MCQ exam (Paper 4)
History and mental state exam
1. You are assessing a 40-year-old woman who
worries that she suffers from panic disorder.
Which of the following features is MOST
important to establish the diagnosis of panic
disorder?
A) Panic attacks are precipitated by exposure to
the fearful situation only.
B) Panic attacks are caused by an underlying
physical disorder.
C) The panic attacks are recurrent.
D) Panic attacks occur after the development of
agoraphobia.
E) There is a secondary gain associated with
panic attacks.
2. You are a medical resident. The nurse informs
you that an 80-year-old man who was admitted
for cellulitis seems to be depressed and
mentions about passive suicidal thought.
When you assess him, he sees ghost in the
ward and expresses paranoid ideation against
nursing staff. Which of the following
assessment is MOST important to establish
the diagnosis?
A. Assess orientation
B. Assess judgement
C. Assess recognition
D. Assess registration and short-term recall
E. Assess somatic symptoms.
Cognitive assessment
3. Which of the following cognitive tasks is NOT
an assessment of short term or long term
memory?
A. Ask the patient to name the current Prime
Minister of Singapore.
B. Ask the patient to name as many animals as
possible that can be found in the Singapore
Zoo.
C. Ask the patient to tell you his or her address
and later, you check the answer with patient’s
medical record.
D. Inform the patient 3 objects (e.g. Apple,
Newspaper and Train) and ask the patient to
name the 3 objects immediately.
E. Inform the patient 3 objects (e.g. Apple,
Newspaper and Train) and ask the patient to
The answer is C.
Panic attacks in a panic disorder
are unexpected, recurrent and
occurred before the development
of agoraphobia. Exclusion criteria
for panic disorder is underlying
medical illness. Panic disorder is
not an abnormal illness behaviour
and is not associated with
secondary gain.
Author: Birit Brokeman
Modified by Roger Ho
Year: 2013
The answer is A.
Explanation: This man may suffer
from delirium and acute
confusional state. It is most
important to assess orientation.
Assessing somatic symptoms is
not useful as it is caused by
medical conditions.
Author: Roger Ho
Year: 2013.
The answer is B.
Explanation: Option B refers to
verbal fluency which is part of the
frontal lobe assessment. Option D
refers to registration and it is an
important component before
assessing the short-term recall
(Option E). To be fair to the
patient, the patient should be given
multiple attempts to register the 3
items before testing short-term
recall in Option E.
Author: Roger Ho
Year: 2013.
 name the 3 objects after 5 minutes.
Psychiatric, epidemiology, etiology, diagnosis and
classification
4. A 20-year-old man with an identical twin is
diagnosed with major depressive disorder.
His twin brother asks you to comment on the
chance he will develop depressive disorder.
Which of the following is the CORRECT
response to his twin brother?
A. ‘Major depressive disorder is a strongly
inheritable disease. You will definitely develop
it as well.’
B. ‘The likelihood of you developing depressive
disorder is higher than other siblings.’
C. ‘The likelihood of you developing depressive
disorder is same as non-identical twins.’
D. ‘There is only a slightly increased risk that you
will become depressed as compared to the
general population.’
E. ‘You do not need to worry because
environmental factor is an important factor to
determine whether you will develop depressive
disorder.’
5. A 35-year-old woman suffers from low mood,
low energy, poor sleep, poor appetite and
recurrent suicidal thoughts. She firmly
believes that she deserves the death sentence
for minor mistakes made in the past. Which of
the following statements is FALSE?
A. For severe depressive episode with psychotic
features, psychotic symptoms usually occur
after manifestation of depressive symptoms.
B. Her psychotic symptoms are considered to be
mood congruent.
C. Based on the case scenario, there is enough
evidence to suggest that she suffers from
schizoaffective disorder.
D. The prescription of antipsychotic drug should
be considered.
E. Electroconvulsive therapy (ECT) is a
recognised treatment for his condition.
6. Which of the following disorders has been
shown to have the GREATEST degree of
heritability?
A. Alcoholism
B. Attention-deficit/hyperactivity disorder (ADHD)
C. Autism
D. Major depressive disorder
E. Schizophrenia.
The answer is B.
Explanation:
Family studies show that a person
has 40-70% chance to develop
depressive episode if a first degree
relative suffer from depressive
episode.
Twin studies show that the
concordance rate for monozygotic
twins is 40 – 50% and for dizygotic
twins is 20%.
Author: Roger Ho
Year: 2013.
The answer is C.
Explanation: This man suffers from
severe depressive disorder with
psychotic features. Option A, B, D
and E are correct.
There is not enough evidence to
suggest the diagnosis of
schizoaffective disorder because
her symptoms do not suggest that
she suffers from schizophrenia.
Author: Roger Ho
Year: 2013.
The answer is C.
Explanation:
Heritability of autism to be more
than 90%. 90% of the differences
between autistic and non-autistic
individuals is due to genetic
effects.
 Author: Roger Ho
Year: 2013.

