Showing posts with label Paper B. Show all posts
Showing posts with label Paper B. Show all posts

Saturday, 9 January 2021

Guidelines for the Pharmacotherapy of Major Depressive Disorder

Guidelines for the Pharmacotherapy of Major Depressive Disorder

I have summarised the following recommendations from the Maudsley prescribing guidelines in Psychiatry, 13th Ed.


Supportive psychotherapy, CBT, interpersonal therapy, marital/couple therapy, dynamic psychotherapy, behavioral activation

Depressive episode


SRI/ Mirtazapine

à A generic SRI; use mirtazapine if sleep needed



  à Most evidence is for a switch to vortioxetine

Step 3

Mirtazapine, vortioxetine, agomelatine

 à if not already trialed

Thursday, 7 January 2021

Best Choice of Treatment for Delirium Tremens

This topic has moved to the main topic on Delirium Tremens

Glutamate Antagonists for the Treatment of Catatonia

Because of its N-methyl-d-aspartic acid antagonist properties, amantadine (100–500mg three times a day), and its derivative memantine (5–20mg/day), have been tried in catatonia.

  1. Carroll and coworkers identified 25 cases of amantadine and memantine use in the treatment of catatonia. All cases improved, mostly after 1–7days.

  2. It should be noted, however, that six were unpublished, and that seven other were cases experiencing a “catatonia-parkinsonian syndrome” while under treatment with the high-potency neuroleptic drugs haloperidol or fluphenazine.
  3. The symptoms diminished when neuroleptics were tapered, and they added amantadine. Since then, they have published eleven additional cases describing the successful use of amantadine or memantine in catatonia.
  4. In one case, in an adolescent girl, catatonia that was resistant to ECT improved after the addition of amantadine.
  5. Only in a review of Hawkins and coworkers, they report a case in which the use of amantadine remained without effect. Should acknowledge, however, that negative cases are less likely to be published.
  6. Given these positive signals in the published literature, and evidence of its efficacy in treating the negative and cognitive symptoms of schizophrenia, amantadine should be further studied as a feasible treatment option for catatonia. There is anecdotal evidence from case reports on the use of various other pharmacological agents, such as bromocriptine and biperiden.
  7. Based on the GABA-hypothesis of catatonia, and the GABA-related working mechanism of several anti-convulsive mood stabilizers, these drugs have been proposed as a viable treatment option to treat catatonia in bipolar patients.
  8. Only a few cases have published reports.
  9. They used valproate in several case reports and found not only to have prophylactic effects but also “an improving effect on the catatonic symptoms”.
  10. In a solitary case report, they advocated levetiracetam as a treatment for catatonia in bipolar disorder, given its mood-stabilizing efficacy.
  11. It is of note, however, that levetiracetam has also been described to provoke catatonia.
  12. Using topiramate and carbamazepine have also been reported.
  13. Although lithium has been anecdotally reported to have a beneficial effect on acute catatonic symptoms, they mostly describe it to be of use in the prevention of recurrent catatonia, albeit with sometimes limited results.


