MCQ exam 2014/2015 Rotation 4

Author: Roger Ho
Vetted by Iris Rawtaer and A/Prof John Wong
History, mental state exam, psychopathology,
diagnosis
1. You are a resident doctor working at the Institute
of Mental Health (IMH). The police officers
bought a 39-year-old man charged with
possessing a scheduled weapon and was sent to
the IMH for a psychiatric evaluation. Although he
speaks English, you cannot make out what he is
saying because his speech becomes diffuse and
unfocused. Which of the following best describes
his psychopathology?
A.
B.
C.
D.
E.

Circumstantiality
Loosening of association
Thought insertion
Thought withdrawal
Tangentiality.

2. You are a resident working at the Accident and

Emergency Department (AED). A 35-year-old
man was sent to the AED for psychiatric
assessment by an ambulance. He was involved
in a road traffic accident. He was a passenger in
a taxi. He told the taxi driver that he was God and
threatened the driver to believe that he was the
saviour of the world. The driver found him very
irritable and he kept hitting the head of the driver.
The driver stopped the taxi and tried to call the
police. The patient drove the taxi at high speed
and crashed the taxi into a lamp post. He was not
under influence of alcohol at the time of accident.
You are required to enter a diagnosis into the
AED computerised system. Based on the
information provided, which of the following
psychiatric diagnosis is most relevant?
A.
B.
C.
D.
E.

The answer is B.
Explanation: Loosening of
association is defined as a
speech where topics seem to be
disconnected and it is hard for
others to establish a logical link
between topics. The speech
becomes diffuse and unfocused.
Author: Roger Ho
Year: 2014.

The answer is B
Explanation: This man suffers
from bipolar disorder, manic
episode as evidence based by
grandiose delusion, irritability,
reckless and dangerous
behaviour.
Author: Roger Ho
Year: 2015.

Antisocial personality disorder

Bipolar disorder
Conversion disorder
Dissociative disorder
Schizophrenia.

Cognitive assessment
3. A 30-year-old woman has received 6 sessions of
electroconvulsive therapy (ECT). After the ECT,
she complains of cognitive impairment and
attributes the following symptoms as side effects
of ECT. Which of the following is most likely
caused by ECT?

The answer is B.
Explanation: Young patients
usually develop retrograde
amnesia of recent events but not
anterograde amnesia (option A)
1

A. Cannot follow the instructions given by her

supervisor after she returns to work
B. Cannot recall the password of her email account
C. Cannot remember details of her ex-marriage
D. Difficulty to perform two tasks at one time
E. Unable to calculate.
4. You are administering the Serial 7 test to a patient.
His answers are listed as follows: 100 7 = 90; 90 7
= 77; 77 7 = 70; 70 7 = 63; 63 7 = 50. What is his
score?
A.
B.
C.
D.
E.

0 out of 5
1 out of 5
2 out of 5
3 out of 5
4 out of 5.

or life events (option C). ECT

does not affect multi-tasking and
calculation.
Author: Roger Ho
Year: 2015.

The answer is C.
Explanation: 100 7 = 90 (0 point)
90-7 = 77 (0 point)
77-7 = 70 (1 point)
70-7 =63 (1 point)
63-7 = 50 (0 point)
Total: 2 points out of 5
Author: Roger Ho
Year: 2014.

Psychiatric epidemiology
5. Which of the following is the most common
psychiatric co-morbidity of panic disorder?
A.
B.
C.
D.
E.

Alcohol misuse
Agoraphobia
Avoidant personality disorder
Benzodiazapine misuse
Generalised anxiety disorder.

The answer is B.
Explanation: Agoraphobia (40%)
> alcohol dependence (30%).
The other options are less likely
to be associated with panic
disorder.
Author: Roger Ho
Year: 2014.

Psychiatric aetiology, diagnosis and classification

The answer is C.
6. The prevalence of borderline personality
disorder in Singapore and worldwide has
increased in the past three decades. The most
likely explanation for this observation is:
A.
B.
C.
D.
E.

Changes in diagnostic criteria

Increase in competition in schools
Increase in divorce rate
Increase in immigration and migration
Increasing urbanization of the population.