7. Which of the following is the MOST common The answer is D.

cause of insomnia among psychiatric patients
in Singapore? Explanation: Underlying psychiatric
disorder is the most common
A. Sleep apnea cause of insomnia among
B. Shift work psychiatric patients. Students
C. Stimulant use should observe this during their
D. Underlying psychiatric illness clinical attachment. Depressive
E. Use of sleeping pills. disorder, bipolar disorder and
generalized anxiety disorder are
associated with insomnia.

Author: Roger Ho
8. Regarding the age of onset in schizophrenia, The answer is D.
which of the following is CORRECT?
Explanation: Current research
A. European women have earlier age of onset findings in schizophrenia show that
than Asian women. men have earlier onset as
B. Current research findings remain compared to women.
inconclusive about the age of onset in
schizophrenia. Author: Roger Ho
C. There is no difference in the age of onset
between men and women.
D. Men usually have earlier age of onset as
compared to women.
E. Women usually have earlier age of onset as
compared to men.

Psychopathology
9. 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. Author: Roger Ho
Year: 2013.
10. Which of the following is MOST suggestive of The answer is D.
the diagnosis of schizophrenia?
A. Acute onset of psychosis Explanation: Hearing own thoughts
B. Apathy or echo de la pense only occurs in
C. Cognitive impairment schizophrenia and is most
D. Hearing own thoughts suggestive of such diagnosis.
E. Persistent deterioration of personality.
Option A can occur in brief
psychosis or acute/transient
psychosis, not necessarily
schizophrenia.

