PASTEST 2020 FOP Behavioural Medicine and PsychiatryQbank 1/2 Questions successfully downloaded Ready to begin?Question 1 of 12 An 8-year-old boy attends clinic for the first time with his mother. He has achieved daytime dryness but wets the bed several nights a week. Urinalysis is clear and there are no abnormal findings on abdominal or neurological examination. No previous intervention has been given to the family. Which one of the following is the most appropriate first-line treatment? Select one answer only Intranasal desmopressin Star chart and encouragement of child and family Oxybutynin Enuresis alarm m)/oO;/O/;/o| > Imipraminete aed ‘An 8-year-old boy attends clinic for the first time with his mother. He has achieved daytime dryness but wets the bed several nights a week. Urinalysis is clear and there are no abnormal findings on abdominal or neurological examination. No previous intervention has been given to the family. Which one of the following is the most appropriate first-line treatment? Select one answer only Intranasal desmopressin A c D E Oxybutynin Enuresis alarm imipramine Explanation # Isolated nocturnal enuresis treatment usually starts with encouragement and a reward system with regular monitoring. Many children and families respond well to simple behavioural interventions and reassurance, with encouragement of the child to participate in changing bedding. Not drinking for 2h prior to bedtime and micturating just before going to sleep are techniques used as a first response to nocturnal enuresis, Desmopressin can be started in children over seven years ifthe rapid onset and/or short term improvement is the priority of treatment, or if an alarm is inappropriate or undesirable, but is not a firstline therapy. COxybutynin is most useful in those with bladder instability affecting both diurnal and nocturnal continence. Its very often used in children five years and older with spina bifida After the age of seven years, if behavioural techniques have failed, an enuresis alarm can trialled. Itprovides more effective treatment than drug therapy, with a low relapse rate, but is dependent (on the child's co-operation Imipramine belongs to a class of medications called tricyclic antidepressants. Its usually used to treat symptoms of depression and sometimes to treat bedwetting in children aged six and older, but itis not a firstine treatment and it has many side-effects. —Question 2 of 12 A 14-year-old boy is admitted to the Emergency Department with delusions, hallucinations and extremely disorganised motor behaviour. He has been exhibiting strange behaviour, withdrawal from friends and trouble sleeping. A toxicology screen is negative. His neurology examination and magnetic resonance imaging (MRI) are normal and there are no signs of infection. A provisional diagnosis of schizophrenia is made. Which of the following characteristics would indicate an unfavourable prognosis? Select one answer only A prolonged pre-morbid history of social withdrawal A schizophrenic second-degree relative Rapid onset of illness Anormal MRI brain scan m)/oO;O/;|W|> Awareness of having the disorderere Ped A 14-year-old boy is admitted to the Emergency Department with delusions, hallucinations and extremely disorganised motor behaviour. He has been exhibiting strange behaviour, withdrawal from friends and trouble sleeping. A toxicology screen is negative. His neurology examination and magnetic resonance imaging (MRI) are normal and there are no signs of infection. A provisional diagnosis of schizophrenia is made. Which of the following characteristics would indicate an unfavourable prognosis? Select one answer only a A schizophrenic second-degree relative Rapid onset of iliness B Cc D_ | Anormal MRI brain scan E Awareness of having the disorder Explanation Left untreated, childhood schizophrenia can result in severe emotional, behavioural and health problems. Complications associated with schizophrenia, such as depression, self-injury and aggressive behaviour, may occur in childhood or later. B. A schizophrenic second-degree relative ‘The risk of developing schizophrenia is 5-20 times higher in first-degree relatives of affected probands compared with the general population. Having a second-degree relative with schizophrenia does not increase the risk. Cae Rica icy In schizophrenia, a sudden onset (within two weeks from baseline function) of illness has a more favourable prognosis than when the onset is insidious. De Changes on MRI are usually associated with more severe symptoms, poor prognosis and. resistance to treatment. rn Rk cd In individuals with schizophrenia, no insight or awareness of their disorder is a predictor of nonadherence to treatment, higher relapse rates and poorer illness course. Peon Tag Question adQuestion 3 of 12 A 4-year-old girl fails to develop intelligible speech and simply repeats bits