation of cognitive ability
Psychiatric epidemiology
7. Which one of the following is LEAST likely to be a The answer is B.
psychiatric comorbidity of trichotillomania?
Explanation: Trichotillomania is the
A. Anxiety disorder compulsion to pull out one’s hair.
B. Antisocial personality disorder The peak age at onset is 12–13 years,
C. Depressive disorder and the disorder is often chronic and
D. Deliberate self-harm difficult to treat Trichotillomania is
E. Obsessive compulsive disorder typically confined to one or two
sites. It most frequently affects the
scalp. Patients tend to be highly
secretive about the condition and to
regard their behaviour as shameful.
The common comorbid psychiatric
disorders in trichotillomania include
mood and anxiety disorder,
obsessive compulsive disorder
substance and eating disorders.
Antisocial personality disorder is not
associated with trichotillomania.
Author: Roger Ho
Year: 2015
Author: Roger Ho
Year: 2015
Author: Roger Ho
Year: 2015
10. All of the following is the MOST IMPORTANT The answer is E.
protective factor against suicide in Singapore?
Explanation: Religion is most
A. Low social class due to lower social expectation important protective factor against
B. Male gender due to commitment to look after family suicide in Singapore. For suicide, the
C. Overinvolved spouse who looks after patient all the male to female gender ratio is 3:1
time and the rate of women is rising.
D. People suffering from borderline personality There is higher risk in the low and
disorder who often harm themselves instead of high social classes and lower risk in
killing themselves the middle social class. Suicide rates
E. Having faith in a religion which condemns suicide in the divorced and widowed are
higher than that of people who are
married. Unemployment, low
socioeconomic status, and certain
occupations such as bar owners,
doctors, and pharmacists are risk
factors. Suicide attempts occur after
significant life events are common
among people with poor social
support and living alone.
Author: Roger Ho
Year: 2015
Author: Roger Ho
Year: 2015
Author: Roger Ho
Year: 2015
19. Which of the following would be most helpful for a The answer is C.
patient suffering from delirium after liver
transplant? Explanation: Prednisolone is
associated with delirium and
A. Being placed in a room far away from the nursing psychosis. Amitriptyline is associated
station with anticholinergic effect.
B. Being placed in a shared room with four other
patients Author: Roger Ho
C. Decreasing the dose of prednisolone Year: 2015
D. Increasing the dose of amitriptyline
E. Increasing the dose of anticholinergic medications
The answer is D.
20. You are seeing a 60-year-old cleaner. He
complains of the following, “I am losing my Explanation: He suffers from mild
ability to remember and learn new information. cognitive impairment as evidenced
I forgot that today is my wedding anniversary by the following:
until my wife tested me. I put the peanut butter
1. MMSE >24
in the fridge when it should actually be left on
the dining table. I tried reading the newspaper 2. Subjective or objective
but could not understand. I got confused over memory loss
the PIN number for my ATM card and needed 3. ADL: independent
to write it down. I am able to function in my 4. Amnesia type of MCI
work”. He scored 25 out of 30 in the Mini 5. He is able to function at
Mental State Examination (MMSE). What of the work.
following is the most appropriate diagnosis?
Author: Roger Ho
A. Alzheimer’s disease
B. Fronto-temporal lobe dementia Year: 2015
C. Generalised anxiety disorder
D. Mild cognitive impairment
E. Pseudo dementia
21. A 77-year-old woman suffering from major The answer is E.
depressive disorder. She was prescribed with
sertraline. The dose of sertraline was titrated up Explanation: This elderly woman
to 150mg per day. One week later, she presents suffers from hyponatremia. Low
nausea and malaise, lethargy, decreased level of sodium levels result in intracerebral
consciousness and headache. She is afebrile. osmotic fluid shifts and brain
Which of the following investigation is MOST oedema. As a result, she complains
RELEVANT? of headache.
24. Which the following is the MOST common age of The answer is A.
onset for oppositional defiant disorder?
Explanation: The prevalence of
A. 8-year- old oppositional defiant disorder has
B. 10-year-old been estimated to be between 6 and
C. 12-year- old 16 percent. The age of onset of
D. 14-year-old oppositional defiant disorder is
E. 16-year-old usually before the age of 10 years.
This differs from that of conduct
disorder. The age of onset of
conduct disorder begins earlier in
boys (10-12 years) as compared to
girls (14-16 years).
Author: Roger Ho
Year: 2015
25. Which of the following is the MOST common cause The answer is A.
of intellectual disability?
Explanation: Down syndrome is the
A. Down syndrome most common cause of intellectual
B. Prader-Willi syndrome disability, with the risk increasing
C. Foetal alcohol syndrome with maternal age. It accounts for
D. Fragile X syndrome 30% of all children with intellectual
E. Turner syndrome. disability. In contrast, fragile X
syndrome is the most common
inherited cause of intellectual
disability. Women with fragile X
syndrome suffer from mild
intellectual disability, while men
suffer from moderate to severe
intellectual disability.
Author: Roger Ho
Year: 2015
Author: Roger Ho
Year: 2015
Substance abuse
27. According to the Central Narcotics Bureau, The answer is C.
possession and consumption of the following
drugs would NOT lead to imprisonment or fine in
Explanation: Methadone is partial
Singapore?
opioid agonist and an opioid
A. Buprenorphine substitute for patients who are
B. Ketamine addicted to heroin. Although it is not
C. Methadone illegal to possess or consume
D. Methamphetamine methadone, it is only prescribed by
E. Nimetazepam.
addiction specialists at the National
Addiction Management Service,
Institute of Mental Health.
Author: Roger Ho
Year: 2015
Author: Roger Ho
Year: 2015
Psychopharmacology
31. A 30-year-old man suffers from erectile The answer is C
dysfunction and requests to take sildenafil. You
are reviewing his medication lists. Which of the Explanation: Nitroglycerin is a
following medications would lead to the MOST nitrate. Sildenafil and nitrate both
dangerous drug interaction?
cause the muscles that control the
size of blood vessels to relax.
A. Fluoxetine
B. Metformin
When these muscles relax, the
vessels enlarge in diameter and
C. Nitroglycerin
may lead to hypotensive crisis.
D. Sodium valproate
E. Simvastatin
Author: Roger Ho
Year: 2015
32. Which of the following side effects is specific for The answer is C.
venlafaxine but not fluoxetine?
Explanation: Venlafaxine is
A. Dry mouth
B. Nausea associated with dose-related
C. Hypertension hypertension. Option A, B, D and E
D. Sexual dysfunction are associated with both fluoxetine
E. Risk of serotonin syndrome and venlafaxine.
Author: Roger Ho
Year: 2015
Author: Roger Ho
Year: 2015
Author: Roger Ho
Year: 2015
Psychotherapy
39. A 30-year-old woman with history of shoplifting The answer is E.
and recurrent self-harm due to anger and
frustration towards her foster parents. After
Explanation: The best answer is
release from the prison, she has applied for
volunteer programme. She wants to turn her sublimation because she expressed
anger and hatred to help needy people. Which of her unacceptable impulses (e.g.
the following BEST describes her defence anger and hatred) in an acceptable
mechanism? way (i.e. volunteer work).
A. Projection
Author: Roger Ho
B. Rationalisation
C. Reaction formation Year: 2015
D. Repression
E. Sublimation
40. A 32-year-old schizophrenia patient wants to The answer is D.
receive psychotherapy. Which of the following
types of psychotherapy is LEAST suitable for
Explanation: Schizophrenia patients
this patient?
suffer from hallucinations and
A. Cognitive behaviour therapy delusions which make them confuse
B. Interpersonal psychotherapy with reality. Schizophrenia patients
C. Problem solving psychotherapy will be confused by interpretations
D. Psychodynamic psychotherapy. offered by the psychotherapist.
E. Supportive psychotherapy
Author: Roger Ho
Year: 2015
Author: Roger Ho
Year: 2015
Author: Roger Ho
Year: 2015
46. Which of the following neuropsychiatric sequelae The answer is A.
is more likely to occur after carbon monoxide
poisoning as compared to post-concussion Explanation: Option B to E are
syndrome? shared by both carbon monoxide
poisoning and PCS. Agnosia is more
A. Agnosia common in carbon monoxide
B. Dizziness poisoning.
C. Headache
D. Lethargy Author: Roger Ho
E. Slow mental processing speed. Year: 2015
Author: Roger Ho
Year: 2015
48. Regarding depression in patients suffering from The answer is D.
Parkinson’s disease, which of the following is
LEAST likely to be an important predisposing Explanation: Female gender rather
factor? male gender is a predisposing factor
for depression in Parkinson’s
A. Early onset disease.
B. Family history of depression
C. Loss of functional independence Author: Roger Ho
D. Male gender Year: 2015
E. Presence of cognitive impairment.
50. The medical team has diagnosed several depressed The answer is B.
patients presenting proximal muscle weakness as
somatisation disorder. The medical team did not Explanation: Hypothyroidism is
order any blood test prior to their diagnosis and associated with proximal muscle
could have missed important medical diagnosis. weakness and depression among all
Which of the following diagnosis is MOST likely to options. The medical team should
be associated with the above presentation? order thyroid function test and
conduct thorough investigations
A. Amphetamine withdrawal before concluding somatisation
B. Hypothyroidism disorder.
C. Insulinoma
D. Phaeochromocytoma Author: Roger Ho
E. Rheumatoid arthritis. Year: 2015
Question 51 – 54
Options
A. Amygdala
B. Broca’s area
C. Cerebellum
D. Corpus callosum
E. Tuberoinfundibular system
Lead-in: Select the most appropriate neuroanatomical areas from the above for the
following signs and symptoms.
52. Non-fluent aphasia (Choose 1 option) Answer: B or no answer: Give one mark
Question 55 – 57
Options
A. Anorexia nervosa
B. Delusional disorder
C. Obsessive compulsive disorder
D. Munchausen syndrome by proxy
E. Schizophrenia
Lead-in: Select the most appropriate clinical diagnosis from the above for the following
scenarios.
55. An 8-year-old girl is admitted due to diarrhoea and weight loss. Her mother has been
feeding her with laxative and hopes that she is admitted to the hospital as a patient.
(Choose 1option) Answer: D
56. An 18-year-old man is admitted for weight loss. He says he cannot eat because he has
heard multiple voices warning him that the demons are poisoning his food. He has
undergone spiritual warfare with the demons for 6 months and the demons are taking
his thoughts away. (Choose 1 option) Answer: E
57. A 28-year-old woman worries that all the food are contaminated by radiation and
antimicrobial drugs in agriculture. She has been washing her food in multiple of
twenty. As a result, she does not have time to eat and results in weight loss. (Choose
1 option)
Answer: C
Question 58 – 60
Options
A. Alcohol
B. Cannabis
C. Heorin
D. Solvent
E. Tobacoo
Lead-in: Select the most appropriate substances from above for the following situations.
58. Which type of addiction has the highest rate of mortality worldwide? (Choose
1 option) Answer: E
59. Which type of addiction is most likely to be associated with blood-borne viral
infection? (Choose 1 option) Answer: C
3. List TWO (2) features that differentiate an obsession from a delusion (4 marks).
Examiner’s use only: / 4 marks
Answer may vary. The examiner is advised to use his or her discretion to decide whether marks should be
awarded.
Differences between obsessions and delusions:
obsessions are ego-dystonic (disharmony with one’s own ego) while delusions are ego-syntonic (in
harmony with one’s own ego) 2 marks or
obsessions involve intact reality testing, whereas in delusions reality testing is impaired (2 marks)
or
obsessions cause anxiety and distress, whereas patients with delusion are usually calm (2marks)
or
obsessions involve compulsive actions to neutralize them, whereas delusions do not (2 marks)
obsessions are not held with absolute certainty whereas delusions are (2 marks).
This is an advanced – level question.