11. A 30-year-old woman mentions that she saw
the face of ‘Monkey God’ appears on the tree
trunk of a particular tree near her apartment.
She can see the face of ‘Monkey God’ every
time when she walks past that tree but not on
the other trees. This phenomenon is known
as:
A. Delusional misidentification
B. Delusion of reference
C. Fantasy
D. Illusion
E. Visual hallucination.
General adult psychiatry
12. Peter is 27-year-old and lives with his parents.
He has been employed as a delivery man for
most of the time since leaving school, but has
recently left his job as a salesman. He has
never taken any illicit drugs. His parents state
that in the last three weeks, he has been
extremely active, requiring less sleep and not
appearing tired, being over-talkative and
disinhibited and – on occasions – quite
irritable. He claimed to have invented a
machine for curing cancer and wished to go to
the U.S. to sell it. When stopped by his
parents, he became violent, and they called
the police. Which of the following diagnosis is
MOST appropriate for this patient?
A. Bipolar I disorder with manic features
B. Bipolar II disorder with hypomanic features
C. Cyclothymia
D. Mixed affective disorder
E. Schizoaffective disorder.
13. Which of the following personality disorders
is LEAST likely to be considered as a
differential diagnosis to schizophrenia?
A. Borderline personality disorder
B. Obsessive compulsive personality disorder
C. Paranoid personality disorder
Option B, D and E occur in both
schizophrenia and dementia.
Author: Roger Ho
Year: 2013.
The answer is D.
Explanation: An illusion is an
involuntary false perception (i.e.
face of Monkey god) in which a
transformation of real object (i.e. a
specific tree in this case) takes
place.
Delusional misidentification occurs
when a patient misidentifies
another person (e.g. Capgras
syndrome) but not an object like a
tree in this case.
Author: Birit Brokeman
Modified by Roger Ho
Year: 2013.
The answer is A.
Explanation: Peter develops
grandiose delusion because he
does not have the capacity to
make a machine to cure cancer
based on his background. The
most appropriate diagnosis is
bipolar disorder with manic
features.
Author: Roger Ho
Year: 2013.
The answer is B.
Explanation: Obsessive
compulsive personality disorder is
least likely to be associated with
psychotic features.
 D. Schizotypal personality disorder
E. Schizoid personality disorder.
14. Which of the following is LEAST likely to be
found in research in the relationship between
depressive disorder and hormones?
A. Blunted adrenocorticotropic hormone (ACTH)
response to the corticotropin-releasing
hormone (CRH)
B. Blunted thyroid stimulating hormone (TSH)
response to thyrotropin-releasing hormone
(TRH)
C. Cortisol suppression with dexamethasone
D. There is an increased cortisol.
E. There is an increased adrenal sensitivity to
ACTH.
15. Which of the following disorders is LEAST
likely to be considered as a differential
diagnosis of a 35-year-old driver develops
nightmare, flashback and hypervigilance after
a road traffic accident?
A. Factitious disorder
B. Generalized anxiety disorder
C. Major depressive disorder
D. Obsessive compulsive disorder
E. Phobic disorder.
16. Rapid eye movement (REM) sleep is
associated with all of the following EXCEPT:
A. Increased parasympathetic activity
B. Increased cerebral blood flow
C. Increased complexity of dreams
D. Maximal loss of muscle tone
E. Transient runs of conjugate eye
movements.
17. A 17-year-old male comes to see you because
he is experiencing tremendous stress in his
new job. He has finished his “O” level
examination and waiting to start the National
Service in 6 months. He got an offer to work in
a shoe shop which specializes in selling
female shoes. He realizes that he feels
sexually aroused by female shoes. He spends
a lot of time fantasizing about female shoes.
He stole multiple pairs of shoes from the shop
and used them for masturbation. He used to
be a normal person. He was a hardworking
student whose main interests were chemistry
Author: Roger Ho
Year: 2013
The answer is C.
Explanation: There is no
suppression of cortisol with
dexamethasone in research finding
in depressive disorder. Option A
indicates the failure of negative
feedback and causes an increase
in cortisol (Option D and E). Option
B is associated with low T3 or T4
level.
Author: Roger Ho
Year: 2013.
This is an advanced-level
question.
The answer is D.
Explanation: OCD is least likely to
share symptoms with post-
traumatic stress disorder (PTSD).
As a result, OCD is least like to be
a DDX of PTSD.
Author: Roger Ho
Year: 2013.
The answer is A.
Explanation: REM sleep is
associated with an increase in
sympathetic activity.
Author: Roger Ho
Year: 2013.
This is an advanced level question.
The answer is B.
Explanation:
This man suffers from fetishism
because he derives sexual
stimulation from an inanimate
object (i.e. female shoes) and his
fetishism causes social and
occupational dysfunction because
he spends inordinate time
fantasizing about female shoes.
 and physics. What is the MOST likely He stole shoes to satisfy his
diagnosis? fetishism and this is not a case of
kleptomania.
A. Adjustment disorder
B. Fetishism Author: Roger Ho
C. Kleptomania Year: 2013.
D. Sadomasochism
E. Voyeurism.