7. Which of the following is least likely to be a risk

factor for delusional disorder?
A. Having a religion

Explanation: increase in divorce

rate is associated with trauma,
neglect and splitting in family.
These are important
predisposing factors for
borderline personality disorder.
There is no major change in
diagnostic criteria. Some of the
factors may occur too late to
affect personality development
(e.g. migration). As Singapore is
a city state, the effect of
urbanization is minimal.
Author: Roger Ho
Year: 2014
The answer is A.
Explanation: Having a religion is
not a risk factor for developing
2

B.
C.
D.
E.

Increased age
Immigration
Sensory impairment
Social isolation.

delusional disorder. The risk of

delusional disorder increases
with age. Hearing loss is a risk
factor. Low socioeconomic status
and severe stress are also risk
factors.
Author: Roger Ho
Year: 2014

8. The genetic polymorphisms of which of the

following neurotransmitter transporter genes
affect the risk of developing depressive disorder?
A.
B.
C.
D.
E.

Dopamine
-Aminobutyric acid (GABA)
Glutamate
Norephinephrine
Serotonin.

9. A 40-year-old patient with schizophrenia presents

to the emergency department with confusion and
agitation following an overdose of haloperidol.
The patient has a temperature of 41 degree
Celsius, blood pressure of 160/100 mm Hg, and
pulse of 120 beats per minute. Physical
examination reveals rigidity, hot, wet skin, and
decreased bowel sounds. This patients
symptoms, are most likely caused by blocking of
which of the following receptors?
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.
He first exhibited first rank symptoms at the age
of 16 and the onset was insidious. He exhibits
anhedonia although his hallucinations are under
control by antipsychotic drug. His uncle suffers
from depressive disorder. All of the following are
poor prognostic factors except?
A.
B.
C.
D.
E.

Anhedonia
Exhibition of first rank symptoms at the age of 16
Family history of depressive disorder
Male gender
Insidious onset.

11. You are the resident working in the Accident and

Emergency Department. A schizophrenia patient

The answer is E.
Explanation: Individuals with
homozygous short alleles at the
serotonin transporter gene are
more likely to develop
depression.
Author: Roger Ho
Year: 2014
The answer is B.
Explanation: This patient
develops neuroleptic malignant
syndrome due to blockage of
dopamine receptors by
haloperidol.
Author: Roger Ho
Year: 2014

The answer is C.
Explanation: Poor prognostic
factors include young onset, no
precipitating factors, insidious
onset, poor premorbid
functioning, family history of
schizophrenia, negative
symptoms, poor support,
neurological symptoms and poor
compliance.
Author: Roger Ho
Year: 2014
The answer is B.

informs you that he has homicidal thought. Which

of the following sign or symptom is least
important in predicting homicide?
A.
B.
C.
D.
E.

Command hallucinations
Delusion of reference
History of previous violence
Irresistible urge to attack
Need to defend oneself as are result of
persecutory delusion.

Explanation: Delusion of
reference is not directly related
to violence and carries lower risk
of homicide as compared to
other signs and symptoms.
Author: Roger Ho
Year: 2014

The answer is C.
12. All of the following are poor prognostic signs for
obsessive compulsive disorder except:
A.
B.
C.
D.
E.

Bizarre compulsions
Childhood onset
Episodic course
Comorbid major depression
Succumbing to obsessions and compulsions.

Explanation:
Poor prognosis:
1. yielding to compulsions
(not resisting)
2. childhood onset
3. bizarre 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

Author: Roger Ho
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 Author: Roger Ho
videos and he feels relieved after the arrest. Year: 2014
Which of the following is the most likely
diagnosis?
A.
B.
C.
D.
E.

Erotomania
Kleptomania
Obsessive compulsive disorder
Sadomasochism
Voyeurism.

14. A 30-year-old woman always believes that she is

socially inept and fears of negative evaluation by
other people. Her sisters describe her as timid
and insecure. She is single and stays with two

The answer is A.
Explanation: She suffers from
avoidance personality disorder
4

elder sisters. She was admitted to the psychiatric

ward due to nervous breakdown after meeting
new colleagues in her workplace. She refuses to
attend family meeting with her sisters because
she feels that her sisters do not like her although
they appear to be very concerned about her
condition. She is isolated and has one best friend
in her work place. Which of the following
personality best describes this patient?
A. Avoidant personality disorder
B. Borderline personality disorder
C. Histrionic personality disorder
D. Paranoid personality disorder
E. Schizoid personality disorder
15. Which of the following is not a common feature of
serotonin syndrome?
A.
B.
C.
D.
E.