4. List TWO (2) types of evidence-based and commonly used treatment for obsessive compulsive
disorder (2 marks).
Examiner’s use only: / 2 marks
Selective serotonin reuptake inhibitors or name of SSRI e.g. fluoxetine (1 mark); antidepressant (0.5
mark); other (0 mark)
Cognitive behaviour therapy (1 mark); Exposure and response prevention (0.5 mark); Other (0 mark)
Administrator’s use only (Total): Administrator 1: / 10 marks Administrator 2: /10 marks
Question 3
A 3-year-old boy has delayed language development. He is of normal height and weight, and has no
obvious physical abnormalities.
1. List THREE (3) main clinical features which you would look for to support the diagnosis of
autistic disorder (3 marks)
Examiner’s use only: / 3 marks
Answer may vary. The examiner is advised to use his or her discretion to decide whether marks should be
awarded.
1. Restricted interests or hobbies or repetitive behaiour.
2. Communication difficulties (both verbal – language delay and non-vebal – lack of eye contact, failure
to understand emotional cues)
3. Stereotyped movements or social interaction difficulty.
2. List TWO other causes for his poor language skills besides autism (2 marks).
Examiner’s use only: / 2 marks
Answer may vary. The examiner is advised to use his or her discretion to decide whether marks should be
awarded. Any two of the following:
1. Maltreatment or abuse
2. Mental retardation
3. Neurological injury
4. Hearing impairment
5. Specific language impairment (such as expressive language disorder)
6. Genetic disorders (Fragile X syndrome)
3. Name THREE (3) investigations which you order to establish the underlying cause for language
delay. (3 marks)
4. Name TWO (2) non-pharmacological interventions which are useful for autism. (2 marks)
2. Name TWO (2) psychiatric disorder commonly associated with catatonia.(2 marks)
Schizophrenia
Bipolar disorder
Depressive disorder
Substance abuse with acute intoxication of recreation drugs.
3. At NAME TWO (2) medical disorders that are known to be associated with catatonia. (2 marks)
4. List ONE (1) most important investigation which you would order to identify the underlying
neurological cause for catatonia.(1 mark)
Magnetic Resonance Imaging (MRI) brain scan (1 mark); Computerized Tomography (CT) brain scan
(1 mark); other answer (0 mark)
You are a General Practitioner. A 30-year-old woman comes to your clinic and she complains of low
mood. You suspect that she suffers from depressive disorder. She read a lot of information on the internet
and has her personal views on treatment. She would like to discuss with you on various treatment options.
1. List Four (4) pieces of information which you would inquire from the history to support the
decision for immediately prescribing an antidepressant to this patient (4 marks).
Answer may vary. The examiner is advised to use his or her discretion to decide whether marks should be
awarded.
1. The severity of depression: her symptoms are severe (e.g. with the presence of suicidal thought and a
lot of biological symptoms).
2. Lack of precipitant in her depression: her depression seems to be endogeneous and it is not a reactive
depression.
3. Presence of family history of depression: suggest biological cause of depression.
4. Previous response to antidepressant or previous relapse after stopping antidepressant.
3. Based on your answer in question 2, select ONE (1) type of psychotherapy and explain
how it works. (4 marks)
Answer may vary. The examiner is advised to use his or her discretion to decide whether marks should be
awarded.
The frequency of Cognitive behaviour therapy (CBT) is usually weekly or fortnightly. It requires 12 to 16
sessions. The cognitive therapy involves identifying negative automatic thoughts and use dysfunctional thought
diary to identify pattern between the time, events, negative thoughts and resulted emotions and behaviours. The
psychologist will read the diary and help patients to question the negative automatic thoughts. Behaviour
therapy involves activity scheduling (for those depressed patients with psychomotor retardation), relaxation
techniques (for those patients with mixed anxiety and depression).
For students who chose to explain IPT:
Interpersonal therapy (IPT) is held weekly or fortnightly. It involves 12 to 20 sessions. IPT is indicated for
depressed patients whom precipitating factor is interpersonal problems. The psychologist closely examines
interpersonal relationship and relates depression to the interpersonal event. The therapist helps the patient to
work on one of the interpersonal problem areas: 1) grief; 2) interpersonal role dispute; 3) role transition; 4)
interpersonal deficits. IPT helps the patient to develop new skills to deal with people and life situations
associated with depressive symptpms. IPT works with the patient to look at interpersonal relationship from
another angle to minimise impact on the mood. The therapist also uses role-play to improve communication
skills.
1
Question 2
You are a general practitioner and looks after a 30-year-old woman who is 14-week pregnant.
She has been drinking alcohol and has poor compliance to antenatal follow-up. Besides alcohol,
she does not use other drug or substance. She feels that it is completely harmless to drink
alcohol during pregnancy. You need to offer psychoeducation to her.
1. What is the name of the syndrome which is of MOST concerned to her foetus? (2 mark)
2. List THREE (3) facial features associated with the syndrome described in Question 1. (3
marks)
Answer may vary. The examiner is advised to use his or her discretion to decide whether marks should be
awarded.
Any three of the following:
Small head
Small eyes
Short nose
Ear lobe abnormality
Short palpebral fissures (measured from inner to outer canthus; reflect underlying brain growth)
Thin upper lip
Long and flat philtrum
3. If her baby is born with the syndrome described in question 1, list THREE (3)
psychiatric impairments which may occur during the childhood of her offspring (3
marks)
Answer may vary. The examiner is advised to use his or her discretion to decide whether marks should be
awarded.
Any three of the following:
intellectual impairment
attention deficit or hyperactivity
difficulty with reasoning
depression
anxiety
oppositional defiant or conduct disorder
4. State TWO (2) specialities which you would refer this patient to consult for her current
problems. Please indicate the reasons for referral. (2 marks)
2
Specialities Reasons for referral
Obstetrics and gynaecology (0.5 mark) Frequent ultrasound monitoring for foetal
abnormalities (0.5 mark)
Psychiatrist or addiction specialist (0.5 mark) For detoxification and treatment of alcohol
dependence (0.5 mark)
For the reasons of referral, the answer may vary. The examiner is advised to use his or her discretion to decide
whether marks should be awarded.
3
Question 3
You are a general practitioner (GP) and seeing a 65-year-old man who complains of memory loss.
He also suffers from depression. His daughter has read information from the internet that he is at
risk of developing Alzheimer’s disease due to his age. She is not certain about the impact of
depression on his memory.
Dementia Pseudodementia
Example: Caused by Alzheimer’s disease Caused by depression
Aetiology
1.
2.
3.
4.
Answer may vary. The examiner is advised to use his or her discretion to decide whether marks should be
awarded.
Dementia Pseudo-dementia
Onset Insidious onset (1 mark) Acute onset (1 mark)
Extent of memory Recent memory loss more severe. Equal loss of recent and remote events.
loss (1 mark) (1 mark)
4
during Mini Mental to fill up memory gap Don’t know answer (1 mark)
State Examination Minimize disability (1 mark)
Variation within a Sun-downer effect (worse in the Diurnal variation (worse in the
day evening) (1 mark) morning) (1 mark)
3. You have assessed the patient and he suffers from depression. You have decided to start
fluoxetine. Name ONE (1) common electrolyte abnormality found in old people taking
SSRI. (2 marks)
Hyponatremia.
4. Four months later, this patient has tried fluoxetine and it does not work. He took
benzodiazepine from another GP for insomnia. He develops suicidal thought. You have
referred this case to a geriatric psychiatrist. The geriatric psychiatrist recommends
electroconvulsive therapy (ECT). Based on the clinical information provided, name TWO (2)
factors which may increase the seizure threshold for this patient (2 marks) during the ECT.
1. Old age
2. Male gender
3. Baldness
4. Usage of benzodiazepine.
5. His daughter is concerned about memory impairment after ECT. State TWO (2)
adjustments which can apply during the administration of ECT to reduce the risk of
cognitive impairment.
1. Unilateral ECT
2. Use lower energy level
3. Reduce frequency of ECT (two times per week instead of three times per week)
5
Question 4
You are a specialist working in renal medicine. A 60-year-old woman suffers from chronic
renal failure and she requires life-long hemodialysis. She wants to discontinue dialysis. It is a
long weekend and the psychiatrist is not available in your hospital. You need to determine her
capacity to make a decision to discontinue dialysis.
1. List FOUR (4) questions which you would ask this patient to assess her capacity to
make a decision to discontinue dialysis (4 marks).
Answer may vary. The examiner is advised to use his or her discretion to decide whether marks should be
awarded. Any three of the following:
1) What is the nature of your medical condition? / What has the treatment team told you about your condition?/
What do you believe is wrong with your health?
2) What is the purpose of the dialysis? / What have you been told about the recommended treatment?
3) Can you tell me the benefits of dialysis? / What have you been told about benefits of dialysis?/ What is the
treatment likely to do for you?
4) Can you tell me the risks/side effects of dialysis? / What have you been told about the risks or discomforts
associated with dialysis?
6) Are there alternative to dialysis? / What have you been told about alternatives to dialysis?
7) Why do you want to discontinue dialysis? / What have you been told about risks and benefits of no
treatment?/ How did you decide to discontinue dialysis?
2. You are reviewing her past psychiatric record. State FOUR (4) psychiatric disorders
that may affect her capacity to give consent.(4 marks)
Answer may vary. The examiner is advised to use his or her discretion to decide whether marks should be
awarded.
3. If this patient is free from psychiatric illness and has the capacity to make decision. You respect
her right to make a decision to discontinue dialysis. State the MOST RELEVANT ethical
principle which support your decision. (2 marks)
6
SAQ (Paper 3)
You are a general practitioner (GP). You are asked to see a 36-year-old woman for the treatment of major depression.
A trial of fluoxetine 40mg every morning by another GP was unsuccessful.
She was very upset with the remarks made by her colleagues. As a result, she quitted her job 6 months ago and
became a housewife. She feels bored as a housewife and has conflicts with her in-laws. She has become more
depressed in the past 6 months. Her husband is supportive and there is no marital conflict. She has a 10-year-old son
and he has good relationship with her. She does not need to worry about his studies as he has done well in school.
She has other chronic medical illnesses and she takes other medications. She forgot to bring the medication and
cannot remember the name of those medications.
1. State THREE (2) MOST RELEVANT points of the history that you would like to clarify regarding previous trial
of fluoxetine? (2 marks) / 2 marks
2. State TWO (2) medications which are used to treat chronic medical illnesses and known to be associated
with depression? (2 marks) / 2 marks
3. Based on the patient’s background, state THREE (3) common medical conditions from different body
systems that is known to be associated with depression. (3 marks) / 3 marks
Answers may vary. Examiners are advised to use his or her own discretion to decide whether marks should be
awarded. Any three of the following:
1) Cardiovascular disorders: hypertension (1 mark)
2) Endocrine disorders: diabetes, hypothyroidism or Cushing syndrome or Addison’s disease (1 mark)
3) Neurological disorders: epilepsy (1 mark)
4) Gastrointestinal system: peptic ulcer or irritable bowel syndrome or inflammatory bowel diseases (1 mark)
5) Immune system: systemic lupus erythematosus (1 mark)
Medical disorders which are more common in older adults or elderly e.g. Parkinson’s disease, cerebrovascular accidents,
chronic obstructive pulmonary disease = 0 mark. Myocardial infarction = 0 mark as ECG is normal. If all answers are from one
single system = 1 mark.
4. Based on the patient’s history, state ONE (1) MOST appropriate and evidence-based psychotherapy that is
suitable for this patient. (1 mark) / 1 mark
Interpersonal psychotherapy
5. Based on the patient’s history, state how the psychotherapy recommended by you (in Question 4) works for
her. (2 marks) /2 marks
Answers may vary. Examiners are advised to use his or her own discretion to decide whether marks should be
awarded. For students who did not state interpersonal psychotherapy in Q.4, they should only get a maximum of 1
mark for question 5.