18. Which of the following psychiatric disorders is The answer is B.

MOST common among patients with bulimia
nervosa? Explanation: Major depressive
disorder is the most common
A. Alcohol use disorder psychiatric comorbidity in bulimia
B. Major depressive disorder nervosa (around 50- 85%)
C. Obsessive compulsive disorder
D. Panic disorder Author: Roger Ho
E. Intermittent explosive disorder. Year: 2013.

Old age psychiatry

19. Manic episodes in old people are associated The answer is A.
with:
Explanation: Mania in old people is
A. Less euphoria associated with less euphoria, less
B. Less ‘mixed’ presentation with depression hyperactivity, less flight of ideas
C. Less paranoid delusions but more mixed presentation and
D. More hyperactivity more paranoid ideation.
E. More flight of ideas.
Author: Roger Ho
Year: 2013.

This is an advanced level question.

20. All of the following statements are true
regarding post-operative delirium EXCEPT:
A. Delirium cannot be diagnosed if all laboratory
results are normal.
B. It can occur in an 80-year-old man after
gastrectomy.
C. It can occur in a 16-year-old girl after renal
transplant.
D. Haloperidol is one of the treatments of choice.
E. Physical restraint should be avoided if possible.
The answer is A.
Explanation: 30% of patients
suffering from delirium may have
normal laboratory results and no
abnormality was found. Delirium
can occur in young people who
undergo a complicated operation
with immunosuppressant.
Author: Roger Ho
Year: 2013.

21. A 70-year-old man with a history of drinking The answer is B.

Chinese wine, hepatitis, chronic renal failure
and hypertension was brought by his wife to
the hospital for treatment of an acute cellulitis.
He was noted to have tachycardia in the
Accident and Emergency Department. You are
the on-call medical resident and this man was
admitted to the medical ward. What is the
MOST appropriate first approach?
Explanation:
This patient is already at a high
risk for delirium based on his age
and medical comorbidities,
including chronic renal failure.
Without adequate collateral

A. Assess short term recall to rule out
dementia on delirium.
B. Obtain history from collaterals whether he
has in fact been drinking Chinese wine
recently.
C. Put him on propranolol 10mg three times
per day to control tachycardia.
D. Start diazepam 5mg three times per day to
prevent delirium tremens.
E. Start lorazepam 1mg three times per day to
prevent delirium tremens.
22. A 70-year-old woman with severe depressive
symptoms and strong suicidal ideation which
is not responded to amitriptyline 150mg daily
and fluvoxamine 200mg daily. Each
medication was tried for 6 months with good
adherence. She has good past health. Her
children consult you for further management.
The MOST appropriate treatment which you
would recommend is:
A. Cognitive behaviour therapy
B. Electroconvulsive therapy
C. Donepezil
D. Olanzapine
E. Repetitive transcranial magnetic stimulation.
23. A 75-year-old man presents with prominent
neurological signs such as apraxia, gait
abnormalities and mild cognitive impairment.
He is MOST likely to suffer from:
A. Alzheimer’s Disease
B. Cortical dementia
C. Delirium
D. Pseudodementia
E. Subcortical dementia.
Child and adolescent psychiatry and intellectual
disability
24. You are helping a mother to develop
behavioural program to deal with her son who
has oppositional defiant disorder. Which of
the following is the MOST significant
component of this program?
A. Extinction
history, providing a high dose
regimen of potentially unnecessary
benzodiazepine puts the patient at
risk of worsened delirium. His
elevated heart rate may reflect
agitation or pain due to acute
cellulitis.
Beta blockers most often mask the
sympathetic outflow signs of
withdrawal of alcohol and the
prescription of propranolol is not
necessary.
Author: Roger Ho
Year: 2013.
The answer is B.
Explanation: This elderly woman
suffers from treatment resistant
depression and electroconvulsive
therapy is the treatment of choice
to treat suicidal ideation.
Old age is not a contraindication
for electroconvulsive therapy.
Author: Roger Ho
Year: 2013.
The answer is E.
Explanation: Subcortical dementia
is characterized by cognitive
deficits and presence of
neurological signs.
Author: Lai YM
Modified by Roger Ho
Year: 2013.
The answer is B.
Explanation: Positive
reinforcement of promoting
desirable behaviours through
rewards is the most significant
component of the program.
 B. Positive reinforcement
C. Punishment Author: Roger Ho
D. School suspension Year: 2013.
E. Strict parenting.