  1. Carroll BT, Goforth HW, Thomas C, Ahuja N, McDaniel WW, Kraus MF, et al. Review of adjunctive glutamate antagonist therapy in the treatment of catatonic syndromes. J Neuropsychiatry Clin Neurosci (2007) 19(4):406–12.10.1176/appi.neuropsych.19.4.406  
  2. Gelenberg AJ, Mandel MR. Catatonic reactions to high-potency neuroleptic drugs. Arch Gen Psychiatry (1977) 34(8):947–50.10.1001/archpsyc.1977.01770200085010  
  3. Obregon DF, Velasco RM, Wuerz TP, Catalano MC, Catalano G, Kahn D. Memantine and catatonia: a case report and literature review. J Psychiatr Pract (2011) 17(4):292–9.10.1097/01.pra.0000400268.60537.5e  
  4. Babington PW, Spiegel DR. Treatment of catatonia with olanzapine and amantadine. Psychosomatics (2007) 48(6):534–6.10.1176/appi.psy.48.6.534  
  5. Muneoka K, Shirayama Y, Kon K, Kawabe M, Goto M, Kimura S. Improvement of mutism in a catatonic schizophrenia case by add-on treatment with amantadine. Pharmacopsychiatry (2010) 43(4):151–210.1055/s-0029-1242821  
  6. Hervey WM, Stewart JT, Catalano G. Treatment of catatonia with amantadine. Clin Neuropharmacol (2012) 35(2):86–710.1097/WNF.0b013e318246ad34  
  7. de Lucena DF, Pinto JP, Hallak JE, Crippa JA, Gama CS. Short-term treatment of catatonia with amantadine in schizophrenia and schizoaffective disorder. J Clin Psychopharmacol (2012) 32(4):569–7210.1097/JCP.0b013e31825ebf6e  
  8. Ene-Stroescu V, Nguyen T, Waiblinger BE. Excellent response to amantadine in a patient with bipolar disorder and catatonia. J Neuropsychiatry Clin Neurosci (2014) 26(1):E43.10.1176/appi.neuropsych.13020038  
  9. Mahmood T. Bromocriptine in catatonic stupor. Br J Psychiatry (1991) 158:437–810.1192/bjp.158.3.437  
  10. Franz M, Gallhofer B, Kanzow WT. Treatment of catatonia with intravenous biperidene. Br J Psychiatry (1994) 164(6):847–810.1192/bjp.164.6.847b  
  11. DelBello MP, Foster KD, Strakowski SM. Case report: treatment of catatonia in an adolescent male. J Adolesc Health (2000) 27(1):69–7110.1016/S1054-139X(00)00109-9  
  12. Kruger S, Braunig P. Intravenous valproic acid in the treatment of severe catatonia. J Neuropsychiatry Clin Neurosci (2001) 13(2):303–410.1176/appi.neuropsych.13.2.303  
  13. Bowers R, Ajit SS. Is there a role for valproic acid in the treatment of catatonia? J Neuropsychiatry Clin Neurosci (2007) 19(2):197–810.1176/appi.neuropsych.19.2.197  
  14. Yoshida I, Monji A, Hashioka S, Ito M, Kanba S. Prophylactic effect of valproate in the treatment for siblings with catatonia: a case report. J Clin Psychopharmacol (2005) 25(5):504–510.1097/  
  15. Muneer A. Catatonia in a patient with bipolar disorder type I. J Neurosci Rural Pract (2014) 5(3):314–610.4103/0976-3147.133652 [PMC free article]  
  16. Chouinard MJ, Nguyen DK, Clement JF, Bruneau MA. Catatonia induced by levetiracetam. Epilepsy Behav (2006) 8(1):303–7.10.1016/j.yebeh.2005.04.016  
  17. McDaniel WW, Spiegel DR, Sahota AK. Topiramate effect in catatonia: a case series. J Neuropsychiatry Clin Neurosci (2006) 18(2):234–8.10.1176/appi.neuropsych.18.2.234  
  18. Rankel HW, Rankel LE. Carbamazepine in the treatment of catatonia. Am J Psychiatry (1988) 145(3):361–2.   
  19. Wald D, Lerner J. Lithium in the treatment of periodic catatonia: a case report. Am J Psychiatry (1978) 135(6):751–2.   
  20. Pheterson AD, Estroff TW, Sweeney DR. Severe prolonged catatonia with associated flushing reaction responsive to lithium carbonate. J Am Acad Child Psychiatry (1985) 24(2):235–710.1016/S0002-7138(09)60454-4  
  21. Gjessing LR. Lithium citrate loading of a patient with periodic catatonia. Acta Psychiatr Scand (1967) 43(4):372–510.1111/j.1600-0447.1967.tb05774.x  

Stuttering and Stammering

Stuttering and Stammering

We may also call stammering. In the Diagnostic and statistical manual fifth edition, they call it Childhood-onset fluency disorder:

Repetitions or prolongations of speech sounds OR
  1. Hesitations/pauses
  2. Marked disturbance in the fluency of speech. 
  3. Frequently associated movements, for example:
    1. Eye blinks 
    2. Tics
    3. Tremors of the lips or face
    4. Jerking of the head
    5. Breathing movements
    6. Fist-clenching
These coincide with the stutters. 

Tip > both Stuttering and Stammering include S as in heSitations

Compare this to Staccato Speech

Psychodynamic Themes in Panic Disorder

  • Difficulty tolerating anger.

  • Physical or emotional separation from a significant person both in childhood and in adult life 

  • Situations of increased work responsibilities may trigger it 

  • Perception of parents as controlling, shocking, cynical, and demanding 

  • Internal representations of relationships involving sexual or physical abuse 

  • A chronic sense of feeling trapped 

  • A vicious cycle of anger at parental rejecting behavior followed by anxiety that the fantasy will destroy the tie to parents.