Intepersonal psychotherapy can help the patient to analyze previous interpersonal problems in her work place.
Interpersonal psychotherapy involves role play and patient can improve her communication with her in-laws. The role
play can identify previous maladaptive communication patterns. Interpersonal psychotherapy can help her to deal
with the role transition from an administrative person to become a housewife.
Question 2 (Total = 10 marks)
You are a general practitioner. A 25-year-old man suffering from schizoaffective disorder is bought to the clinic by her mother. He
was diagnosed to suffer from schizoaffective disorder 6 months ago. Her mother is concerned about his recent weight gain of 10 kg
in 3 months. According to her mother, his psychiatrist from a restructured hospital started a new antipsychotic and mood stabilizer
to control his psychiatric symptoms.
1. State TWO (2) antipsychotics which are MOST likely to cause weight gain in this patient. (2 marks) /2 marks
2. State TWO (2) mood stabilizers which are MOST likely to cause weight gain in this patient. (2 marks) /2 marks
3. State THREE (3) MOST relevant blood tests which you would like to order and abnormalities you would like to rule out for
this patient. (3 marks) / 3 marks
Investigations Abnormalities
/0.5 mark /0.5 mark
Investigations Abnormalities
Fasting glucose (0.5 mark) Rule out diabetes (0.5 mark)
Liver function tests (0.5 mark) Rule out raised AST and ALT / fatty liver / liver impairment
(0.5 mark)
Thyroid function test Rule out hypothyroidism and associated weight gain
4. State ONE (1) MOST RELEVANT AND SPECIFIC symptom in schizophrenia which may contribute to obesity (2 marks).
1. Avolition or ahehdonia or lack of interest to do exercise (2 marks)
2. Negative symptom (1 mark)
3. Other negative symptom e.g. apathy, alogia, attentional deficit (0 mark)
5. State ONE (1) antipsychotic that has the LOWEST RISK to cause weight gain. (1 mark)
Aripiprazole/ haloperidol (1 mark). Other antipsychotic = 0 mark
Question 3
You are a paediatric resident working in the Child and Accident Emergency Department. You
are seeing an 11-year-old boy who was brought in by his foster parents. According to his
foster parents, he has a lot of behavioural problems at home and school. He cannot sit still to
do his homework at home. He also breaks school rules. Tonight, he had a fight with his foster
parents. This boy is a victim of child abuse.
1. State TWO (2) MOST RELEVANT diagnoses (2 marks) that this boy may suffer from and
indicate THREE (3) additional clinical features (6 marks) which you will look for to
support your diagnosis. (total 8 marks)
2.
3.
/1 mark /3 marks
2. 1.
2.
3.
/1 mark / 3 marks
/ 3 marks
2. If you have a chance to speak to the child protection officer, state TWO (2) MOST
relevant psychiatric disorders that his parents may suffer from. (2 marks)
/ 2 marks
Adult ADHD = 0 mark (It is unlikely MFS needs to foster out the child if parent has adult ADHD).
Question 4
You are a geriatric resident. A 70-year-old man presents with dementia. His son wants to find out
more about the treatment for dementia.
1. State the name of TWO (2) acetylcholinesterase inhibitors available in Singapore. (2 marks)
/ 2 marks
Any two of the following:
Donepezil (1 mark) or
Rivastigmine (1 mark) or
Galantamine (1 mark).
2. List TWO (2) types of dementia for which acetylcholinesterase inhibitors are indicated (2
marks) / 2 marks
5. His son wants to know potential benefits that can be expected from treatment with
acetylcholinesterase inhibitors. List TWO (2) potential benefits (2 marks).
/ 2 marks
Answers may vary. Examiners are requested to use his or her own discretion to decide whether
marks should be awarded.
Question 1
You are the resident working in the Accident and Emergency Medicine Department. A 50-year-
old man is admitted as a result of paracetamol overdose. He was treated in the Institute of
Mental Health for alcohol dependence 7 years ago.
1. State Four (4) clinical features which you would elicit in this man during history taking
to establish the diagnosis of alcohol dependence. (4 marks) Examiner: /4 marks
2. State TWO (2) medical or surgical disorders from two different body systems which will
result from prolonged alcohol usage. (2 marks) Examiner: /2 marks
/1 mark
Any 2 of the following (The list is not completed and examiner will use his or her discretion to decide
whether marks should be awarded).
CNS complications: withdrawal fits/epilepsy, head injury as a result of fall, cerebellar damage
Gastrointestinal system: cancer in the oral cavity (e.g. tongue, throat), oesophagitis, gastritis,
gastric cancer.
Hepatobiliary system: pancreatic cancer, liver cirrhosis, alcohol hepatitis.
Peripheral nervous system: peripheral neuropathy
Rheumatology: gouty arthritis
Reproductive system: erectile dysfunction.
3. State TWO (2) physical signs which you will elicit from two different body systems to
support the diagnosis of alcohol dependence. (2 marks) Examiner: /2 marks
/1 mark
Any 2 of the following (The list is not completed and examiner will use his or her discretion to decide
whether marks should be awarded).
This patient suffers from alcohol hepatitis due to AST: ALT ratio > 2.
Question 3
1. From her history, list FOUR (4) specific risk factors for postpartum depression. (4 marks)
Examiner: /4 marks
2. State TWO (2) MOST important psychotic features which you would elicit as part of the risk
assessment (2 marks) Examiner: /2 marks
Answer may vary. Examiner will use his or her discretion to decide whether marks should be
awarded.
1. Command hallucination which asks her to harm herself and her infant.
2. Delusion which suggests that the infant is malformed/abnormal or possessed by demons and
she need to attack the infant.
Other mood congruent delusions e.g. delusion of guilt or nihilistic delusion 0.5 marks
3. She has an appointment to see a psychiatrist in one month. She cannot wait and wants to
seek your opinion. She is very keen to continue breastfeeding. If she wants to take an
antidepressant such as a selective serotonin reuptake inhibitor (SSRI) and continues
breastfeeding, state TWO (2) advices to minimize SSRI exposure to the infant. (2 marks)
Examiner: / 2 marks
Answer may vary. Examiner will use his or her discretion to decide whether marks should be
awarded. Any two of the following:
Other answers:
Question 4
You are a general practitioner. A mother brings her 13-year-old girl to see you. She complains
of low mood, poor sleep, poor appetite and recurrent self-harm. She often cuts her wrist with a
pen knife. She has difficulty to cope with her study in Secondary 1. She often brings a pen
knife to school and cuts herself in the toilet. Her mother breaks into tear in the middle of the
interview because her husband is dependent on alcohol and has history of violence. The
patient is very close to her mother. As a result, the patient and her mother have no
communication with her father.
Question 1: Her mother worries about her personality development. State ONE (1) personality
disorder which she will MOST likely develop if the above pattern continues without any
intervention? (2 marks) Examiner: / 2 marks
Question 2: Based on your answer in Question 1, state TWO (2) MOST relevant comorbid
psychiatric disorders. (2 marks) Examiner: / 2 marks
Question 3 Her mother hopes that you can prescribe a psychotropic medication to
stabilize her. State ONE (1) psychotropic medication which is most suitable to her. (2 marks)
Examiner: / 2 marks
/1 mark /1 mark
/1 mark /1 mark
Question 4 Besides cognitive behaviour therapy, state TWO (2) MOST relevant
psychotherapy which will benefit this patient. (2 marks)
Examiner: /2 marks
Any two of the following:
1. Dialectical behaviour therapy
2. Metalization based therapy
3. Interpersonal psychotherapy
4. Family therapy.
Question 5 Her mother is concerned about her safety in the next few weeks while waiting for
the effect of the medication. List TWO (2) MOST relevant strategies to manage safety issues in
this patient. (2 marks) Examiner: /2 marks
Examiner has to use his or her own discretion to decide whether marks should be awarded. Any two
of the following:
1. Discuss need for her mother and teacher to monitor for changes in behaviour or self-harm at
home and in school.
2. Remove sharp objects, weapons or pen knives or unnecessary medications from home and
school.
3. Provide information and access to crisis services in the emergency department.
4. Her mother needs to supervise and administer antidepressant to patient.
5. Frequent and regular review by doctors to monitor response and side effects
SAQ 2014 EOPT – First rotation
2. List TWO (2) medications from different classes that can treat her symptoms? (4
marks)
( /1 mark) ( /1 mark)
( /1 mark) ( /1 mark)
3. She wants to receive psychotherapy. Please state the most evidence based
psychotherapy based on your diagnosis. (1 mark)
1
Cognitive behaviour therapy; other psychotherapy (0 mark) ( /1 mark)
4. She wants to know more how psychotherapy works. Based on your answer in
Question 3 and her clinical history, list TWO (2) specific strategies which can
help her. (4 marks)
Other logical answers are acceptable. Examiner is advised to use his or her discretion to
decide whether marks should be awarded.
( / 4 marks)
2
Question 2 (10 marks)
A 40-year-old woman with a bipolar disorder was stable on sodium valproate till a
year ago when she suffered three episodes of relapses. Her psychiatrist recommends
switching to lithium. She uses recreational drugs, sometimes forgets to take her
medication when she is clubbing till 5 am and has had unprotected sex many times in
the past three months. A friend asks her to borrow $10,000 to invest in a food and
beverage business.
Question 1 She wants to know the systemic side effects of lithium when the dose is within
therapeutic range. State FOUR (4) body systems affected by lithium and Name ONE (1) specific
side effect of lithium under each system. (4 marks)
Other logical answers are acceptable. Examiner is advised to use his or her discretion to
decide whether marks should be awarded. Signs of lithium toxicity e.g. ataxia, coarse tremor,
cardiac arrest, respiratory difficulty does not count.
( /0.5 mark)
( /1 mark)
3
( /0.5 mark) ( /1 mark)
Question 2 Based on her history and the possibility of starting lithium, List THREE (3) most
relevant laboratory investigations (3 marks)
( / 3 marks)
Question 3 Based on her current lifestyle, offer THREE (3) MOST relevant advices. (3
marks)
( / 3 marks)
4
Question 3
Question 1 During your assessment, state FOUR (4) most relevant risk factors
suggesting high suicide risk which you would explore.
Other logical answers are acceptable. Examiner is advised to use his or her discretion to
decide whether marks should be awarded.
1. Poor relationship with parents and family members (1 mark) or
2. Previous suicidal ideation or attempts (1 mark) or
3. Belief about lethality of paracetamol overdose (1 mark) or
4. Circumstances of suicide (e.g. suicide notes, isolation, avoidance of discover) (1 mark) or
5. Current plans for further suicidality (1 mark) or
6. Strong preoccupation with the relationship/ suicide as a mean to salvage the relationship
(1 mark) or
7. Presence or absence of alcohol intoxication (1 mark) or
8. Family history of psychiatric illness (1 mark) or
9. Current or past history of major depression or other psychiatric illness/or chronic medical
illness (1 mark).
( / 4 marks)
Question 2 During your assessment, state TWO (2) most relevant protective factors
against suicide which you would explore.
Other logical answers are acceptable. Examiner is advised to use his or her discretion to
decide whether marks should be awarded.
1. Religion (1 mark) or
2. Seeing a counsellor or psychologist (1 mark) or
3. Regret over suicide attempt (1 mark) or
4. Positive plan in the near future (e.g. return to study) (1 mark).
( / 2 marks)
Question 3 State FOUR (4) most appropriate management orders for this patient in
the Accident and Emergency Department.
Other logical answers are acceptable. Examiner is advised to use his or her discretion to
decide whether marks should be awarded.
