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Clinical Atlas Prestige · Evidence-first

Psychiatry Fellowship MEQs / SAQs

Psych · MEQs / SAQs

MEQs / SAQs

274 units across 191 domains — Modified-essay (MEQ) and short-answer stems with full-mark model answers.

Back to PsychJump to first domain
Units
274
Domains
191
Consultation-liaison psychiatry — abnormal illness behaviourEmergency psychiatry — absconding and missing patientsEmergency psychiatryAddiction psychiatryChild and adolescent psychiatry — neurodevelopmentalGeneral adult psychiatry — trauma and stressor-relatedChild and adolescent psychiatry — eating disordersSpecialty psychiatry — sleep medicine interfacefoundations — advanced EBM and evidence synthesisOld age psychiatry — Alzheimer diseaseSpecialty psychiatry — eating disordersGeneral adult psychiatry — personality disordersGeneral adult psychiatry — feeding and eating disordersChild and adolescent psychiatry — attachment disordersIntellectual disability psychiatry — neurodevelopmental dual diagnosisConsultation-liaison psychiatryFoundations — basic neuroscience for psychiatryPsychotherapyIntellectual disability psychiatry — genetic syndromesPsychopharmacology — benzodiazepine prescribing and taperingOld age psychiatry — grief and lossFoundations — biostatistics for psychiatry examsGeneral adult psychiatry — bipolar and related disordersGeneral adult psychiatry — OCRDProfessional — boundary violations and sexual misconductOld age psychiatry — dementia neuropsychiatryPsychopharmacology — phototherapy and chronotherapyPublic-community — disaster and mass casualty psychiatryAddiction psychiatry — cannabis and psychosisIntellectual disability — capacity and supported decision-makingConsultation-liaison — capacity and consentOld age psychiatry — capacity, guardianship and end of lifePsychopharmacology — carbamazepine and oxcarbazepinePublic and community psychiatry — carers and family-inclusive practiceGeneral adult psychiatryIntellectual disability psychiatryChild and adolescent psychiatry — anxiety disordersChild and adolescent psychiatry — depressionChild and adolescent psychiatry — child protection for psychiatristsChild and adolescent psychiatry — childhood trauma and maltreatmentChild and adolescent psychiatry — OCRDChild and adolescent psychiatry — children of parents with mental illnessFoundations — research methods and study designPsychopharmacology — first-generation antipsychoticsPsychopharmacology — antipsychoticsPsychopharmacology — antidepressantsForensic psychiatry — civilGeneral adult psychiatry — clinical high risk / attenuated psychosisAddiction psychiatry — pharmaceutical and OTC misuseFoundations — cognitive psychologyPublic and community psychiatry — collaborative care and primary careProfessional — complaint management and regulationGeneral adult psychiatry — trauma and stressor-related disordersChild and adolescent psychiatry — disruptive behaviourProfessional practice — critical appraisal and EBMProfessional — cultural formulation and Indigenous mental healthProfessional — psychological therapiesOld age psychiatry — delirium and acute cognitive syndromesGeneral adult psychiatry — psychotic disordersForensic psychiatry — morbid jealousy and erotomaniaOld age psychiatry — Lewy body dementiasfoundations — descriptive psychopathologyFoundations — psychological and neuropsychological testingFoundations — rating scales and measurement-based careChild and adolescent psychiatry — developmental assessmentGeneral adult psychiatry — DID and dissociative amnesiaChild and adolescent psychiatry — DMDDGeneral adult psychiatry — dissociative disordersProfessional — doctor health, burnout and impairmentIntellectual disability psychiatry — Down syndromePsychopharmacology — drug interactions and QTcAddiction psychiatry — dual diagnosis and integrated careChild and adolescent psychiatry — early-onset psychosisFoundations — EEG and clinical neurophysiologyOld age psychiatry — elder abuse and vulnerabilityChild and adolescent psychiatry — elimination disordersFoundations — epidemiologic methods for psychiatryPsychopharmacologySpecialty psychiatry — sexual medicine interfaceForensic psychiatry — expert evidencePsychotherapy — behavioural therapiesForensic psychiatry — FII / medical child abuseGeneral adult psychiatry — factitious disorder and malingeringOld age psychiatry — falls polypharmacy frailtyProfessional — psychosocial interventionsGeneral adult psychiatry — early psychosis pathwayForensic psychiatry — fitness and criminal responsibilityIntellectual disability — neurodevelopmentalForensic psychiatry — risk assessmentOld age psychiatry — neurocognitive disordersAddiction psychiatry — behavioural addictionsSpecialty psychiatry — gender diversity ethics and systemsSpecialty psychiatry — gender and sexualityGeneral adult psychiatry — anxiety disordersAddiction psychiatry — hallucinogen-related disordersAddiction psychiatry — public health and systemsSpecialty psychiatry — clinical paraphilic disordersForensic psychiatry — homicide and mental disorderGeneral adult psychiatry — somatic symptom and relatedAddiction psychiatry — inhalant-related disordersPsychopharmacology — long-acting injectable antipsychoticsPsychopharmacology — monoamine oxidase inhibitorsPsychopharmacology — lithiumPsychopharmacology — cognitive enhancersPsychopharmacology — clozapinePsychopharmacology — ketamine and esketaminePsychopharmacology — stimulants and ADHD medicationsintellectual disability psychiatryGeneral adult psychiatry — impulse controlProfessional — working with interpreters and CALD communitiesForensic psychiatry — mental health lawPsychopharmacology — lamotrigineOld age psychiatry — anxiety disordersOld age psychiatry — mood disordersOld age psychiatry — psychosisFoundations — behavioural scienceConsultation-liaison — transplant and ICU psychiatryGeneral adult psychiatry — mood disordersFoundations — attachmentProfessional — formulationPsychotherapy — trauma-focused CBT and EMDRPsychotherapy — combined treatmentFoundations — history of psychiatryPsychopharmacology — metabolic syndrome and psychotropic monitoringPsychopharmacology — atypical and multimodal antidepressantsPsychopharmacology — mood stabilisersProfessional practice — psychological therapiesAddiction psychiatry — psychosocial interventionsGeneral adult psychiatry — psychosisAddiction psychiatry — neonatal abstinencefoundations — neuroscience for fellowship psychiatryAddiction psychiatry — nicotine and behavioural addictionsIntellectual disability — forensic dual disabilityAddiction psychiatry — substance use disordersgeneral-adultGeneral adult psychiatry — perinatalPsychopharmacology — pregnancy and lactationFoundations — personality sciencePsychopharmacology — pharmacogenomicsfoundations — philosophy of mindPsychopharmacology — ECT and neurostimulationGeneral adult psychiatry — mood disorders / women's mental healthOld age psychiatry — psychopharmacologyFoundations — prevention and early interventionForensic psychiatry — prison mental healthFoundations — psychiatric genetics and epigeneticsPsychotherapy — psychoeducation and family interventionsFoundations — psychoneuroendocrinology and psychoimmunologyGeneral adult psychiatry — psychosis rehabilitationForensic psychiatry — arson and fire-settingGeneral adult psychiatry — secondary / organic psychosisPsychopharmacology — renal and hepatic diseasePsychopharmacology — fitness to drivePublic-community — quality improvement and patient safetyGeneral adult psychiatry — reactive attachment and disinhibited social engagementPublic-community — military and veteran psychiatryConsultation-liaison — hepatic encephalopathy and advanced transplant psychiatryPublic and community psychiatry — rural and remotePublic and community psychiatry — school and workplace mental healthChild and adolescent psychiatry — school refusal and school anxietyPublic-community psychiatry — restrictive practicesPsychopharmacology — rTMS, VNS and DBSEmergency psychiatry — self-harm and crisisConsultation-liaison — burns and critical illness psychiatrySpecialty psychiatry — sexual dysfunction and paraphiliasForensic psychiatry — sexual offendingPsychopharmacology — anxiolytics and hypnoticsPsychopharmacology — SNRIs and NRIsFoundations — social determinants of mental healthFoundations — social psychologyGeneral adult psychiatry — somatic symptom and related disordersChild and adolescent psychiatry — specific learning disorderProfessional — spirituality and religion in psychiatryPsychopharmacology — SSRIsForensic psychiatry — stalking and harassmentProfessional — stigma, recovery and rights-based careAddiction psychiatry — stimulant and methamphetamine useAddiction psychiatry — acute stimulant syndromesProfessional skills — mental state examinationAddiction psychiatry — substance-induced mood and anxiety disordersGeneral adult psychiatry — substance/medication-induced psychosisEmergency psychiatry — suicide riskProfessional — teaching and supervision skillsPublic and community psychiatry — telepsychiatryForensic psychiatry — therapeutic securityChild and adolescent psychiatry — service interfaceGeneral adult psychiatry — OCRD / BFRBForensic psychiatry — victimologyEmergency psychiatry — violence riskForensic psychiatry — young offendersChild and adolescent psychiatry — youth self-harm and suicide
AtlasPsychMEQs / SAQs

Domain

Consultation-liaison psychiatry — abnormal illness behaviour

1

Abnormal illness behaviour and the sick role — C-L MEQ

A 46-year-old office worker is referred to C-L after the fifth medical admission in 18 months for chest pain, palpitations and ‘impending doom.’ Serial ECGs, troponins, CTPA and stress testing are normal. They demand implantable loop monitoring ‘to catch the heart attack early,’ check their pulse hourly, search cardiac forums nightly, and have stopped working. PHQ-9 is 14; no psychosis. GP notes 28 encounters this year. Partner has taken over household tasks and says ‘they are too sick to try rehab.’ (i) Define the sick role, illness behaviour and abnormal illness behaviour, and locate this presentation on Pilowsky’s axes. (ii) Outline differential diagnosis including DSM-5-TR mappings and discriminators from factitious disorder and malingering. (iii) Structure a C-L assessment including measures, risk and investigation policy. (iv) Give a management plan spanning communication, psychological care, comorbidity treatment and service design. (v) State prognosis factors and pitfalls. (20 marks)

Open

Domain

Emergency psychiatry — absconding and missing patients

1

Absconding from acute ward with suicide risk (MEQ)

A 27-year-old man detained under a local inpatient treatment order for first-episode psychosis is found missing at 14:30 during 15-minute observations. He was last seen at 14:10 in outdoor clothes near the garden door. Yesterday he said voices told him staff were poisoning him and that he would be 'better off dead outside.' He has one prior abscond from another unit. He is unemployed and recently street-homeless. (i) Define absconding/AWOL and distinguish related pathways. (ii) Outline immediate actions and police thresholds. (iii) Formulate risk factors and likely motives. (iv) Detail prevention strategies with named evidence (multi-element intervention; Safewards). (v) Describe post-return assessment and documentation priorities, including why off-ward suicide matters. (20 marks)

Open

Domain

Emergency psychiatry

7

Acute agitation and rapid tranquillisation ladder (MEQ)

A 34-year-old man with bipolar disorder is brought to ED after 48 hours of decreasing sleep and increasing irritability. He is pacing, shouting, refusing oral medication, and swinging at staff when approached. Capillary glucose 5.4 mmol per litre, SpO2 98 percent, HR 118, BP 156/94, temperature 37.2 C. ECG QTc is 430 ms. Collateral: he stopped lithium 3 weeks ago and may have used methamphetamine last night. A junior doctor wants to give IM olanzapine 10 mg immediately followed by IM lorazepam 2 mg in the same syringe. (i) Outline your immediate assessment and de-escalation priorities. (ii) Critique the proposed medication plan and provide a safer RT pathway with named doses, routes and monitoring. (iii) Explain how agent choice differs for primary mania versus stimulant SBD and for alcohol withdrawal. (iv) Address capacity and least-restrictive legal principles for treatment. (v) State post-event documentation and disposition considerations. (20 marks)

Open

Acute agitation and toxidrome emergency — assessment and management (MEQ)

A 31-year-old man with schizophrenia is brought to ED after 2 days of increasing paranoia. He is pacing, shouting, diaphoretic and threatening staff. Temperature 37.0 C, HR 110, BP 148/92, SpO2 98 percent, glucose 5.8 mmol per litre. He refuses oral medication. Collateral reveals he restarted olanzapine 20 mg daily 5 days ago after a 3-month gap; family also found empty packets of an SSRI belonging to his partner. Thirty minutes after IM olanzapine 10 mg he remains agitated; a junior doctor proposes immediate IM lorazepam 2 mg. Separately, nursing notes document intermittent ankle clonus. (i) Outline your immediate assessment priorities including safety and medical exclusion. (ii) Critique the proposed IM lorazepam and state a safer RT plan with named doses and monitoring. (iii) Construct a differential for his presentation including toxidromes with discriminators. (iv) Outline capacity and least-restrictive legal principles for treatment. (v) State your disposition algorithm once he is calmer. (20 marks)

Open

Acute behavioural disturbance and contested excited delirium (MEQ)

A 31-year-old man is brought by police after a 20-minute struggle in hot weather. Collateral suggests possible methamphetamine use. He is continuously thrashing, diaphoretic, HR 140, SpO2 96 percent on air, temperature 39.4 C, capillary glucose 6.1 mmol per litre. Staff are holding him prone. A registrar writes 'excited delirium' in the notes and proposes IM olanzapine 10 mg plus IM midazolam 5 mg together. (i) Critique the terminology and documentation plan. (ii) Outline immediate medical priorities including restraint positioning. (iii) Provide a safer parenteral sedation pathway with named doses, routes, monitoring and rescue options. (iv) List key investigations and differential drivers. (v) Address capacity, least-restrictive legal principles, and disposition. (20 marks)

Open

Deliberate self-poisoning with mixed psychotropics (MEQ)

A 41-year-old man with bipolar disorder is brought to ED 45 minutes after taking approximately 30 amitriptyline 50 mg tablets, an unknown number of diazepam tablets, and possibly paracetamol. GCS 11, HR 122, BP 90/58, SpO2 94% on oxygen. Pupils mid-size. ECG QRS 130 ms. His partner says he has been stockpiling medicines after a relationship breakdown. (i) Outline immediate resuscitation priorities and key investigations. (ii) Explain the mechanism and specific treatment of TCA cardiotoxicity including named therapy. (iii) State decontamination decisions and flumazenil policy in this case. (iv) Address paracetamol risk. (v) After medical stabilisation, outline psychiatric risk assessment and means-restriction plan. (20 marks)

Open

Lithium toxicity — acute-on-chronic emergency (MEQ)

A 62-year-old man with bipolar I disorder has taken lithium carbonate 900 mg at night for 12 years. Baseline troughs were 0.7–0.8 mmol/L. Three weeks ago his GP started ibuprofen for knee pain and increased ramipril. After two days of vomiting and poor oral intake he presents with coarse tremor, ataxia, dysarthria and fluctuating confusion. HR 92, BP 108/70, dry mucous membranes, SpO2 98 percent, temperature 36.9 C. Capillary glucose 5.8 mmol/L. ECG shows T-wave flattening. Serum lithium 2.6 mmol/L; creatinine 180 micromol/L (baseline 95); sodium 133 mmol/L. (i) Classify the toxicity pattern and explain the mechanisms linking his precipitants to the level. (ii) Outline immediate management including investigations and supportive care with named fluid strategy principles. (iii) Apply EXTRIP recommendations to decide on extracorporeal treatment and state preferred modality plus post-treatment monitoring. (iv) Discuss differentials you must not miss. (v) After recovery, outline prevention, monitoring, and the lithium restart decision. (20 marks)

Open

Neuroleptic malignant syndrome diagnosis and management (MEQ)

A 41-year-old man with schizophrenia is day 4 of an inpatient admission for relapse. Olanzapine was increased to 20 mg and he received two doses of IM haloperidol 5 mg for agitation. Over 36 hours he becomes diaphoretic, mute, and rigid. Temperature is 38.9 C then 39.4 C; HR 128 (baseline 78); RR 28 (baseline 14); BP fluctuates from 95/55 to 168/102. CK is 1,860 U/L (ULN 200). Reflexes are reduced. There is no clonus. He is not on serotonergic drugs. (i) Apply international consensus diagnostic thinking and state the working diagnosis with key discriminators from serotonin toxicity and malignant catatonia. (ii) Outline immediate management including what must be stopped. (iii) Discuss the evidence status of bromocriptine, dantrolene, and ECT. (iv) Explain a safe later antipsychotic rechallenge plan if ongoing treatment is essential. (20 marks)

Open

Serotonin toxicity recognition and management (MEQ)

A 38-year-old woman with major depression has taken phenelzine 45 mg daily for nine months. Three hours after receiving tramadol 100 mg for acute back pain she becomes agitated, diaphoretic, and tremulous. HR 132, BP 168/98, temperature 38.6 C, SpO2 97 percent. Pupils dilated. Ankle clonus is inducible bilaterally with lower-limb hyperreflexia. Bowel sounds are hyperactive. She is confused but protecting her airway. A junior doctor suggests bromocriptine for neuroleptic malignant syndrome and wants to continue her evening phenelzine. (i) State your working diagnosis and apply diagnostic criteria. (ii) Outline immediate management including named drug doses where relevant. (iii) Explain why this is not NMS and what must not be given. (iv) List high-risk drug combinations relevant to psychiatry practice. (v) Address disposition and restart planning for antidepressants. (20 marks)

Open

Domain

Addiction psychiatry

6

Addiction in older adults — late-onset alcohol and long-term benzodiazepine (MEQ)

A 71-year-old woman is brought by her daughter after a fall. She has drunk half a bottle of wine most nights since her husband died 18 months ago, and has taken nitrazepam 5–10 mg at night for 9 years. She minimises both. Mini-Cog is borderline; GGT is raised; she has passive death wishes without a plan. She wants 'nothing changed' before her granddaughter's wedding next month. (i) Formulate early- vs late-onset and iatrogenic contributors and explain age-related vulnerability. (ii) Outline assessment including screens, risk (falls, suicide, capacity), and key investigations. (iii) Describe acute safety and withdrawal management principles. (iv) Construct a stepped definitive plan including SBIRT/psychosocial care, alcohol pharmacotherapy options with doses, and benzodiazepine deprescribing evidence. (v) Address prognosis and disposition. (20 marks)

Open

Alcohol use disorder — detox, Wernicke, and relapse prevention (MEQ)