Acidosis
Diaphoresis
Hyperreflexia
Hypothermia
Myoclonus.

16. You are a resident working in the accident

and emergency department (AED). A single
mother was sent to the AED with her 2-yearold daughter. She was arrested by police
because she tried to assault her daughter
and stopped by passer-by. According to the
informant, her partner refuses to marry her
due to her drug habit. She does not have
past forensic history. She appears to be
agitated and restless. At one moment, she
wants to stay in the AED. At another
moment, she wants to walk out of the AED.
Physical examination reveals nystagmus.
Which of the following diagnosis is most
relevant?
A. Antisocial personality disorder
B. Cannabis intoxication
C. Delusion of jealousy
D. Paranoid schizophrenia
E. Phencyclidine intoxication
Old age psychiatry
17. You are about to start a selective serotonin
reuptake inhibitor (SSRI) for an 80-year-old man
who suffers from depression. Which of the
following pharmacokinetic changes has the least
effect on drug therapy in the elderly?
A. Absorption
B. Distribution

as evidenced by pervasive
tension (e.g. nervous
breakdown), unwilling to be
involved unless being liked (e.g.
family meeting with her sister),
fear of criticism, showing
restraint in intimate relationship
(e.g. being single) and inhibition
of new interpersonal situations
(e.g. meeting new colleagues)
and belief of socially inept.
Author: Roger Ho
Year: 2014
Answer: D
Explanation: Serotonin syndrome
actually causes fever. Metabolic
acidosis in seen in 9% of
patients.
Author: Roger Ho
Year: 2014

The answer is E.
Explanation: The immediate
diagnosis is PCP intoxication
as evidenced by
unpredictability (staying in
AED versus walking out of
AED), assaultativeness on her
daughter, agitation and
nystagmus. Antisocial
personality disorder requires
further evidence as forensic
history is negative and cannot
explain nystagmus.

Author: Roger Ho
Year: 2014

The answer is A.
Explanation:
There
is
no
consistent
age
effect
on
absorption of antidepressant in
elderly. For distribution, the
elderly have more fat stores;
therefore they will have lower
5

C. Excretion
D. Metabolism
E. Protein binding.

plasma concentrations of lipid

soluble drugs, but will have
larger distribution volumes of
these drugs and therefore longer
half-lives. This may cause
problems for elderly taking
fluoxetine.
For metabolism, all psychotropic
medications metabolized in the
liver have their elimination halflife increased two or three-fold in
the elderly.
For excretion, decreased GFR
and renal blood flow lead to
decreased clearance of lithium
and antidepressant metabolites.
For protein binding, the elderly
have lower levels of plasma
albumin due to malnutrition, and
therefore have an increased free
fraction of protein bound drugs.
Author: Roger Ho
Year: 2014
This is an advanced level
question.

18. A 79-year-old man complains of extreme

drowsiness when he goes to toilet at midnight
and he almost fell down on several occasions. He
wants to avoid fall at night. The following is the
list of his medications. Which of the following
medications should be stopped?
A.
B.
C.
D.
E.

Melatonin
Mirtazapine
Risperidone
Rivastigmine
Sodium valproate.

The answer is B.
Explanation: Mirtazapine is the
most sedative medication among
all the options.
Author: Roger Ho
Year: 2014

The answer is D.
19. A 70-year-old woman suffering from bipolar
disorder and her daughter came to see you
today. Her daughter read about the symptoms of
bipolar disorder and found her mother different
from younger adults suffering from the same
condition. Which of the following clinical features
is more likely to be found in this 70-year-old
woman?

Explanation: Elderly with bipolar

disorder are more likely to be
paranoid and present with mixed
clinical presentations. Elderly are
less likely to develop flight of
ideas, hyperactivity and
overspending.