1. Order investigations including Full blood count, liver function tests, renal function
tests, paracetamol levels, urine drug screen, electrocardiogram etc (1 mark) or
5
2. Activate charcoal to reduce absorption (1 mark) or
3. Suicide precaution (1 mark) or
4. Start N-acetylcystine (NAC) (1 mark) or
5. Inform family about her suicide attempt or to obtain collateral information (1 mark) or
6. Inform on-call psychiatrist for assessment (1 mark) or
7. Admit to the medical ward for further management (1 mark).
( / 4 marks)
6
Question 4 (10 marks)
A 70-year-old man was bought in by his family because he claims he has been seeing
ghosts for the past few months and is now hearing voices asking him to jump from his
9th floor flat. He has hypertension which is well-controlled and has been in good health.
Question 1 During the assessment, state THREE (3) risk factors for late onset
psychosis. (3 marks)
Other logical answers are acceptable. Examiner is advised to use his or her discretion to
decide whether marks should be awarded.
1. Sensory impairment (e.g. deafness) (1 mark) or
2. Social isolation (1 mark) or
3. Paranoid or schizoid or schizotypal personality trait (1 mark) or
4. Past psychiatric illness (e.g. history of schizophrenia/ severe depression/ bipolar
disorder) (1 mark) or
5. Past medical illness or underlying medical illness (e.g. stroke, head injury, brain
tumour) or medication which causes psychosis – steroid induced psychosis/
Parkinson’s disease (1 mark)
( / 3 marks)
Question 2 State TWO (2) differences between psychotic features found in an old
person and psychotic features found in a young person suffering from schizophrenia (
/ 2 marks)
Other logical answers are acceptable. Examiner is advised to use his or her discretion to
decide whether marks should be awarded.
1. Elderly exhibits less first rank symptoms / the content of psychotic symptoms (e.g.
auditory hallucination) is often less elaborated in elderly (1 mark) or
2. Elderly exhibits less negative symptoms as compared to young people suffering from
chronic schizophrenia (1 mark) or
3. Elderly are more likely to exhibit more paranoid ideas or delusions compared to
young people (1 mark).
Question 3 Based on his history, state THREE (3) most likely psychiatric diagnoses
(3 marks)
7
Question 4 The family informs you that a family doctor started risperidone and he
developed severe rigidity and tremor. State ONE (1) antipsychotic drug which is MOST
suitable for him. (2 marks)
( / 2 marks)
8
SAQ – 2014 Rotation 2
Question 1
You are a general practitioner. Depression is a common mental health problem. You are about
to start a patient on an antidepressant.
1. List FOUR (4) factors related to the patients which you would consider in choosing an
antidepressant for a patient suffering from depression (4 marks). ( /4 marks)
Name of antidepressants Other therapeutic effects (besides Specific side effects associated with
antidepressant effect and anxiety antidepressant (besides gastric
reduction effect) discomfort, headache, giddiness)
Name of antidepressants Other therapeutic effects (besides Specific side effects associated with
antidepressant effect and anxiety antidepressant (besides gastric
reduction effect) discomfort, headache, giddiness)
You are a general practitioner. A 25-year-old man presents with disorganized thinking and speech.
You have a few psychiatric differential diagnoses.
1. State and define ONE (1) common type of disorganised thinking that are found in people
without any mental illness.(4 marks) ( /4 marks)
( /2 marks) ( /2 marks)
2. State and define TWO(2) common types of disorganised thinking that are found in people
suffering from schizophrenia. (4 marks) ( /4 marks)
( /1 mark) ( /1 mark)
( /1 mark) ( /1 mark)
3. State and define ONE (1) common type of disorganised thinking that is found in people
suffering from bipolar disorder. (2 marks) ( /2 marks)
( /1 mark) ( /1 mark)
Answers to question 2
1. State and define ONE (1) common types of disorganised thinking that are found in people
without any mental illness.(4 marks) ( /4 marks)
(2 marks) (2 marks)
2. State and define THREE (3) specific types of disorganised thinking that are found in people
suffering from schizophrenia. (6 marks) ( /6 marks)
3. State and define ONE (1) specific type of disorganised thinking that is found in people
suffering from bipolar disorder. (2 marks) ( /2 marks)
Flight of ideas A continuous speech which topics jump rapidly from one
(1 mark) to another and there is a logical link between ideas.
( 1 mark)
Question 3
You are a paediatric resident. You are seeing an 11-year-old boy with repetitive eye blinking
and this has caused social dysfunction. He exhibits facial tics and gets frequent facial tics
when he is anxious. He sometimes cannot control his hand movements which affect his
writing.
1. You suspect that he suffers from Tourette’s syndrome. State the most APPROPRIATE
question which you would ask to establish the diagnosis of Tourette’s syndrome (2
marks) ( / 2 marks)
2. What distinguishes Tourette’s disorder from a chronic motor or vocal tic disorder? (2
marks) ( /2 marks)
Answer: Patients suffering from Tourette’s disorder present with both motor and vocal tics.(2
marks)
3. State ONE (1) psychiatric condition often comorbid with Tourette’s syndrome. (2
marks) ( /2 marks)
4. State ONE (1) psychiatric medication that can be used to treat Tourette’s syndrome. (2
marks) ( /2 marks)
5. State Two (2) psychological interventions that can be used to treat Tourette’s
syndrome. (2 marks) ( /2 marks)
Question 4:
You are a general practitioner (GP). The son of a 60-year-old man is concerned because his father is
taking a medication called, Flunitrazepam (Rohypnol) for 2 years. The patient obtained Rohypnol
from another GP who had retired 1 month ago. Rophypnol is a very potent benzodiazepine and is a
derivative of nitrazepam. Rophypnol is highly addictive and is listed as a controlled drug by the
Central Narcotics Bureau. His son has noted the following symptoms: anxiety, aggression, getting
high, insomnia, memory loss, slurred speech, tremor in his father. The patient was admitted to the
hospital due to fits.
1. Based on the symptoms reported by his son (underlined), classify the symptoms as
intoxication or withdrawal symptoms associated with benzodiazepine (4 marks)
( / 4 marks)
Answers:
2. State the MOST APPROPRIATE psychotropic medication to treat his withdrawals (2 marks).
( / 2 marks)
Sedative antidepressant
( /2 marks)
Other sedative medication (non-
benzodiazapine)
( /2 marks)
Question 1
1. SSRI may cause erectile dysfunction. Can you name ONE (1) antidepressant that
has relatively less sexual side effect as compared to SSRI? (2 marks)
2. If he wants to continue SSRI, state TWO (2) management strategies to improve his
erectile function if he develops SSRI induced erectile dysfunction. (2 marks)
Any two of the following:
1) Reduce the dose or prescribe the lowest dose of SSRI (1 mark)
2) Drug holiday or stop SSRI during weekend or take a long acting SSRI on alternate
day (1 mark)
3) Add sildenafil or PDE5 inhibitor (1 mark)
4) Refer patient to sensate focus or sex therapy / vacuum pump (1 mark)
Not grip method – for premature ejaculation
3) He understands that the combination of SSRI and other medication may lead to
high fever. What is the name of such condition? (1 mark)
Serotonin syndrome (1 mark) Not Neuroleptic malignant syndrome
4) State ONE (1) medication that may cause serotonin syndrome if he takes together
with SSRI (1 mark)
Monoamine oxidase inhibitor or irreversible monoamine oxidase inhibitor (1 mark),
moclobemide (0.5 mark) MAOI (0.5 mark) (Isocaroxazid, phenelzine – irreversible MAOI
1 mark)
5) State FOUR (4) signs or symptoms associated with serotonin syndrome (4 marks)
Any 4 of the following:
Rigidity, myoclonus, uncontrollable shivering
Sweating or tremor or hyperthermia or coma
Hyperkinesia or bradykinesia
High blood pressure, labile blood pressure
hyper-reflexia, headache
dysphagia, dilated pupils
cardiovascular collapse
confusion (delirium)
decreased level of consciousness/mutism
disorientation
status epilepticus
ataxia
Question 2
You are a resident working in the Accident and Emergency Department (AED).
A 25-year-old man is brought in by his mother to see you after he reveals to
her about his great plan to fly to Europe by “changing the magnetic pole of the
earth”. He is very talkative and appears to be very excited. He disturbs
other patients in the AED.
1) State THREE (3) MOST LIKELY psychiatry diagnoses that you would
consider. (3 marks)
2) You are unable to perform any blood test as he is very agitated. Name TWO
(2) MOST relevant psychotropic medications to sedate this patient at the
AED. (2 marks)
3) List TWO (2) most important laboratory investigations you would do before
beginning lithium (2 marks)
4) State THREE (3) common side effects associated with lithium. (3 marks)
You are a resident working in surgery. A 45-year-old man with a dual diagnosis of schizophrenia
and alcohol dependence is admitted to the ward due to upper gastrointestinal bleeding. The on-
call consultant recommends urgent oesophagogastroduodenoscopy (OGD).
1. You need to take an informed consent from this patient. State THREE (3) important pieces
information you must inform this patient before seeking his consent. (3 marks)
1. Explain the potential diagnosis of Mallory-Weiss syndrome which is associated with alcohol
misuse (1 mark) or
2. Explain purpose and nature of the diagnostic procedure about OGD (e.g. passing an
endoscope to examine the stomach and identify bleeding site, may take some tissues) (1
mark) or
3. Explain risks and benefits of OGD (e.g. small risk of perforation of feeding tube; benefit: can
assist diagnosis) (1 mark) or
4. Alternative investigation (e.g. monitor haemoglobin levels but bleeding may continue) ( 1
mark) or
5. Prognosis if without this investigation (e.g. continue bleeding) (1 mark)
2. State THREE (3) criteria which you would like to assess in order to certify he has the capacity to
take consent. (3 marks)
3) After the OGD is done, his wife hopes that he can quit drinking. List Four (4) techniques of
motivational interviewing which you could use to maximize his motivation to quit drinking (4
marks)
You are a general practitioner. A 65-year-old woman has taken haloperidol for 30 years is concerned
about a side effect called tardive dyskinesia (TD).
2. You are about to perform a physical examination. State TWO (2) anatomical structures and
ONE (1) clinical feature under each anatomical structure which you would look for to
confirm the presence of TD (4 marks). ( / 4 marks)
( / 1 mark) ( / 1 mark)
( / 1 mark) ( / 1 mark)
Wrong answers:
There is not enough evidence to suggest anticholinergic as good treatment for TD.
A 68-year-old woman presents with poor sleep and decreased appetite for two months.
She has stopped reading because she cannot concentrate, and she is no longer seeing
friends that she is close to because she does not have the energy. She tells you that her
symptoms started after her son moved out of the house two months ago. Prior to
that, she was an energetic person who took care of her affairs and enjoyed life.
1. Besides major depressive disorder, state ONE (1) other psychiatric diagnosis based
on the above information (1 mark) ( / 1 mark)
In the later part of interview, she mentions about the death of her husband three years ago.
She admits that she has kept everything in her late husband’s room exactly the same since
his death.
3. State the term which describes the above phenomenon. (2 marks) ( /2 marks)
4. With the additional information, you suspect the patient may suffer from abnormal
grief reaction although she claims she has coped well with the death of her husband.
State FOUR (4) clinical features which are found in abnormal grief but not normal
grief (4 marks) ( /4 marks)
Any 4 of the following:
- Prolonged grief with duration longer than 6 months (1 mark) or
- Inhibited grief at the time of death (1 mark) or
- Delayed grief (i.e. no grief reaction at the time of death but appeared some time later) (1 mark)
- Strong suicidal ideation to join the deceased (1 mark) or
- Psychotic experience other than deceased (1 mark) or
- Severe psychomotor retardation (1 mark) or
- Severe feeling of worthlessness or hopelessness (1 mark)
The public relation department of your hospital has received queries from a local newspaper. A
reporter wants to write about an article about alcohol misuse. You are invited to address the following
questions raised by the reporter.