of sentences that she has heard. She spends hours sitting alone, facing a wall and rocking back and forth. She shows little affection for others and sometimes bangs her head against the floor. A diagnosis of autistic spectrum disorder (ASD) is made. Her parents want more information What is the best advice regarding the aetiology of ASD? Select one answer only Children of older mothers have no greater risk of ASD Rubella has been disproven to increase the risk of ASD This child is less likely to have a sibling with ASD Measles-mumps-rubella (MMR) vaccination is not indicated as a cause m)/oO;/O/;/o| > Maternal use of valproic acid is now permitted during pregnancyere ae ‘A 4-year-old girl fails to develop intelligible speech and simply repeats bits of sentences that she has heard. She spends hours sitting alone, facing a wall and rocking back and forth. She shows little affection for others and sometimes bangs her head against the floor. A diagnosis of autistic spectrum disorder (ASD) is made. Her parents want more information. What is the best advice regarding the aetiology of ASD? Select one answer only Children of older mothers have no greater risk of ASD Rubella has been disproven to increase the risk of ASD This child is less likely to have a sibling with ASD. A B Cc Bo es STS 7 E Matemal use of valproic acid is now permitted during pregnancy Explanation % There have been concerns about vaccines as a postnatal environmental cause for ASD. The focus has been on either the MMR vaccine or the thimerosal preservative as a causative factor. All available data have not supported either hypothesis. A. Children of older mothers have no greater risk of ASD Advanced maternal or paternal age and extremely premature birth (< 26 weeks gestational age), as well as family members with learning or social disabilities or Pena disorders have been identified as risk factors, Ce nue ec If rubella occurs in the first weeks of pregnancy, up to 85% of neonates are born with a pattern of growth restriction and major birth defects known as congenital rubella syndrome. Late-onset Sequelae of rubella in early pregnancy include autism and diabetes. PASC LOCOS Rin There is a high recurrence risk (2-19%) for ASD among siblings, as well a higher concordance rate (37-90%) in twin studies E. Maternal use of valproic acid is now permitted during pregnancy Environmental exposures early in the first trimester of pregnancy that have been linked to ASD in epidemiologic studies include thalidomide, misoprostol, valproic acid and organophosphates, eee eee Tag Question ee tonQuestion 4 of 12 A 14-year-old girl complains that her mother interferes in every aspect of her life and tries to control her. The girl no longer speaks to her parents or eats meals with them. The mother has increased her efforts to maintain control. Which condition is most likely to arise from this situation? Select one answer only Anorexia nervosa Dissociative identity disorder Narcissistic personality disorder Schizophrenia m)/O;/O;wW|> Separation anxiety disorderere aed A 14-year-old girl complains that her mother interferes in every aspect of her life and tries to control her. The girl no longer speaks to her parents or eats meals with them. The mother has increased her efforts to maintain control. Which condition is most likely to arise from this situation? Select one answer only TS y B c D E Dissociative identity disorder Narcissistic personality disorder Schizophrenia Separation anxiety disorder Family dynamics are strongly implicated in the development of anorexia nervosa. Food restriction, With avoidance of family meaitimes and weight loss are postulated as attempts to regain some control and avoid sexual issues. B. Dissociative identity disorder Dissociative identity disorder is associated with childhood sexual abuse, which is not mentioned inthe vignette, Ituntikely that narcissitic personality disorder would arise from this specific family environment compared to anorexia nervosa, which is much more common. ‘Schizophrenia is not associated with family dynamics. E, Separation anxiety disorder There is no situation here that could cause separation anxiety disorder. Penge testes —Question 5 of 12 A 5-year-old boy resists going to school because he wants to stay with his mother. He becomes terrified whenever his parents leave the house. During the day, he worries that his family may never come back home. Which disorder is this boy at most risk of developing as an adult? Select one answer only Dysthymic disorder Obsessive—compulsive disorder (OCD) Panic disorder Schizophrenia Pain disorder m)/O;/O;wW|>ere ed A 5year-old boy resists going to school because he wants to stay with his mother. He becomes terrified whenever his parents leave the house, During the day, he worries that his family may never come back home. Which disorder is this boy at most risk of