A. Demonstrates less paranoid ideas as compared

to adult patients

Author: Roger Ho
Year: 2014
6

B. Demonstrates more flight of ideas as compared

to adult patients
C. More likely to be hyperactive as compared to
adult patients
D. More likely to demonstrate mixed
(depressive/manic) clinical presentations as
compared to adult patients
E. More spending as compared to adult patients.
20. Which of the following is most important risk
factor for vascular dementia?
A.
B.
C.
D.
E.

History of depression
History of poor academic performance
History of hypertension
High level of physical activity
High level of high density lipoproteins.

The answer is C.
Explanation: Among all the
options, hypertension is the most
significant risk factor for vascular
dementia.
Author: Roger Ho
Year: 2014

21. You are the visiting physician of a nursing home.

The nursing home staffs feel very helpless when
handling aggression in dementia patients and
they need to seek your advice. Which of the
following psychotropic medication have the most
evidence in managing aggression in patients
suffering from dementia?

The answer is A.

A.
B.
C.
D.
E.

Author: Roger Ho
Year: 2014

Antipsychotic drug
Beta-blocker
Benzodiazapine
Lithium
Stimulant.

Child and adolescent psychiatry

22. In children and adolescents, high stimulationseeking behaviour is associated with which of the
following conditions?
A.
B.
C.
D.
E.

Adolescent-onset schizophrenia
Autism
Conduct disorder
Obsessive-compulsive disorder
School refusal.

23. Children with autism are most comfortable in

which of the following situations?
A. Attending a party where there are a lot of
surprises and have a chance to meet different
people.
B. Attending drama classes and imagines oneself
playing different roles in the drama.
C. Looking for toys in a multi-storey department

Explanation: Antipsychotic drug

(e.g. risperidone) has the most
evidence in improving
aggression in dementia patients
among all options.

The answer is C.
Explanation: Young people with
conduct disorder have to be
involved in delinquent behaviour
to get high stimulus.
Author: Roger Ho
Year: 2014
The answer is D.
Explanation: Travelling in a bus
because it has a predictable
route (i.e. the bus stops at every
bus stop and there is
uncertainty).
Author: Roger Ho
7

store from one level to another level.

D. Travelling in a bus when it stops at every bus
stop until it reaches the bus terminal.
E. Going to school where there are multiple classes
to attend in a day and teaching content varies
from subject to subject.
24. Which of the following statements is most correct
regarding the impact of divorce on children?
A. Boys aged two to four are not significantly
affected.
B. Children do best if they have no contact with the
father for two years.
C. Most children have no significant problems after
three to six months.
D. Socio-economic status is not associated with the
degree of impairment.
E. To evaluate the impact, one must take into
consideration the age and the developmental
level of the child.
25. A 15-year-old obese female is brought by her
parents for an evaluation as part of the admission
process for a weight management program. The
adolescent agrees with the fact that she is
overweight and she is keen to lose weight.
Which of the following is most indicative that she
will be successful in the program?
A. Her current BMI is between 26 and 30.
B. Mother suffered from obesity and successfully
lost weight
C. No family history of eating disorders
D. Motivation to take antidepressant
E. Willingness to change her eating habits.
Substance abuse
26. Methylene dimethylamphteamine (street name:
ecstasy) usually cause people with which of the
following symptom?
a. Amotivation
b. Closeness to others
c. Depression
d. Introversion
e. Phobia.
27. A 30-year-old adult claims to suffer from adult
onset attention deficit and hyperactivity disorder
(ADHD). He has been seeing different doctors to
obtain methylphenidate. He claims that he lost all
methylphenidate in the bus few days ago and his
wife has noticed that he looks very tired. Which
of the following is most appropriate explanation
for his tiredness?