1. How does long-term alcohol misuse damage our body systems? Please state FOUR (4)
physiological systems and name ONE (1) complication under each system (4 marks)
( / 4 marks)
Physiological system Complication (The candidate needs to state one complication under
each physiological system)
Nervous system Blackouts/head injury, withdrawal fits/epilepsy, acute confusional
state, subdural haematoma, degeneration of cerebellum/ataxia,
peripheral neuropathy/loss of pain sensation, alcohol dementia,
Wernicke encephalopathy, Korsakoff psychosis, central pontine
myelinolysis, Marchiafava-Bignami syndrome, depression, anxiety,
morbid jealousy
Opthalmological Optic atrophy, retrobulbar neuropathy, loss of central vision,
system bilateral central scotoma
Gastrointestinal Cancer of mouth, larynx, pharynx, oesophagus, upper
system gastrointestinal bleeding, gastritis, malabsorption syndrome
Cardiovascular Hypertension, cardiomyopathy, atrial fibrillation
system
Respiratory system Increase in risk in respiratory infection (e.g. pneumonia,
tuberculosis)
Hepatobiliary system Cirrhosis, liver cancer, alcohol hepatitis, fatty liver, pancreatitis,
hepatic encephalopathy
Urogenital system Erectile dysfunction, sexual dysfunction, infertility, loss of
secondary sexual characteristics
Musculoskeletal Myopathy, gouty arthritis, palmar erythema.
system
Endocrine Cushing syndrome
Haematological Macrocytic anaemia
system
2. If an alcoholic stops drinking for 1 day, what would happen to him/her? State TWO (2) common
symptoms. (2 marks) ( / 2 marks)
3. If an alcoholic wants to join peer support group, name ONE (1) organisation which can support
the person (2 marks) ( /2
marks)
4. If an alcoholic wants to be admitted to a hospital to detoxify from alcohol, what are the
indications. State TWO (2) indications. (2 marks) ( / 2 marks)
You are a medical resident. The accident and emergency department has sent a 55-year-old man to the
medical ward for further management due to change in mental state. When you assess him, he appears
to be manic.
1. State FIVE (5) neurological disorders which may cause mania. (5 marks) ( / 5marks)
2. State TWO (2) medications (not illicit drugs) which may cause mania (2 marks) ( /2
marks)
o Steroid / prednisolone
o Antidepressant
o Anticholinergic drug
o Levodopa / bomocrptine
o Bronchodilator
3. When you are clerking the patient, he suddenly becomes very aggressive and tries to run
away from the ward. You have tried verbal de-escalation but fails. You need to apply
physical restraint. State THREE (3) specific instructions to nursing staff to ensure the physical
restraint will be applied successfully. (3 marks) ( / 3 marks)
1. Call for additional manpower (e.g. call security guards for help, at least 4 additional staff) (1
mark) or
2. Obtain adequate physical restraints (e.g. 1 body jacket, 1 restraint per limb) (1 mark) or
3. Standby psychotropic medication (e.g. rapid dissolvable antipsychotics or intravenous
lorazepam / haloperidol) (1 mark) or
4. The doctor will ensure the airway is not blocked. Other staffs will focus on the body and four
limbs. (1 mark)
SAQ (Paper 11)
James is a 40-year-old man. He is unemployed because of his constant worries lasting for years
about simple daily events. He now lives with his parents. Although he was an overachiever
throughout his teaching career in a secondary school, his parents are disappointed with his recent
resignation from the Ministry of Education. James resigned because he kept sweating and having
tremor and diarrhoea during his classes. He mainly focused on the minor mistakes made in his
classes but ignored his good teaching performance. His parents find James lazy and unmotivated
to even find a job in a tuition centre. He likes to spend his time in crowded shopping malls instead.
Mental state examination shows that James is easily irritated, distracted and quite tense. He
complains of giddiness, dry mouth, nausea. At the end of the interview, he says, “I failed my job. I
fail everything in my life.”
Question 1 Based on the history provided, state the MOST likely psychiatric diagnosis? ( /1
mark)
Question 2 Based on the history provided, state TWO (2) MOST RELEVANT psychiatric
differential diagnosis? ( / 2 marks)
Question 3 Stated ONE (1) MOST important blood test to rule out a medical diagnosis which
has similar clinical presentation as seen in James. ( / 1 mark)
Question 4 James wants to discuss the different types of medications that are available for
providing relief from his disorder. He wants to take benzodiazepines. What are the pros and cons
of prescribing benzodiazepines to James? ( / 2 marks)
Question 6 James wants to have psychotherapy to figure out his problems. Based on his
history, name two cognitive errors which can be challenged by cognitive therapy. ( / 2 marks)
Author: Roger Ho
Year: 2015
Question 2 (10 marks)
Dennis, a 30-year-old man was admitted to the surgical ward following the collision of his
car into a road barrier on the Ayer Rajah Expressway (AYE). He reported that he was not
under influence of alcohol, but that he was looking at his lips in the rearview mirror when
he lost control of his car. No one else was with him during the accident.
He sustained a fractured ankle which required internal fixation. While on the ward, Dennis
spent a lot of time in the bathroom picking at his lips, looking at his lips in the mirror, and
tried to manipulate his way out of physiotherapy sessions to spend his time looking at his
lips. He often has his hand over his mouth and wears a mask.
Dennis works as a freelance apps developer and he mainly works at home. He feels
rejected by other people because of his lips. He becomes convinced that he will be more
appealing to others if he has cosmetic operation on his lips.
Question 2 State TWO (2) common psychiatric comorbidity or condition related to the
psychiatric diagnosis established in question. ( /2 marks)
Question 3 Besides his lips, state TWO (2) common anatomical areas commonly affected
in this condition. ( / 2 marks)
Question 4 State the most important question to ask Dennis during risk assessment. (
/ 1 mark)
Will you operate on your lips if the doctors decline cosmetic surgery?
Question 5 State ONE (1) class of psychotropic medication that has the most evidence to treat
his condition and name ONE (1) example. ( /2 mark)
Question 6 Dennis is keen to consider cognitive behaviour therapy. Explain how cognitive
behaviour therapy works in his case. ( /2 marks)
Answers may vary. Examiner needs to use his or her own discretion to decide the marks to be
awarded.
Cognitive therapy provides cognitive restructuring or challenges his belief that his lips are abnormal
although it is normal during physical examination. (1 mark)
Behaviour therapy involves exposure and response prevention such as avoiding frequent mirror
checking on his lips. (1 mark)
Author: Roger Ho
Question 3
You are going to assess a 75-year-old man whose daughter is concerned that he is
becoming forgetful and confused. He suffers from visual impairment and cannot see
clearly. He had secondary school education and worked as a technician in the past.
1. Name TWO (2) main differences in clinical features between dementia and
delirium? ( /2 marks)
Answer may vary. The examiner is advised to use his or her discretion to decide whether
marks should be awarded.
1. The mental state and cognitive function of delirious patients fluctuate more often than
dementia patients.
2. The main cognitive impairment in delirium involves attention while dementia
involves memory.
3. Delirious patients are more likely to experience visual hallucations or illusions as
compared to dementia.
4. The clinical course of illness in delirium is shorter and more likely to be reversible as
compared to dementia.
2. Based on the history provided, name THREE (3) cognitive tasks which he would
have difficulty to perform during the Mini-Mental State Examination. ( /3
marks)
3. State THREE (3) specific tests of frontal lobe functioning which can be
performed on this patient. ( / 3 marks)
Author: Roger Ho
Question 4 A 16-year-old male is bought in by his family. He has refused to attend school
or sit for the “O” level examination. He has spent a lot of time playing online games and
surfing the internet. He has been verbally abusive toward his parents when they try to remove
the computer from him. His school has asked him to discontinue his study because he shows
no interest in his study.
Question 1 State five (5) questions which you would ask to screen or establish the
diagnosis of internet addiction. ( / 5 marks)
Answers may vary. Examiners are advised to use his or her discretions to decide on the marks
awarded.
1) Tolerance: Do you spend more or more time on the internet to get excitement? If so, was it
over a period of time? (1 mark) or
2) Withdrawal: Do you feel uneasy, depressed or agitated when you are not allowed to play
online game or use internet? (1 mark) or
3) Have you given up your interest or hobbies as a result of internet use? (1 mark) or
4) Do you continue to spend a lot of time online despite failure in academic study? (1 mark) or
5) Do you feel that you need to cut down on online gaming or internet usage? (1 marks) or
6) Do you feel annoyed by your family members when they criticise your internet usage? (1
mark) or
7) Do you feel that it is a compulsion or strong urge to play online game which you cannot stop
or control (1 mark) or
8) Do you ever need to tell lies about your excessive internet usage or gaming activities (1
mark) or
9) Do you spend more and more money to purchase items for the online game? If so, how
much (1 mark) or
10) Do you feel guilty about your excessive online gaming or internet usage? (1 mark) or
11) Do you play online game or surf internet first thing in the morning or after you wake up and
ignore other activities (1 mark)?
Question 2 State THREE (3) techniques to motivate him to consider quitting online game and
to receive treatment. ( / 3 marks)
Answers may vary. Examiners are advised to use his or her discretions to decide on the marks
awarded.
Question 3 State TWO (2) Most common physical complication associated with internet
addiction? ( / 2 marks)
Answers may vary. Examiners are advised to use his or her discretions to decide on the marks
awarded.
You are a resident working at the Accident and Emergency Department (AED) of the
National University Hospital. A 25-year-old nurse was found unconscious by her
parents. Her parents suspected that she attempted suicide by taking unknown
medications. Her parents mentioned that she was stressed by interpersonal problems
at work.
1. Given the fact that she works as a nurse, state TWO (2) MOST fatal medications
which she can take from the hospital and administer to herself to attempt
suicide. (2 marks) Examiner: / 2 marks
The answers can be any two of the following. For other answers, examiner can use
his or her judgement to decide whether marks should be awarded.
Insulin (1 mark) or
Lignocaine (1 mark) or
Digoxin (1 mark) or
Fetanyl (1 mark) or
Succinylcholine (1 mark) or
Adrenaline (1 mark) or
Potassium Chloride injection (1 mark) or
Propofol (1 mark) or
Midazolam (1 mark) or
Phenobarbitone (1 mark) or
Sodium thiopental (1 mark) or
Morphine (1 mark) or
Warfarin (1 mark) or
Tricyclic antidepressant (1 mark)
Lithium (1 mark)
2. The police officers came to the AED and informed you that they found burnt
charcoal in her bed room and the windows were sealed. State TWO (2) MOST
relevant laboratory investigations which you should order in the Accident and
Emergency Department (AED) (2 marks)
Examiner: / 2 marks
The answers can be any two of the following. For other answers (e.g. thyroid function
test), mark will not be awarded because it is less relevant for this case.
The answers can be any two of the following. For other answers, examiner can use
his or her judgement to decide whether marks should be awarded.
4. List TWO (2) MOST relevant neuropsychiatric sequelae which can be found in
this patient when her condition is stable. (2 marks) Examiner: /2
marks
5. The patient has stayed in the ward for one month and recovered without any
neuropsychiatric sequelae. She is keen for psychotherapy. Please state the
MOST relevant psychotherapy (1 mark) and explain how it works. (1 mark)
Examiner: / 2 marks
The answers can be any two of the following. For other answers, examiner can use his
or her judgement to decide whether marks should be awarded.
The psychologist will closely examine her interpersonal problems and works with the
patient to look at interpersonal relationship from another angle to miminise impact on her
mood. The psychologists can use role – play to improve her communication skills (1
mark)
If students answer other forms of psychotherapy e.g.cognitive behaviour therapy,
psychodynamic psychotherapy, marks will be awarded by it depends on the quality of the
answer.
Question 2 A 30-year-old man suffers from the first episode of schizophrenia and
he has tried risperidone 2mg daily. His first rank symptoms have subsided but
negative symptoms persist. He has read the internet and found a medication called
clozapine. He believes that clozapine is the ultimate treatment for schizophrenia.