A 51-year-old man with twenty years of heavy daily drinking is admitted after a fall. Last drink was 18 hours ago. He is tremulous, sweaty, HR 118, BP 162/96, oriented to person but not time. AUDIT is high. He has poor nutrition, horizontal nystagmus, and a wide-based gait. He asks for 'something to stop the shakes' and says he will discharge against advice tonight to drink. (i) State DSM-5-TR severity logic if he meets seven criteria and contrast with ICD-11 dependence language. (ii) Outline immediate assessment including named withdrawal scale and risk domains. (iii) Manage acute withdrawal and suspected Wernicke with named drug doses/routes where standard teaching applies. (iv) Plan post-detox pharmacotherapy options with doses and key contraindications. (v) Address psychosocial care, dual diagnosis screening, and disposition. (20 marks)

Open

Alcohol withdrawal and delirium tremens — CIWA, seizures, DT, thiamine (MEQ)

A 52-year-old man with long-standing heavy daily drinking is brought to ED after a witnessed generalised tonic-clonic seizure. Last drink was about 20 hours ago. He is post-ictal then becomes tremulous, sweaty, HR 120, BP 168/98. He has poor dentition and nutrition. There is no known epilepsy. (i) Map the expected clinical timeline of alcohol withdrawal and place this presentation on it. (ii) Outline bedside assessment including named scales and key investigations. (iii) Give an acute management plan with named benzodiazepine strategy, seizure care, and thiamine regimen with doses/routes where standard teaching applies. (iv) List criteria that would mandate inpatient rather than ambulatory detox. (v) State three exam pitfalls that worsen outcome. (20 marks)

Open

Alcohol-related brain injury and Korsakoff — Wernicke emergency to long-term care (MEQ)

A 54-year-old man with twenty-five years of heavy drinking is brought from a hostel. He is thin, has horizontal nystagmus and gait ataxia, and is intermittently disoriented. Last drink was about 30 hours ago; he is tremulous and sweaty. CT head is reported normal. Nursing staff ask whether oral thiamine tablets are enough and whether he has Alzheimer disease because he invents answers about breakfast. (i) Define ARBI, Wernicke encephalopathy, and Korsakoff syndrome and state how they relate. (ii) Apply Caine criteria to this case and list key differentials including coexistent withdrawal. (iii) Detail acute thiamine and supportive management with named doses/routes and regional teaching points. (iv) Outline investigation strategy including MRI role and limitations. (v) Plan long-term care, capacity, and disposition once medically stable. (20 marks)

Open

Anti-craving pharmacotherapy — agent selection, COMBINE, and safety (MEQ)

A 48-year-old man with severe alcohol use disorder finishes inpatient detox. Last drink was five days ago. He is oriented, CIWA-Ar is low, and he wants medicines 'so I do not go back to binge Fridays'. History includes prior rib fractures treated with oxycodone (finished two weeks ago), GGT 110, ALT 48, eGFR 88 mL/min, no known heart disease. He lives with a supportive partner who can supervise tablets. He declines mutual aid but will attend CBT. (i) Define the phase-of-care distinction between detox and anti-craving pharmacotherapy. (ii) Propose a first-line regimen with dose, route, monitoring, and hard contraindications you have excluded. (iii) Outline acamprosate and disulfiram as alternatives with doses and selection rules. (iv) Interpret COMBINE for the examiner. (v) Build a psychosocial and disposition plan. (20 marks)

Open

Benzodiazepine dependence — structured taper after withdrawal seizure (MEQ)

A 45-year-old man has used alprazolam up to 6 mg daily (prescribed 2 mg daily plus illicit top-ups) for three years. He also drinks a bottle of wine most evenings. After two days without alprazolam he has a generalised seizure at home. In ED he is post-ictal then recovers; CT head is normal; blood alcohol is low; electrolytes normal. He wants to 'never take benzos again starting today' and asks for something 'non-addictive like zolpidem' for sleep. (i) Explain the neurobiology of his seizure risk and why abrupt cessation is unsafe. (ii) Outline immediate and short-term medical management including principles of benzodiazepine reinstatement and alcohol assessment. (iii) Design a stepwise outpatient or inpatient taper plan including diazepam substitution rationale, approximate pace, and monitoring. (iv) Address Z-drugs, elderly-type harms if relevant later, and psychosocial/deprescribing supports with named evidence. (v) Discuss opioid co-use counselling even though he is not currently on opioids. (20 marks)

Open

Domain

Child and adolescent psychiatry — neurodevelopmental

3

ADHD across the lifespan — assessment and multimodal management (MEQ)

A 10-year-old boy is referred by his school with incomplete work, impulsive calling out, and playground risk-taking. Parents report similar difficulties since early primary school at home and with grandparents. Teacher Conners and parent scales are elevated. He has no known cardiac disease. There is a family history of ADHD in his father. He has mild oppositional behaviour but no clear manic episodes. He is beginning to experiment with his older brother's energy drinks. (i) Outline assessment priorities including multi-informant evidence, differentials and baseline work-up before medication. (ii) State working diagnosis and key discriminators from anxiety, learning disorder and bipolar spectrum. (iii) Outline a multimodal plan including a named first-line stimulant approach with monitoring, and an alternative non-stimulant with approximate dosing framework. (iv) Explain how MTA findings inform the relative roles of medication and behavioural treatment. (v) List counselling points on substance risk and, looking ahead, driving. (20 marks)

Open

Autism spectrum disorder — assessment to irritability management (MEQ)

A 7-year-old boy with longstanding social-communication difficulties, intense interest in train timetables, and distress at minor routine changes is brought after 3 months of daily aggression and self-hitting causing bruising. School describes meltdowns when plans change. Hearing was normal at age 3; no seizures. He meets clinical criteria for ASD. (i) State the DSM-5-TR structure required for ASD and how severity is rated. (ii) Outline key differentials from ADHD, intellectual disability, social anxiety and social (pragmatic) communication disorder with discriminators. (iii) Describe the non-pharmacological package and name at least two landmark intervention trials. (iv) Indicate when risperidone or aripiprazole would be considered, with a named starting approach, monitoring and an evidence landmark for each class of agent. (v) List capacity/transition issues you would anticipate for later adolescence. (20 marks)

Open

Language and communication disorders — DLD, SPCD and SLT-first care (MEQ)

A 6-year-old boy is referred for 'ADHD and oppositional behaviour'. Teachers say he does not follow instructions, disrupts the class when frustrated, and has poor reading. Parents report late first words, short sentences, and that he 'only understands if we show him'. Hearing has never been tested. He is bilingual (English and home language). There are no restricted/repetitive behaviours. He has sound/syllable repetitions when excited. (i) Map the differential across speech, language and social communication and state the most likely primary developmental formulation. (ii) Outline assessment priorities including investigations and who should assess. (iii) Present a management plan including first-line therapy evidence, school accommodations, and the approach to possible stuttering. (iv) Explain how behavioural problems relate to language impairment with named evidence. (v) Address bilingualism and the ASD/SPCD trap. (20 marks)

Open

Domain

General adult psychiatry — trauma and stressor-related

2

Adjustment disorders — diagnosis, risk and stepped care (MEQ)

A 41-year-old project manager is referred 8 weeks after compulsory redundancy. She describes tearfulness, anxiety about finances, initial insomnia and reduced socialising. She denies pervasive anhedonia or worthlessness most of the day. PHQ-9 is 9; GAD-7 is 11. She has intermittent passive thoughts that 'my family would be better without my stress' without plan or intent. She drinks three glasses of wine most evenings since the redundancy. No Criterion A trauma. TSH last year normal. (i) Outline diagnostic formulation including DSM timing rules and key differentials with discriminators. (ii) Detail risk assessment priorities and why the AD label does not lower risk standards. (iii) Outline a stepped management plan including watchful waiting criteria, brief psychological ingredients, and when you would name an antidepressant with dose and monitoring. (iv) Discuss occupational/return-to-work principles. (v) State ICD-11 contrast points examiners may ask. (20 marks)

Open

Grief and prolonged grief disorder — criteria, differential and CGT plan (MEQ)

A 54-year-old man is referred 16 months after his adult daughter's death in a road traffic collision. He describes daily intense yearning, sets a place at the table for her, avoids the stretch of road and all photographs, feels 'half of me died', and has stopped seeing friends. He works part-time but is underperforming. He denies pervasive anhedonia for activities unrelated to her memory and denies worthlessness about unrelated matters. PHQ-9 is 11. He has intermittent thoughts that he 'might as well be with her' without plan or intent. He drinks four beers most evenings. No prior psychiatric admissions. (i) Formulate using DSM-5-TR PGD criteria and state the ICD-11 duration contrast. (ii) Discriminate from normal grief and from major depression with clear discriminators. (iii) Detail risk assessment priorities including reunion ideation. (iv) Outline a first-line psychological treatment plan with named CGT/CBT ingredients and when you would add an antidepressant with dose and monitoring. (v) Address cultural and alcohol factors in the plan. (20 marks)

Open

Domain

Child and adolescent psychiatry — eating disorders

1

Adolescent anorexia nervosa — medical risk, FBT and refeeding (MEQ)

A 15-year-old girl is brought by parents after fainting at school. She has lost 12 kg in 5 months, exercises 2 hours daily, and restricts to under 800 kcal by parent estimate. BMI is on the 8th centile. Resting HR 42, postural systolic drop 20 mmHg, temperature 35.6°C, K 3.3 mmol/L, phosphate normal today. She says she is 'fine' and refuses hospital. Parents are exhausted and blame themselves. (i) Define AN (DSM-5) and list key differentials. (ii) Outline medical risk assessment and admission rationale. (iii) Describe refeeding principles including refeeding syndrome prevention and StRONG takeaway. (iv) Explain FBT phases to the parents (exam standard). (v) State the role (and non-role) of SSRIs and legal/capacity principles if she refuses life-saving treatment. (20 marks)

Open

Domain

Specialty psychiatry — sleep medicine interface

6

Adolescent delayed sleep-wake phase with school failure (MEQ)

A 16-year-old with possible ADHD traits has not attended school for 6 weeks. He falls asleep around 03:30, wakes at 12:30 if left alone, and feels refreshed. Forced 07:00 rises produce profound sleepiness, irritability, and late arrivals. Parents call him lazy. He uses a phone in bed until 02:00. No elevated mood, no snoring history, BMI normal. (i) Formulate diagnosis and key differentials. (ii) Outline assessment including tools. (iii) Explain two-process and PRC mechanisms relevant to treatment. (iv) Propose a timed light/melatonin/schedule plan with evidence anchors. (v) Address school liaison, ADHD interface, and pitfalls. (20 marks)

Open

Chronic insomnia disorder with residual depression and long-term Z-drug use (MEQ)

A 46-year-old woman with recurrent MDD reports 5 years of sleep-onset and maintenance insomnia (≥4 nights/week), ISI in the moderate–severe range, and daytime fatigue without true sleepiness. She drinks one to two glasses of wine most nights 'to switch off,' has used zopiclone most nights for 20 months, and has residual PHQ-9 of 13 after two antidepressant trials. BMI 33 kg/m²; partner reports loud snoring. She drives and had one near-miss after nodding at traffic lights. (i) Formulate diagnoses and key differentials. (ii) Outline assessment and investigations. (iii) Propose stepped non-drug and drug management including CBT-I and hypnotic deprescribing. (iv) Address OSA and occupational risk. (v) Link insomnia to depression and suicide risk with evidence. (20 marks)

Open

Chronic insomnia with depression and hypnotic dependence (MEQ)

A 48-year-old woman with recurrent MDD reports 4 years of sleep-onset and maintenance insomnia (≥5 nights/week), ISI in the moderate–severe range, and daytime fatigue. She drinks two glasses of wine most nights 'to switch off,' uses zopiclone most nights for 18 months, and has had three antidepressant trials with residual insomnia. BMI 34 kg/m²; partner reports loud snoring. PHQ-9 remains 14. She drives a forklift and had one near-miss after nodding off at work. (i) Formulate the sleep diagnoses and key differentials. (ii) Outline assessment and investigations. (iii) Propose a stepped non-drug and drug plan including CBT-I and hypnotic deprescribing. (iv) Address OSA and occupational risk. (v) Link insomnia to depression/suicide risk with evidence. (20 marks)

Open

Restless legs syndrome with SSRI-associated worsening and low-normal ferritin (MEQ)

A 39-year-old woman with recurrent MDD reports 18 months of evening leg crawling and irresistible urge to move that worsens when sitting and is relieved by walking. Symptoms begin earlier and more intensely after escitalopram was increased 8 weeks ago. She uses zopiclone most nights. Morning ferritin is 62 ng/mL; haemoglobin normal. BMI 24; no snoring. Partner reports occasional leg kicks in sleep. (i) Diagnose and differentiate key mimics. (ii) Explain pathophysiology relevant to iron and antidepressants. (iii) Outline investigations and non-drug plan. (iv) Propose stepped pharmacologic management including augmentation prevention. (v) Address mood treatment interactions. (20 marks)

Open

Suspected narcolepsy type 1 with near-miss driving and cataplexy (MEQ)

A 24-year-old university student is referred from student health with 'treatment-resistant depression and laziness.' For 3 years she has had irresistible daytime sleep attacks, automatic behaviour in lectures, and bilateral knee buckling with laughter while remaining aware. She describes dream-like images as she falls asleep and occasional sleep paralysis. She sleeps 8–9 hours yet wakes unrefreshed. BMI 23 kg/m²; no snoring. Two near-miss driving events occurred this semester. Sertraline 100 mg daily for 6 months helped mood slightly but sleepiness persists. (i) Formulate diagnoses and key differentials. (ii) Outline assessment and investigations including MSLT preconditions. (iii) Propose non-drug and drug management for EDS and cataplexy with monitoring. (iv) Address driving/occupational risk and psychiatry interface. (v) Explain NT1 pathophysiology with evidence. (20 marks)

Open

Treatment-resistant depression with probable OSA (MEQ)

A 55-year-old man with recurrent MDD has had four antidepressant trials (two SSRIs, venlafaxine, mirtazapine) with residual PHQ-9 of 16. He sleeps 8–9 hours but wakes unrefreshed. BMI 37 kg/m², neck circumference large, blood pressure 158/96 mmHg on two agents. Partner reports loud snoring and breathing pauses. He uses temazepam 20 mg most nights for 2 years and drinks three beers most evenings. He drives a delivery van and has had two near-miss microsleep episodes. (i) Formulate diagnoses and mechanisms linking OSA and mood. (ii) Outline assessment and investigations. (iii) Give a definitive management plan including PAP, lifestyle, psychotropics, and deprescribing. (iv) Address occupational/driving risk and evidence caveats (SAVE). (v) State special monitoring when SGAs or sedatives are considered. (20 marks)

Open

Domain

foundations — advanced EBM and evidence synthesis

1

Advanced appraisal of a psychiatry meta-analysis and non-inferiority claim (MEQ)

You are the registrar preparing a FRANZCP/MRCPsych-style advanced critical appraisal station. Materials: (A) Random-effects meta-analysis of SSRI X versus placebo for major depression (12 RCTs, n=3,200). Pooled RR for response 0.80 (95% CI 0.72–0.89), I-squared 68%, tau-squared elevated, 95% prediction interval 0.55–1.16. Funnel plot asymmetric (Egger p=0.04). Several included trials had unclear allocation concealment and unblinded outcome raters. (B) Separate industry press release claims a new LAI antipsychotic is 'non-inferior' to oral risperidone based on a superiority RCT whose 95% CI for relapse difference was −4% to +11% (no pre-specified non-inferiority margin). (i) Interpret the forest-plot diamond versus the prediction interval and the I-squared for panel A. (ii) List GRADE downgrade domains you would apply and propose a certainty rating with justification. (iii) Explain what absolute numbers you need before counselling a patient using NNT language. (iv) Appraise the non-inferiority claim in panel B. (v) Give a one-paragraph applicability conclusion for an older adult with multimorbidity excluded from most of the SSRI trials. (25 marks)

Open

Domain

Old age psychiatry — Alzheimer disease

1

Alzheimer disease — diagnosis, enhancers, and BPSD care (MEQ)

A 78-year-old woman is referred with two years of progressive short-term memory loss, repeated questions, word-finding difficulty, and declining ability to manage medications and finances. She still dresses and feeds herself. Collateral confirms insidious onset without stepwise strokes. MoCA is 18/30 with impaired delayed recall. She is bradycardic at 52 bpm on a beta-blocker. Her daughter reports new evening irritability and night-time wandering. (i) Apply NIA-AA probable/possible AD criteria and state your working diagnosis including severity framing. (ii) Outline investigation priorities including why biomarkers need careful framing. (iii) Propose a cognitive pharmacotherapy plan with named agents, doses, titration, and monitoring, incorporating cardiac caution. (iv) Outline BPSD assessment using a structured non-drug-first approach and antipsychotic caveats. (v) Address capacity, driving, and care planning. (20 marks)

Open

Domain

Specialty psychiatry — eating disorders

1

Anorexia nervosa — medical risk, refeeding, and stepped care (MEQ)

A 17-year-old girl is brought by parents after collapsing at ballet class. BMI is 14.8 kg/m² (down from 19 over 8 months). Resting HR 42 bpm, BP 88/58 mmHg, temperature 35.4°C. She restricts to under 400 kcal/day, runs 15 km daily, and insists she is 'fine' and 'not thin enough.' Phosphate is at the lower limit of normal before any hospital food. Parents have been 'not wanting to fight at dinner.' (i) State DSM-5-TR diagnosis with subtype and severity band and key differentials. (ii) Outline immediate medical risk assessment and investigations. (iii) Explain refeeding syndrome risk and a safe refeeding monitoring plan. (iv) Propose psychological treatment once medically appropriate. (v) Discuss capacity and when compulsory treatment might be considered. (20 marks)

Open

Domain

General adult psychiatry — personality disorders

10

Antisocial personality disorder — dual diagnosis crisis and risk (MEQ)