developing as an adult? Select one answer only, Dysthymic disorder Obsessive-compulsive disorder (OCD) Schizophrenia Pain disorder m|o Fy |> Explanation % ‘Separation anxiety is normal in very young children (8-14 months). When a fear occurs in a child aged over six, is excessive and lasts longer than four weeks, the child may have separation anxiety disorder, which later in adulthood can present as panic disorder. ea Dysthymic disorder is a persistent depressive disorder with @ chronic course and an early and insidious onset (before age 21). This boy has symptoms of separation anxiety, not depression. ST eu EE ac ae} Obsessive fears and compulsive behaviours can be learned from watching family members or gradually learned over time. However, children with separation anxiety are less likely to develop OCD than panic disorder. ‘Schizophrenia is associated with a history of emotional withdrawal, not separation anxiety from a parent, during childhood, Pain disorder is chronic pain experienced by a patient in one or more areas and is thought to be caused by psychological stress. Itis usually seen in patients with depression. Rate this question: —Question 6 of 12 A 16-year-old girl is reviewed in the psychiatric clinic. Her expected weight is 55 kg, and since follow up began, her lowest weight has been 49.5 kg. She goes through episodes of binge eating and vomiting and reports prolonged fasts. She is scared of putting on weight and has missed her last two periods. What is the most likely diagnosis? Select one answer only Anorexia nervosa (purging type) Anorexia nervosa (with binge eating) Bulimia nervosa Personality disorder m)/oO;/O/;/o| > Depressionree a ed A 16-year-old girl is reviewed in the psychiatric clinic. Her expected weight is 55 kg, and since follow up began, her lowest weight has been 49.5 kg, She goes through episodes of binge eating and vomiting and reports prolonged fasts, She is scared of putting on weight and has missed her last two periods. What is the most likely diagnosis? Select one answer only Anorexia nervosa (purging type) B | Anorexia nervosa (with binge eating) D | Personality disorder ES a Depression Explanation Binge episodes and fasting episodes can be seen in both anorexia and bulimia, but purging behaviours, eg vomiting and laxative and diuretic abuse are more characteristic of bulimia Predisposing factors for bulimia include a history of anorexia, being overweight, mood disorder ‘and borderline personality disorder, as well as illicit drug use. The prognosis in bulimia is variable. Young people with the purging type of anorexia nervosa place severe restrictions on the amount and type of food they consume. Additionally, they display purging behaviour such as self-induced Vomiting or deliberately misusing laxatives, diuretics or enemas. B. Anorexia nervosa (with binge eating) Binge eating involves eating a large amount of food and feeling a ‘loss of controt’. For a diagnosis of anorexia, the weight must be > 15% below the expected weight with amenorthoea, defined as, the continuous absence of three menstrual cycles. DCE R es A personality disorder is a mental disorder characterised by a rigid and unhealthy pattern of thinking, functioning and behaving. Difficulties perceiving and relating to situations and people cause difficulties in relationships and social activities. Depression and obsessive-compulsive disorder are frequently associated with anorexia, which has a high long-term mortality of 18-20%; however, this is not the primary diagnosis. Rate this question: ——Question 7 of 12 A 9-year-old boy constantly disobeys his parents and teachers. He gets along well with his peers and completes projects that he likes. His developmental milestones are normal and he has no history of fighting, theft or destruction of property. Mental status examination reveals an assertive child who tells the examiner that he does not wish to discuss his problems. What is the most likely diagnosis? Oppositional defiant disorder Mental retardation Conduct disorder Childhood disintegrative disorder m)/oO;O;|WD|> Attention-deficit hyperactivity disorder (ADHD)ete ad ‘A 9-year-old boy constantly disobeys his parents and teachers. He gets along well with his. peers and completes projects that he likes. His developmental milestones are normal and he has no history of fighting, theft or destruction of property. Mental status examination reveals an assertive child who tells the examiner that he does not wish to discuss his problems. What is the most likely diagnosis? Mental retardation Conduct disorder Childhood disintegrative disorder B Cc D E Attention-deficit hyperactivity disorder (ADHD) Explanation Oppositional defiant disorder involves problems in relating to authority figures, Such children get along well with their peers and have no other problems of conduct or development. Cee Mental retardation is