25. An 11-year-old boy presents with motor and The answer is D.

vocal tics for 2 years. Which of the following
medications is the BEST first-line treatment? Explanation:
The first-line treatments of
A. Fluoxetine Tourette's syndrome and chronic
B. Lorazepam tic disorders are antipsychotic
C. Methylphenidate medications such as haloperidol or
D. Risperidone risperidone.
E. Sodium valproate.
Author: Birit Brokeman
Modified by Roger Ho
Year: 2013.

26. Which of the following factors are LEAST The answer is D.

likely to be the aetiological factors in attention
deficit and hyperactivity disorder (ADHD)?
A. Antenatal exposure to alcohol
B. Antenatal exposure to nicotine
C. Delivery complications
D. High birth weight
E. Traumatic brain injury during infancy
and early childhood.
27. You are a general practitioner. A 40-year-old
woman consults you as a result of high blood
pressure. General inspection shows ptosis, a broad
neck and indistinct hairline. Her chest appears to be
broad. Auscultation reveals cardiac murmurs. She is
single and stays with her parents. She completed her
education in the Institute of Technological Education
(ITE) and works as a store room officer. If
chromosome analysis is performed, the MOST likely
finding is:
A. XO syndrome
B. XXY syndrome
C. XXXY syndrome
D. XYY syndrome
E. YO syndrome.
28. You are a paediatric resident. A 7-year-old boy
is suspected to suffer from autism. You
referred this boy to see an education
psychologist for assessment. The education
psychologist sends a report to you and you
need to explain the findings to her mother. His
strength is MOST likely found in which of the
following areas?
Explanation: Low birth weight, not
high birth weight is associated with
the risk of developing ADHD.
Author: Roger Ho
Year: 2013.
The answer is A.
Explanation: She suffers from Turner’s
syndrome (XO syndrome) as
evidenced by webbed neck (a broad
neck and a low or indistinct hairline),
coarctation of aorta (cardiac
murmurs, hypertension) and normal
/borderline intelligence. She may
have infertility. Her single status
cannot confirm the infertility but it
remains a possibility.
Author: Roger Ho
Year: 2013.
This is an advanced-level
question.
The answer is B.
Explanation: In autism,
performance IQ (Block design) is
higher than verbal IQ.
Author: Roger Ho
Year: 2013.
 A. Abstract thinking
B. Block design
C. Explain similarities
D. Oral presentation skills
E. Verbal concept formation

Substance abuse
29. 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 Author: Roger Ho
E. Raphe nucleus. Year: 2013

30. A 50-year-old man is admitted to the The answer is B.

hepatobillary ward as a result of pancreatitis.
You are the resident on call. His wife tells you
that she has seen him intoxicated with alcohol
in the past few days. The patient denies.
Which of the following is the BEST method
available in a general hospital in Singapore to
confirm that this patient has been drinking
recently?
A. Carbohydrate-deficient transferrin (CDT)
B. Gamma-glutamyl transferase (GGT)
C. Mean corpuscular volume (MCV)
D. Serum alcohol level
E. Serum amylase.
Explanation: GGT is an early
indicator of alcohol relapse,
SENSITIVITY is 40-60% and
SPECIFICITY is 80%. 4 drinks per
day for the past 2 weeks will
increase GGT. CDT is a very
sensitive and specific test but it is
not readily available in a general
hospital in Singapore. The cost
CDT is much higher than GGT.
Author: Roger Ho
Year: 2013