A 29-year-old man is brought to ED after threatening to 'finish' his ex-partner. He has prior assault convictions, childhood conduct problems (fighting, theft, truancy before age 15), repeated deceit at work, reckless driving, and remorseless accounts of harming others. He uses methamphetamine most days and drinks heavily. He is not psychotic. Observations are stable after medical clearance. (i) State working diagnosis with DSM operational requirements. (ii) Distinguish ASPD from psychopathy and from BPD with discriminators. (iii) Outline a structured violence risk formulation (static, dynamic, protective). (iv) Immediate multi-agency management priorities including partner safety. (v) Medium-term treatment plan including evidence limits for ASPD-specific therapy, substance treatment, and one named comorbid prescribing scenario with monitoring. (20 marks)

Open

Avoidant personality disorder — criteria, differentials and stepped care (MEQ)

A 28-year-old software engineer is referred for 'social phobia and possible personality issues.' Since adolescence he has avoided meetings, refused promotion that would require presenting, and delayed dating because he is 'sure people will find me awkward and reject me.' He wants friends but has only online contacts. He drinks four standard drinks before rare work social events. After a critical email from his manager he took an impulsive overdose of 12 ibuprofen tablets, then called a friend. He scores high on social anxiety screens; developmental history does not suggest autism spectrum disorder. (i) State working diagnosis with operational criteria and justify dual diagnosis decisions. (ii) List key differentials with discriminators. (iii) Outline risk assessment priorities after the overdose. (iv) Propose a medium-term psychological treatment plan with named ingredients. (v) State principles of pharmacotherapy with one named agent, dose, route, monitoring and review. (20 marks)

Open

Borderline personality disorder — crisis assessment and stepped management (MEQ)

A 26-year-old woman is brought to ED after taking 20 sertraline tablets and cutting her forearms following a relationship breakup. She has a 6-year history of recurrent self-harm, unstable relationships, identity disturbance, intense anger, and chronic emptiness. She describes mood swings lasting hours. She drinks heavily when distressed. She denies current intent to die but says 'I want the pain to stop.' Observations are stable after medical clearance. (i) Outline your risk assessment priorities specific to BPD. (ii) State working diagnosis and key differentials with discriminators. (iii) Outline immediate crisis management and disposition options. (iv) Propose a medium-term treatment plan including a named psychotherapy model with structure. (v) State principles of pharmacotherapy and one named medication scenario with monitoring/review. (20 marks)

Open

Cluster A and C personality — differentials and stepped management (MEQ)

A 31-year-old software engineer is referred after prolonged sick leave. He avoids meetings, believes colleagues will humiliate him if he speaks, feels socially inept, and has only one distant friend. He wants a relationship but has never dated for fear of rejection. He denies magical thinking, hearing voices, or desire to be alone for its own sake. He spends hours rewriting emails for perfect wording. Collateral from his sister: shy since school, no early language delay, no frank psychosis. (i) List working diagnosis and key differentials with discriminators. (ii) Outline assessment priorities including risk. (iii) Propose a psychological treatment plan with a named model and structure. (iv) State principles of pharmacotherapy with one named scenario (agent, route, monitoring). (v) Note ICD-11 dimensional framing in one sentence. (20 marks)

Open

Dependent personality disorder — criteria, risk and stepped care (MEQ)

A 29-year-old woman is referred after her partner of eight years left. Since adolescence she has needed others to make major decisions (housing, finances, medical appointments), struggles to disagree for fear of losing support, feels helpless when alone, and moved in with a new acquaintance within two weeks of the breakup 'so I am not left to cope alone.' She has major depressive symptoms and intermittent passive suicidal ideation without plan. She volunteers that her previous partner controlled her bank card and she 'went along with it to keep him.' Developmental history suggests overprotective parenting without autism spectrum features. (i) State working diagnosis with operational criteria and justify dual diagnosis decisions. (ii) List key differentials with discriminators. (iii) Outline risk and safeguarding priorities after the separation. (iv) Propose a medium-term psychological treatment plan with named ingredients. (v) State principles of pharmacotherapy with one named agent, dose, route, monitoring and review. (20 marks)

Open

Histrionic personality disorder — criteria, differentials and frame-based care (MEQ)

A 29-year-old woman is referred after a low-lethality overdose of 16 paracetamol tablets following a partner saying he needs 'space.' Since late adolescence she has formed intense relationships within days, becomes distraught if not the centre of social attention, and describes emotions that 'change like weather.' Ward staff report flirtatious behaviour with a junior doctor and rage when nursing attention is shared. She denies reduced sleep need or sustained elevated mood. Collateral confirms a longstanding pattern without clear conduct-disorder history. (i) State working diagnosis with operational criteria and justify whether dual diagnosis is needed. (ii) List key differentials with discriminators. (iii) Outline risk assessment priorities after the overdose. (iv) Propose a medium-term psychological treatment plan including frame and named evidence anchors. (v) State principles of pharmacotherapy with one named agent, dose, route, monitoring and review. (20 marks)

Open

ICD-11 dimensional personality disorder — diagnostic formulation and stepped care (MEQ)

A 27-year-old man is referred after a third ED presentation in 4 months with self-cutting and alcohol bingeing after relationship conflict. He has a 10-year history of intense unstable relationships, chronic emptiness, identity disturbance, impulsive spending, and rage. Mood shifts last hours to 1–2 days. There is no clear period of elevated mood with reduced sleep need lasting ≥4 days. He works intermittently. Collateral from his sister confirms lifelong interpersonal chaos from late adolescence. (i) Formulate an ICD-11 personality disorder diagnosis including severity, likely trait domains, and whether borderline pattern applies. (ii) List key differentials with discriminators. (iii) Outline assessment priorities including risk. (iv) Propose a stepped management plan linking severity to care intensity, naming one evidence-based psychotherapy structure. (v) State principles of pharmacotherapy with one concrete comorbidity scenario. (20 marks)

Open

Narcissistic and Cluster B spectrum — crisis, formulation and management limits (MEQ)

A 38-year-old company director is brought to ED after taking an overdose of his partner's quetiapine following a public fraud investigation that went viral on social media. He is medically cleared. On interview he oscillates between contempt for 'incompetent' doctors and tearful statements that he cannot live with the humiliation. Collateral from his partner describes years of entitlement, exploitation of staff, rage at criticism, and intermittent cold withdrawal with envy. There is no childhood conduct disorder history and no frank criminal violence, but there is heavy weekend alcohol use. He demands a private room, a senior-only team, and 'something stronger than therapy.' (i) Formulate the personality pattern including grandiose/vulnerable poles and key differentials. (ii) Outline risk assessment priorities after narcissistic injury. (iii) Describe countertransference risks and how you will protect the frame. (iv) Propose a medium-term management plan including a named psychotherapy approach and explicit pharmacotherapy limits. (v) State disposition options and what you will not do. (20 marks)

Open

Paranoid personality disorder — workplace grievance and risk (MEQ)

A 46-year-old man is referred by occupational health after repeated workplace complaints that colleagues are 'plotting to destroy' his reputation. For more than 15 years he has been reluctant to confide, bears long grudges, reads demeaning meanings into neutral emails, and has recurrent unjustified suspicions that his partner is unfaithful. He has never had hallucinations or formal thought disorder. He drinks heavily at weekends. He is not currently expressing a timed plan to harm a named person, but he says he will 'make them pay legally and otherwise' if pushed. (i) State working diagnosis with DSM operational requirements. (ii) Discriminate from delusional disorder and from schizotypal PD. (iii) Outline mechanisms including trauma/threat-bias framing. (iv) Immediate risk and engagement priorities. (v) Medium-term management including psychotherapy approach, comorbidity care, and one named prescribing scenario with monitoring if depression is confirmed. (20 marks)

Open

Schizotypal personality disorder — assessment and stepped management (MEQ)

A 27-year-old man is referred by his GP after losing his warehouse job. He has always been a loner with few friends, wears unusual layered clothing, and believes that newspaper headlines sometimes contain personal messages for him, though he agrees this 'might be my mind connecting things.' He describes brief feelings that strangers are talking about him, which ease if he leaves the shop. He has never had clear voices or fixed persecutory delusions lasting days. Over 4 months he has become more withdrawn, smokes cannabis nightly, and screens positive for depression. (i) State working diagnosis and key differentials with discriminators. (ii) Outline your assessment priorities including risk and conversion monitoring. (iii) Propose a medium-term psychosocial plan. (iv) State principles of pharmacotherapy with one named medication scenario including dose, route, monitoring, and review. (v) Outline disposition and when to involve early psychosis services. (20 marks)

Open

Domain

General adult psychiatry — feeding and eating disorders

2

ARFID — diagnosis, medical risk, and specialised treatment (MEQ)

A 15-year-old boy is referred after losing 8 kg over 5 months. He eats only three brands of dry crackers and plain pasta. He gags if foods touch on the plate. After choking on a chicken piece 6 months ago he also refuses all meat and most solids with mixed textures. BMI is 15.4 kg/m²; resting HR 48 bpm; sitting BP 92/58 mmHg. He says he is 'not trying to be thin' and becomes tearful when asked about body shape — he wants to gain weight for cricket but 'can't make himself eat other food.' Parents have stopped family meals out and cook only his accepted list. (i) State the preferred diagnosis with presentation formulation and key differentials. (ii) Outline immediate medical assessment and investigations. (iii) Explain refeeding considerations if admitted. (iv) Propose psychological and family treatment once medically appropriate. (v) Discuss autism screening and why medication is not first-line. (20 marks)

Open

Pica and rumination — medical risk, discrimination, and first-line treatment (MEQ)

A 19-year-old woman with mild intellectual disability is brought by her residential support worker. For 4 months she has been found eating flakes of old paint from a window sill and chewing ice constantly. Ferritin is 8 µg/L; Hb 98 g/L. Separately, a 28-year-old man is referred from gastroenterology after 2 years of 'refractory reflux.' He describes food effortlessly coming into his mouth within 15 minutes of meals; he often rechews and reswallows. He has no binge–purge intent and no fear of fatness. PPIs have not helped. BMI 20.4 kg/m². (i) State preferred diagnoses for each case with key differentials. (ii) Outline immediate medical assessment and investigations for the woman. (iii) Explain the mechanism and first-line behavioural treatment for the man. (iv) Discuss when baclofen might be considered, including a typical trial dose used in RCT evidence and monitoring. (v) Address environmental and behavioural management principles for pica in intellectual disability. (20 marks)

Open

Domain

Child and adolescent psychiatry — attachment disorders

1

Attachment disorders in children — RAD/DSED assessment and caregiving-first care (MEQ)

A 3-year-old girl is referred from an adoption clinic. She spent her first 18 months in an understaffed institution overseas, then had three short foster placements before a stable adoptive home for 9 months. Adoptive parents report she still greets strangers by climbing onto their laps and has twice tried to leave a supermarket with an unfamiliar adult. At home she is warmer than initially but still shows limited comfort-seeking when hurt. School nursery staff say she is 'indiscriminately affectionate.' Parents ask whether she has autism, whether they caused the problem, and whether holding therapy recommended online will help. (i) Discriminate RAD, DSED and insecure attachment style; state the insufficient-care criterion. (ii) Outline multi-source assessment including ASD/ADHD differentials and risk. (iii) Give a first-line management plan aligned with AACAP, including named carer-focused intervention concepts. (iv) Address coercive attachment therapies using APSAC principles. (v) Counsel prognosis including relative persistence of disinhibited features. (20 marks)

Open

Domain

Intellectual disability psychiatry — neurodevelopmental dual diagnosis

1

Autism and ID dual diagnosis — assessment to behaviour and epilepsy (MEQ)

A 10-year-old non-verbal boy with longstanding global developmental delay is referred for aggression and self-hitting. School reports limited peer reciprocity beyond what teachers expect for his developmental level, intense distress at timetable changes, and hand stereotypies. Hearing was normal at age 4. Parents mention brief staring spells. (i) Define dual diagnosis of ASD and ID and state the relative-to-developmental-level rule. (ii) Outline a dual-diagnosis assessment including communication/AAC. (iii) Explain the epilepsy interface and what you would investigate. (iv) Formulate challenging behaviour and non-drug management priorities. (v) Indicate when risperidone or aripiprazole might be considered, with starting approach, monitoring, and why Tyrer 2008 matters for adult ID practice. (20 marks)

Open

Domain

Consultation-liaison psychiatry

16

Autoimmune encephalitis presenting as first-episode psychosis (MEQ)

A 22-year-old university student is brought to ED after 12 days of progressive insomnia, persecutory delusions, and agitation following a brief flu-like illness. On day 3 of the psychiatry ward stay she becomes nearly mute with repetitive orofacial movements; temperature is 37.6 C; sodium is normal. IM olanzapine has been given twice with little benefit. MRI brain overnight is reported as normal. Staff ask you to 'just increase the antipsychotic' and consider depot. (i) List red flags and state the leading organic differential with key discriminators from primary FEP. (ii) Outline a complete investigation plan including what not to rely on alone. (iii) Describe first-line and second-line immunotherapy principles and the role of tumour search. (iv) Explain your approach to symptomatic psychotropics, capacity/legal principles, and communication with family. (20 marks)

Open

Cardiac psychiatry — post-ACS depression, trials, safety (MEQ)

A 64-year-old man is 10 days after NSTEMI treated with stents. He is on dual antiplatelet therapy, a beta-blocker, ACE inhibitor, and statin. Ward staff report tearfulness, anhedonia, early waking, and passive suicidal ideation; he has refused cardiac rehab, saying 'the next one will kill me anyway.' A junior doctor wants amitriptyline 'because it helps sleep' and to stop the beta-blocker 'which always causes depression.' Another junior asks whether starting an SSRI will prevent reinfarction based on 'the big American trial.' (i) Formulate the psychiatric issues and prognosis framing. (ii) Outline assessment and investigations relevant to psychotropic start. (iii) Give an evidence-informed treatment plan with named agents/doses, trial literacy (SADHART, ENRICHD, CREATE), and rehab/collaborative care. (iv) Address the beta-blocker request, suicide risk, and disposition. (20 marks)

Open

Delirium diagnosis, work-up, and management (MEQ)

A 79-year-old woman with mild Alzheimer disease is day 3 of a medical admission for community-acquired pneumonia. Overnight she was agitated and tried to leave the ward; this morning she is quiet, eyes closed, and answers only after long delays. She fails months-of-the-year backward. Collateral confirms she was conversant at baseline last week. Medications include oxybutynin, temazepam PRN, and oxycodone. Staff request 'something strong for psychosis' and plan self-discharge paperwork because she said 'yes' to going home. (i) State the working diagnosis with CAM reasoning and motor subtype. (ii) Outline precipitants and an immediate work-up and non-drug plan. (iii) Discuss the evidence-based role and limits of antipsychotics, with example cautious dosing if used for safety. (iv) Address capacity and disposition. (20 marks)

Open

Dementia and major NCD — assessment, BPSD, and pharmacotherapy (MEQ)

An 78-year-old woman is referred from the medical ward. She has a two-year history of progressive forgetfulness and now needs help with shopping and medications. Three days after a UTI she became more confused, pulled out her IV, and struck a nurse. Staff request 'regular olanzapine and a depot'. Collateral reveals dream-enactment behaviour for years, fluctuating alertness, and well-formed visions of children in the room even before this admission. MoCA is 18/30 with marked attentional and visuospatial errors. She is not on cognitive enhancers. (i) Formulate the neurocognitive diagnosis and acute problem, with key discriminators. (ii) Outline immediate management of agitation including what not to do. (iii) Discuss longer-term cognitive and BPSD pharmacotherapy with named evidence and doses where appropriate. (iv) Outline how you would assess capacity for discharge destination decisions. (20 marks)

Open

Demoralisation vs adjustment vs MDD in medical illness (MEQ)

A 62-year-old woman with progressive heart failure is referred to C-L psychiatry. For 8 weeks since a bad-news clinic she has said life feels pointless, she feels trapped and unable to cope, and she sometimes wishes death would come sooner. She still brightens briefly with her daughter's visits. Sleep is broken by orthopnoea. PHQ-9 is 12 with mixed somatic items. She does not have pervasive anhedonia or marked worthlessness. Nursing staff ask for 'an antidepressant and something to sleep.' (i) Formulate demoralisation, adjustment disorder, and MDD with discriminators. (ii) Outline assessment including risk/DHD and measurement options. (iii) Give a management plan including named therapies and when (not) to use antidepressants, with example dosing if MDD evolves. (iv) Address liaison and disposition. (20 marks)

Open

Endocrine psychiatry: thyroid, Cushing, Addison, and steroids (MEQ)

A 46-year-old woman is referred from endocrinology and the medical ward. Six months of progressive depression, irritability, poor concentration, central weight gain, and new diabetes led to a diagnosis of Cushing disease; she has passive death wishes. Separately, her sister (age 41) was admitted last year with Graves thyrotoxicosis mislabelled as panic disorder until TSH was checked. A third relative takes lithium and has never had thyroid tests. Overnight, a different patient on the ward — day 4 of high-dose dexamethasone — develops insomnia and grandiose delusions. (i) Map the psychiatric syndromes across thyroid excess/deficiency, Cushing, Addison/AI, and exogenous steroids with key discriminators. (ii) Outline acute and definitive management for the Cushing depression and the steroid psychosis cases, including doses where you use psychotropics. (iii) State investigation priorities and crisis red flags (including adrenal crisis principles). (iv) Advise on lithium–thyroid monitoring and prognosis after Cushing control. (20 marks)

Open

FND in the medical setting — C-L ward MEQ

You are the C-L psychiatry registrar. A 29-year-old woman is day 3 on a medical ward after an ED presentation with prolonged shaking and then left arm weakness. CT head was normal. Neurology finds positive Hoover's sign, give-way weakness, and tremor entrainment; they diagnose functional neurological disorder with mixed motor features. Overnight nursing notes call her 'attention-seeking'. She is terrified she has a brain tumour. The medical team asks psychiatry to 'take her because she is functional' and to approve discharge today without follow-up. (i) Define your diagnostic formulation using modern nosology and positive signs. (ii) Outline how you would explain the diagnosis at the bedside and repair pejorative language with staff. (iii) Give an acute-to-discharge C-L management plan including MDT roles and named evidence anchors (physio/psychology). (iv) List red flags and dual-pathology issues that would change your approach. (20 marks)

Open

HD depression, irritability, suicide risk, and VMAT2 interface (MEQ)