Year: 2014

The answer is E.
Explanation: Options A and B
have no evidence base. For
option C, most children take 3-5
years to recover. Socioeconomic status affects the
outcome.
Author: Roger Ho
Year: 2014

The answer is E.
Explanation: The patient must
agree to use conservative
methods including changing diet
habits, seeing a dietician and
going for exercise to lose weight.
Author: Roger Ho
Year: 2014

The answer is B.
Explanation: Ecstasy is also
known as an empathogen and
makes the patient to feel close to
others.
Author: Roger Ho
Year: 2014
The answer is D.
Explanation: This patient is
doctor shopping and tries to
obtain methylphenidate because
he is dependent on this
medication. He lost the
medication few days ago and
8

A. He develops depression and psychomotor

retardation
B. He exhibits secondary gain and seeking
attention from his wife
C. He suffers from comorbid somatisation
disorder in addition to ADHD
D. He suffers from psychological withdrawal
symptoms from stimulant misuse
E. He suffers from stimulant intoxication.
28. The most important objective of
psychological intervention in treating people
suffering from alcohol misuse is:
A. To conduct in a group therapy format
B. To apply cognitive behaviour therapy (CBT) as
the first approach
C. To combine psychological intervention and
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
associated with weight gain?
A.
B.
C.
D.
E.

Clozapine
Mirtazapine
Olanzapine
Sodium valproate
Topiramate.

developed psychological
withdrawal symptoms including
depression, tiredness,
oversleeping and overeating.
Author: Roger Ho
Year: 2014

The answer is D.
Explanation: Achieving
abstinence or reduction of
alcohol use is most important
psychotherapeutic objective.
Author: Roger Ho
Year: 2014.

The answer is E.
Explanation: Topiramate is
associated with weight loss and
not weight gain.
Author: Roger Ho
Year: 2014

30. A 60-year-old man is started on an

antidepressant for treatment of major depressive
disorder. Three weeks later, he complains of
blurred vision, dry mouth, constipation, urinary
retention and tachycardia. Which of the following
medications is most likely to have caused this
presentation?

The answer is D.

A.
B.
C.
D.
E.

Author: Roger Ho
Year: 2014

Agomelatine
Duloxetine
Fluoxetine
Imipramine
Mirtazapine

31. Which of the following medications is most likely

to be associated with polycystic ovarian
syndrome in female patients?
A. Carbamazapine
B. Lamotrigine
C. Lithium

Explanation: Imipramine is a
tricyclic antidepressant and
associated with anticholinergic
side effect.

The answer is D.
Explanation: Sodium valproate is
associated with polycystic ovary
syndrome in female patients.
Author: Roger Ho
9

D. Sodium valproate
E. Topiramate.

Year: 2014

32. Regarding an antidepressant called bupropion,

which of the following statements is false?

The answer is C.

A. It causes insomnia.
B. It has a half-life of approximately 12 hours.
C. It is safe for patients suffering from bulimia
nervosa.
D. It is an antidepressant used for depressed
patients with cardiovascular disease and habit of
smoking.
E. It does not cause weight gain.
33. Mirtazapine is associated with lesser sexual side
effects. Which of the following
pharmacodynamics actions explains this
phenomenon?
A.
B.
C.
D.
E.

Serotonin receptor 5HT1A agonism

Serotonin receptor 5HT2A antagonism
Serotonin receptor 5HT2C antagonism
Serotonin receptor 5HT3 antagonism
Histamine receptor antagonism.

34. Which of the following side effects is least likely

to occur in patients taking quetiapine?
A.
B.
C.
D.
E.

Antihistamine effects
Orthostatic hypotension
Increase in liver transaminase
Increase in prolactin
Weight gain.

35. Which of the following is the best treatment

option for severe depressive episode with
psychotic features?
A.
B.
C.
D.
E.

Amitriptyline
Cognitive behaviour therapy
Lamotrigine
Methylphenidate
Electroconvulsive therapy.

36. A 35-year-old man suffers from schizophrenia

symptoms and his GP has started him a
medication to treat his symptoms. He develops
jaundices after taking the medication. Which of
the following medications is most likely to cause

Explanation: bupoprion works on

noradrenaline and dopamine but
not serotonin. It is not
recommended for eating disorder
because of the risk of seizure.
Author: Roger Ho
Year: 2014
The answer is B.
Explanation: Mirtazapine
antagonises 5HT2A receptors and
leads to anxiolytic effects,
restores sleep and less sexual
side effects.
Author: Roger Ho
Year: 2014
The answer is D.
Explanation: Quetiapine is
associated with antihistamine
effects, orthostatic hypotension,
increase in liver transaminase
and weight gain.
Author: Roger Ho
Year: 2014
Answer is E.
Explanation: ECT has the most
evidence in treating psychotic
depression as compared to other
treatment options.
Author: Roger Ho
Year: 2014
The answer is B.
Explanation: Chlorpromazine is
associated with cholestatic
jaundice and is most likely to
cause jaundice among all
options.
10

jaundice?
A.
B.
C.
D.
E.