31. A common and safe pharmacological The answer is E.

treatment for reducing relapse in alcohol
dependence has direct actions upon which Explanation: This question refers
receptors? to naltrexone, a common and safe
pharmacological treatment for
A. Benzodiazapine reducing relapse in alcohol
B. Cannabinoid dependence.
C. Dopamine
D. γ-Aminobutyric acid (GABA) Author: Roger Ho
E. Opioid. Year: 2013

32. Which of the following is LEAST consistent The answer is D.

with the objective of motivational
interviewing? Explanation: Motivational
interviewing emphasizes on
A. Allow the patient give their inputs without individual’s patient’s needs and
interruption. avoid empirical advice.
B. Establishing a collaborative patient-therapist
relationship. Author: Roger Ho
 C. Identifying appropriate reinforcements. Year: 2013
D. Providing empirical advice.
E. Usage of open-ended questions.

33. A 23-year-old man is brought by his family The answer is B.

members to the Emergency Department for
acute onset of bizarre behaviour. He is Explanation: The patient presents
agitated and very fearful that gangsters are with agitation, paranoia, dilation of
going to kill him. He had locked himself in his pupil and hyper-reflexia. The most
bedroom and hid under the bed for ten hours likely diagnosis is amphetamine
crying and shouting. He has no prior medical intoxication.
or psychiatric history. On examination, the
blood pressure is 150/110 mmHg, heart rate is Author: Dr. Lai YM
100 beats per minute, pupils are dilated and Explanation added by Roger Ho
deep tendon reflexes are increased. His signs
and symptoms are MOST consistent with: Year: 2013.
A. Alcohol intoxication
B. Amphetamine intoxication
C. Brief psychotic episode
D. Delirium
E. Delusional disorder.

Psychopharmacology
34. 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.
Author: Roger Ho
Year: 2013
35. 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. Author: Roger Ho
Year: 2013
36. Which of the following is NOT an The answer is A.
acetylcholinesterase inhibitor?
A. Buprenorphine Explanation: Buprenorphine is a
B. Donepezil partial opioid agonist which is used
C. Galantamine in the treatment of opioid
D. Rivastigmine dependence but this medication
E. Tacrine. was banned in Singapore due to
diversion and misuse.

Author: Roger Ho
Year: 2013.

37. Which of the following regarding side effects The answer is E.

 of risperidone is FALSE?
Explanation: The risk for weight
A. Akathisia is common with high dose of gain and metabolic syndrome is
risperidone. lower than olanzapine.
B. Prolactin elevation, probably greater than that
seen with other second generation Author: Roger Ho
antipsychotics. Year: 2013.
C. Insomnia, headache and nausea are common.
D. Rhinitis is a possible side effect.
E. The risk for weight gain and the metabolic
syndrome is higher than olanzapine.

38. Tricyclic antidepressants should be avoided The answer is A.

with all of the following EXCEPT
A. Patients hospitalized for severe melancholic
depression
B. Recent myocardial infarction
C. Right bundle branch block
D. Untreated glaucoma
E. Urinary retention.
Explanation: TCA may be helpful
in severe depression. The other
are relative contraindications.
Author: Roger Ho
Year: 2013.

39. Which of the following is CORRECT regarding The answer is C.

galactorrhoea induced by antipsychotic
drugs?
A. Antipsychotic drugs modulate the hypothalamic
function and lead to galactorrhoea.
B. Antipsychotic drugs cause pituitary adenoma
and galactorrhoea.
C. Bromocriptine can treat galactorrhoea induced
by antipsychotic drugs.
D. Galactorrhea is caused by antipsychotics acting
directly on the breast tissue.
E. Galactorrhoea is caused by the concurrent use
of anticholinergic medication.
Explanation: Galactorrhoea can be
treated with bromocriptine.
Galactorrhoea is due to a direct
effect on the anterior pituitary by
dopamine secreting
tuberoinfundibular neurons, which
normally inhibit prolactin release.
Antipsychotic drugs do not cause
pituitary adenoma.
Author: Roger Ho
Year: 2013