A 46-year-old woman with genetically confirmed Huntington disease (motor-manifest for 4 years) is referred to CL. She takes tetrabenazine 25 mg three times daily (recently increased) and no antidepressant. Her husband reports 6 months of short fuse, two episodes of throwing objects, tearfulness, early morning wakening, and statements that 'the children would be better without a cursed mother.' She denies feeling sad on direct enquiry but scores high on a depression scale; she sits for long periods unless prompted (possible apathy overlap). No fever; swallow is impaired but weight is stable. (i) Formulate the neuropsychiatric syndromes and key differentials including delirium and pure apathy. (ii) Outline suicide risk assessment and acute safety steps. (iii) Give a stepped management plan for depression and irritability including example drug starts/doses and non-drug measures, and address the tetrabenazine–mood interface. (iv) Disposition, genetics/family issues, and advance care planning points. (20 marks)

Open

Lupus psychosis and attribution in NPSLE (MEQ)

A 26-year-old woman with a 3-year history of SLE (prior arthritis and rash; on hydroxychloroquine and low-dose prednisolone) presents with 10 days of insomnia, persecutory delusions, and auditory hallucinations. Temperature is 37.4 C. There is mild proteinuria and low C3. Family insist this is 'ordinary schizophrenia' and want depot antipsychotic only. (i) List the ACR-relevant psychiatric syndromes and outline how you attribute this presentation to SLE versus alternatives. (ii) Detail investigation priorities including antibodies and infection exclusion. (iii) Describe mechanism-based definitive treatment principles (inflammatory vs thrombotic) and symptomatic psychotropic approach with one dose example. (iv) Explain communication with family and capacity/legal principles without inventing statute numbers. (20 marks)

Open

Mild cognitive impairment — diagnosis, conversion, and management (MEQ)

A 72-year-old retired teacher is referred to CL after an elective hip replacement. Nursing staff noted he needed more prompting with his medication chart than expected. Collateral from his wife: for 18 months he has repeated questions, forgotten recent conversations, and uses a notebook for appointments, but he still drives locally, pays bills (with her double-check), and cooks simple meals. MoCA on the ward day 2 is 22/30 with weak delayed recall; he is attentive and not fluctuating. He has hypertension, diet-controlled diabetes, and takes oxybutynin for urge incontinence. He asks for 'the Alzheimer tablet so it does not get worse'. (i) Formulate the neurocognitive diagnosis and key differentials. (ii) Outline your work-up and immediate medication review. (iii) Discuss conversion risk counselling including what not to promise. (iv) Outline evidence-based management, specifically addressing cholinesterase inhibitors with named evidence. (20 marks)

Open

MS depression, suicide risk, PBA, and steroid mania (MEQ)

A 34-year-old woman with relapsing-remitting MS for 6 years is referred to CL after an optic neuritis relapse treated with high-dose intravenous methylprednisolone. Three days later she is sleepless, irritable, and grandiosely planning a business she cannot fund. Two months earlier her partner reported brief episodes of uncontrollable crying lasting seconds without feeling sad, which staff labelled 'depression.' She now discloses passive death wishes, PHQ-9 is high, and she asks to stop her interferon because 'it makes me suicidal.' Cognition is subjectively slow; she fears job loss. (i) Formulate the neuropsychiatric syndromes and key differentials. (ii) Outline acute management of the steroid-associated affective/psychotic risk state and suicide assessment. (iii) Plan definitive care for depression and PBA with psychological and pharmacological options including access issues for dextromethorphan/quinidine. (iv) Advise on DMT mood concerns, cognition, and shared disposition. (20 marks)

Open

Perinatal psychiatry on the maternity ward: PPP, OCD, lithium, and disposition (MEQ)

You are the CL psychiatry registrar. Midwifery urgently pages you about a 29-year-old woman, day 3 after emergency caesarean for pre-eclampsia. Overnight she has had almost no sleep, is talking rapidly about the baby being 'switched,' and tried to leave the ward with the infant. Partner reports she stopped lithium at a positive pregnancy test after a previous postpartum manic episode two years ago. Separately, the woman next door is distressed by images of harming her baby but says she would never act and is checking constantly. (i) Differentiate postpartum psychosis from perinatal OCD and outline dual-risk priorities for the first patient. (ii) Acute medical and psychiatric management of suspected PPP including organic exclusion. (iii) Peripartum lithium counselling principles with reference to cardiac malformation evidence and peri-delivery logistics. (iv) Disposition options including mother-baby unit principles. (20 marks)

Open

Postictal psychosis and interictal depression after seizure cluster (MEQ)

A 41-year-old man with drug-resistant temporal lobe epilepsy is admitted after a cluster of four secondarily generalised seizures. On day 0 he is postictally confused for 2 hours then recovers orientation. On day 2 he becomes sleepless, declares he is a prophet, and assaults a nurse. He takes levetiracetam 1500 mg BD and carbamazepine. Collateral notes progressive low mood and NDDI-E score 18 over the past 3 months, never treated. (i) Differentiate postictal psychosis from postictal confusion and forced normalisation; state key risk issues. (ii) Outline acute management of the psychosis including investigations you would escalate. (iii) Present a plan for his interictal depression including screening interpretation, psychological and pharmacological options with a concrete SSRI start, and AED considerations. (iv) Address seizure-threshold psychopharmacology and discharge shared-care. (20 marks)

Open

SSD, illness anxiety, and chronic pain dual diagnosis (MEQ)

A 47-year-old woman is referred to C-L after a third medical admission this year for chest tightness, abdominal pain, and fatigue. Extensive cardiac, GI, and endocrine work-ups are unrevealing. She scores high on PHQ-15, meets criteria for major depression, catastrophises about undiagnosed cancer, and has been started on oxycodone PRN by multiple GPs. She becomes angry when a junior doctor says 'it is all psychological.' (i) Formulate DSM-5-TR diagnoses and discriminators from IAD, FND, factitious disorder, and malingering. (ii) Outline assessment priorities including scales and opioid risk. (iii) Present a stepped management plan with psychological evidence and cautious medication options (named agents/doses). (iv) Address the opioid interface and communication strategy. (20 marks)

Open

Stroke psychiatry — PSD, location myth, capacity (MEQ)

A 68-year-old woman is 6 weeks after left MCA ischaemic stroke with residual mild expressive aphasia and right hemiparesis. She is on aspirin and clopidogrel. Rehab staff report tearfulness, anhedonia, early waking, and passive suicidal ideation; she has stopped participating in physiotherapy. A junior doctor says depression is 'inevitable with a left frontal lesion' and asks for fluoxetine 'for the arm and the mood.' She wants to sign sale papers for her house this week so her son can 'take over.' (i) Formulate the psychiatric issues and correct the location claim. (ii) Outline assessment including aphasia and risk. (iii) Give an evidence-informed treatment plan with named agents/doses and trial literacy (prevention vs motor recovery). (iv) Address capacity for the house sale and disposition. (20 marks)

Open

TBI psychiatry — depression, aggression, capacity (MEQ)

A 46-year-old man is 5 months after moderate TBI (nadir GCS 11, PTA 6 days, bifrontal contusions). He has anhedonia, early waking, and passive suicidal ideation. On the rehab unit he has punched a wall twice when frustrated; staff want 'regular olanzapine'. His wife says he is disinhibited and 'not himself' but he scores 28/30 on a brief cognitive screen and wants to sign a complex business sale this week. (i) Formulate the psychiatric syndromes. (ii) Outline non-drug and drug management of depression and aggression with named evidence. (iii) Address capacity for the business sale. (iv) List disposition and risk priorities. (20 marks)

Open

Domain

Foundations — basic neuroscience for psychiatry

1

Basic neuroscience for psychiatry — MEQ

You are teaching a psychiatry registrar. (i) Outline the levels of explanation from synapse to large-scale network that are useful in clinical psychiatry and state how RDoC differs from DSM/ICD. (ii) Explain LTP in terms of NMDA coincidence detection and give one clinical learning implication. (iii) Map the four major dopamine pathways to clinical effects and summarise dopamine hypothesis version III. (iv) Contrast the roles and limits of structural MRI, fMRI BOLD, EEG, and PET occupancy in psychiatric practice. (v) Translate network or circuit concepts into formulation language for psychosis and for major depression, naming at least two landmark evidence anchors. (20 marks)

Open

Domain

Psychotherapy

9

Behavioural activation for major depression (MEQ)

A 38-year-old teacher with a 4-month major depressive episode has PHQ-9 of 18, anhedonia, and spends most evenings in bed 'waiting for motivation.' She declined long CBT waitlists. She drinks little alcohol, has no psychosis, and denies current suicidal intent but has passive death wishes when inactive. (i) Define BA and outline its maintaining model. (ii) Contrast BA with full cognitive therapy and with BATD. (iii) Describe assessment steps and a first two-session BA plan including TRAP/TRAC. (iv) Summarise landmark evidence (Jacobson, Dimidjian, Dobson, COBRA, meta-analyses/Cochrane). (v) State two situations where pure elective BA is deferred. (20 marks)

Open

Cognitive analytic therapy (MEQ)

You are a psychiatry registrar in a community service. A 29-year-old with recurrent interpersonal crises, identity instability, and cutting after perceived criticism is referred for 'CAT'. Your service can offer time-limited individual psychotherapy with CAT-trained supervision. (i) Define CAT and reciprocal role procedures. (ii) Name traps, dilemmas, and snags with one clinical example each relevant to this patient. (iii) Outline reformulation, recognition, revision, and ending tools (letter, map, goodbye). (iv) Summarise landmark evidence (include Chanen adolescent early intervention and Clarke adult PD RCT, plus one synthesis or acceptability paper). (v) State how CAT differs from CBT and MBT, and list two fidelity pitfalls. (20 marks)

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Mentalisation-based treatment (MEQ)

You are a psychiatry registrar in a community service. A 27-year-old woman with borderline personality disorder has recurrent cutting after perceived rejection, two low-lethality overdoses this year, and a pattern of demanding admission as the only proof that staff care. She asks specifically for 'MBT like Bateman'. Your service has structured case management and a general psychotherapy clinic, but no dual-format MBT programme. (i) Define mentalising and the three pre-mentalising modes with clinical examples. (ii) Outline the attachment-arousal model of mentalising collapse. (iii) Describe standard outpatient adult MBT structure and core therapist stance/techniques. (iv) Summarise landmark Bateman/Fonagy evidence including the 2009 SCM comparison and at least one extension (adolescent or ASPD). (v) Propose a stepped, safety-focused plan if full MBT is not available. (20 marks)

Open

MEQ: ACT formulation and plan for anxiety with control agenda

You are the psychiatry registrar in an outpatient clinic. A 29-year-old graduate student presents with 8 months of generalised anxiety and panic (GAD-7 = 16). They spend hours trying to 'get rid of anxious thoughts,' avoid seminars when chest tightness appears, and have dropped a research collaboration that mattered to them. They take escitalopram 10 mg daily for 5 weeks with partial benefit and ask for 'therapy that is not just challenging my thoughts on worksheets.' No mania; no psychosis; intermittent passive death wish without plan. (i) Define ACT and psychological flexibility; name the six hexaflex processes (5). (ii) Formulate this presentation using experiential avoidance and cognitive fusion; contrast one key difference from traditional CBT (5). (iii) Outline a structured ACT treatment sequence and one concrete first homework (5). (iv) Discuss combining ACT with antidepressant treatment and when ACT would not be the priority today (5). (20 marks)

Open

MEQ: Couples therapy for depression with marital discord and safety rules

You are the psychiatry registrar in an outpatient clinic. A 42-year-old accountant with recurrent major depression (PHQ-9 = 17) presents with their partner of 11 years. Arguments about money and intimacy have escalated for 2 years; they sleep in separate rooms. The patient drinks 4–5 standard drinks most evenings ‘to cope with the rows.’ No mania history; no psychosis. They take escitalopram 10 mg daily for 5 weeks with partial effect. Both ask for ‘couples counselling.’ In private, the partner denies fear of physical violence but describes occasional coercive control (checking the patient’s phone). (i) Define couples therapy and name three major evidence-based models; which dual targets apply here (5). (ii) Outline assessment priorities including IPV and substance use (5). (iii) Discuss evidence for couple therapy in depression and for behavioural couples approaches when alcohol is involved (5). (iv) Propose a treatment plan including combined care, model choice, and when conjoint work would be unsafe (5). (20 marks)

Open

MEQ: Designing and leading an outpatient group for depression

You are the psychiatry registrar planning a new outpatient group. The CMHT has a long wait for individual CBT. Twelve adults with moderate major depression (PHQ-9 12–18) are on the waitlist; two have comorbid social anxiety; one recently disclosed passive death wishes without plan. Management asks you to start a 12-session closed group. (i) Define group psychotherapy and distinguish it from peer support and psychoeducation (4). (ii) Outline pre-group assessment, composition decisions, and who you would defer (5). (iii) Describe frame, phase structure, and leadership tasks including how you would handle scapegoating (5). (iv) Summarise key evidence that group formats can be effective for depression and that group may approximate individual outcomes when matched; name one process variable linked to outcome (6). (20 marks)

Open

MEQ: IPT formulation and treatment plan after partner role dispute

You are the psychiatry registrar in an outpatient clinic. A 34-year-old software engineer presents with 4 months of major depression (PHQ-9 = 18) after their partner of 6 years began working overseas. Arguments about finances and intimacy escalated; they now sleep in separate rooms when the partner visits. They feel ‘a failure as a partner,’ have withdrawn from friends, and drink 3–4 standard drinks most nights. No prior mania; no psychosis. They take sertraline 50 mg daily for 3 weeks with partial effect and ask for ‘therapy that is not just CBT worksheets.’ (i) Define IPT and name the four classic problem areas; which primary focus fits this case and why (5). (ii) Outline the initial-phase tasks including sick role and interpersonal inventory (5). (iii) Describe middle-phase techniques for this focus and one safety caveat (5). (iv) Discuss combining IPT with antidepressant treatment and when IPT would not be the priority today (5). (20 marks)

Open

Schema therapy (MEQ)

You are a psychiatry registrar in a community personality disorder pathway. A 29-year-old woman with borderline personality disorder has recurrent cutting after perceived rejection, chronic emptiness, and a lifelong sense of being 'defective'. She has had two short CBT courses with little lasting change. She asks for 'schema therapy like Young'. Your service has structured case management and a DBT skills group waitlist, but no dual-format schema therapy programme. (i) Define early maladaptive schemas, coping styles, and schema modes with clinical examples. (ii) Outline limited reparenting and core ST techniques, including safety sequencing for experiential work. (iii) Summarise landmark ST evidence (Giesen-Bloo SFT vs TFP; at least one of Farrell group ST, Bamelis mixed PD, or Arntz group/combined ST; note Nadort implementation if space). (iv) Contrast ST with DBT and with structured generalist care. (v) Propose a stepped, safety-focused plan if full ST is not available. (20 marks)

Open

Supportive psychotherapy techniques (MEQ)

A 46-year-old with recurrent depression and recent job loss presents to your community clinic. PHQ-9 is 16. There is no psychosis. Passive death wishes occur when demoralised; no plan or intent today. CBT waitlist is 6 months. You plan a course of supportive psychotherapy while reviewing sertraline. (i) Define supportive psychotherapy and locate it on the expressive–supportive continuum. (ii) List six core techniques with a one-line purpose for each. (iii) Outline a structured 20-minute medication-visit session using supportive technique. (iv) Summarise key evidence (Winston/Pinsker, Hellerstein, Misch, Markowitz BSP, alliance/rupture–repair). (v) State two situations where pure elective exploratory work is deferred in favour of support-first care. (20 marks)

Open

Domain

Intellectual disability psychiatry — genetic syndromes

1

Behavioural phenotypes and genetic syndromes (MEQ)

A 19-year-old with mild intellectual disability, repaired tetralogy of Fallot and a history of hypernasal speech presents with 3 months of social withdrawal, second-person auditory hallucinations and persecutory delusions. Mother recalls recurrent hypocalcaemia in childhood. Separately, the consultant asks you to contrast this presentation with behavioural phenotypes of Down syndrome, fragile X, Prader-Willi and Angelman syndromes. (i) Define behavioural phenotype. (ii) What genetic diagnosis is most likely here and what is the approximate adult psychosis risk teaching point? (iii) Outline key behavioural/psychiatric phenotypes of Down, fragile X, PWS and Angelman with one genetic mechanism each. (iv) List essential medical investigations and multidisciplinary steps now. (v) State psychopharmacology principles in ID for treating his psychosis. (20 marks)

Open

Domain

Psychopharmacology — benzodiazepine prescribing and tapering

1

Benzodiazepine initiation, conversion and taper (MEQ)

A 42-year-old office worker has taken alprazolam 0.5 mg three to four times daily for 18 months for 'stress and sleep,' started after a relationship breakdown. They also take oxycodone PRN for chronic back pain. The GP asks you to take over. (i) Outline the key harms and interaction risks you will counsel on. (ii) Propose a structured outpatient taper plan including equipotency conversion principles and a reduction scaffold with monitoring. (iii) Name non-GABAergic treatments for the underlying anxiety/insomnia. (iv) List three red flags that would trigger specialist or inpatient escalation. (20 marks)

Open

Domain

Old age psychiatry — grief and loss

1

Bereavement in later life — assessment and management (MEQ)

An 79-year-old man is referred 15 months after his wife's death from cancer. He lives alone, still sets two places at meals, avoids their bedroom, drinks more whisky, and says 'I only want to be with her.' PHQ-9 is 8. He scores highly on a prolonged-grief inventory. He is not delirious. (i) Define bereavement, grief, and mourning, and state DSM-5-TR and ICD-11 duration thresholds for prolonged grief disorder in adults. (ii) Discriminate adaptive grief, PGD, and major depression in this man. (iii) Outline suicide risk assessment priorities for older bereaved men. (iv) Describe evidence-based psychological treatment, naming the key elderly CGT trial. (v) Discuss the role of antidepressants and practical supports. (20 marks)

Open

Domain

Foundations — biostatistics for psychiatry exams

1

Biostatistics calculations from a psychiatry abstract (MEQ)