Question 1 He does not want to waste time with other antipsychotics and wants to
try clozapine. What is your advice? ( / 2 marks)
Answer may vary. For other answers, examiner can use his or her judgement to decide
whether marks should be awarded.
He should try another psychotic drug (e.g. first generation antipsychotic drug) before
considering clozapine (1 mark) or
Clozapine is reserved for treatment resistant schizophrenia but not first episode of
schizophrenia (1 mark) or
Clozapine requires some investigations (e.g. full blood count) before starting clozapine
and patients cannot go straight to clozapine (1 mark).
Question 2 What is the one major side effect of clozapine that requires regular blood test?
State the blood test required. ( / 2 marks)
Answer:
Answer:
Question 4 State TWO (2) psychosocial interventions for negative symptoms (2 marks)
You are a paediatric resident working in the Child and Accident Emergency Department. You
are seeing an 11-year-old boy who was brought in by his foster parents. According to his
foster parents, he has a lot of behavioural problems at home and school. He cannot sit still to
do his homework at home. He also breaks school rules. Tonight, he had a fight with his foster
parents. This boy was abused by his biological parents.
1) You suspect that this boy suffers from attention deficit and hyperactivity disorder
(ADHD). Besides that fact that he cannot sit still to do homework, state THREE (3)
inattention symptoms and THREE (3) hyperactivity symptoms. ( / 6 marks)
( / 1 mark) ( / 1 mark)
( / 1 mark) ( / 1 mark)
( / 1 mark) ( / 1 mark)
2) State TWO (2) other psychiatric diagnoses which must be ruled out? ( /2
marks)
You are a general practitioner. A 25-year-old man has returned from the United States (US). He
has obtained a Master degree in business administration. He consults you because he has been
using a drug called oxycodone in the US. After coming back to Singapore, he has repetitive
thoughts about using oxycodone. He has imagined pain in his arm when he is not using
oxycodone. He hopes that you can prescribe oxycodone to him.
Question 1 Will you prescribe oxycodone to him? (1 mark) Please justify your reason (1
mark).
( /1 mark) ( /1 mark)
Question 2 State FOUR (4) SPECIFIC withdrawal symptoms associated with termination of
oxycodone use (4 marks). Please do not repeat the symptoms stated in the case vignette.
Question 3 As a general practitioner, state TWO (2) medications which you can prescribe to
him to reduce his withdrawal symptoms (2 marks)
Question 4 What is the class status of oxycodone under the Drug of Misuse Act (Singapore)? (1
mark)
Class A (1 mark)
Question 5 State the specialist service which you will refer him to manage his condition (1
mark)
Name of specialist service (0.5 mark) Hospital which provides this service (0.5 mark)
Name of specialist service (0.5 mark) Hospital which provides this service (0.5 mark)
National Addictions Management Service (0.5 Institute of Mental Health (0.5 mark)
mark)
SAQ (Paper 13)
Question 1
You are a General Practitioner. A 30-year-old woman comes to your clinic and complains of low
mood and anxiety. She has read a lot of information on the internet and has her personal views on
treatment. She would like to discuss with you on various treatment options.
Highest mark: 10 Lowest mark: 3.5
1) List THREE (3) ways in which anxiety can be distinguished from depression.
Any three of the following and other answers are acceptable. Examiner needs to use his or her discretion to
decide whether marks should be awarded.
Answers from students: Depression: predominant low mood or other symptoms (e.g.anhedonia,
energy),psychomotor retardation VS anxiety not predominant low mood; concerns of minor issues; usually no
psychosis, muscle tension, anticipatory anxiety
Mental State Examination: Anxiety: nervous and fearful on Mental State Examination; Depression: sad,
furrow eye brow, eye looking down to the floor, tearful, withdrawn on Mental State Examination (1 mark)
Somatic symptoms: Anxiety: more often associated with palpitations, tachycardia, dizziness; Depression:
most often associated with chest pain, headache (1 mark)
Pregnancy and avoid adverse effects of psychotropic medication on foetus (1 mark)
Anxiety: react to phobia; depression reactive to negative life event (1 mark)
Future: Anxiety: worry or apprehension; Depression: hopelessness (1 mark)
Anxiety: no diurnal variation, depression: diurnal variation (1 mark)
Guilt: Anxiety: no guilt; Depression: Guilt (1 mark)
Suicide: Anxiety: less likely to have suicide thought/ideation; depression: more likely to have suicidal
thought/ideation (1 mark)
Family history: Anxiety: family history of anxiety disorder; depression: family history of depressive
disorder (1 mark)
Psychotic feature: Anxiety: less likely to have psychotic feature; more likely to have mood congruent
psychotic features (1 mark)
2) She wants to try psychotherapy instead of antidepressant. List THREE (3) pieces of information
which you would inquire from the history taking to support the decision to consider psychotherapy
for this patient instead of antidepressant (3 marks).
Any three of the following and other answers are acceptable. Examiner needs to use his or her discretion to
decide whether marks should be awarded.
The aetiology of depression is due to psychosocial (e.g. an event) causes rather than biological causes.(1
mark)
Previous side effects associated with antidepressants. (1 mark)
The severity of depressive symptoms is mild (1 mark)
Previous good response to psychotherapy (1 mark)
Patient is very insistent on psychotherapy or agree to complete 12 sessions (1 mark)
Patient is psychological minded / good motivation/ in touch with feelings; explore life history; (1 mark)
Patient is willing to do homework / afford the time to go for psychotherapy (1 mark)
Clear focus – cognitive bias( 1mark)
Patient may be unable to make informed decision regarding pharmacotherapy after initial assessment, and
may wish to consider it further (1 mark)
Stable in mental state / no strong suicidal ideation/ not floridly psychotic (1 mark)
Cannot tolerate side effects of antidepressants (1 mark)
Patient is keen to augment psychotherapy with antidepressant (1 mark)
3) List TWO (2) poor prognostic factors for depressive disorder which you would inquire from the
history. (2 marks)
Any two of the following:
Insidious onset (1 mark)
Early onset and long history of depression (1 mark)
Endogenous depression (1 mark)
Low self – esteem ( 1 mark)
Psychotic symptoms
Past and multiple hospitalizations for depression (1 mark)
Past suicide attempts or strong suicidal ideation ( 1mark)
co-morbid dysthymic disorder or physical illness (1 mark)
substance or alcohol abuse (1 mark)
comorbid anxiety disorder symptoms or personality disorder (1 mark)
past history of recurrent depressive episodes or failure in antidepressant treatment (1 mark)
poor inter-episode recovery (1 mark)
Strong family history of depressive disorder (1 mark)
Poor socio-economic status or social support (1mark)
Non-compliance to past treatment or poor insight (1 mark)
4) She read the internet and discovered a medication called clonazepam. She believes
that clonazepam is effective in treating mixed anxiety and depression. What is your
advice to the patient (2 marks).
1) Inform patient that clonazepam is only indicated for short term use and it has addiction
potential (1 mark)
2) Advise patient to consider selective serotonin reuptake inhibitor (SSRI) as regular treatment
for mixed anxiety and depression (1 mark)
Question 2 You are a resident working in renal medicine. A 45-year-old woman
suffering from schizophrenia and chronic renal failure. Due to her deteriorating renal
function, she was admitted to the renal ward 3 days ago. She has been receiving
haemodialysis for the past but wants to discontinue haemodialysis from today onwards.
1. List FOUR (4) questions you would ask the patient to assess her capacity to make
decision to discontinue haemodialysis. (4 marks)
Answers:
Any four of the following and other answers are acceptable. Examiner needs to use his or her discretion to
decide whether marks should be awarded.
1) Does the patient know her medical condition (i.e. renal failure) or the indication for dialysis? (1
mark)
2) Does the patient know the consequence for stopping the haemodialysis / risks and benefits of
haemodialysis? (1 mark)
3) Can the patient retain information about her condition and haemodialysis and use those
information to make a decision? (1 mark)
4) Does she experience any schizophrenia symptom which may affect her understanding of her
condition and haemodialysis? (1 mark)
5) What is her reason for stopping the dialysis or is the patient able to communicate her decision
in written or verbal format? (1 mark)
2. What are the TWO (2) most important questions you would ask the ward nurse taking care of
her? Answer must be different from Q.1. (2 marks)
Answers:
Any two of the following and other answers are acceptable. Examiner needs to use his or her discretion to
decide whether marks should be awarded.
1) Does the patient exhibit any first rank symptom (e.g. third person auditory hallucination, thought
interference, passivity experience or delusion of persecution) in the ward? (1 mark)
2) Does the patient exhibit any sign of delirium (e.g. disorientation, visual hallucination) in the ward? (1
mark)
3) Does she experience any recent complication associated with haemodialysis? (1 mark)
3. What are the TWO (2) most important questions you would ask her family members?
Answer must be different from Q.1 and Q.2. (2 marks)
Answers:
Any two of the following and other answers are acceptable. Examiner needs to use his or her discretion to
decide whether marks should be awarded.
1) Does she encounter any financial difficulty associated with haemodialysis? (1 mark)
2) Is she compliant to antipsychotic medication? (1 mark)
3) Did she refuse haemodialysis in the past? (1 mark)
4. State one indication in which you might request an ethics consult for this case. (2 mark)
Other answers are acceptable. Examiner needs to use his or her discretion to decide whether marks should be
awarded.
The patient has the capacity to make decision and insists to refuse dialysis and her renal functions become
critical and she is in life threatening situation. (2 marks) or
Question 3 You are a general practitioner. A 70-year-old man came to your clinic and needs to be
certified that he is fit to drive. He has seen a private psychiatrist for 3 years but not certain about his
diagnosis. He is taking psychotropic medications. He has good past health and does not suffer from other
chronic medical illness.
1. List TWO (2) classes of psychotropic medications and adverse drug reactions that have a
negative impact on his ability to drive. (3 marks)
Classes of psychotropic medications Adverse drug reactions which have a negative impact on
driving
3. List TWO (2) questions you would ask the patient to assess his safety record in driving
(2 marks)
Any three of the following and other answers are acceptable. Examiner needs to use his or her
discretion to decide whether marks should be awarded.
1) Changes in driving patterns in the past year (e.g. difficulty to drive on expressway) (1 mark)
2) Use of seatbelt (1 mark)
3) Number of road traffic accidents in the past (1 mark)
4. State THREE (3) different and relevant physiological systems which you would examine to assess
his fitness to drive. Please explain how to assess each physiological system. (3 marks)
Eye or vision (0.5 mark) Snellen eye chart for vision (0.5 mark)
Musculoskeletal system (0.5 Cervical spine, hip, and knee mobility test for arthritis or
mark) Get-up-and-go test (0.5 mark)
Neurological system (0.5 mark) Neurological exam for signs of Parkinson’s disease (0.5
mark) or
Look for signs associated with cerebellum dysfunction
such as performing the balance test (0.5 mark) or
Get-up-and-go test (0.5 mark)
Question 4
A 40-year-old man used to be a successful banker in Singapore. He moved to Hong Kong 3 years
ago and started misusing cocaine there. His sister has noticed changes in his behaviour after he
misused cocaine. His behavioural changes include depression, exhaustion and oversleeping.
3. How would you explain to his sister regarding his behavioural change? (2 marks)
Other answers are acceptable. Examiner needs to use his or her discretion to decide whether marks should be
awarded.