This is an advanced-level
question.
40. 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. Author: Roger Ho
Year: 2013

41. Which of the following is FALSE about The answer is B.

clozapine?
Explanation: It has low affinity for
A. It can cause agranulocytosis. D2 receptors.
B. It has high affinity for D2 receptors.
 C. It has low risk of extrapyramidal side effects. Author: Roger Ho
D. It is associated with metabolic syndrome. Year: 2013
E. It is good for treatment resistant schizophrenia.

42. A 30-year-old woman with 3 episodes of major The answer is A.

depression in the past 5 years responds to
fluoxetine 40mg every morning. Her last
episode was 6 months ago. In order to
minimize the risk of relapse, which of the
following treatment strategies is MOST
effective?
Explanation: This patient has 3
episodes of major depression in
the past 5 years and the number of
episodes is considered to be
frequent.

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. Author: Roger Ho
C. Provide intermittent maintenance Year: 2013
electroconvulsive therapy.
D. Stop fluoxetine and restart it at the first sign of
relapse.
E. Stop fluoxetine and start cognitive behaviour
therapy.

Psychotherapy
43. Which of the following treatment strategies
has the MOST evidence for treating obsessive
compulsive disorder?
A. Fluoxetine and brief dynamic
psychotherapy
B. Fluoxetine and exposure and response
prevention
C. Fluoxetine and eye movement
desensitization and reprocessing
D. Fluoxetine and hypnotherapy
E. Fluoxetine and interpersonal
psychotherapy.
The answer is B.
Explanation: Exposure and
response prevention is part of the
cognitive behaviour therapy and
has the most evidence for treating
obsessive compulsive disorder.
Author: Roger Ho
Year: 2013

44. You have to study anaesthesia, emergency The answer is E.

medicine, obstetrics and gynaecology,
otolaryngology, ophthalmology and Explanation: This student
psychiatry in less than two weeks. Your first demonstrate selective abstraction:
thought is, “I will never be able to study all six focus on current negative aspect
subjects in such a short time! The upcoming but ignore the positive aspects in
examination is very stressful.” You ignore the the past.
fact that you were successful in the previous
professional MBBS examinations and you Author: Roger Ho
could handle multiple subjects in one Year: 2013
examination in the past. From a cognitive
therapy perspective, what is the BEST
description of this type of thinking?

A. Catastrophic thinking
B. Magnification
C. Minimization
 D. Personalization
E. Selective abstraction.
Ethics and laws
45. In Singapore, a person who is disturbed and
aggressive, with poor insight into his illness,
refusing treatment and threatening family
members can be admitted involuntarily under
the:
A. Advanced Care Directive
B. Mental Health (Care and Treatment) Act
C. Mental Capacity Act
D. Mental Health Act
E. Psychiatric Disorders and Treatment Act.
Liaison and neuropsychiatry
46. Which of the following medical conditions is
LEAST likely to present with panic attacks?
A. Asthma
B. Cushing syndrome
C. Insulinoma
D. Phaeochromocytoma
E. Thyrotoxicosis.
47. Which of the following statements about
management of depression during pregnancy
is CORRECT?
A. All pregnant women suffering from depression
require psychotherapy.
B. All pregnant women suffering from depression
require pharmacotherapy.
C. Lithium is a safe antidepressant to treat
antenatal depression.
D. Risks and benefits from psychotropic drug
should be considered, including gestational
age, symptoms, a history of depression and
other clinical factors.
E. Suicidal ideation and acute psychotic
symptoms can be managed by the obstetrician
without referral to psychiatrist.
48. A 50-year-old man suffering from
schizophrenia and he has been taken
haloperidol for the past 20 years. His QTc is
550 ms. The medical resident wants to find the
potential medical complication if he continues
to take haloperidol. Which of the following
complications is LEAST LIKELY:
The answer is B.
Explanation: Mental Health (Care
and Treatment) Act was passed in
2008 and this is the most correct
answer.
Author: Roger Ho
Year: 2013.
The answer is B.
Explanation: Cushing syndrome is
more likely to be associated with
depression rather than panic
attacks.
Author: Roger Ho
Year: 2013.
The answer is D.
Explanation: Not all patients will
require psychotherapy. There can
be good reasons to choose for
pharmacotherapy. This depends
on risks and benefits including
gestational age, symptoms, and
previous psychiatric history. A
psychiatrist will be important to
take care of suicidal and acute
psychotic symptoms, while working
together with an obstetrician.
Lithium is associated with
teratogenic effects on the foetus
(e.g. Ebstein’s anomaly).
Author: Birit Brokeman.
Modified by Roger Ho
Year: 2013.
The answer is A.
Explanation: A prolonged QTc
mainly affects the ventricles,
leading to ventricular fibrillation,
torsade de pointes and sudden
cardiac death. Palpitation is a
 recognized complication.
A. Myocardial infarction Myocardial infarction is unlikely to
B. Palpitation be associated with prolonged QTc.
C. Ventricular fibrillation
D. Sudden cardiac death Author: Roger Ho
E. Torsade de pointes. Year: 2013.