Clozapine
Chlorpromazine
Haloperidol
Risperidone
Sulpiride.

Author: Roger Ho
Year: 2014

37. A 60-year-old man suffers from depressive

disorder and you have increased the dose of
antidepressant. He is seeing you today. His blood
pressure is 180/90. Which of the following
medications should be stopped?

The answer is E.

A.
B.
C.
D.
E.

Author: Roger Ho
Year: 2014

Diazepam
Quetiapine
Fluvoxamine
Hydroxyzine
Venlafaxine.

38. A 25-year-old woman with bipolar disorder is

pregnant for the first time. Throughout the
pregnancy, she has been maintained on a mood
stabilizer. At the time of birth, the baby is noted
to have Ebsteins anamoly. Which of the
following medications is most responsible for this
teratogenic effect?
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
because she is very upset after being scolded by
her manager. The chief executive officer (CEO)
of her company has raised the standard for
annual performance. Her manager is very upset
this arrangement and scolds her for no reason.
Which of the following is the defence mechanism
exhibits by the manager?
A.
B.
C.
D.
E.

Altruism
Denial
Displacement
Repression
Reaction formation.

40. You are a doctor working in polyclinic. A 25-yearold man bought his 55-year-old mother to see
you. He is concerned that his mother suffers from
depression
but
she
refuses
to
take
antidepressant. You realise that the mother and

Explanation: Venlafaxine is
associated with dose-dependent
hypertension.

The answer is C
Explanation: Ebsteins anomaly
is associated with lithium.
Author: Roger Ho
Year: 2014

The answer is C.
Explanation: The manager
transferred his anger to his
subordinate which carries less
emotional risk as compared to the
CEO. This is known as displacement.
Author: Roger Ho
Year: 2014

The answer is E.
Explanation: Family therapy such
as structural family therapy
focusing on boundary is helpful
11

son are enmeshed as the son is unmarried and in this situation.

not able to work. He claims that he needs to look
after his mother although she has good past Author: Roger Ho
health. The mother and son hold very negative Year: 2014
view against the father who is the sole
breadwinner of family. There is a psychologist
working in your polyclinic. Which of the following
forms of psychological treatment is most
appropriate?
A.
B.
C.
D.
E.

Couple therapy
Dialectical behaviour therapy
Problem solving psychotherapy
Supportive psychotherapy
Family therapy.

41. A national serviceman is seeing a male

psychologist because he suffers from adjustment
disorder and he finds his army supervisor
uncaring. Furthermore, he is very angry with his
own father. He recalls an incident in camp about
getting angry with his male supervisor. The
psychologist asks a factual question about the
circumstance and rage in the patient. Then the
patient complains that the psychologist is
uncaring and trying to find fault in him. The
psychologist says, I wonder if what youve
feeling right now is just like the feeling you have
in camp, when you attributed the same uncaring
attitude toward your father and supervisor in
camp.
These
repetitive
patterns
of
misunderstanding seem to make you very upset
in different situations and affect your life. Which
of the following most accurately describes the
psychotherapeutic technique?
A.
B.
C.
D.
E.

The answer is E.
Explanation: Interpretation is a
statement made by the
psychologist to enhance patients
understanding of his or her own
thoughts or behaviours.
Affirmation refers to confirmation
of validity of previous judgement
or behaviour in a patient.
Empathetic validation refers to
the situation when the therapist
tries to put himself into the
patients shoes and tries to
understand patients inner state.
Author: Roger Ho
Year: 2014

Affirmation
Clarification
Empathic validation
Observation
Interpretation.

42. A medical student used to be very keen to

become an orthopaedic surgeon. He has
assisted an orthopaedic surgeon to conduct
research since the second year of medical
school. During the residency application, he tells
other classmates that he does not bother whether
he is accepted by the orthopaedic residency. He
also encourages other classmates not to apply
for orthopaedic surgery as this specialty is not a
good career choice. On the other hand, he is
secretly asking his orthopaedic mentor to prepare
him for the orthopaedic residency intake
interview. What is his defence mechanism?