It is due to psychological withdrawal from cocaine and he “crashes” into depression, exhaustion and
overlapping. (2 marks) or
It is due to psychological withdrawal from cocaine and the symptoms are opposite to the effect of cocaine
intoxication. (2 marks)
4. He returned to Singapore 6 months ago. He could not find cocaine in Singapore and started to
misuse alcohol. His sister requests inpatient detoxification to help him to quit drinking. State
THREE (3) indications for inpatient detoxification. (3 marks)
A 35-year-old woman presented with elated mood, grandiosity, high sexual drive, meeting
multiple sexual partners and racing thoughts. She was admitted to the medical ward because
your hospital does not have a psychiatric ward. She has history of bipolar disorder with last
episode being depressed. The inpatient medication record (IMR) shows that she is treated with
lithium 800mg at night but the serum level is 0.2 mmol/L (normal level: 0.4- 0.8 mmol/L). Her
renal function and thyroid function tests are normal. The IMR also shows that she is treated
with high-dose of bupropion 450mg per day. She has been using illicit drugs lately.
1. State the MOST IMPORTANT immediate action to prevent her mood from getting more
elated. (2 marks) Examiner: / 2 marks
2. State THREE (3) MOST IMPORTANT investigations which you should order based on
the history provided (3 marks) Examiner: /3 marks
3. She admits that has stopped taking lithium due to its side effects. State THREE (3)
common side effects of lithium which she may experience (excluding impairments on
renal and thyroid functions because the laboratory results show normal findings) (3
marks) Examiner: / 3 marks
4. Name TWO (2) illicit drugs which are MOST LIKELY to lead to the above clinical
features. (2 marks) Examiner: / 3 marks
1. Amphetamine (1 mark) or
2. Cocaine (1 mark) or
3. MDMA abbreviation is acceptable for MDMA (1 mark)
1
A 30-year-old Singaporean man survived a bomb attack overseas one week ago. He has returned
to Singapore for further inpatient treatment. He suffers from burn and multiple fractures. His girl-
friend was killed in the bomb attack. When you interviewed him, he recalled seeing a lot of dead
bodies at the scene immediately after the bomb attack. He complained of anxiety. He could not
sleep at night and slept around 1-2 hours per night. Then he burst into tears when talking about
the death of his girlfriend.
1. After your assessment, you need to enter a psychiatric diagnosis in the medical record. What is
the current psychiatric diagnosis? (1 mark) Examiner: / 1 mark
2. Besides major depressive disorder, state TWO (2) most possible psychiatric diagnoses
which he will develop in the next 6 months (2 marks). For each diagnosis, state THREE (3)
specific clinical features under each diagnosis (3 marks). Examiner: / 5 marks
Diagnosis 1: Diagnosis 2:
Answers (other answers are acceptable. Marks will be awarded based on examiner’s discretion
Flashback/intrusive recollection Strong suicidal ideation to join his late girl friend
2
friend
(Examiner: 0.5 mark)
(Examiner: 0.5 mark)
Specific clinical feature 3 (for diagnosis 1) Specific clinical feature 3 (for diagnosis 2)
Avoidance to talk about topic of bomb attack Prolonged grief (last for several years) and
and visit the city where the bomb attack took impair his function
place.
(Examiner: 0.5 mark)
(Examiner: 0.5 mark)
Other answers: Other answers:
Hypervigilance Severe psychomotor retardation
Emotional numbness Severe worthlessness or guilt
Derealisation
Depersonalisation Please note that delayed grief and inhibited grief
Dissociative amnesia are unlikely based on case scenario.
Exaggerated startle response/autonomic arousal
Avoid reminder of the bomb attack
Detachment from family and friends
3. Based on his symptoms, state TWO CLASSESS of psychiatric medications which are most
suitable for this patient. Please name one specific example which you would prescribe. (2
marks) Examiner: / 2 marks
Answer:
Psychotropic medication 1 Psychotropic medication 2
Class of psychotropic medication Class of psychotropic medication
Benzodiazepine (Short term use) Selective serotonin reuptake inhibitor
4. State ONE (1) type of psychotherapy which is most beneficial for the patient (1 mark) and
explain how it works for this patient (1 mark) Examiner: / 2 marks
3
Answer:
During the cognitive therapy, the psychologist will identify his inaccurate beliefs related to the bomb
attack (e.g. the patient will be guilty for not offering enough protection to his late girl friend or
should cancel the trip beforehand), the psychologist will challenge such beliefs and inform him that
the bomb attack was inevitable.
During behaviour therapy, the psychologist will assist the patient to recall the traumatic memories
or have in-vivo exposure to the objects related to bomb attack or his late girlfriend. The psychologist
will help him to practise relaxation exercise to inoculate his anxiety. (1 mark)
Other psychotherapies such as Eye Movement Desensitization and Reprocessing (EMDR) and grief
therapy are acceptable answers. Marks will be awarded based on the explanation offered by
student.
12 Failed (lowest: 2- 9)
4
A 70-year-old woman attempted suicide because she could not tolerate the drinking behaviours of
her husband and her son. You realise that it is important to treat the alcohol dependence of her
husband and her son to avoid future suicide attempt in the wife.
1. Comparing elder alcoholics and younger alcoholics, state TWO (2) specific phenomenon
which are more common in elder alcoholics (2 marks).
Answer may vary. Examiners will decide whether marks should be awarded.
1) Elder alcoholics are more likely to use cheaper alcohol such as Chinese wine (1 mark) or
2) Elder alcoholics are more likely to develop complications associated with alcohol misuse
(e.g. fall, hallucination if they have sensory impairment, head injury, delirium tremens,
Wernicke/Korsakoff/alcohol dementia/ liver cirrhosis due to prolonged use) (1 mark)
3) Elder alcoholics are less violent or aggressive when intoxicated when compared to
younger people (1 mark).
4) Elder alcoholics are more likely to drink at home (alone) or nearby hawker centre rather
than social occasions (1 mark) due to retirement or
5) Elder alcoholics are less likely to join alcoholic anonymous/ less motivated to quit (1
mark).
2. Based on the Cloninger’s Classification System, which type of alcoholism do the father and
son belong to? (1 mark)
3. Based on your answer in Q.2, state THREE (3) specific clinical features (not mentioned in
the clinical scenario) to elicit from the father and son to support the type of alcoholism
which you have chosen. (3 marks)
4. Do you recommend controlled drinking or total abstinence for the father and son. Please
delete the inappropriate answer (1 mark)
5. State ONE (1) most commonly used medication which can help the father and son to quit
alcohol. (1 mark)
5
Answer: Naltrexone (1 mark)
6. State TWO (2) common side effects associated with the medication chosen in Q.5 (2
marks)
Any two of the following:
1. Abdominal pain/cramps ( 1 mark)
2. Diarrhoea (1 mark)
3. Anxiety ( 1 mark)
4. Other acceptable answers: Nausea, Headache, dizziness, fatigue, insomnia, liver
impairments
6
Question 4 (10 marks)
A 70-year-old man is brought by his family to see you. In the past one year, he developed poor
memory, seeing ghosts in the house and frequent falls. Physical examination reveals cogwheel and
lead-pipe rigidity in his upper limbs.
2. Based on clinical presentation, how to differentiate his condition from dementia caused by
Parkinson’s disease (2 marks)
Answer: For dementia related to Parkinson’s disease, the cognitive impairment has to be
after 1 year interval. (2 marks)
3. The family claims that he is very disturbed by the ghosts he sees at home. Please
recommend the MOST appropriate psychotropic medication for this patient (1 mark) and
justify your selection (1 mark)
Answer: I would prescribe quetiapine (1 mark) because it has low risk to cause extra-pyramidal side
effects (1 mark)
4. The family wants to prevent his memory from further deterioration. Please recommend
the MOST appropriate psychotropic medication for this patient (1 mark)
5. Based on your answer in Question 4, state TWO (2) common side effects (2 marks)
Answer: Muscle cramp (1 mark), diarrhoea(1 mark), bronchospasm (1 mark), insomnia (1 mark),
nausea/vomiting (1 mark), bradycardia (1 mark), anorexia/weight loss (1 mark), anxiety/agitation (1
mark), incontinence (1 mark)
6. His family complains that he does not sleep well at night. What is your explanation? (2
marks)
Answer: He suffers from rapid eye movement (REM) sleep disturbance and experiences a lot of
nightmares at night (2 marks). REM sleep disturbance is associated with Lewy Body Dementia.
7
Objective Structured Clinical Examination (OSCE) – (M4-R1)
of medical undergraduates.
SP:
Age range: 30 - 60
Gender: Female/Male
Level of training: Trained
Introduction
Construct: This is a station designed to test the candidate’s ability to take a history
of oppositional defiant disorder.
Time: 8 minutes
Instructions to Candidates
You are a general practitioner. Mr/Mrs Tan comes to see you. His/her 11-year-old
son exhibits difficult behaviour such as being disrespectful, spiteful and
argumentative at home and school. His behaviour starts to concern his parents and
teachers.
Tasks:
1. Take a history from the parent to establish a diagnosis.
2. Perform a risk assessment
3. At the end of your interview with the parent, please write down your diagnosis
and pass it to the examiner.
Time: 8 minutes
Student’s sticker
Answer sheet
Please write down the diagnosis of this patient and pass it to your examiner.
___________________________________________________________________
Background
Your name is Ms. Tan. You are married and has a single child, an 11-year-old
son called Jason. You are currently staying in a 3-room HDB flat. You worked as
an administrative officer in a company and your spouse also works as an
administrative staff in another company.
You have a 11-month-old son (Jason). When yourself and your spouse go to
work, he is looking after by a domestic helper at home. He goes to school by
school bus. However, there were no problems in the pregnancy and giving birth.
He has normal development (e.g. normal in speaking, hearing and walking)
Jason has average results from Primary 1 to Primary 4. He did not have
behavioural problems in the past.
He is your first child. Yourself and your spouse cannot afford to have a second
child.
Yourself and your spouse have no past or family history of mental illness.
Yourself and your spouse do not have forensic history.
Symptoms
Main symptoms
Jason currently studies in Primary 5 and he finds the subjects in Primary 5 are
difficult to study. In the past one year, he has been disrespectful to you, your spouse,
domestic helper and his teachers. He is noted to be defiant in almost any situation
(at home, going out with family and school). He finds his temper is bad and worse
than other children of his age. He has been argumentative, spiteful and challenges
you and the teacher the reasons to do homework. He wanted to go for a buffet
dinner last weekend but the family wants to save money and ask him to wait until
next school holiday. He was very anger and throws things at home.
Your spouse is very exhausted and gives in and tells your son that, “Yes, you do not
need to do your homework.” Jason then argues, “There is no need to study”. This
type of behaviour, over and over, leaves you and your spouse feeling overwhelmed
and exhausted. Your domestic helper finds Jason very annoying and blames her for
his mistakes.
You met the teacher last week. In this academic year, the teacher finds Jason
struggling in school and keeping his old friends. Jason deliberately annoys his
classmates. The teacher finds him refuse to take responsibility and blame his
classmates for his mistakes. His academic performance was above average last
year and he got a borderline pass this year. His results are similar across subjects.
He does not have a favoured subject. He has no attention problems in school and he
can sit still to do his work. He have not broken any school rule and never being
suspended before.
His mood is normal. He sleeps and eats well. No self-harm and no suicide.
He is not nervous. He always attends school and never skips school.
There is no history of truancy.
He does not have other unusual experiences such as hearing voices or seeing
things that are not there.
He does not use recreational drugs. He does not sniff glue.
His IQ should be normal. He studies in a normal neighbourhood school.
He does not have specific learning problem (e.g. he can read, write, spell and do
mathematics)
He has normal attention and can sit still to study at home and in school.
He has normal development and there is no delay in walking and speaking.
He likes to watch TV and plays computer games. He is not addicted to internet.
Risks
Although his behaviour is difficult to manage, there are some good things
about Jason. Jason does not violate more serious rules like running away
from home or breaking school rules. He has never been physically aggressive
toward other people (parents, classmates) and animals. Jason never initiates
a fight. He does not bully other children. He lies about minor things but never
tells a big lie. He never steals and never damages others’ properties. He has
no trouble with the police.
He does not harm himself
He does not harm other people.