This is an advanced-level
question.
49. A 40-year-old schizophrenia patient presents The answer is C.
with high urine volume, low urine osmolality,
low serum sodium and low urine sodium. Explanation: He suffers from
Which of the following is the MOST likely psychogenic polydipsia because
diagnosis? there is a dilution in urine volume,
urine osmolality, serum sodium
A. Diabetes mellitus and urine sodium due to fluid
B. Nephrogenic diabetes insipidus overload and a result of excessive
C. Psychogenic polydipsia drinking.
D. Simple hyponatremia
E. Syndrome of inappropriate antidiuretic hormone Author: Roger Ho
secretion. Year: 2013.

50. You are a resident working in the gynaecology The answer is B.

ward. A 35-year-old woman was admitted for
ovarian cystectomy. She suffers from major Explanation: It is reasonable that
depressive disorder and insomnia. She patient may not be able to see her
consults a psychiatrist at the Institute of psychiatrist shortly after operation.
Mental Health (IMH). She is prescribed with Her suicide risk may not be
venlafaxine, zolpidem, lorazepam and genuine in this case because it is
hydroxyzine. She is due for discharge today after a condition (if no medication
and she wants to go home. She expresses is given).
concern that she cannot see her psychiatrist
in the coming weeks due to pain associated In real situation, the best answer is
with the operation. She requests to obtain 3- to assess her suicide risk by
month supply of her psychiatric medications yourself or your hospital
from you. She also requests a pain killer psychiatrist. This option is not
called tramadol. She threatens that if you do available and you need to choose
not give her medication, she will commit the next best answer.
suicide. What is the BEST approach to handle
this situation? Option A may cause a relapse of
her psychiatric illness by not giving
A. Do not give her any psychotropic medication her any psychotropic medications.
and tramadol. Discharge her the same day.
B. Negotiate with her for shorter duration of Option C will intensify her
psychotropic medications and tramadol. disappointment and postpone
Obtain earlier appointment at IMH. Discharge discharge does not offer solution.
her today.
C. Postpone discharge and use this to motivate Option D: 3-month supply
her not to request for more psychotropic medication is too long and it may
medications. pose risk to patients.
D. Give her 3-month supply of psychotropic
medications and tramadol. Discharge her Option E will affect therapeutic
today. alliance and it is important to
E. Send her to IMH for assessment because she further assess her suicide risk. She
threatens that she will commit suicide. mentions about suicidal thought as
a sign of anger.

Author: Roger Ho
Year: 2013

This is an advanced-level
question.