Abstract (fictional numbers for exam practice): Double-blind RCT of Drug X versus placebo in adults with moderate major depression. N=200 (100 per arm). Primary dichotomous outcome: response (50% HAM-D reduction) at 8 weeks by ITT. Response: Drug X 52/100, placebo 34/100. Authors headline a '53% relative improvement in response odds' and p=0.01. Secondary: mean HAM-D difference −2.8 (95% CI −4.9 to −0.7). A diagnostic substudy of a new brief screen vs structured interview in the same sample (prevalence of MDD by interview = 100% of enrolees by design — not a screening population) is not reported with community predictive values. (i) Calculate CER, EER, ARR, RRR, RR, and NNT for response; interpret in one sentence. (ii) Explain why the '53% relative improvement in odds' is not the same as RRR and when OR ≈ RR. (iii) Define the p-value for the primary comparison and state what it does not mean. (iv) Interpret the mean difference CI clinically versus statistically. (v) Explain why PPV from this clinic sample cannot be exported unchanged to a 3% prevalence primary-care screen. (20 marks)

Open

Domain

General adult psychiatry — bipolar and related disorders

4

Bipolar I disorder — acute mania and maintenance (MEQ)

A 31-year-old man is brought by police after three nights of almost no sleep, pressured speech, grandiose plans to buy a hotel chain, and reckless spending. He has no prior psychiatric diagnosis. Collateral from his partner confirms 10 days of escalating elevated and irritable mood with sexual risk-taking. MSE shows flight of ideas, impaired insight, and no clear hallucinations. Urine drug screen is negative. (i) State working diagnosis with DSM-5-TR mania criteria applied. (ii) Outline assessment priorities including risk, capacity/legal status, and organic exclusion. (iii) Give an acute pharmacological plan with two named first-line options including doses and monitoring. (iv) Explain why antidepressant monotherapy is inappropriate if he later develops bipolar depression. (v) Outline a 12-month maintenance plan referencing BALANCE and lithium anti-suicide evidence. (20 marks)

Open

First manic episode and bipolar I initiation (MEQ)

A 24-year-old man is brought by police after three nights with almost no sleep, spending AUD 12,000 on online trading, and telling neighbours he has been chosen to restructure the national economy. He is irritable, pressured, grandiose, and has poor insight. Urine drug screen is positive for cannabis. Observations are normal; bedside glucose is 5.1 mmol per litre. There is no prior psychiatric diagnosis. His mother reports a paternal uncle with 'manic depression' on lithium. (i) Outline assessment priorities including risk, organic exclusion, and legal status principles. (ii) State working diagnosis and key differentials with discriminators. (iii) Outline acute management including a named antimanic regimen with doses and monitoring. (iv) Discuss maintenance options after remission with reference to landmark evidence (including lithium). (v) Explain how you would counsel about cannabis and early warning signs. (20 marks)

Open

Missed bipolar II, antidepressant monotherapy, and polarity-safe rebuild (MEQ)

A 36-year-old woman is referred after three sequential antidepressant trials (escitalopram, venlafaxine, then augmentation with mirtazapine) for 'recurrent depression.' She remains depressed with passive death wishes. Collateral from her partner reveals several 5–7 day periods over the past 5 years of needing only 3 hours sleep with high energy, rapid speech, overspending, and increased libido; she was never hospitalised and never psychotic during those periods. She calls those times 'when I was well.' Current medications: venlafaxine 225 mg and mirtazapine 30 mg, no mood stabiliser. Baseline bloods last year normal; none repeated. (i) Formulate diagnosis using operational criteria and explain misdiagnosis pathway. (ii) Outline acute risk assessment priorities. (iii) Detail immediate medication changes with doses, titration, monitoring, and evidence against antidepressant monotherapy. (iv) Give a 12-month psychosocial and maintenance plan including lamotrigine counselling points. (20 marks)

Open

Mixed features crisis and rapid-cycling reformulation (MEQ)

A 29-year-old woman with previously diagnosed bipolar I disorder is brought to ED by her partner. For 10 days she has slept 2–3 hours/night with high energy, spoken rapidly, spent excessively, and been irritable. Simultaneously she is tearful, says she is 'a failure who should die,' and has researched lethal means. She has been taking sertraline 150 mg monotherapy for 8 weeks after a GP diagnosis of 'depression.' Over the past year she has had two manias and three major depressions with incomplete recovery. TFT last year was normal; none repeated since lithium was stopped by the patient 14 months ago. Urine drug screen is negative; observations and bedside glucose are normal. (i) Formulate the current episode and 12-month course using operational specifiers. (ii) Outline acute risk management and legal status principles. (iii) Detail immediate pharmacotherapy changes with doses/monitoring and justify avoiding antidepressant monotherapy with evidence. (iv) Present a 12-month plan for rapid-cycling drivers, maintenance, and psychosocial care. (20 marks)

Open

Domain

General adult psychiatry — OCRD

3

Body dysmorphic disorder — assessment and stepped management (MEQ)

A 26-year-old graphic designer is referred after her GP noted depression. She spends 3–5 hours daily checking her skin and nose in mirrors, applies heavy makeup, and has cancelled two jobs after believing colleagues were staring at a 'hideous scar' that examiners cannot see. She knows others say the scar is invisible but still 'knows' she is deformed (poor insight). She has had one filler procedure with brief relief then new chin concern. PHQ-9 is 18; she has passive death wishes without plan. She takes sertraline 50 mg for 4 weeks. (i) Define BDD and discriminate from OCD, eating disorders, and psychosis. (ii) Outline assessment including risk and BDD-YBOCS concept. (iii) Propose specialised psychological treatment. (iv) Optimise pharmacotherapy with agent, dose concept, trial duration. (v) Advise regarding further cosmetic procedures and next steps if non-response. (20 marks)

Open

Hoarding disorder — assessment, differential and stepped care (MEQ)

A 54-year-old librarian is referred after fire officers found blocked exits and inactive smoke alarms. Living areas are filled with newspapers, clothes and unopened free items; the bed and stove are unusable. She has saved 'important information' since her twenties and becomes tearful if relatives discard anything. She denies contamination fears or checking rituals. PHQ-9 is 14; she has no plan for suicide. She refuses a total cleanout but will discuss 'making pathways.' (i) Define hoarding disorder and discriminate from OCD, ADHD-related clutter, and severe domestic squalor. (ii) Outline assessment including home visit and key scales. (iii) Formulate environmental risk and capacity principles for safety interventions. (iv) Propose specialised psychological treatment. (v) Discuss pharmacotherapy evidence limits and multiagency next steps. (20 marks)

Open

Obsessive-compulsive disorder — assessment and stepped management (MEQ)

A 27-year-old software engineer is referred with 4 years of intrusive contamination fears and hand-washing that occupies 3–4 hours daily. He knows the fears are excessive (good insight) but cannot stop. He has tried 'CBT' once without exposures. He takes sertraline 50 mg for 3 weeks with little benefit and wants to stop because of sexual side-effects. PHQ-9 is 14; he has passive death wishes without plan. Partner washes door handles for him each morning. (i) Define OCD operationally and list key differentials with discriminators (OCPD, psychosis, ASD, BDD). (ii) Outline assessment including Y-BOCS concept and risk. (iii) Propose a first-line psychological plan (ERP structure). (iv) Optimise pharmacotherapy with named agent, dose range, trial duration and monitoring. (v) State next steps if inadequate response including augmentation evidence. (20 marks)

Open

Domain

Professional — boundary violations and sexual misconduct

1

Boundary violations and sexual misconduct (MEQ)

You are a psychiatry registrar. A 42-year-old outpatient you have treated for 10 months for complex trauma says they are in love with you, asks to meet for coffee, and notes you have been texting them personally after hours. Separately, they disclose that a previous psychiatrist initiated a sexual relationship during treatment three years ago. (i) Define boundary crossing vs boundary violation and apply both to this scenario. (ii) Outline your immediate self-management and frame reset. (iii) Outline your response to the historical sexual misconduct disclosure (no invented statute numbers). (iv) List five early warning signs of progressive boundary erosion. (v) State the ethical status of sexual contact with current patients and of post-termination sexual relationships. (20 marks)

Open

Domain

Old age psychiatry — dementia neuropsychiatry

1

BPSD — assessment, non-drug care and antipsychotic risk (MEQ)

An 81-year-old woman with moderate Alzheimer disease in residential care has become increasingly agitated over 10 days: resisting personal care, striking a carer once, and calling out at night. She has osteoarthritis and chronic constipation. Staff request 'something to settle her' and ask whether risperidone can be started long-term. (i) Outline your structured assessment including DICE/ABC and medical exclusion. (ii) List key differentials with discriminators. (iii) Detail a non-pharmacological and pain-first management plan. (iv) If an antipsychotic is used, state agent, approximate starting dose, risks you must discuss (including evidence), monitoring and deprescribing plan. (v) How do CATIE-AD and DART-AD inform your counselling of staff and family? (20 marks)

Open

Domain

Psychopharmacology — phototherapy and chronotherapy

1

Bright light therapy and chronotherapy for winter depression (MEQ)

A 29-year-old teacher in southern Australia presents each June–August with major depression featuring hypersomnia, carbohydrate craving, and anergy, remitting by October for three consecutive years. No prior mania. PHQ-9 is 18; passive suicidal ideation without plan. She wants to avoid medication if possible but will consider an SSRI. (i) Define seasonal pattern and justify bright light therapy as a first-line option. (ii) Prescribe a concrete BLT protocol (device, lux, duration, timing, technique). (iii) Compare with fluoxetine using Can-SAD-level evidence. (iv) List key adverse effects and hard stop rules including hypomania and ocular red flags. (v) Outline when you would add wake therapy/chronotherapy packages or escalate beyond light. (20 marks)

Open

Domain

Public-community — disaster and mass casualty psychiatry

1

Bushfire mass casualty — stepped disaster mental health response (MEQ)

You are the psychiatry registrar seconded to a regional emergency operations centre 36 hours after a catastrophic bushfire. A high-impact township has mass casualties, an evacuation centre, and disrupted community mental health services. (i) Define disaster psychiatry tasks across response and early recovery phases and outline an exposure gradient. (ii) Contrast normal distress, ASD/PTSD, depression/grief, and SMI relapse; name key epidemiology anchors. (iii) Detail immediate mental health interventions including Hobfoll elements and PFA, and explain why mandatory single-session CISD is not recommended. (iv) Outline stepped definitive care including trauma-focused therapy evidence and an SSRI adjunct plan with dose and monitoring. (v) List pitfalls, special populations, and disposition. (20 marks)

Open

Domain

Addiction psychiatry — cannabis and psychosis

1

Cannabis use and psychosis — dual formulation to integrated care (MEQ)

An 18-year-old college student is brought by parents after 4 weeks of believing classmates track him through his phone and 2 weeks of third-person auditory commentary. He smokes high-THC cannabis most nights since age 15. Last joint was yesterday. He is alert, afebrile, and without focal neurology. Insight is partial. Urine immunoassay is cannabis-positive. (i) Formulate the differential including intoxication, cannabis-induced psychotic disorder, and primary FEP with comorbidity. (ii) List assessment priorities including cannabis history elements that change risk. (iii) Outline acute and definitive management of both psychosis and cannabis use disorder, with a named oral antipsychotic example (dose and monitoring) if you start one. (iv) Counsel the family on potency, adolescent risk, conversion risk after substance-induced psychosis, and follow-up. (20 marks)

Open

Domain

Intellectual disability — capacity and supported decision-making

1

Capacity and supported decision-making in ID (MEQ)

You are the psychiatry registrar covering intellectual disability services. A 34-year-old man with moderate intellectual disability and limited literacy is admitted for elective laparoscopic cholecystectomy for symptomatic gallstones. Surgeons want consent today. His mother says she 'always signs everything' and that he 'doesn't understand doctors'. He appears calm, greets you, and says he is 'scared of hospitals'. He is not under a mental health order and there is no formal guardianship order on file. (i) Define decision-making capacity and contrast it with legal capacity under UNCRPD Article 12 principles. (ii) List the four functional abilities and how you would adapt assessment with supports. (iii) Outline your bedside assessment sequence and documentation. (iv) Explain supported vs substitute decision-making and guardianship least-restrictive principles. (v) Describe management branches if capacity is present vs absent after supports, including emergency vs elective distinctions (no invented statute section numbers). (20 marks)

Open

Domain

Consultation-liaison — capacity and consent

1

Capacity assessment for surgical refusal after psychosis (MEQ)

You are the C-L psychiatry registrar. A 46-year-old man with first-episode psychosis is medically admitted with acute appendicitis. Surgeons recommend laparoscopic appendicectomy today. He understands he has abdominal pain and can recite infection risk if untreated, but he believes the appendix is a tracking device implanted by intelligence services and refuses surgery. He is not currently under a mental health order. (i) Define decision-making capacity and list the four functional abilities. (ii) Structure your bedside assessment including supports and documentation. (iii) Explain how mental health law principles differ from capacity/consent pathways for general medical treatment (no invented section numbers). (iv) Outline management options if capacity is absent versus present. (v) Name two key evidence anchors (e.g. tools or landmark papers) relevant to capacity assessment. (20 marks)

Open

Domain

Old age psychiatry — capacity, guardianship and end of life

1

Capacity, guardianship and goals of care in dementia (MEQ)

You are the old-age psychiatry registrar. An 86-year-old woman with moderate Alzheimer disease is admitted with aspiration pneumonia. She has no formal advance directive on the chart. Her daughter holds an enduring power of attorney for health (jurisdiction-valid) and says her mother always refused life-prolonging treatment if she would not return home. A son arrives demanding full ICU escalation including intubation. The patient is drowsy, fails teach-back for treatment options this afternoon, but was more lucid yesterday. She is not under a mental health order. (i) Define decision-making capacity and list the four Appelbaum–Grisso abilities. (ii) Outline your capacity assessment plan including fluctuation and supports. (iii) Explain substitute decision standards and how you would work with the conflicting family. (iv) Outline advance care planning principles and evidence anchors for end-of-life discussions. (v) Describe psychiatric issues you would screen for at end of life and disposition principles without inventing statute numbers. (20 marks)

Open

Domain

Psychopharmacology — carbamazepine and oxcarbazepine

1

Carbamazepine and oxcarbazepine: mania evidence, autoinduction, HLA and hyponatraemia (MEQ)

A 42-year-old man with bipolar I is admitted with mixed mania. Lithium caused unacceptable tremor and diabetes insipidus symptoms previously; valproate caused marked weight gain. He is of Han Chinese ancestry. He takes a statin and a combined oral contraceptive is not relevant. Baseline FBC, LFT and Na are normal. (i) Outline the modern RCT evidence supporting carbamazepine in acute mania and name key historical lineage papers. (ii) Explain autoinduction and how it affects monitoring and dose. (iii) Detail the HLA-B*1502 issue and pre-start actions. (iv) Compare oxcarbazepine as an alternative, including hyponatraemia and the Wagner youth trial relevance even though he is an adult. (v) List teaching trough range and major interaction counselling themes for CBZ. (20 marks)

Open

Domain

Public and community psychiatry — carers and family-inclusive practice

1

Carers and family-inclusive practice — from EE to structured FPE (MEQ)

You are the consultant for a community psychosis team. A 24-year-old man with first-episode schizophrenia lives with his parents. He is willing for them to be involved in care planning but not for them to hear private therapy content. His mother is exhausted and critical; his father is withdrawn. Relapse risk is high after a recent admission. (i) Define family-inclusive practice and expressed emotion. (ii) Outline a carer assessment. (iii) Negotiate confidentiality versus partnership. (iv) Describe components of structured family psychoeducation and landmark evidence. (v) Address carer distress and implementation pitfalls. (20 marks)

Open

Domain

General adult psychiatry

2

Catatonia recognition and management (MEQ)

A 32-year-old man with bipolar disorder is day 5 of a manic relapse. He becomes mute, stares, postures with arm held against gravity, and refuses food and fluids. Bush-Francis screening shows multiple items at severity 2–3. Temperature is 37.1 C; HR 88; no clonus. He has not received antipsychotics in 48 hours. (i) State the working diagnosis using DSM-5-TR criteria language and phenotype. (ii) Outline bedside assessment and essential investigations. (iii) Describe the lorazepam challenge and subsequent pharmacological plan with doses. (iv) Explain when and why you would escalate to ECT, and list key complications of untreated catatonia. (20 marks)

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Functional neurological disorder — diagnosis and MDT care (MEQ)

A 28-year-old teacher develops sudden right arm weakness and a shaking tremor three days after a minor wrist sprain and a panic attack at work. MRI brain is normal. On examination, power is inconsistent; Hoover's sign is positive on the weak side; the tremor stops when she is asked to copy a rhythm with the left hand and then reappears at the new frequency (entrainment). She is terrified she has multiple sclerosis. She asks if this means she is 'crazy or faking'. (i) State the working diagnosis using modern nosology and justify it with positive clinical features. (ii) Outline how you would explain the diagnosis without pejorative language. (iii) Describe a multidisciplinary management plan including physiotherapy and psychological elements, with named evidence anchors. (iv) List key differentials and red flags that would change your approach. (20 marks)

Open

Domain

Intellectual disability psychiatry

3

Challenging behaviour and PBS — functional analysis to limited medication (MEQ)

A 28-year-old man with moderate intellectual disability and limited speech lives in supported accommodation. Over 3 months he has punched staff during showering twice weekly, causing bruises. He is on risperidone 2 mg nocte started 2 years ago for 'behaviour' with no documented psychosis. Staff want the dose increased. (i) Define challenging behaviour and distinguish it from a psychiatric diagnosis. (ii) Outline a functional assessment including likely functions and ABC approach. (iii) Describe the core elements of a positive behaviour support plan. (iv) Summarise NICE NG11 principles and the Tyrer 2008 finding on antipsychotics for aggressive CB in adults with ID. (v) State your approach to the current risperidone, including when any medicine might still be justified and what monitoring is required. (20 marks)

Open

Epilepsy in intellectual disability — peri-ictal behaviour to SUDEP (MEQ)

A 34-year-old man with moderate intellectual disability and longstanding epilepsy lives in supported accommodation. He has weekly seizures despite two AEDs. Staff report escalating aggression. He is on levetiracetam (recently increased) and long-term risperidone 2 mg for 'behaviour' with no documented psychosis. (i) Outline the epidemiology of epilepsy in ID relevant to this case. (ii) Classify possible relationships between his epilepsy and behavioural change, including postictal psychosis and AED effects. (iii) Summarise acute safety priorities including why AEDs must not be stopped abruptly. (iv) Outline definitive joint management including psychotropic principles and non-drug care. (v) State key counselling on mortality/SUDEP and water safety. (20 marks)

