PLAB (PSYCHIATRY) Sample Questions Set-3
Categories: U.K. PLAB (Professional and Linguistic Assessments Board)
Question. A 30 year old woman comes to the clinic in tears trying to describe the constant irritability she is in when dealing with her 2 small children. She describes herself as easily startled. She is unable to concentrate for long but attributes it to poor sleep as she often gets nightmares of a house fire. Her husband died in a house fire while she was sleeping in the other room last year. What is the SINGLE most appropriate management?
A. Reasurance
B. Relaxation therapy
C. Quietiapine
D. Lofepramine
E. Fluoxetine
Answer: (e) [This woman is suffering from post-traumatic stress disorder. Fluoxetine is an SSRI. SSRIs are used second to CBT. As CBT was not an option in this question, fluoxetine would be the next best choice.
POST-TRAUMATIC STRESS DISORDER (PTSD): Develops following a traumatic event
Features:
i. Re-experiencing: Flashbacks, nightmares
ii. Avoidance: Avoiding people, situations or circumstances resembling or associated with the event
iii. Hyperarousal: Hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
iv. Emotional numbing: Lack of ability to experience feelings
Management: i. Trauma-focused cognitive behavioural therapy (TF-CBT) and eye movement desensitization and reprocessing (EMDR): are first-line treatments. It is very common to have questions with a patient with clear symptoms of PTSD and the question would ask which is first line. If CBT is present, that is usually the answer.
ii. SSRI’s would be the second line. e.g. paroxetine, sertraline are licensed for PTSD. Other unlicensed possibilities include: fluoxetine, citalopram, escitalopram, and fluvoxamine. If you find all these names of SSRI’s difficult to remember. Just remember these 3 → Paroxetine, sertraline, and fluoxetine.]
Question. A 34 year old man who is a known schizophrenic has been going through a depressive phase for the past few months since the death of his father. During discussions with his siblings and friends, he is seen laughing and smiling inappropriately while talking about his father’s death. He does not seem to realise that his actions are inappropriate. What is the SINGLE most appropriate term that describes his symptoms?
A. Flight of ideas
B. Flat affect
C. Emotional lability
D. Incongruent affect
E. Clang association
Answer: (d) [Incongruent affect: The term “incongruent” means out of place. Incongruent affect is sometimes seen in schizophrenia where their behaviour is out of place. Example, talking about problems in their family while laughing or laughing when your pet dies. These behaviours are seen as not consistent with the patient’s current mindset. This is also seen in bipolar patients.]
Question. A 23 year old woman has had several sudden onset episodes of palpitations, sweating, nausea and overwhelming fear. On one occasion she was woken from sleep and had the fear that she was going insane. She has no previous psychiatric medical history and is not on any medication. What is the SINGLE most likely diagnosis?
A. Pheochromocytoma
B. Panic disorder
C. Generalized anxiety disorder
D. Hypnophobia
E. Acute stress disorder
Answer: (b) [It is quite difficult to differentiate generalized anxiety disorder with panic disorder. People with generalized anxiety disorder feel anxious most days and often struggle to remember the last time they felt relaxed. As soon as one anxious thought is resolved, another may appear about a different issue. Panic disorder, however is where you have recurring and regular panic attacks, often for no apparent reason similar to this stem where she had several sudden onset episodes of panic.
Panic disorder: Panic disorder is classified as having 2 recurrent panic attacks, which are not secondary to substance misuse, medical conditions, or another psychiatric disorder. Frequency of occurrence may vary from many attacks a day to only a few a year. Usually patients have a persistent worry about having another attack or consequences of the attack.
Symptoms/signs: i. Physical symptoms/signs related to autonomic arousal (e.g. tremor, tachycardia, tachypnoea, hypertension, sweating)
ii. Concerns of death from cardiac or respiratory problems may be a major focus, leading to patients presenting (often repeatedly) to emergency medical services.]
Question. A 48 year old man states he is a well known professor teaching rocket science in a London University. He states that the number of people who attend are within the thousands and they would fly in from different parts of the world to hear his lectures. He states that he owns the majority of the United Kingdom and in a few years people would think of him as a god. What is the SINGLE most likely disorder?
A. Delusion
B. Mania
C. Identity disorder
D. Bipolar disorder
E. Substance abuse disorder
Answer: (a) [This is a difficult question and many of the choices are potentially correct however the one disorder that stands out is delusion. A delusion is a mistaken belief that is held by the person with strong conviction despite true evidence against the belief. The subtype of delusion called “grandiose delusions” is likely what this man is suffering from. This subtype of delusions are seen in manic episodes of bipolar disorder, schizophrenics and occasionally in substance abuse disorders. The option of mania and bipolar disorder is not entirely wrong but delusion fits better as the answer.
GRANDIOSE DELUSIONS: Delusions of grandeur is a subtype of delusion involving the fantastical beliefs that one is famous, omnipotent, wealthy, or otherwise very powerful. They believe that they have exceptional abilities or talents and keep praising themselves. This is primarily seen in patients in manic states of bipolar disorder or patients with schizophrenia. The delusions may involve supernatural or science fiction themes.
Examples: i. A professor who thinks he would become a king or god later in life which is seen to be untrue
ii. A powerful man who is helping the prime minister which is seen to be untrue]
Question. A 10 year old boy with behavioural problems is taken to the clinic by his parents. During the appointment, the boy barks and shouts expletives. He is constantly blinking his eyes and unable to sit still. What is the SINGLE most likely diagnosis?
A. Asperger syndrome
B. Cotard syndrome
C. Rett syndrome
D. Ekbom syndrome
E. Tourette’s syndrome
Answer: (e) [This is a classic scenario for Tourette’s syndrome in PLAB 1. Other clues that may appear on PLAB 1 may be the child yelling in class intermittently or shouting expletives. Most Tourette’s syndromes are diagnosed at 6-8 years, maximum to the age of 13.
The other syndromes are less likely to be the answer:
Asperger syndrome → Characterized by severe persistent impairment in reciprocal social interactions, repetitive behaviour patterns, and restricted interests. IQ and language are normal or, in some cases, superior. Although tics (like the above case) can also be found in asperger syndrome, it is more specific for Tourette’s syndrome. Not to mention, the question would include an impairment of social skills if the PLAB examiners wanted you to have picked Asperger syndrome.
Cotard’s syndrome → is a rare mental illness in which an afflicted person holds the delusion that they are dead.
Rett’s syndrome → There is normal development for 2–3yrs, followed by a loss of acquired motor, language, and social skills between ages 3 and 4yrs. Stereotypies and compulsions are common.
Ekbom’s syndrome → Also called restless leg syndrome. Unpleasant, often painful sensations in the legs, particularly on sleep onset.
Tourette’s syndrome:
Presentation: i. Young (6-8 years old) mostly male
ii. Repetitive movements or gestures that are disruptive in the classroom or to people around the child (can be motor or vocal) → Tics
iii. Jerks, blinks, sniffs, nods, spitting, stuttering, irrepressible explosive obscene verbal ejaculations, grunts, and squeaks
Diagnosis: Clinical diagnosis
Treatment: i. Risperidone or haloperidol ii. Behavioral therapy - Habit-reversal training]