QUESTION 25: A 45-year-old man is found running naked in the street, shouting he is ‘God’s messenger.’ He has not slept in 5 days, has pressured speech, and is highly agitated.
What is the most likely diagnosis?
A) Schizophrenia
B) Bipolar I disorder, manic with psychotic features
C) Delusional disorder, grandiose type
D) Substance-induced psychotic disorder
Answer: B) Bipolar I disorder, current episode manic with psychotic features
Explanation:
This is a severe manic episode with mood-congruent psychotic features.
1. Manic Symptoms: Decreased sleep (5 days), pressured speech, psychomotor agitation.
2. Psychotic Features: Grandiose delusion (‘God’s messenger’) and bizarre behavior (running naked).
Why not others?
- Schizophrenia: Requires 6 months duration.
- Delusional Disorder: Requires 1 month of delusions without other manic symptoms and functioning is usually preserved.
- Substance-induced: Always rule out with a tox screen, but Bipolar I is the best clinical fit for the complete syndrome.
QUESTION 26: A 50-year-old woman experiences sudden palpitations, sweating, trembling, chest pain, and a ‘feeling she is going to die’ while grocery shopping. The episode lasted 10 minutes and was ‘out of the blue.’
Most likely diagnosis?
A) GAD
B) Panic disorder
C) Social anxiety disorder
D) Myocardial infarction
Answer: B) Panic disorder
Explanation:
The patient is experiencing an unexpected (uncued) panic attack.
Criteria for Panic Attack: Abrupt surge of fear reaching a peak within minutes with ≥4 symptoms (she has 7: palpitations, sweat, tremble, SOB, chest pain, fear of dying, intense anxiety).
AMC Rule: Recurrent unexpected attacks + 1 month of persistent worry/behavior change = Panic Disorder.
Medical Rule: Always rule out MI (ECG) and Hyperthyroidism (TSH) in new-onset panic symptoms in a 50-year-old.
[Image of symptoms of a panic attack]
QUESTION 27: A 25-year-old student reports excessive worry about grades, finances, health, and relationships for 8 months. He feels restless, has muscle tension, and sleep disturbance. He cannot control the worry.
Most likely diagnosis?
A) Panic disorder
B) Generalized anxiety disorder (GAD)
C) OCD
D) MDD
Answer: B) Generalized anxiety disorder (GAD)
Explanation:
GAD Mnemonic: WATCHERS (Worry, Anxiety, Tension, Concentration, Hypervigilance, Energy loss, Restlessness, Sleep disturbance).
Criteria:
1. Excessive worry about multiple domains.
2. Duration ≥ 6 months.
3. ≥3 associated symptoms (Restlessness, tension, sleep).
Why not others?
- OCD: Involves ego-dystonic obsessions/compulsions, not real-life worries.
- Panic Disorder: Focuses on discrete attacks, not constant diffuse worry.
QUESTION 28: A 30-year-old woman avoids social gatherings, public speaking, and eating in public due to intense fear of negative evaluation and embarrassment. She has felt this way for 2 years.
Most likely diagnosis?
A) Panic disorder
B) GAD
C) Social anxiety disorder (SAD)
D) Avoidant personality disorder
Answer: C) Social anxiety disorder (social phobia)
Explanation:
Core Fear: Negative evaluation/scrutiny by others.
Key Features: Situational anxiety (palpitations/sweating) triggered by social interaction or performance.
Management:
- Generalized: SSRIs (Sertraline) + CBT.
- Performance-only: Beta-blockers (Propranolol) 30-60 mins before.
Why not Avoidant PD? AVPD is a pervasive, lifelong identity-based pattern, whereas SAD is often more situation-specific.
QUESTION 29: A 40-year-old woman is unable to leave her house without her husband. She avoids crowds and public transport for fear of being unable to escape if she has a panic attack.
Most likely diagnosis?
A) Social anxiety disorder
B) Specific phobia
C) Panic disorder with agoraphobia
D) GAD
Answer: C) Panic disorder with agoraphobia
Explanation:
Agoraphobia involves fear/avoidance of ≥2 situations (Public transport, open spaces, enclosed spaces, crowds, being outside home alone).
Core Fear: Escape might be difficult or help unavailable during panic-like symptoms.
Management: Combination of SSRI + CBT with Exposure Therapy.
AMC Distinction: In SAD, you fear judgment. In Agoraphobia, you fear being trapped during a panic attack.
QUESTION 30: What is the first-line pharmacological treatment for Panic Disorder and GAD?
Answer: SSRIs (e.g., Sertraline, Escitalopram, Paroxetine).
Explanation:
- SSRIs are preferred for long-term management.
- Start at a LOW dose because SSRIs can initially increase anxiety/jitteriness.
- Full effect takes 4-6 weeks.
- SNRIs (Venlafaxine) are also first-line.
QUESTION 31: A performer has intense anxiety only when playing the violin on stage, but is fine in social groups. What is the best situational medication?
Answer: Propranolol (Beta-blocker).
Explanation:
- Use: Performance-only Social Anxiety.
- Timing: 10-40mg taken 30-60 minutes before the event.
- Goal: Blocks physical symptoms (tremor, tachycardia) without causing sedation or cognitive clouding.
QUESTION 32: A 65-year-old patient with no psych history suddenly becomes confused and sees ‘little men’ in the room. What is the FIRST step in management?
Answer: Rule out an organic cause (Delirium).
Explanation:
- Step 1: Physical exam and Vitals.
- Step 2: Investigations (FBC, UECs, Glucose, TSH, B12, Urine MCS, Chest X-ray).
- AMC Logic: New-onset psychosis/hallucinations in the elderly is Delirium until proven otherwise.
QUESTION 33: A patient with Anorexia (BMI 14) is started on aggressive feeding. Two days later, they develop heart failure and low serum phosphate. What is the treatment?
Answer: Immediate IV Phosphate replacement and slow down feeding.
Explanation:
- Diagnosis: Refeeding Syndrome.
- Prevention: Start low calories (10-15 kcal/kg), give Thiamine before feeding, and monitor daily electrolytes (Phosphate, Magnesium, Potassium).
QUESTION 34: A patient presents with sudden blindness after witnessing a violent crime. Pupils are reactive, and the neurological exam is normal. What is the diagnosis?
Answer: Conversion Disorder (Functional Neurological Disorder).
Explanation:
- Core: Neurological symptoms (blindness, paralysis, seizures) that are incompatible with recognized anatomy/pathology.
- Trigger: Often follows a psychological stressor.
- Insight: Patient is often ‘notably unconcerned’ (La Belle Indifference).