Open

Psychiatric disorders in intellectual disability — dual diagnosis MEQ

A 28-year-old man with moderate intellectual disability and limited speech is brought by residential carers after 6 weeks of new self-hitting, refusal of previously preferred activities, early waking, and tearfulness. Staff say 'this is just his ID'. He has chronic constipation and no recent dental review. He is already on risperidone 2 mg at night 'for behaviour' for 3 years without documented mental illness diagnosis or review. (i) Define diagnostic overshadowing and why it matters here. (ii) Outline how presentation of depression may be modified in moderate ID. (iii) Explain the role of DC-LD relative to ICD/DSM. (iv) Give a hierarchical assessment and immediate management plan including medical exclusion. (v) Discuss psychotropic strategy with reference to landmark evidence (Tyrer, Sheehan, Deb) and treatment adaptations. (20 marks)

Open

Domain

Child and adolescent psychiatry — anxiety disorders

1

Child and adolescent anxiety — school refusal, CBT and SSRI evidence (MEQ)

A 10-year-old boy has missed 8 of the last 12 school weeks. He develops abdominal pain and panic-like symptoms on weekday mornings that resolve if allowed to stay home gaming with his mother nearby. He fears something bad will happen to his parents if he leaves. At weekends he is bright and plays with cousins. Teachers describe clinginess at drop-off and no bullying. Parents give extensive reassurance and often keep him home 'to settle'. MSE: tense, tearful when school is mentioned, no suicidal ideation, no psychosis. (i) Give the most likely diagnosis and key differentials. (ii) Outline a structured assessment including functional analysis of school refusal. (iii) Describe first-line psychological treatment and family interventions. (iv) Summarise landmark pharmacotherapy evidence (CAMS, RUPP, fluoxetine) and how you would start an SSRI if indicated, including monitoring. (v) Outline a graded return-to-school plan and safety/legal principles. (20 marks)

Open

Domain

Child and adolescent psychiatry — depression

1

Child and adolescent depression — assessment and TADS/ADAPT-informed management (MEQ)

A 15-year-old school student is referred with 10 weeks of irritable and low mood, anhedonia, early insomnia, falling grades, social withdrawal, and passive death wishes. PHQ-A is 18 with item 9 positive several days per week. There is no volunteered mania. She has weekly non-suicidal cutting for affect regulation. Parents are separated and conflictual; she asks that 'nothing is told to them'. (i) Outline your multi-informant assessment including risk, bipolar screen, competence/confidentiality, and organic exclusion. (ii) State working diagnosis and key differentials with discriminators. (iii) Outline initial management including a named psychological intervention, school plan, and whether/how you would start fluoxetine (dose, monitoring). (iv) Explain how TADS and ADAPT would inform a viva discussion of combined treatment. (v) If she fails an adequate first SSRI, how does TORDIA change your next step? (20 marks)

Open

Domain

Child and adolescent psychiatry — child protection for psychiatrists

1

Child protection thresholds and multi-agency response (MEQ)

You are the CAMHS psychiatry registrar. A 9-year-old is referred for 'behavioural problems.' School reports chronic hunger, unexplained bruises, and the child saying 'Mum's boyfriend hits me if I cry.' Mother has untreated depression and alcohol use; she is also your team's adult-service patient via a dual-care arrangement and begs you 'not to ruin the family.' There is a 2-year-old sibling at home. (i) Define child maltreatment and list major subtypes relevant here. (ii) Outline immediate assessment including interview strategy, documentation, and sibling risk. (iii) Explain reporting thresholds and confidentiality limits without inventing statute section numbers. (iv) Describe multi-agency management and how you handle dual loyalty. (v) Outline parental capacity assessment principles and mental health care for child and parent. (20 marks)

Open

Domain

Child and adolescent psychiatry — childhood trauma and maltreatment

1

Childhood maltreatment — assessment, reporting and TF-CBT (MEQ)

A 10-year-old girl is brought by her aunt after disclosing that her stepfather has been sexually abusing her for months. She has nightmares, avoidance of men, hypervigilance, school refusal, and says she is 'dirty and worthless'. The stepfather still lives in the home with two younger siblings. Mother minimises the disclosure. (i) Outline immediate safety and statutory reporting priorities. (ii) Structure a trauma-informed assessment including private interview and measures. (iii) Map ACE/maltreatment formulation and likely psychiatric diagnoses. (iv) Propose a definitive psychological treatment plan naming TF-CBT PRACTICE components. (v) State when an SSRI might be considered and with what monitoring caveats. (20 marks)

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Domain

Child and adolescent psychiatry — OCRD

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Childhood-onset OCD — ERP, POTS and SSRI monitoring (MEQ)

A 12-year-old girl is referred with two years of progressive contamination fears, prolonged handwashing until skin cracks, rewriting homework until letters look 'perfect', and nightly checking of door locks. She spends several hours daily on rituals. Parents answer dozens of reassurance questions and have stopped family outings. She is ashamed of intrusive thoughts that she might harm her baby brother 'by mistake'. Attendance has fallen and peers tease her about smelling of soap. No clear acute post-infectious onset. (i) State the working diagnosis with DSM-5-TR logic and key differentials including tic-related and PANDAS considerations. (ii) Outline assessment priorities including a named severity scale and family accommodation. (iii) Present a stepped management plan including psychoeducation, ERP structure, and when to use SSRI with agent examples, dose framework and monitoring. (iv) Summarise POTS and POTS II implications for combination/augmentation. (v) Outline school and risk counselling points. (20 marks)

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Domain

Child and adolescent psychiatry — children of parents with mental illness

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Children of parents with mental illness — family-focused care (MEQ)

You are the adult psychiatry registrar. A 38-year-old man with bipolar I disorder is admitted with mania. He is a single parent of a 10-year-old girl and a 6-year-old boy. Neighbours have been feeding the children for three days. School reports the 10-year-old has been arriving late, caring for her brother, and looking exhausted. The patient insists 'my kids are fine' and forbids any contact with children's services. (i) Define COPMI and outline key epidemiology and multi-outcome risk evidence. (ii) Describe immediate safety assessment and childcare planning for this admission. (iii) Explain parenting capacity principles and dual loyalty. (iv) Outline definitive multi-level management including treatment of the parent, family prevention, and child support. (v) List pitfalls and disposition essentials. (20 marks)

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Domain

Foundations — research methods and study design

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Choosing and defending study designs in psychiatry (MEQ)

You are the psychiatry registrar designing (or advising on) three separate research questions for a departmental academic meeting. (A) Does adjunctive CBT reduce 6-month relapse compared with medication management alone in adults with remitted major depression? (B) Among people starting clozapine, what is the incidence of severe neutropenia over 12 months, and which baseline factors predict it? (C) What are the lived experiences of Aboriginal and Torres Strait Islander carers supporting a relative with first-episode psychosis? For each question: (i) name the most appropriate primary study design and justify the match; (ii) name the single most important structural validity threat if methods are weak; (iii) name the most relevant reporting guideline. Finally, (iv) explain in three to four sentences why an RCT is not the default answer for questions B and C. (20 marks)

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Domain

Psychopharmacology — first-generation antipsychotics

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Choosing and monitoring a first-generation antipsychotic (MEQ)

A 34-year-old man with multi-episode schizophrenia had good positive-symptom response to oral haloperidol years ago but stopped after 'stiffness and restlessness.' He relapsed after stopping olanzapine because of weight gain (BMI now 38, new type 2 diabetes). He prefers a 'cheap tablet or injection that actually works like before.' MSE: paranoid delusions, no acute dystonia now. No prior TD documented. (i) Position FGAs using CATIE, CUtLASS and EUFEST (and state why EUFEST is less applicable here). (ii) Compare high- vs low-potency FGA adverse-effect maps and propose a rational oral choice with consent points. (iii) Outline pre-start investigations and EPS/prolactin/TD monitoring. (iv) Describe immediate management of acute dystonia and of severe akathisia. (v) State when you would move to depot and when you would instead pursue TRRIP/clozapine. (20 marks)

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Domain

Psychopharmacology — antipsychotics

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Choosing and monitoring an antipsychotic in first-episode psychosis (MEQ)

A 21-year-old man with first-episode schizophrenia agrees to start medication after shared decision-making. BMI 31, fasting glucose 5.9 mmol per litre, non-smoker, no cardiac history. He is highly concerned about weight gain and sexual side-effects. (i) Justify your first-line oral antipsychotic choice with a starting dose and the evidence context (CATIE/CUtLASS/EUFEST/Leucht). (ii) List baseline and early monitoring. (iii) Define an adequate trial and your plan if the first agent fails. (iv) State when you would offer a LAI and when you would move toward clozapine. (v) Outline management if he develops acute dystonia in week 1. (20 marks)

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Domain

Psychopharmacology — antidepressants

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Choosing, monitoring and escalating antidepressants in treatment-resistant depression (MEQ)

A 41-year-old woman with recurrent unipolar MDD (two prior episodes) has residual anhedonia and insomnia after 7 weeks of sertraline 150 mg with good adherence. PHQ-9 improved from 22 to 14. No hypomania history. BMI 29, sodium 138, no cardiac disease. She is distressed by new sexual dysfunction. (i) Define an adequate trial and interpret her current status (response vs remission). (ii) Outline two evidence-based next pharmacological strategies with agent, dose, rationale and monitoring — include at least one augmentation option. (iii) Explain STAR*D logic relevant to her step. (iv) Counsel on sexual side-effects and early suicide/activation monitoring principles. (v) State washout rules if an irreversible MAOI were considered later. (20 marks)

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Domain

Forensic psychiatry — civil

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Civil forensic psychiatry — testamentary capacity and disability IME (MEQ)

You are the psychiatry registrar providing a medico-legal opinion. Scenario A: An 81-year-old man with possible mild dementia executes a new will two weeks before death, leaving his home to a recently hired carer and excluding his two children. The solicitor notes he was drowsy at times. Scenario B (same sitting): You are retained by an insurer to assess a 42-year-old after a motor-vehicle collision claiming PTSD and inability to work. (i) For Scenario A, outline how you assess testamentary capacity (concurrent vs retrospective principles) using Banks v Goodfellow teaching criteria, and how undue influence differs. (ii) Address delirium and deathbed wills. (iii) For Scenario B, outline an AAPL-informed psychiatric disability/IME structure including role ethics. (iv) How would you approach causation, impairment vs disability vs job fitness, and symptom validity? (v) List report structure essentials and three exam pitfalls. (20 marks)

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Domain

General adult psychiatry — clinical high risk / attenuated psychosis

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Clinical high risk and attenuated psychosis — assessment to stepped care (MEQ)

A 18-year-old Year 12 student is referred by the GP after 5 months of social withdrawal, falling grades, and saying classmates 'might be talking about me' though she still half-doubts this. She hears her name called 2–3 times a week when alone and knows it 'is probably my mind.' She smokes high-THC cannabis most weekends. She has a first-degree relative with schizophrenia. MSE shows residual insight, no fixed delusions, no sustained frank hallucinations. Risk of suicide is passive ideation without plan. (i) Define UHR/CHR and state which entry criteria she may meet. (ii) Give approximate conversion expectations and stratified risk points. (iii) Outline structured assessment and investigations. (iv) Give a stepped management plan with evidence names (CBT, omega-3 equipoise, antipsychotics). (v) State monitoring and the threshold to switch to FEP care. (20 marks)

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Domain

Addiction psychiatry — pharmaceutical and OTC misuse

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Codeine combination dependence and OTC misuse (MEQ)

A 38-year-old woman is referred from gastroenterology after admission with melaena, haemoglobin 78 g/L, and a bleeding gastric ulcer. She discloses taking 25–35 codeine–ibuprofen combination tablets daily for 3 years, previously purchased over the counter from rotating pharmacies and, since 2018, via three different GPs. She also uses pregabalin 300 mg three times daily bought from a friend ‘to sleep’. She denies injecting drugs, rejects the word ‘addict’, and asks only for ‘stronger painkillers so I can stop the chemist ones’. (i) Formulate the substance problems and key medical risks. (ii) Outline acute and definitive management including whether opioid agonist treatment is appropriate. (iii) Explain the relevance of Australian codeine rescheduling. (iv) Address gabapentinoid co-use. (v) Describe how you would engage her given identity conflict about addiction. (20 marks)

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Domain

Foundations — cognitive psychology

1

Cognitive psychology applied to depression, panic, and psychosis (MEQ)

A 28-year-old with major depression says “I always fail,” cannot recall a single specific success from the past month, and loses multi-step clinic instructions. A second patient has panic with pulse-checking and sitting down “so I don’t die.” A third has schizophrenia with remitted hallucinations but cannot hold a job and misreads neutral faces as hostile. (i) Define working memory (Baddeley) and relate it to the first patient’s instruction failure; contrast Miller vs Cowan capacity teaching points. (ii) Explain overgeneral autobiographical memory and Beck’s cognitive architecture in the first patient. (iii) Apply Clark’s model to the panic patient including safety behaviours. (iv) Map schizophrenia cognitive and social-cognitive domains (Green/MATRICS line) to functional outcome in the third patient. (v) Outline bedside assessment and one intervention target for each case. (20 marks)

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Domain

Public and community psychiatry — collaborative care and primary care

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Collaborative care — principles to multimorbidity implementation (MEQ)

A primary health network asks you, as consultant psychiatrist, to design collaborative care for depression and anxiety across 12 general practices. GPs currently refer only crisis patients; many adults with PHQ-9 of 12–18 receive a single SSRI script without follow-up. (i) Define collaborative care and distinguish it from co-location. (ii) Name the three core roles and five principles. (iii) Outline measurement-based care including PHQ-9/GAD-7 use and red flags. (iv) Summarise landmark evidence (IMPACT, TEAMcare, Cochrane/Gilbody, CADET). (v) Describe implementation pitfalls and when to step up to specialty/crisis care. (20 marks)

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Domain

Professional — complaint management and regulation

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Complaint management and professional regulation (MEQ)

You are the psychiatry consultant covering clinical governance. A family lodges a formal written complaint after their adult son dies by suicide three days after a voluntary ED mental health assessment by your registrar. They allege rushed assessment, dismissive communication, and inadequate safety planning. Separately, the registrar develops insomnia, shame, and passive suicidal thoughts after receiving the complaint letter. A different consultant on your team has attracted three formal relationship-domain complaints in 18 months. (i) Distinguish complaint, claim, and regulatory fitness-to-practise processes. (ii) Outline immediate actions for the family complaint including open disclosure principles. (iii) Outline assessment and support for the registrar as a second victim. (iv) Outline how you would respond to the recurrent-complaint pattern using epidemiological principles. (v) Name four landmark literature anchors relevant to complaints, disclosure, or doctor impact. (20 marks)

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Domain

General adult psychiatry — trauma and stressor-related disorders

2

Complex PTSD — diagnosis, differential and phase-based management (MEQ)

A 29-year-old woman with a history of childhood sexual abuse and adult intimate partner violence presents with nightmares and flashbacks of abuse, avoidance of intimacy, chronic hypervigilance, emotional flooding and shutdown, deep shame ('I am worthless'), and a pattern of intense then withdrawn relationships. She has no clear mania. She drinks heavily some nights. She asks if she has 'complex PTSD' and whether exposure therapy will 'destroy her'. (i) State working diagnosis using ICD-11 architecture and key differentials including BPD. (ii) Outline trauma-informed assessment priorities including risk and measures. (iii) Propose a psychological treatment plan with phase-based evidence and the de Jongh caution. (iv) If she wants medication, name an agent with starting dose and monitoring. (v) List trauma-informed care principles relevant to her service experience. (20 marks)

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PTSD and acute stress disorder — assessment and trauma-focused management (MEQ)

A 34-year-old paramedic is referred 8 weeks after a multi-fatality road incident. She has daily intrusive images, nightmares, avoidance of highway driving (affecting work), persistent guilt that she 'should have saved them', emotional numbing, hypervigilance and startle. She drinks a bottle of wine most nights to sleep. PHQ-9 is 16; she denies active suicide plan but has passive wishes she 'had died instead'. No prior mania. (i) State working diagnosis including DSM-5-TR duration logic and key differentials. (ii) Outline trauma-informed assessment priorities including risk and standardised measures. (iii) Propose a first-line psychological treatment with mechanism. (iv) If she declines therapy, name a first-line medication with starting dose and monitoring. (v) Discuss prazosin for nightmares with evidence balance. (20 marks)

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Domain

Child and adolescent psychiatry — disruptive behaviour

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Conduct and oppositional disorders — multi-domain assessment and stepped care (MEQ)

A 12-year-old boy is referred after repeated school suspensions for arguing with teachers, leaving class, and fighting. Parents report chronic defiance since early primary school, lying about homework, and recent shoplifting with older peers. He is restless and inattentive; Conners teacher ratings suggest ADHD. There is harsh, inconsistent discipline at home and maternal depression. He denies remorse about the fight that injured a peer's lip. There is no clear manic episode. (i) Outline multi-informant assessment priorities including ODD vs CD discrimination, CU features, comorbidity and risk. (ii) Formulate using developmental pathway language (e.g. Moffitt) and family coercive processes. (iii) Give a stepped psychosocial plan including a named parenting approach and when MST would be considered. (iv) State the limited role of medication, including ADHD treatment priority and monitoring if an antipsychotic is used for severe aggression. (v) Discuss prognosis and adult ASPD risk communication with the family. (20 marks)

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Domain

Professional practice — critical appraisal and EBM

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Critical appraisal of an antidepressant RCT abstract (MEQ)