  • Failure of signal anxiety function in ego related to self fragmentation and self-other boundary confusion 

Evaluation, Differential Diagnosis, and Treatment of Catatonia


Evaluation, Differential Diagnosis, and Treatment


Effective treatment starts with a swift and correct diagnosis. In any patient exhibiting marked deterioration in psychomotor function and overall responsiveness, we should consider catatonia. Any patient that is admitted to a psychiatric ward with a severe psychiatric disorder, such as depression, bipolar disorder, a psychotic disorder, or autism spectrum disorder, should be examined routinely. Some signs and symptoms are clear upon observation of the patient during a psychiatric interview. Other specific symptoms, however, such as automatic obedience, ambitendency, negativism should be elicited during a neuropsychiatric examination.


We can use a rating scale as a screening instrument and aid in the detection and quantification of catatonia. We have found several rating scales reliable, sensitive, and specific:

  1. Rogers Catatonia Scale
  2. Bush-Francis Catatonia Rating Scale
  3. Northoff Catatonia Rating Scale
  4. Braunig Catatonia Rating Scale
Early detection of catatonia is of great importance, since catatonic signs possess significant prognostic and therapeutic value.


Unfortunately, no laboratory test specifically defines catatonia. The “diagnostic weight” of several proposed laboratory and imaging tests is limited. Laboratory tests, primarily to assess various underlying conditions, including a complete blood count and metabolic panel, erythrocyte sedimentation rate, blood urea nitrogen, creatinine, serum iron, and creatinine-phosphokinase, antinuclear antibodies, and urinalysis, and magnetic resonance imaging, electroencephalogram, cerebrospinal fluid analysis. Given the frequent association with anti-NMDAR-encephalitis, detection of IgG antibodies to NMDAR in cerebrospinal fluid or serum is advisable. Since we found serum iron to be reduced in NMS compared to catatonia, some authors see low serum iron as a risk factor for developing NMS after using antipsychotics in a catatonic patient. A drug screen to detect common illicit and prescribed substances is necessary.

An Overview of Catatonia

An overview of Catatonia

Catatonia is a severe motor syndrome with an estimated prevalence among psychiatric inpatients of about 10%. Catatonia can accompany many psychiatric illnesses and somatic diseases. A minority of catatonic patients suffer from schizophrenia, while a majority has a bipolar disorder. They have also linked catatonia to other psychiatric disorders, such as obsessive-compulsive disorder, post-traumatic stress disorder, or withdrawal from alcohol or benzodiazepines. In up to 25% of cases, they relate catatonia with general medical or neurologic conditions. Recent studies show repeatedly that catatonic symptoms are observable in most patients diagnosed with anti-N-methyl-d-aspartate receptor encephalitis. In adolescents and young adults with autism, we find catatonia in 12–17%. Pediatric catatonia also emerges in patients with tic disorders, and a variety of other (developmental) disorders. The same principles of evaluation and treatment seem to apply to pediatric patients as in adult patients.

Lethal Catatonia

A life-threatening situation occurs when catatonia manifests with fever and autonomic abnormalities. Malignant catatonia, as Stauder in 1934 coined “lethal catatonia”, presents as a constellation of catatonia, stuporous exhaustion, autonomic instability, respiratory failure, collapse, coma, and often death if left untreated. This clinical picture is remarkably close to what we observe in neuroleptic malignant syndrome, which several experts consider a drug-induced form of catatonia.

Disulfiram-like reaction

Disulfiramlike Reaction

Disulfiram irreversibly inhibits aldehyde dehydrogenase, by competing with nicotinamide adenine dinucleotide at the cysteine residue. Aldehyde dehydrogenase is a hepatic enzyme of alcohol metabolism converting ethanol to acetaldehyde. At therapeutic doses of disulfiram, alcohol consumption causes elevated serum acetaldehyde, causing manifestations given below.


Facial flushing

We call this constellation of symptoms the disulfiram-alcohol reaction; it discourages alcohol intake. The severity of the reaction is proportional to the dose of disulfiram, and that of alcohol. It is NOT an anti-craving drug and DOES NOT affect the neurobiology of addiction.