associated with delayed developmental milestones and other evidence of impaired intellectual abilities. earn et ead Conduct disorder is characterised by violation of age-appropriate social norms, fighting, runaway behaviour, theft and destruction of property and is less likely given the clinical scenario. Conduct disorder is a sequel to oppositional defiant disorder. D. Childhood disintegrative disorder Childhood disintegrative disorder involves the development of severe disturbances in social, ‘communicative and cognitive functions following a period of normal development, E. Attent COD) ficit hyperacti Attention-deficit hyperactivity disorder is characterised by inattention, impulsivity and hyperactivity. Individuals with ADHD would be unlikely to complete projects even if they were interested in them. Pecks es ie ion:Question 8 of 12 A 6-year-old girl presents with soiling; she has never mastered toilet training. She regularly passes normal-formed stools into her underclothes. Her parents separated when she was three years old. Her erratic bowel habits have much improved with lactulose 5 ml twice daily. Her examination is normal except for a slightly distended abdomen. What is the best next step in managing this girl symptoms? Select one answer only Increase her laxatives Refer to social services Liaise with her schoolteacher Switch off her favourite TV programme whenever she soils m|/o0|/oO/;o0/|> Refer to Child and Adolescent Mental Health Services (CAMHS)ere oe ‘A 6-year-cold girl presents with soiling; she has never mastered toilet training. She regularly passes normal-formed stools into her underclothes. Her parents separated when she was three years old, Her erratic bowel habits have much improved with lactulose 5 ml twice daily Her examination is normal except for a slightly distended abdomen, What is the best next step in managing this girl symptoms? Select one answer only Increase her laxatives Liaise with her schoolteacher A B | Refer to social services c D Switch off her favourite TV programme whenever she soils ful Encopresis is an inappropriate passage of formed faeces, usually on to the underwear, after the age of four years. Psychiatric disturbance is common, and enuresis often coexists. Treatment consists of exclusion of physical problems eg Hirschsprung’s disease, hypothyroidism or hypercalcaemia, The next step is education for the parents and child, as well as a referral to the CAMHS team, a uC She is already taking mild laxatives with good effect, with little to suggest significant constipation because she passes normal stools regularly, although not in the toilet Pan res ea A social services referral may be indicated at a later time, but is mainly indicated if there are specific child protection concems, which is not the case in this scenario. Cee rc ‘School involvement is usually helpful in view of support and continuation of care, but not as a first-line treatment, D. Switch off her favourite TV programme whenever she soils Behavioural programmes may well be helpful, but not the use of negative reinforcement, which may well be counterproductive and can be perceived as punishment. Rate this question: ——Theme: Psychiatric disorders A Anorexia nervosa B Asperger syndrome C Attention deficit-hyperactivity disorder D Autism E Depression F Factitious Illness G Psycho-social deprivation H Post-traumatic stress disorder 1 Rett syndrome J Temper tantrums For each of the following scenarios, please choose the most likely diagnosis from the list above. Each item may be used once, more than once or not at all. A3-year-old boy is brought to you, as his mother is concerned about his attention span. You note that he has very poor eye contact and poor verbal skills (having only a four-word vocabulary). His weight and height are appropriate for his age Please select > A 4yyear-old gil is referred for speech therapy as she speaks very little. She has not had her MMR or pre-school boost. She appears withdrawn and shy but will play games if encouraged. Her weight is on the 2nd centile for her age (2 years ago was on 50th). Her dentition is poor. Please select > ‘An 11-year-old git! is confrontational at home and argues with her parents. She enjoys going out with her friends. Her school performance is falling and her concentration is poor. She has had thoughts of deliberate self-harm in the past and presents with some superficial lacerations to her left wrist. Taking a detailed history you elicit that she was sexually assaulted by a family friend 1 year ago has repeated distressing memories of the event. Please select >ree ed ‘Theme: Psychiatric disorders. A Anorexia nervosa B Asperger syndrome C Attention deficit-hyperactivity disorder D Autism E Depression F Factitious illness G Psycho-social deprivation H Post-traumatic stress disorder IRett syndrome ‘J Temper tantrums For each of the following