You are preparing for journal club and MRCPsych/FRANZCP-style critical appraisal. Abstract (fictional numbers for exam practice): Double-blind RCT of Drug A versus placebo in adults with moderate major depression (HAM-D 18–24). N=180 randomised (90 per arm). Allocation described as 'randomised by clinic staff using open list'. Primary outcome: mean HAM-D change at 8 weeks. Completer analysis (28% dropout on drug, 18% on placebo) shows mean difference −3.2 points (p=0.04). Abstract headline: 'Drug A reduces depression by 40% relative to placebo'. Absolute response rates (50% HAM-D reduction) not reported in the abstract. (i) Write a PICO for the study. (ii) List the major validity threats and map each to a bias domain. (iii) Explain what additional numbers you need to compute ARR and NNT for response, and why RRR alone is inadequate. (iv) Interpret a hypothetical response rate of 50% drug vs 35% placebo (ARR, RRR, NNT). (v) Give a one-sentence applicability conclusion for a comorbid substance-using outpatient excluded by the trial. (20 marks)

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Domain

Professional — cultural formulation and Indigenous mental health

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Cultural formulation for an Aboriginal man with depression and mistrust (MEQ)

You are the psychiatry registrar in a regional ED. A 34-year-old Aboriginal man is brought by family after two weeks of low mood, insomnia, and passive death wishes. He is medically stable. He speaks English fluently but is reserved. He says previous hospital care felt racist and he does not want tablets. His aunt asks to stay. (i) Define cultural formulation and list the main OCF/CFI domains. (ii) Outline how you would structure a culturally safe assessment today, including risk, explanatory model, and supports. (iii) Explain social and emotional wellbeing (SEWB) and why it matters beyond a DSM depression label. (iv) Discuss working with family and Aboriginal health workers, and pitfalls of stereotyping. (v) Name key evidence anchors (CFI field trial; cultural safety; racism–health pathways). (20 marks)

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Domain

Professional — psychological therapies

2

DBT and third-wave therapies (MEQ)

You are a psychiatry registrar in a community service. A 26-year-old woman with borderline personality disorder has had four presentations this year with cutting after relationship ruptures, two overdoses of low medical lethality, and three early dropouts from brief counselling. She asks for 'DBT'. Your service has a weekly DBT skills group, limited individual capacity, and no formal phone-coaching roster. (i) Define comprehensive DBT (modes, modules, Stage 1 hierarchy) and state how your current offer differs. (ii) Outline biosocial theory and map it to the four skills modules. (iii) Summarise key RCT/meta-analytic evidence for DBT/specialised therapies in BPD and self-harm, including the McMain GPM teaching point. (iv) Compare DBT with ACT and MBCT for indication matching. (v) Propose a stepped, safety-focused plan if full-model DBT is not immediately available. (20 marks)

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MEQ: CBT formulation and treatment plan for panic with agoraphobia

You are the psychiatry registrar in an outpatient clinic. A 29-year-old teacher presents with 8 months of unexpected panic attacks (palpitations, breathlessness, fear of dying). She now avoids trains, shopping centres, and staff meetings. She checks her pulse repeatedly and carries diazepam ‘just in case’ but rarely takes it. PHQ-9 is 11; she drinks two standard drinks most nights ‘to switch off’. No chest pain on exertion; recent ECG and bloods normal. She wants ‘to fix her thinking’ and asks whether she still needs medication. (i) Outline the cognitive model of panic and name two maintaining safety behaviours in this case (5). (ii) Construct a brief CBT cross-sectional formulation using the five-area model (5). (iii) Describe session structure and a behavioural experiment you would design in the first treatment phase (5). (iv) Discuss integrating pharmacotherapy and when CBT is not the priority today (5). (20 marks)

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Domain

Old age psychiatry — delirium and acute cognitive syndromes

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Delirium in older adults — assessment and management (MEQ)

An 82-year-old woman with mild Alzheimer disease is admitted with pneumonia. On day two she is quieter, eating poorly, and fails months of the year backward. Nursing staff call her 'settled'. Family say she was conversing normally two days ago. She is on oxybutynin and temazepam at home. CAM is positive. (i) Define delirium and state the CAM diagnostic rule. (ii) Explain why hypoactive presentations are high-risk and list predisposing and precipitating factors relevant here. (iii) Outline non-pharmacological prevention and treatment measures (HELP-style). (iv) Discuss the role of benzodiazepines and antipsychotics, including dose philosophy if a drug is required for severe distress. (v) Outline capacity, risk, and disposition planning. (20 marks)

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Domain

General adult psychiatry — psychotic disorders

4

Delusional disorder — diagnosis, risk and management (MEQ)

A 46-year-old employed man is referred after police were called when he confronted a neighbour he believes has been ‘running a camera ring’ against him for 14 months. He describes an elaborate system of evidence (car number plates, ‘coded’ rubbish collection days). He denies hearing voices. Work performance is intact. His wife reports he has also begun accusing her of secret affairs and checking her phone nightly for 3 months. He drinks heavily on weekends. MSE: clear sensorium, systematised persecutory and jealous delusions, no formal thought disorder, limited insight, irritable affect, no active suicidal plan, but he says he ‘may have to stop them before they stop me.’ (i) State the most likely diagnosis with subtype(s) and justify. (ii) List key differentials with discriminators. (iii) Outline acute risk management including partner safety. (iv) Propose engagement strategy and a stepwise pharmacological and psychosocial plan with named agents, doses or targets, and monitoring. (v) State what the evidence allows you to claim about DD-specific RCTs. (20 marks)

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First-episode schizophrenia — assessment and initial management (MEQ)

A 19-year-old university student is brought by his parents after 4 months of social withdrawal, declining academic performance, and 6 weeks of believing classmates are spying on him through his laptop camera. He hears a running commentary on his actions. He smokes cannabis most evenings. There is no prior psychiatric history. He is alert, afebrile, observations normal, bedside glucose 5.4 mmol per litre. He has limited insight and is ambivalent about treatment. (i) Outline your assessment priorities including risk and organic exclusion. (ii) State your working diagnosis and key differentials with discriminators. (iii) Outline your initial management plan including a named first-line antipsychotic with starting dose, monitoring, and psychosocial interventions. (iv) Explain how duration of untreated psychosis influences prognosis and how early intervention services alter care. (v) Outline the threshold and next steps if he fails two adequate antipsychotic trials. (20 marks)

Open

Schizoaffective disorder — diagnosis and management (MEQ)

A 29-year-old woman has had continuous psychiatric illness for 5 years. Collateral and records show recurrent major depressive episodes and one clear manic admission with decreased need for sleep, grandiosity and pressured speech. For most of the 5 years she has met full major mood episode criteria. Between poles, for three separate periods of 3–4 weeks each, she experienced third-person commentary hallucinations and a fixed belief that microphones were implanted under her skin while family describe euthymic mood and normal sleep need. She smokes cannabis twice weekly. She presents now depressed, hearing commands to die, with passive death wishes and poor adherence to oral olanzapine 10 mg. (i) State the most likely diagnosis with type specifier and justify using operational criteria. (ii) List key differentials with discriminators. (iii) Outline acute risk management. (iv) Propose a stepwise pharmacological and psychosocial plan including named agents, doses or targets, and monitoring. (v) Explain when clozapine would enter the plan. (20 marks)

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Schizophreniform and brief psychotic disorder — duration, prognosis and FEP care (MEQ)

A 22-year-old university student is brought after 3 weeks of new third-person auditory hallucinations, persecutory delusions, and mild formal thought disorder. Premorbid function was excellent. Onset of frank psychosis was within 2 weeks of a sudden academic crisis. At interview he appears perplexed. Affect is not blunted. He used high-THC cannabis most weekends for 6 months but last used 10 days ago. Urine toxicology is now negative. No fever, normal observations, clear sensorium. (i) Give the best current DSM working diagnosis and justify duration thresholds. (ii) List good prognostic features present and state their clinical meaning. (iii) Outline acute assessment and investigation priorities. (iv) Propose a pharmacological and psychosocial plan with named agent, dose framework, and monitoring. (v) Explain diagnostic instability and post-remission maintenance counselling. (20 marks)

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Domain

Forensic psychiatry — morbid jealousy and erotomania

1

Delusional jealousy with partner assault and alcohol dependence (MEQ)

You are the psychiatry registrar on call. A 48-year-old man with longstanding heavy alcohol use is brought by police after assaulting his partner. She reports months of phone checks, forced confessions of affairs, and social isolation. He is adamant she is unfaithful with a work colleague he cannot name. He has no formal prior psychiatric diagnosis. Breath alcohol is still elevated; he is irritable but oriented. Children (8 and 11) were in the house. (i) Define the clinical constructs and differential you would use. (ii) Outline risk assessment and immediate safety priorities. (iii) Investigations and secondary-cause work-up. (iv) Short-term management including pharmacotherapy principles if a primary delusional disorder is confirmed after detoxification. (v) Longer-term multi-agency and forensic interfaces. Do not invent statute section numbers. (20 marks)

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Domain

Old age psychiatry — Lewy body dementias

1

Dementia with Lewy bodies — diagnosis and safe prescribing (MEQ)

A 74-year-old man is brought by his wife after six months of progressive cognitive decline, day-to-day fluctuation in alertness, recurrent well-formed visual hallucinations of people in the house, and dream enactment with punching during sleep for two years. Examination shows mild bilateral bradykinesia and rigidity. He has not yet been labelled with Parkinson disease. A junior doctor plans intramuscular high-dose haloperidol for agitation overnight. (i) Apply McKeith 2017 criteria and the 1-year rule to formulate the working diagnosis versus PDD and key differentials. (ii) Outline assessment and investigations including when DaT SPECT helps. (iii) Propose non-drug and drug management including a named cholinesterase inhibitor with dose, route, titration, and monitoring; explicitly address the antipsychotic plan. (iv) Cover RBD safety, prognosis themes, and follow-up. (20 marks)

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Domain

foundations — descriptive psychopathology

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Descriptive psychopathology domains, first-rank symptoms, and MSE language (MEQ)

You are the psychiatry registrar teaching a new resident. A 26-year-old presents with two weeks of fearfulness. On interview they speak with topic shifts that lose logical connection, believe a microchip was implanted by intelligence services, hear a second-person voice warning them not to trust doctors, and say 'thoughts that are not mine are being put into my head.' They deny being unwell. Attention is impaired; orientation to person and place is intact. (i) Define descriptive psychopathology and distinguish mood from affect and thought form from content. (ii) Label the key phenomena in this presentation with precise terms. (iii) List Schneiderian first-rank experiences relevant here and state their modern diagnostic status with evidence anchors. (iv) Outline organic red flags and how you would document insight multidimensionally. (v) Give two multi-board exam pearls on elicitation and culture. (20 marks)

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Domain

Foundations — psychological and neuropsychological testing

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Design a cognitive assessment pathway for complex presentations (MEQ)

You are the psychiatry registrar. A 68-year-old with late-onset psychotic depression has residual low mood, family report of forgetfulness, and MoCA 22/30 after partial response to an antidepressant. Separately, a 29-year-old with schizophrenia is being considered for a vocational rehabilitation programme. (i) Distinguish bedside cognitive screening from formal neuropsychological assessment and from symptom rating scales. (ii) Interpret the MoCA result with carefully cited caveats and list immediate confounds to exclude (including delirium). (iii) State when you would refer for formal NP and what the referral question should specify. (iv) For the schizophrenia patient, name evidence-based cognitive assessment approaches (e.g. MCCB/BACS) and why cognition matters for function (Green). (v) Outline how you would explain testing and results to each patient in plain language. (20 marks)

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Domain

Foundations — rating scales and measurement-based care

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Design and defend a measurement-based care pathway (MEQ)

You are the psychiatry registrar establishing measurement-based care in a community mood clinic. A 34-year-old with recurrent major depression starts an SSRI. Baseline PHQ-9 is 18 with item 9 = 1; GAD-7 is 12. (i) Define MBC and distinguish it from collecting questionnaires without acting. (ii) Interpret the baseline scores with carefully cited cut-offs and outline immediate risk actions. (iii) Choose clinician-rated adjuncts (HAM-D or MADRS) and justify. (iv) Describe a 12-week remeasurement and decision algorithm for non-response, citing key evidence. (v) Name two psychometric concepts (reliability/validity or PANSS-related if discussing general scale literacy) examiners expect you to explain. (20 marks)

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Domain

Child and adolescent psychiatry — developmental assessment

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Developmental assessment in CAP — history, tools, adaptive function and formulation (MEQ)

A 4-year-old boy is referred by his GP after nursery staff report limited phrases, poor peer play and delayed self-care. Parents say they have been 'worried about speech since age 2' but were told to wait. Pregnancy was complicated by preterm birth at 32 weeks. There is no known hearing test. He has not lost skills. Teachers complete an SDQ with elevated peer and hyperactivity scales. Parents ask whether he is 'autistic or just slow,' whether an IQ test alone will answer everything, and whether medication will make him catch up. (i) Outline a structured developmental history and domain milestone map. (ii) Distinguish surveillance, screening and diagnostic testing; name appropriate tool classes including ASD risk screening. (iii) Explain why adaptive function is essential alongside intellectual assessment. (iv) List key differentials and early investigations. (v) Write a brief 4P/biopsychosocial formulation skeleton and multiagency plan. (20 marks)

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Domain

General adult psychiatry — DID and dissociative amnesia

1

DID and dissociative amnesia — assessment, differential and phase-oriented management (MEQ)

A 32-year-old woman is brought after police found her at a distant bus station without ID. She cannot recall her name, address, or the past two weeks. Once partially oriented by a cousin, she reports chronic 'time loss', finding clothes she does not remember buying, and internal arguments between a 'protector' and a 'child part'. Childhood sexual abuse is disclosed later. PHQ-9 is 17. She has cut her forearms twice this month when 'someone else was in control'. She denies external command hallucinations and has no prior mania. UDS negative. (i) Working differential for the amnesia/fugue presentation and for chronic identity symptoms — with discriminators. (ii) Trauma-informed assessment plan including instruments and risk. (iii) Acute management of the fugue/amnestic state. (iv) Phase-oriented longer-term treatment with evidence caveats. (v) Pharmacotherapy principles and two iatrogenic pitfalls. (20 marks)

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Domain

Child and adolescent psychiatry — DMDD

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Disruptive mood dysregulation disorder — assessment, hierarchy, and management (MEQ)

An 8-year-old boy is referred after repeated school exclusions. For 18 months he has had near-daily angry mood and explosive temper outbursts 4–5 times per week at home and school, with property damage and hitting. Teachers describe him as 'always cranky'. There is no period of elevated mood, grandiosity, or decreased need for sleep. He meets ADHD criteria; parents argue constantly and use harsh inconsistent discipline. (i) Outline multi-informant assessment including bipolar screen, risk, and age/duration rules for DMDD. (ii) State working diagnosis and key differentials with discriminators, including ODD hierarchy. (iii) Outline first-line management including named psychosocial approaches and ADHD optimisation. (iv) Discuss what Dickstein (lithium) and Towbin (citalopram+stimulant) mean for medication decisions. (v) What adult outcome message do you give parents, citing longitudinal evidence? (20 marks)

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Domain

General adult psychiatry — dissociative disorders

1

Dissociative disorders — assessment, differential and phase-oriented management (MEQ)

A 29-year-old woman is referred after telling her GP she 'loses time', finds clothes she does not remember buying, and hears internal arguments between a 'protector' and a 'child part'. She has a childhood history of sexual abuse (not detailed in the letter). PHQ-9 is 18. She has cut her forearms twice in the past month when 'someone else was in control'. She denies external voices commanding harm from outside her head. No prior mania. Urine drug screen negative last week. (i) State a working differential including DID, OSDD, PTSD with dissociative symptoms, BPD, and primary psychosis — with key discriminators. (ii) Outline a trauma-informed assessment plan including risk and instruments. (iii) Propose a phase-oriented treatment framework with evidence caveats. (iv) Discuss pharmacotherapy principles and one DPDR-relevant psychological approach if depersonalisation dominates. (v) Name two iatrogenic pitfalls to avoid. (20 marks)

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Domain

Professional — doctor health, burnout and impairment

1

Doctor health, burnout and impairment (MEQ)

You are the psychiatry advanced trainee on call for governance. A 29-year-old registrar on your team has become irritable, cynical about patients, and exhausted after months of heavy night cover. Last week they made a near-miss prescribing error. Today they disclose passive suicidal ideation after a patient complaint. Separately, a consultant colleague was noted smelling of alcohol before a morning clinic last month. (i) Define burnout using the Maslach triad and contrast it with major depression and with impairment. (ii) Outline your immediate assessment and safety plan for the registrar. (iii) Outline organisational and individual interventions supported by evidence. (iv) Outline your approach to the potentially impaired consultant (patient-safety and reporting principles; no invented statute numbers). (v) Name four landmark literature anchors relevant to physician burnout, suicide risk, or doctor mental health. (20 marks)

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Domain

Intellectual disability psychiatry — Down syndrome

1

Down syndrome and mental health (MEQ)

A 49-year-old woman with Down syndrome and moderate intellectual disability, who previously enjoyed her day programme and lived with supportive parents, has 3 months of progressive withdrawal, reduced speech, weight loss of 4 kg, tearfulness and new incontinence. Parents worry she has 'early Alzheimer disease' after reading online. TSH was last checked 4 years ago. She snores loudly. (i) List the priority differential diagnoses. (ii) Outline history, MSE and investigation plan. (iii) Explain the neurobiological basis of Alzheimer risk in DS. (iv) Describe assessment tools for dementia in DS. (v) Outline management if depression is primary versus if progressive Alzheimer dementia is confirmed. (20 marks)

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Domain

Psychopharmacology — drug interactions and QTc

1

Drug interactions, smoking and QTc risk (MEQ)

A 42-year-old woman with schizophrenia is on clozapine 350 mg/day and smokes 20 cigarettes/day. QTc on admission is 438 ms. She is treated for community-acquired pneumonia with clarithromycin and is counselled to stop smoking in hospital. The GP also recently started fluvoxamine 100 mg for OCD symptoms. On day 4 she is sedated, hypersalivating, K+ 3.2 mmol/L, and repeat QTc is 498 ms. (i) Classify the interaction types present. (ii) Explain the CYP mechanisms for smoking and fluvoxamine with clozapine. (iii) Outline immediate management of her cardiac and toxicity risks. (iv) Propose a safer medium-term psychotropic and monitoring plan. (v) State TdP emergency principles if she develops polymorphic VT. (20 marks)

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Domain

Addiction psychiatry — dual diagnosis and integrated care

1

Dual diagnosis — models of care to integrated recovery (MEQ)