NICE guidelines on the Use of Disulfiram

Disulfiram should be considered in combination with a psychological intervention for patients who wish to achieve abstinence, but for whom acamprosate or naltrexone is not suitable. Treatment should be started at least 24 hours after the last drink and should be overseen by a family member or a carer. Monitoring is recommended every 2 weeks for the first 2 months, then monthly for the following 4 months. Medical monitoring should be continued at 6 monthly intervals after the first 6 months. Patients must not consume any alcohol while taking disulfiram

CATIE Clinical Antipsychotic Trials of Intervention Effectiveness

CATIE Clinical Antipsychotic Trials of Intervention Effectiveness

A Multicenter, double-blind, parallel-group, randomized, controlled trial

NICE Stepped Care Model for Obsessive-compulsive Disorder (OCD)



MRCPsych Paper B


Critical Review


You are checking the frequency of “the Perceived stress scale among doctors serving at various Government and private hospitals in Faisalabad. (JPMA-2020-02-232)”

If you aimed for a specific category of doctors, then that will be your target population. For example juniors, seniors, permanent visiting, etc.


Once we plan a survey or a research experiment, then we have a target population in mind. For example, some surveys cover the entire population of the country like census and political elections. If we take an example for census first, then what sample size do you think would be the correct representative in that case? The obvious answer is 100% of the population of the country, not a single percent less.


Now take the example of the political elections, let’s say 50% was the turnout on polls. Would that be an excellent election turn out? Probably not, because half the population of the country didn’t take Part in it. If the turnout was 80% then it is stronger because a good proportion took part and we can conclude that the results represent the voters in our country.

The above examples highlight that sample size determination will depend upon what population we aim to get the data from and what is the purpose of the data collection.

You are checking the frequency of “the Perceived stress scale among doctors serving at various Government and private hospitals in Faisalabad. (JPMA-2020-02-232)”

What you need to ask yourself is that what is the total population of such doctors in this hospital? If you aimed for a specific category of doctors, then that will be your target population. For example juniors, seniors, permanent visiting, etc.

Let's assume that you know the population of such doctors in question. And for sake of a hypothetical exercise, let’s say that 100 doctors are your target population. If you are checking the frequency then how much sample size do you think would represent these doctors?

Follow this link on the sample size calculator website and put the values Sample Size Calculator. Once you put a population size of 100, then you find that to be 95% confident that this sample truly represents the target population you need to examine at least 80 people out of 100. Now 5% is the margin of error. If you increase the margin of error to 20%, you will need a sample size of 20 only. Now put your population size into this calculator and choose your margin of error, and you will find the sample size that you must have aimed for.

Sampling Methods


Stratified & Random 

A dog in the snow.

A small green rectangle to divide sections of the document

Stratified Sampling

Random sampling refers to sampling via which every member of the target population has an equal chance of making it to the sample. Assign numbers and choose random, place names in a box and select. 

A small green rectangle to divide sections of the document

Random Sampling

Stratified sampling is when the demographic characteristics of the target population are reflected in the sample. For example, if there are 1% working females in a target population, then the sample should also have 1% working females. 

Can you appear in MRCPsych Paper B with 12 months' of an experience only?

Can you appear in MRCPsych Paper B with 12 months' of an experience only?

Can someone appear in MRCPsych paper B if she has done just MO-ship ( non-trainee) in a private sector for 12 months in psychiatry, especially if her supervisor is a Consultant registered with the Royal College of Psychiatrists?

Yes, you can as far as I understand, but you need to submit the confirmation of the following as stated on the RCPsych website :

Eligibility criteria for Paper B

  1. You are in an approved training program. They recommend you have 12 months’ experience in psychiatry before attempting Paper B. OR:
  2. You are in a post recognized by your hospital or trust as having contracted time and funding for educational training. Your job plan must include dedicated time for academic and educational activities such as attending journal clubs, grand rounds, attending an MRCPsych course of equivalent, study leave, and weekly educational supervision.

Tuberous sclerosis

Tuberous Sclerosis

Tuberous sclerosis (epiloia) has an Autosomal dominant inheritance pattern. Clinical features include Epilepsy, adenoma sebaceous on the face, white skin patches, shagreen skin, retinal phakoma, subungual fibromata, multiple renal, and other tumors. ID usually is Mild. Autism and other psychiatric disorders are common.