The answer is E.
Explanation: His external attitude
and behaviours (not caring about
orthopaedic surgery) is the
opposite of the internal intention
(wanted to join orthopaedic
surgery).
Author: Roger Ho
Year: 2014

12

A. Altruism
B. Denial
C. Displacement
D. Repression
E. Reaction formation.
43. Which of the following is the most effective
approach for a 30-year-old woman with
obsession about contamination and washes her
hands every time she touches something which
she considers dirty?
A. Having the patient place her hands in a container
of worms to create extreme phobia and ability to
overcome obsession
B. Having the patient snap her wrist with a rubber
band when she thinks about contamination and
about to wash her hands
C. Having the patient touch a dirty object, then not
allowing her to wash her hands for several hours
D. Highlighting to the patient that her obsession is a
cognitive error.
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
of post-traumatic stress disorder after surviving
an accident which his tank fell into the river from
a bridge. He was driving a tank on a bridge when
it suddenly collapsed. Several army officers were
seriously injured in this accident. As part of the
treatment, the psychologist asks the patient to
imagine that he is safely driving his tank over a
bridge. Which of the following best describes this
therapeutic intervention?
A.
B.
C.
D.
E.

The answer is C.
Explanation: Option C is known
as exposure and response
prevention (ERP) and is the most
effective approach among all
options. Option D is not good
enough because the
psychologist should guide the
patient to further challenge the
obsessions rather than just
highlighting the obsessions.
Option B is thought stopped and
is not as effective as ERP.
Author: Roger Ho
Year: 2014
The answer is C.
Explanation: The psychologist is
providing in-vivo exposure by
imaging the accident scene to
overcome fear and anxiety
associated with flashback.
Author: Roger Ho
Year: 2014

Aversion therapy
Cognitive therapy
Exposure therapy
Interpersonal therapy
Supportive therapy.

Ethics, management dilemma and laws

45. You are a paediatric resident. A 14-year-old girl
has stayed in the paediatric ward for 1 week after
a suicide attempt by drug overdose. She is due
for discharge tomorrow. At 6 pm, she suddenly
claims that her elder sister had physically abused
her prior to admission. Her medical record
reveals that she suffers from conduct disorder.
She also made similar reports of physical abuse
in the past. The police officer and social worker
found her claims inconclusive and did not
investigate further. She is ambivalent to make a

The answer is E.
Explanation: As this female
adolescent suffers from conduct
disorder, she has the tendency
to tell lies to avoid discharge. As
the patient is currently in the
ward and she is safe, there is no
need to inform the police
immediately without further
clarification from the treatment
13

report about the alleged abuse and she is

keen for discharge. You try to contact
consultant in charge of this case but
consultant is not contactable. Which of
following is most appropriate action?

not
the
the
the

A. Banning her parents from visiting her.

B. Call 995 to inform the police immediately
C. Inform the on-call team and request the on-call
doctors to inform the police before midnight
D. Refer the patient to gynaecologist for further
assessment
E. Discuss with the consultant-in-charge and the
social worker on the next day.
46. A 35-year-old man was hospitalised for treatment
of severe depressive episode in September. The
inpatient team prescribed two antidepressants for
the patient and then referred the patient to
polyclinic. The patient came to the polyclinic for
review in October and November respectively.
The patient had a relapse of depression and
committed
suicide
in
December.
The
computerised record shows that the polyclinic
doctors
had
forgotten
to
prescribe
antidepressants since the first visit. Which of the
following best describes the above situation
based on the Common Law?
A.
B.
C.
D.
E.