He seldom has accident. E.g. falling from height due to excessive climbing or
running too fast.
Other points:
You have not consulted any doctor or counsellor on this matter.
You want to seek advice from the GP.
Time: 8 minutes
EXAMINER’S REPORT
of medical undergraduates.
SP:
Age range: 30 - 50
Gender: Female
Level of training: Trained
Introduction
Time: 8 minutes
Instructions to Candidates
You are a resident working in the Accident and Emergency Department (AED). Ms.
Lim was bought to the AED by police because she tried to attempt suicide by
jumping from height. Your hospital is new and does not have a psychiatric ward.
Tasks:
1. Take a history from Ms Lim to assess her suicide attempt and current suicide
risk.
2. Assess depressive symptoms and obtain further relevant information.
3. At the end of your interview with Ms Lim, please select the MOST
APPROPRIATE management strategy and pass to the examiner.
Time: 8 minutes
Student’s sticker
Answer sheet
Background:
You are Ms. Gigi Lim, a 35-year-old woman tried to jump down from the roof
of her HDB flat tonight.
You are bought in by the police because someone spotted that you wanted to
jump down from a building and called the police who stopped you.
You are an unemployed, recently tested to be pregnant in urine pregnancy
test 2 weeks ago. This is an unplanned pregnancy. You do not use
contraception.
You are not married with your boyfriend. He is doing odd-job with unstable
income.
Suicide attempt
Why did you want to jump down tonight?
After you had argued with your boyfriend tonight, you wanted to jump from
height. You have thought about jumping for 2 weeks since you know the urine
result is positive.
Your relationship with him is not good in the past 1month. You have thought
of jumping down to end it all because he is not good to you and both of you
have no savings.
You want to get married with him as you are two-week pregnant. You
discovered the urine pregnancy test was positive 2 weeks ago. You have
known this boyfriend for 1 year but relationship has been unstable. He is not
keen to get married. He works as an odd job worker with unstable income.
You feel hopeless because there will not be enough money to support the
baby after the baby is born.
After you had argued with him, your boyfriend left the HDB flat.
As your boyfriend does not look after you and will leave you alone while you
are pregnant, you think there is no way out but to die.
Behaviour
Depressed; Still suicidal
If doctor says that he needs to transfer you to IMH, you do not look too happy
but you do not violently object.
Time: 8 minutes
EXAMINER’S REPORT
of medical undergraduates.
SP:
Age range: 40-65
Gender: Male or female
Introduction
Time: 8 minutes
Instructions to Candidates
You are a General Practitioner. A 45-year-old man comes to see you today because
he injured his head after he was assaulted by another man in a pub.
Tasks:
1. Obtain the answer sheet (with your name label on it).
2. Take a brief history (less than 4 minutes) from the patient to assess post-
concussion syndrome, risk assessment and sequelae after head injury.
3. Perform cognitive tasks listed on the left hand side of the table found on your
answer sheet.
4. Fill the right hand side of the table and provide the scores for the patient and
indicate maximum score for each task.
Time: 8 minutes
Background of patient
Your name is Mr. Tan, a 45-year-old married person, staying with your spouse and son.
You work as an account manager. You have university education.
You have NO personal or family history of mental illness or dementia.
You have good past health.
You are a non-smoker and a social drinker. You go to drink in a pub once a while.
One month ago, you went to a pub and drank with your friends. You had an argument
with another man in the pub. He used a baseball bat to hit the front part and both sides
of your head.
You had a black-out for 30 minutes and your scalp was bleeding from superficial wound.
Your friends sent you to the hospital immediately. You can remember events before and
after the fight.
You were treated at the Accident and Emergency Department. The doctor said the head
injury was mild. You were not required to stay in the hospital. The brain scan did not
show major internal bleeding in the head. No surgery was required. No bleeding from
ear, nose and throat. No bruising from eyes.
The man who attacked you left the pub and police could not catch him. Insurance
company thinks the injury is mild and refuses to compensate.
After head injury, you find your brain function not very good. You cannot concentrate at
accounting work and often make mistakes. Your supervisor asks you to take no pay
leave to consult a doctor. You cannot plan or make decision.
In your head, you experience headache over the frontal part of your head and giddiness.
You lost your balance a few times after getting up from bed and almost fell down.
For your eyes and ears, you are very sensitive and become irritable to light and noise.
You hear “wee” sound in your eyes (Tinnitus).
For your mental functions, you are slow in mental speed and cannot think as fast as the
past. You have noticed increased difficulty in finding the right words to express yourself.
You are also unable to play crossword puzzles which you used to enjoy as you are
unable to come up with the right words.
Your memory is failing you: misplacing things (wallet), forgetting recent conversations
you had with your family, forgetting what you just ate for meals.
For your mood, you are sad all the time but sometimes becomes angry for no reason,
poor appetite, poor sleep (4 hours at night, cannot fall asleep), low energy level, loss of
interest (e.g. tennis), loss of sexual drive, poor concentration and attention, feels
hopeless after the head injury. Your mood swings from normal mood to anger.
You do not have suicidal thought. You do not hear voices or see things that are not
there.
You feel nervous most of the time and easily startled. You worry that the head injury
caused a lot of problems in your head. You cannot sit still, need to pace around in the
Time: 8 minutes
Student’s sticker
Answer sheet
2. Please perform the following cognitive assessments and fill the right side of the
table
Maximum score:
Maximum score:
Maximum score:
of medical undergraduates.
SP:
Age range: 30 - 49
Gender: Female
Level of training: Trained
Introduction
Construct: This is a station designed to test the candidate’s ability to take a history
of borderline personality disorder.
Time: 8 minutes
Instructions to Candidates
You are a resident working at the Accident and Emergency Department (AED). Amy,
a 35-year-old woman comes to see you because she has cut her thighs. Your
colleague has put dressing on her thighs and the wounds are superficial.
Tasks:
1. Take a history from Amy to assess her personality and establish a diagnosis.
2. Assess common psychiatric comorbidity associated with her diagnosis.
3. At the end of your interview with Amy, please write down the most likely
psychiatric diagnosis and pass it to the examiner.
Time: 8 minutes
Student’s sticker
Answer sheet
Please write down the most likely psychiatric diagnosis of this patient and
pass it to your examiner.
___________________________________________________________________
Background:
Your name is Amy, a 35-year-old woman. You live alone in a one-room HDB flat.
You are estranged from your family, being an only child whose father died of
cancer when you were 6 years old, and who has a very difficult relationship with
her mother. You have a history of physical abuse in childhood and her mother
was the perpetuator and she caned you very often for no reason. You are not in
contact with your mother. There is no history of sexual abuse.
You had a number of relatively short-lived jobs in the past as a caregiver for the
elderly in nursing home. You resigned from your last job after an argument with
the manager and have been unemployed for several years.
You consult the accident and emergency department today because you are very
stressed and cut your thigh.
You have no known medical illness. No known family history of mental illness.
Symptoms
Main symptoms:
The doctor may ask you a question how to describe yourself. You tell the doctor
that you don’t know how to describe yourself. You are confused about who you
are. You are lost about yourself.
The doctor may ask you how your friends describe you. You tell the doctor that
you have a small number of close female friends, but find that people often let
you down so you do not have a wide social network. You feel that people in
general do not like you. It is very hard to maintain relationship with others.
The reason for cutting yourself is to re-experience the pain. The pain inflicted
by your mother during the childhood abuse. You are not suicidal at this moment.
You always cut your thighs with pen knife. You have no intention to kill yourself.
Relationship: You have a history of brief unstable relationships. You had 10 boy
friends in the past who were physically abusive. You have not been in a close
relationship for several years and no recent sexual activities..
Past suicide attempts: You are well apart from the lacerations, with no significant
medical history. You have scars on your thighs from past superficial lacerations. You
have had several past psychiatric admissions for self-harm or suicidality by drug
overdose across the last few years.
You use emergency A&E services at times. You have recently been admitted with
overdoses twice in the last month. “I’m just fed up and I can’t go on.”
Other problems:
You have nightmare, the images of childhood abuse popping up into your mind.
You have binge eating when under stress but no self-induced vomiting.
For your mood, very unpredictable and always have mood swings.
Your sleep, appetite and energy are normal.
You are not in any relationship at this moment and no sexual activity recently.
No other medical problem. When you were admitted, the blood tests show normal
results.
No difficulty in breathing, no shortness of breath, no panic attack
No fear of losing control
No fear of dying/going to die
No fear of going out of the house. No fear of using MRT or bus.
No fear of going to a shopping mall or crowded place/enclosed space
No fear to centre of attention, no fear of talking to other people.
No fear of blood, height or spider.
No repetitive checking or hand-washing
No repetitive thoughts of contamination
Not hearing voices
Behaviour
You are cooperative during the interview.
Time: 8 minutes
EXAMINER’S REPORT
of medical undergraduates.
Instructions to Candidates
You are a paediatrician working in a private medical group. A mother bought her 15-
year-old daughter, Angela to see your paediatric colleague because of low body
weight and lethargy. Angela used to be a high academic achiever in school but she
was not able to sit for examination in November last year. Your colleague has
ordered a set of investigations but he needs to go off to attend some urgent matter.
He has asked you to review the laboratory results and electrocardiogram (ECG) on
his behalf.
Tasks:
After entering the room, please review your colleagues’ record, laboratory results
and ECG and identify abnormalities.
Please double check your name is correct before answering the questions.
Please pass your answer sheet to the circuit administrator at the end of the station.
You are required to stay in the room until the end of the 8th minute. You cannot
leave the room if you finish early.
Time: 8 minutes
Outpatient record
(To be placed on the desk of the candidate’s room)
History:
Angela was bought in by her mother due to low body weight
and lethargy.
Weight: 40 kg
Height: 170 cm
PE:
Her physical examination showed marked malnutrition
and paleness.
Plan:
Order full blood count, liver function test, renal function test,
thyroid function test and electrocardiogram.
Laboratory results:
1. Based on her height and weight, calculate her body mass index (BMI). (2 marks)
(Examiner’s Use only: /2 marks)
2. Please review the laboratory results and electrocardiogram. Identify THREE (3)
abnormalities. (6 marks) (Examiner’s Use only: /6 marks)
3. Based on the above information, state the MOST LIKELY psychiatric diagnosis. (2 marks)
(Examiner’s Use only: /2 marks)
4. Based on your psychiatric diagnosis, state FOUR (4) additional questions which you would
ask the patient to confirm your diagnosis (Examiner’s Use only: /4 marks)
5. Based on your psychiatric diagnosis, state FOUR (4) additional clinical signs which you
would look for during physical examination to confirm your diagnosis. (Examiner’s Use only:
/4 marks)
6. Based on your psychiatric diagnosis, state TWO (2) additional investigations which your
colleague forgot to order but relevant to this condition (2 marks) (Examiner’s Use only:
/2 marks)
This companion guide includes past exam papers to help you practice for the following
components in the actual exam:
• Multiple choice questions
• Short Answer questions
• OSCE stations
This book is a joint effort between authors from Singapore & Authors from the University of
Toronto.
Melvyn WB Zhang MBBS (Singapore), Diploma (Cl Psychiatry) (RCP&S Ireland), MRPCPsych(UK)
Associate Consultant, National Healthcare Group
Cyrus SH Ho MBBS (Singapore), Diploma (Cl Psychiatry) (RCP&S Ireland), MRCPsych (UK)
Associate Consultant, National University Healthcare System (NUHS)
Roger CM Ho MBBS (Hong Kong), DPM (Psych) (Ireland) Diploma (Cl Psychiatry) (RCP&S Ireland), DIP
(Psychotherapy) (NUS), MMed (Psych) (Singapore), MRCPsych (UK), FRCPC
Associate Professor and Consultant Psychiatrist, Department of Psychological Medicine,
Yong Loo Lin School of Medicine, National University of Singapore