Wednesday, 6 January 2021

Neuroleptic malignant syndrome

Neuroleptic malignant syndrome 



  • Fever
  • Encephalopathy
  • Vitals
  • Unstable
  • Enzymes
  • Rigidity of Muscles


  • Dantrolene
  • D2 agonists (e.g., bromocriptine).

Child Psychiatry MCQ for MRCPsych Paper B

Child Psychiatry MCQ for MRCPsych Paper B

A 7-year-old child came with his mother to your Outpatient clinic for assessment because of ongoing difficulties for the past 1 year. The mother shared that the child is always on the go and cannot sit still. Recently, he nearly had an accident when he dashed across the traffic junction. The school report card mentions he is inattentive most of the time.

What psychometric tool will you apply in this case?






Tuesday, 5 January 2021

MRCPsych Paper B: 600 MCQs and EMIs

MRCPsych Paper B: 600 MCQs and EMIs

MRCPsych examination has changed from Paper 1,2,3 to Paper A and B and the first-ever sitting of the `Paper B' examination was on 14th April 2015. MRCPsych Paper B: 600 MCQs and EMIs is the sole review book that covers the new Paper B examination syllabus. 

This book comprises 3 full test papers; 2 matching the syllabus to help with revision and one unstructured to provide authentic mock examination paper practice. MRCPsych Paper B: 600 MCQs and EMIs offer the most up-to-date and comprehensive collection of practice questions for trainees preparing for the new MRCPsych Paper B. they have plotted the questions plotted per the syllabus to present organised revisions on all the key topics, allowing readers to focus on areas of weakness. 

Featuring a wealth of practice questions and answers, this book is an essential revision tool to maximise the chances of examination success.

Key Points

  • 600 MCQs and EMIs reflect the breadth of topics encountered in the examination
  • Straightforward answers to help you merge knowledge and understand key concepts
  • An unstructured mock paper allows candidates to practice under exam conditions

Extended-Matching Items

Extended matching items 

What are the extended matching questions and how many can you expect in the MRCPsych Exam?

An extended-matching items/question (EMI or EMQ) is a written examination format similar to multiple-choice questions but with one key difference, that they test knowledge in a far more applied, in-depth, sense. We often use it in medical education and other healthcare subject areas to test diagnostic reasoning.


The structure has three key elements:

Answer option list

Sources suggest using a minimum of eight answer options for a ratio of five scenarios or vignettes to ensure that the probability of getting the correct answer by chance remains reasonably low.[1] The logical number of realistic options should dictate the exact number of answer options. The logical number of realistic options should dictate the exact number of answer options. This ensures that the test item has authenticity and validity.

Lead-in question:

This should be as specific as possible and upon reading the lead-in question it should understand exactly what the student needs to do - without needing to look at the answer options. If you need to look at the answers to understand the question, the item has not been well-written.

Two or more scenarios or vignettes:

There should be at least two vignettes, otherwise, this becomes an MCQ. Because the item allows for an in-depth test of knowledge, we should relate each of the scenarios to one another by a theme that summarises the question overall. Each scenario should be roughly similar in structure and content, and each has one 'best' answer from amongst the series of answer options given.

Preparing for MRCPsych Paper B with Parsa Amin

Preparing for MRCPsych Paper B with Parsa Amin

I passed paper B using an online exam in October and thought I’d just share what I did while it’s still fresh in my brain so it can help a few. I had an extremely comfortable pass & this is what I did. 1. SPMM Qbank - as I meant to do this exam in March 2020 (Thanks COVID19)- I ended up doing the Qbank average 4 - 5 times. (I didn’t study between March 2020-May2020). I technically did 4 months before this exam knowledge from previous revision pre-March 2020. I used google/ NICE guidelines to read up on only topics I didn’t understand. Focus on EMI’s on SPMM the month before the exam - if you are scoring well, it shows you know your stuff. SPMM 13 timed mocks (they updated it to simulate a real exam, worth the price) - did only once- timed like in the exam situation, I sat them using the area I sat the actual exam. Cambridge Critical Appraisal course - I also did it twice as I was meant to take an exam in March. SPMM statistics videos - they are so good. I also did the SPMM paper B crash course in Feb 2020 - could have potentially skipped this. I did mrcpsychmentor only once - I really didn’t like it, so I avoided it I made my own flashcards with high yield materials only. 


Please get an Ethernet cable for the exam - way too many people had terrible experiences because of the poor internet. The last thing you need.

Sunday, 27 December 2020

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