Battery
Diminished responsibility
Intentional torts
Negligence
Tarasoffs rule

Liaison psychiatry and neuropsychiatry

47. You are a resident in obstetrics. Which of the
following is the safest medication to be given to a
pregnant woman who develops psychosis during
pregnancy?
A. Aripiprazole
B. Haloperidol
C. Olanzapine
D. Quetiapine
E. Risperidone
48. A 25-year-old man expresses concerns that he
got infected with HIV after visiting commercial sex
workers last week. According to him, he only
received hand-genital stimulation and there was
no vaginal intercourse. He also mentions that the
commercial sex worker kissed his body. He has
sought his girl-friends forgiveness. Today, he
requests HIV test urgently. He consulted you one

team. Furthermore, the patient is

ambivalent to make a report. The
best approach is to discuss with
the treatment team and they can
clarify with her parents whether
the elder sister did physically
abuse her.
Author: Roger Ho
Year: 2014

The answer is D.
Explanation: The polyclinic
doctors forgot to prescribe
antidepressants and resulted in
relapse and suicide. Their act is
considered to be negligence /
unintentional torts. Option A is
intentional torts and not relevant
for this case. Diminished
responsibility only applies in
murder cases. Tarasoffs rule
involves duty to warn when a
patient expresses his/her wish to
harm another person.
Author: Roger Ho
Year: 2014

The answer is B.
Explanation: Haloperidol is the
oldest medication and is the
safest among all options.
Author: Roger Ho
Year: 2014
The answer is B.
Explanation: It is common in
clinical practice for patients
asking for urgent HIV test after
they engaged in activities which
did not transmit HIV. The
patients request for such test as
14

year ago for similar concern after he kissed

another lady without informing his girl-friend.
What is the most likely explanation of his
behaviour?
A. Underlying depression
B. Underlying guilt
C. Underlying obsession
D. Underlying psychosis
E. Underlying somatic concern
49. You are orthopaedic resident. A 25-year-old
construction worker had a fall, fractured his spine
and injured the brain. He develops pain in
multiple sites. He has one episode of epilepsy
after the injury. He is depressed but does not
have suicidal thought. Electrocardiogram is
normal. Which of the following medication is most
helpful in this situation?
A. Amitriptyline
B. Bupropion
C. Chlorpromazine
D. Duloxetine
D. Moclobemide

50. You are a medical resident and rotated to

rheumatology. A 24-year-old woman suffers
from systemic lupus erythematosus (SLE).
She suffers from lupus nephritis and requires
dialysis three times a week. She was very
concerned about her illness and felt
hopeless. She took an overdose of her lupus
medications and admitted to the medical
ward. You need to take a history from her.
Which of the following is not part of the
neuropsychiatric symptoms of SLE
experienced by this patient?
A. Anxiety
B. Binge eating
C. Cognitive impairment
D. Epilepsy
E. Headache.

a result of guilt. It is unlikely to be

caused by obsession as the
patient requests for the HIV test
after sexual activity but not a
thought. The patient does not
have any somatic concern.
Author: Roger Ho
Year: 2014
The answer is D.
Explanation: Duloxetine is an
antidepressant indicated for both
depression and pain. Bupropion,
amitriptyline and chlorpromazine
increases the risk of seizure.
There is no indication to
prescribe moclobemide in this
case.
Author: Roger Ho
Year: 2014

The answer is B.
Explanation: Binge eating is not a
recognised neuropsychiaric
symptom of SLE.
Author: Roger Ho
Year: 2014

15

EMI
Author: Cyrus Ho
Modified by Roger Ho
Vetted by Iris Rawtaer, A/Prof John Wong

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 DiClementes 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

16

Question 54 57

Options:
A.

Deficiency of thiamine

B.

Deficiency of vitamin B12

C.

Presence of amyloid plaques and neurofibrillary tangles

D.

Presence of eosinophilic intracytoplamic neuronal inclusions with abnormal phorphorylation

E.

Raised growth hormone level with dysregulation of hypothalamic-pituitary-adrenal axis

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
and unsteady gait. On physical examination, he has opthalmoplegia and nystagmus.
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.

17

Answer: E

Question 58 59
Options:
A.

Alcohol intoxication

B.

Cannabis intoxication

C.

Frontal lobe dementia

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

18

Question 59 - 60
Options:
A.

Acetaldehyde dehydrogenase inhibitor

B.

Acetylcholine dehydrogenase inhibitor

C.

Dopamine D2 receptor antagonist

D.

NMDA receptor antagonist

E.

Partial dopamine D2 agonist

Lead-in Select the most likely mechanism of drug action from above.

59. Disulfiram
Answer: A

60. Haloperidol
Answer: C

19