scenarios, please choose the most likely diagnosis from the list above. Each item may be used once, more than once or not at all. |A B year-old boy is brought to you, as his mother is concerned about his attention span. You note that he has very [poor eye contact and poor verbal skills (having only a four-word vocabulary). His weight and helght are appropriate fornis age. vo Explanation Autism is an increasing problem. It was first described by Kanner in 1943. itis a triad of ‘communication difficulties, socialisation problems and attention problems. This 3-year-old shows poor language skills and poor eye contact (socialisation problem). The features of autism are mostly present before 2 years of age but the diagnosis may not necessarily be made at that time. The language difficulties can be profound and up to 30% of autistic children may never develop, language. Treatment modalities include speech and language therapy, behavioural therapy to improve socialisation and attention, ‘A-year-old girs refered for speech therapy as she speaks very litle. She has not had her MMR or preschool boost. She ‘appears withdrawn and shy but wil play games if encouraged. Her weights onthe 2nd centile for her age (2 years ago was on 80th). Her dentition is peor ©. Peycte-ecel eprvton oa Explanation Ina child who was previously thriving but is now growth faltering, and who has some developmental delay, the diagnosis of psychosocial deprivation must always be considered. This, isa diagnosis of exclusion, once organic causes have been ruled out. In this case there are other Warning sign of this diagnosis - she has missed some immunisations, she will play games (s0 probably has no socialisation difficulties) and her dentition is poor, a possible sign of neglect. {An 11-year-old git is confrontational at home end argues with her parents. She enjoye going out with her fiends. Her shoo! performance is falling and her concentration is poor. She has had thoughts of deliberate self-harm inthe past and presents with some superficial lacerations toher lft wrist. Taking a detailed history you elit that she was sexually ‘assaulted by @ family frend 1 year ago has repeated cistressing memories ofthe event. H.Post-troumatie stress disorder oS Explanation Post-traumatic stress disorder, although still uncommon, is an increasing diagnosis in paediatric psychiatry. The trauma of the sexual assault has led to the behavioural problems in this gir Posttraumatic stress disorder can be due to sexual assault, physical assault or indeed any experience of very traumatic situations (eg refugees from a conflict zone). It can present in a myriad of ways: concentration difficulties, mood instability, aggression, flashbacks, sleep disturbance, anxiety, depression and parasuicide. Cognitive-behavioural therapy and counselling may help the disclosure of the trigger, and provide effective results. Explanation CeIn Tag Question etoPoE EL) Clean ard A 13-year-old girl has been recurrently admitted to the paediatric ward with chronic abdominal pain. Extensive investigations including blood and stool analyses, abdominal ultrasound and gastroscopy are normal; no organic cause was identified. On examination, she is well nourished and weight and height are following the 25th centile. The mother asks for more investigations What is the best advice for these parents? Select one answer only Pharmacological treatment is required This girl should be managed solely by mental health services This girl's physical symptoms have a psychological cause More investigations are required m)/oO;O/;|W|> Long-term consequences for the child or family are unlikelyA 13-year-old girl has been recurrently admitted to the paediatric ward with chronic abdominal pain, Extensive investigations including blood and stool analyses, abdominal ultrasound and Gastroscopy are normal; no organic cause was identified. On examination, she is well ourished and weight and height are following the 25th centile. The mother asks for more investigations. What is the best advice for these parents? Select one answer only Pharmacological treatment is required This girl should be managed solely by mental health services More investigations are required oo ye Long-term consequences for the child or family are unlikely Explanation See Families may be resistant to considering 2 psychological cause of their child's symptoms, so careful explanation and reassurance are essential at all stages. Somatoform issues are a common problem in childhood, and over 10% of children experience such symptoms. itis important to search for any underlying stressors. Most run a short course, but if symptoms persist and involve several systems, the term ‘somatisation disorder is used. ‘A. Pharmacological treatment is required Pharmacological treatment may be considered when other psychiatric disorders are co-occurring, specifically, depressive and anxiety disorders, CRS COU Eo MCS C SUR Mental health services are helpful in managing patients with more severe symptoms, often jointly with medical involvement. De) Exclusion of organic cause is the major diagnostic concern, but extensive unwarranted medical investigation often only delays the diagnosis and implementation of appropriate treatment, Long-term consequences for the child or family are unlikely tis common for children to express emotional distress as physical pain, and transient episodes do not affect overall functioning. However, the persistent experiences associated with a disorder will often interfere with school, home life and friendships. Penge teeta ——Question 11 of 12 A 7-year-old girl is afraid of loud noises and starts screaming and crying during thunderstorms. She hides under a blanket and stays there until the storm passes. Her parents are concerned about her behaviour and worried that her fears can develop into phobias. Which one of the following fears is most common in school-age children? Select one answer only Monsters Injury Strangers Separation m)/O;/O;wW|> MasksCee) A 7-year-cold girl is afraid of loud noises and starts screaming and crying during thunderstorms, She hides under a blanket and stays there until the storm passes. Her parents are concerned about her behaviour and worried that her fears can develop into phobias. Which one of the following fears is most common in school-age chi Select one answer only, A G c D E ren? Strangers Separation Masks Explanation ‘ When children are seven or older, imaginary creatures are less likely to scare them, as they know they are not real. At this age, some children begin to fear things that could happen in real life. They may fee! afraid about natural disasters they hear about. They may fear getting hurt or that a loved one could die. Toddlers are not usually scared of real dangers or afraid to interact with strangers. However, they do react to fictitious or imaginative creatures such as ghosts or monsters, which are made to appear fearsome and scary in comics, cartoons and movies. This is less likely in older children When children are about 8-9 months old, they can recognise the faces of people they know. That's why new faces can seem scary to them, even a new babysitter or relative. This passes as they grow older. Between ten months and two years, many toddlers start to fear being apart from a parent. They do not want a parent to leave them in the daytime or at bedtime. This is a normal part of development, and usually eases as the child grows. Dressing up and scary costumes creates fear in toddlers because they cannot differentiate them from reality, Older children are less likely to be afraid. Rate this question: _PoE EL) Question 12 of 12 A 15-year-old girl presents with a 6-month history of avoiding ‘fattening’ foods and exercising more than usual. Her intense fear of gaining weight has stopped her from socialising. Her height is on the 75th centile and weight less than 0.4th centile. She looks pale and has not started her periods yet. You calculate her body mass index (BMI). What BMI value best marks the beginning of ‘red’ (high-risk) criteria for anorexia nervosa? Select one answer only 15 kg/m? 16 kg/m? 17 kg/m? 18 kg/m? m|/o0|/oO/;o0/|> 19 kg/m?OMe unr oeTy A 15ear-old gil presents with a 6-month history of avoiding ‘fattening’ foods and exercising more than usual. Her intense fear of gaining weight has stopped her from socialising. Her height is on the 75th centile and weight less than 0.4th centile. She looks pale and has not started her periods yet. You calculate her body mass index (BMf)), ‘What BMI value best marks the beginning of ‘red’ (high-risk) criteria for anorexia nervosa? Select one answer only BMI of 15 kg/m? is considered as a high risk for muttiorgan complications. Percentage median BMLis less than 70%, below the 0.4th BMI centile. On intial assessment, electrolytes and electrocardiogram (ECG) are mandatory and hospital admission should be considered, as well as Urgent referral to the mental health team. BMI of 16 kg/m? is considered ‘amber (lert to high concern). Percentage median BML is 70- 80%, between the 2nd and 0.4th BMI centile. A patient with this BMI will require mental health referral and further investigations should be considered BMI of 17 kg/m? is classified as ‘green’ (moderate risk). Percentage median BMI is 80-85%, between the Sth and 2nd BMI centile. If weight loss is rapid or BMI has fallen below the threshold of 17.5 kg/m?, referral to specialist services should be considered ‘A BMI of 18 kg/m? is considered low but still within the normal limits. A basic blood test and assessment should be performed to exclude possible chronic conditions such as coeliac disease. A. BMI of 19 kg/m? is classified as normal, and no further investigations would be required at this time. Teste —