A 28-year-old man with schizophrenia is declined mental health follow-up until he is 'clean of cannabis for a month.' He uses high-THC cannabis daily, is precontemplative about stopping, has partial insight, and has had two recent relapses of psychosis. His mother asks why services keep bouncing him between mental health and AOD. (i) Define dual diagnosis and name sequential, parallel and integrated models. (ii) Apply stages of change and outline a motivational interviewing approach. (iii) Summarise etiological models of co-occurrence (name at least three). (iv) Give an integrated management plan including pharmacotherapy principles and systems fixes. (v) State what recovery means beyond abstinence and cite key evidence limitations honestly. (20 marks)

Open

Domain

Child and adolescent psychiatry — early-onset psychosis

1

Early-onset psychosis — CAP assessment to clozapine threshold (MEQ)

A 14-year-old is brought by parents after 4 months of school failure and 10 weeks of believing classmates track him via his phone. He hears a third-person commentary. He has a prior autism spectrum diagnosis and smokes high-THC cannabis most weekends. He is afebrile and alert; observations and bedside glucose are normal. Insight is partial. Parents ask if this is 'just autism' and whether medication will ruin his metabolism. (i) Define EOP vs VEOP/COS and calculate the clinical importance of DUP here. (ii) Outline the CAP differential (including autism, trauma, substance, organic) with discriminators. (iii) List baseline investigations before antipsychotics and when you escalate organic tests. (iv) Give a named first-line oral antipsychotic with a youth start-low plan, monitoring and trial length. (v) Describe multi-element youth care (family, school, substance) and the clozapine threshold if two adequate trials fail. (20 marks)

Open

Domain

Foundations — EEG and clinical neurophysiology

1

EEG and clinical neurophysiology in psychiatry — MEQ

A 24-year-old woman is admitted with first-episode psychosis, fluctuating awareness, and brief staring spells. She is started on an antipsychotic. Later she requires clozapine for treatment resistance and has a tonic-clonic seizure after dose escalation. (i) Outline indications for EEG in psychiatric practice and what a normal EEG does and does not exclude. (ii) Explain how you would approach possible nonconvulsive status epilepticus including recording type. (iii) Summarise clozapine-related EEG changes and seizure risk with management principles. (iv) Contrast the clinical status of routine EEG with research tools such as MMN/P300 and qEEG. (v) Name one encephalitis-related EEG signature and the clinical action it should trigger. (20 marks)

Open

Domain

Old age psychiatry — elder abuse and vulnerability

1

Elder abuse in dementia caregiving (MEQ)

You are the old-age psychiatry registrar. An 82-year-old woman with moderate Alzheimer disease is brought to ED by ambulance after neighbours found her dehydrated and bruised. She lives with her son, who provides full-time care and says she 'falls and refuses food.' He answers all questions and becomes angry when staff ask to speak with her alone. Bills are unpaid despite a full pension and savings. She is not under a mental health order. (i) Define elder abuse and list major subtypes. (ii) Outline your immediate assessment including interview strategy, capacity principles, and documentation. (iii) List key risk factors in this scenario and relevant evidence anchors. (iv) Describe multi-agency management and reporting principles without inventing statute section numbers. (v) Outline psychiatric management of mental health sequelae and safe disposition criteria. (20 marks)

Open

Domain

Child and adolescent psychiatry — elimination disorders

1

Elimination disorders — enuresis and encopresis stepped care (MEQ)

A 7-year-old boy is referred to CAMHS after school exclusion from a camp because of bedwetting and because classmates tease him about 'smelly pants.' He has never been dry at night. He voids normally by day without urgency. Parents describe large infrequent stools, toilet withholding, and liquid staining of underwear that they treated as diarrhoea. Father has begun making him wash sheets as punishment. Teachers report inattention and fidgeting. Parents ask for 'the tablet that fixes bedwetting' before next term's camp and whether he is being deliberately dirty. (i) State DSM age thresholds and classify the likely elimination diagnoses using DSM and ICCS language. (ii) Outline assessment including red flags and investigations. (iii) Give a management plan for enuresis and encopresis with named first-line strategies and medication safety points. (iv) Address punishment and school stigma. (v) Counsel prognosis and disposition. (20 marks)

Open

Domain

Foundations — epidemiologic methods for psychiatry

1

Epidemiologic measures and inference in psychiatry (MEQ)

You are the psychiatry registrar preparing a teaching session for core trainees after a journal club abstract claimed that 'childhood adversity causes 40% of adult depression' based on a cross-sectional survey OR of 2.8 and a quoted population attributable fraction of 40%. Separately, the local public health unit asks whether a new online depression screen (sensitivity 90%, specificity 90%) should be rolled out to all adults in a region where true major depression prevalence is about 2%. (i) Define point prevalence, period prevalence, cumulative incidence, and incidence rate, and state which measure best describes current community caseload for service planning. (ii) Explain the difference between a relative risk, an odds ratio, and a population attributable fraction, including when OR may mislead if read as RR. (iii) List three major bias families that could distort the adversity–depression association and give a psychiatry-specific example of each. (iv) Using the screening numbers above, explain qualitatively why PPV will be low in community rollout and what programme criteria (Wilson–Jungner tradition) you would require before endorsing screening. (v) Outline how you would rewrite the journal club causal claim in scientifically defensible language. (20 marks)

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Domain

Psychopharmacology

1

EPS spectrum and tardive dyskinesia management (MEQ)

A 34-year-old man with schizophrenia is day 3 of admission. He received risperidone titration to 6 mg and two doses of IM zuclopenthixol acetate. He develops painful torticollis and oculogyric crisis, which resolve after parenteral anticholinergic. Two weeks later he reports constant inner restlessness and paces the corridor; staff want more IM antipsychotic for 'agitation'. Six months later, on stable oral risperidone, he develops new tongue-darting and chewing movements. (i) Explain the tempo classification linking these three presentations. (ii) Outline immediate and secondary management of acute dystonia including a named parenteral dose. (iii) Differentiate akathisia from psychotic agitation and give an evidence-informed treatment plan including a named propranolol regimen orientation. (iv) Outline TD assessment (including AIMS), antipsychotic strategy, and the RCT evidence base for VMAT2 inhibitors. (20 marks)

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Domain

Specialty psychiatry — sexual medicine interface

2

Erectile disorder and premature ejaculation — assessment and management (MEQ)

A 49-year-old man is referred by his GP. He has type 2 diabetes (HbA1c 8.4%), takes metformin and as-needed GTN spray for infrequent angina, and has progressive erectile failure for 2 years with absent morning erections. He also reports that when an erection is partial he ejaculates within under a minute and feels ashamed. Six months ago sertraline 100 mg was started for depression (now partial response, PHQ-9 = 12). He asks for 'Viagra and something to last longer.' (i) Formulate the sexual diagnoses and organic vs psychogenic contributions. (ii) Outline assessment priorities including cardiovascular and medication factors. (iii) Discuss PDE5 inhibitor suitability and safety. (iv) Manage the ejaculatory complaint and antidepressant-related issues. (v) Disposition and safety-net. (20 marks)

Open

Female sexual interest/arousal disorder after SSRI treatment and comorbid dyspareunia (MEQ)

A 38-year-old woman with recurrent MDD is in partial remission (PHQ-9 = 9) on sertraline 150 mg orally daily for 8 months. She reports 7 months of markedly reduced sexual interest, reduced subjective arousal, and entry dyspareunia with avoidance of intimacy. She is distressed and fears her relationship will end. No alcohol binge pattern. Gynaecology review 1 year ago for heavy periods was unremarkable; she is perimenopausal-range irregular cycles. Partner is frustrated and has said she is 'broken.' (i) Formulate diagnoses and key differentials. (ii) Outline assessment. (iii) Propose a stepped management plan including psychosexual care and medication options with doses where relevant. (iv) Address relationship/safety and communication issues. (v) State prognostic and disposition points. (20 marks)

Open

Domain

Forensic psychiatry — expert evidence

1

Expert evidence and forensic report writing (MEQ)

You are retained as an independent psychiatric expert. Scenario A: A solicitor instructs you in a contested civil disability claim after a motor-vehicle collision. The brief is incomplete and counsel telephones asking you to 'just confirm total permanent disability' before records arrive. Scenario B (same sitting): You are the long-term treating psychiatrist of a defendant who is now facing trial; defence counsel asks you to write a full contested fitness and criminal-responsibility expert report as if you were independent. (i) Outline the ethical dual-role and impartiality issues in both scenarios. (ii) Describe a structured forensic assessment method before writing. (iii) List the essential sections of a forensic psychiatric report and how opinions should be linked to legal questions. (iv) How would you handle oral testimony and cross-examination challenges on bias and missing data? (v) Name three high-yield pitfalls including ultimate-issue and invented-statute traps. (20 marks)

Open

Domain

Psychotherapy — behavioural therapies

1

Exposure and response prevention for residual OCD on an SRI (MEQ)

A 29-year-old software engineer with DSM-5-TR OCD (contamination and checking) has been on sertraline 200 mg oral daily for five months with partial benefit (Y-BOCS fell from 28 to 20). He washes for two hours daily, seeks partner reassurance, and avoids public toilets. He has had 'CBT' for eight sessions that were mostly supportive discussion without homework exposures. He declines antipsychotics. (i) Define ERP and explain the maintaining cycle it targets. (ii) Outline assessment steps and hierarchy design for this man, including family accommodation. (iii) Summarise landmark trial evidence relevant to offering EX/RP now (include Foa 2005 and Simpson augmentation trials). (iv) List four fidelity failures that would make further 'CBT' look like non-response. (v) State how you would integrate ongoing sertraline with ERP and when you would step up care. (20 marks)

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Domain

Forensic psychiatry — FII / medical child abuse

1

Fabricated or induced illness — recognition, safeguarding, and forensic role (MEQ)

A 3-year-old is admitted with recurrent unexplained seizures. Multiple EEGs on the ward are normal. Events cluster when mother (a former healthcare assistant) is alone with the child. Prior hospitals document normal video-EEG and a sibling who died of 'unascertained causes' in infancy. Mother demands further invasive tests and becomes hostile when negative findings are discussed. (i) Map terminology (MSBP, FII/PP, MCA/CFI, FDIA) and the continuum of caregiver behaviour. (ii) List high-yield red flags and acute safety steps. (iii) Outline multi-source assessment and the role of separation/covert video principles. (iv) Differentiate genuine disease, anxious parenting, malingering by proxy, and FDIA. (v) Describe child and caregiver management plus family-court opinion limits. (20 marks)

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Domain

General adult psychiatry — factitious disorder and malingering

1

Factitious disorder vs malingering — assessment, ethics and non-collusive management (MEQ)

A 34-year-old healthcare assistant is admitted with recurrent polymicrobial bacteraemia. Blood cultures repeatedly grow gut organisms. No abdominal source is found on CT. Nursing staff note that fevers spike after the patient spends time alone in the bathroom with a closed bag. Prior records from three hospitals show unexplained infections and two laparoscopies. The patient demands further central lines and becomes angry when a psychiatric review is suggested. There is no current litigation. PHQ-9 is 16. (i) Define factitious disorder imposed on self and differentiate from malingering, FND and SSD. (ii) Outline a multidisciplinary assessment including collateral, risk and documentation. (iii) Propose an acute and definitive management plan emphasising non-collusion. (iv) Discuss ethical and legal issues including capacity and information-sharing. (v) State prognosis factors and follow-up arrangements. (20 marks)

Open

Domain

Old age psychiatry — falls polypharmacy frailty

1

Falls, polypharmacy and frailty in old-age psychiatry (MEQ)

An 83-year-old woman living in residential care has moderate Alzheimer disease, hypertension on a thiazide, two falls in the past month (one with facial bruising), and staff report evening 'agitation' during personal care. Medications include risperidone 0.5 mg twice daily (started 10 months ago for 'behaviour,' no review date), temazepam 10–20 mg most nights, oxybutynin, and recently started sertraline 50 mg. Daughter asks whether to 'give something stronger to settle her' and whether falls mean all psychotropics must stop forever. (i) Define frailty frameworks relevant to her risk and why falls, polypharmacy and frailty are one clinical problem. (ii) Critically review her regimen using Beers/STOPP and FRID concepts. (iii) Outline a multifactorial falls assessment and evidence-based prevention plan. (iv) Discuss deprescribing versus continued psychotropic treatment, including antipsychotic black-box framing and an illustrative safer antidepressant monitoring plan. (v) Address family communication and disposition. (20 marks)

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Domain

Professional — psychosocial interventions

1

Family intervention after first-episode psychosis (MEQ)

A 20-year-old with first-episode schizophrenia is discharged to live with his parents. His mother is highly anxious, makes frequent critical comments about 'laziness', and sits with him continuously 'to keep him safe'. His father is withdrawn. The patient agrees to paliperidone LAI. Relapse risk and carer burden are high. (i) Define expressed emotion (EE) and its components, with the evidence link to relapse. (ii) Outline aims and core components of structured family intervention for psychosis. (iii) How would you engage this family without blaming them? (iv) State when joint family sessions should be deferred. (v) List two outcomes beyond symptom relapse that family work targets. (20 marks)

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Domain

General adult psychiatry — early psychosis pathway

1

First-episode psychosis pathway — assessment to recovery (MEQ)

A 19-year-old university student is brought by his parents after 5 months of social withdrawal and 8 weeks of believing classmates are tracking him through his phone. He hears a third-person commentary. He smokes high-THC cannabis most evenings. Observations and bedside glucose are normal; he is alert and afebrile. Insight is partial. (i) Define FEP and calculate the clinical importance of DUP in this case. (ii) Outline organic exclusion and baseline investigations before antipsychotics. (iii) Give a named first-line oral antipsychotic with starting dose, monitoring and trial length. (iv) Describe the multi-element early intervention package and the evidence base (name at least two landmark programmes or syntheses). (v) Counsel on maintenance duration after remission and on cannabis. (20 marks)

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Domain

Forensic psychiatry — fitness and criminal responsibility

1

Fitness to stand trial and mental impairment defence (MEQ)

You are the forensic psychiatry registrar. A 29-year-old man with untreated schizophrenia is charged with arson of a neighbour's car. He tells custody staff that his lawyer works for the fire service and is planting thoughts. He can name the judge after teaching but cannot accept any defence advice. Counsel raises fitness. Separately, the alleged offence occurred six months earlier during an untreated psychotic relapse with documented command content about 'cleansing the street'. (i) Distinguish the fitness question from the criminal responsibility question. (ii) Outline a structured fitness assessment mapped to Presser/Pritchard/Dusky principles. (iii) How would you approach restorability and immediate management? (iv) Outline principles of a criminal responsibility (mental impairment/insanity) analysis for the offence. (v) List report and ethical pitfalls to avoid. (20 marks)

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Domain

Intellectual disability — neurodevelopmental

2

Foetal alcohol spectrum disorder — diagnosis, neurobehaviour and management (MEQ)

A 9-year-old boy in kinship care is referred for 'treatment-resistant ADHD' and school exclusion after impulsive aggression. Birth records note maternal binge drinking in the first half of pregnancy. Growth is on the 10th centile; philtrum is smooth and upper lip thin; palpebral fissures appear short. He has average verbal scores but very weak working memory, planning and adaptive daily living skills. (i) Define FASD and outline how you would apply a named diagnostic framework (Hoyme, Cook/Canadian or 4-digit). (ii) Describe the expected neurobehavioural profile and key differentials from ADHD alone, ASD and trauma. (iii) Outline non-pharmacological management and how early diagnosis affects secondary disabilities. (iv) Discuss pharmacotherapy principles for comorbidities, with monitoring caveats. (v) State prevention messages you would give the kinship carers and any adolescent siblings of childbearing potential. (20 marks)

Open

Fragile X syndrome — genetics, phenotype and management (MEQ)

A 6-year-old boy is referred for 'treatment-resistant ADHD', social anxiety and mild intellectual disability. He has a long face, prominent ears and gaze aversion. His maternal uncle attended a special school; his mother had premature ovarian insufficiency at 35. (i) Define fragile X syndrome and outline FMR1 allele classes with approximate CGG ranges. (ii) Explain the molecular mechanism of full mutation versus premutation pathophysiology. (iii) Describe the expected behavioural/psychiatric phenotype and key differentials. (iv) Outline investigation and cascade counselling. (v) Discuss non-pharmacological care and principles of comorbidity psychopharmacology, including what you would not claim about disease-modifying drugs. (20 marks)

Open

Domain

Forensic psychiatry — risk assessment

1

Forensic risk assessment for leave and step-down (MEQ)

A 34-year-old man with schizophrenia and two prior convictions for assault is detained in a medium secure unit after an index offence of wounding a neighbour he believed was poisoning him. After 10 months he has good antipsychotic response, negative drug screens for 4 months, and improved insight. The team is considering graduated leave. Static actuarial ranking remains elevated because of his violence history. (i) Outline how you would structure a forensic risk assessment using SPJ principles. (ii) Distinguish static, dynamic, and protective factors in this case. (iii) Explain the role and limits of actuarial tools. (iv) Write two risk scenarios and a risk management plan for leave. (v) List essential elements of your report to the tribunal or multi-disciplinary review. (20 marks)

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Domain

Old age psychiatry — neurocognitive disorders

2

Frontotemporal dementia — assessment and management (MEQ)

A 54-year-old company director is brought by his wife because over 18 months he has become tactless at work, lost empathy for family distress, developed a rigid sweet-food ritual, and made impulsive financial gifts to strangers. He denies any problem and scores 28/30 on MMSE. There is a family history of 'ALS' in his brother and 'personality change' dementia in their mother. Neurologic exam shows rare fasciculations in the upper limbs. (i) Outline diagnostic formulation including Rascovsky criteria and key differentials. (ii) Discuss genetic considerations including C9orf72, MAPT, and GRN. (iii) Detail assessment of risk, capacity, and investigations. (iv) Propose a management plan including non-drug care and the role (and limits) of medication. (v) Explain ALS-FTSD implications. (20 marks)

Open

Young-onset dementia — assessment and management (MEQ)

A 56-year-old project manager is referred after 2 years of progressive work errors, getting lost on familiar routes, and word-finding difficulty. His wife reports he is no longer safe managing the household finances. He scores 22/30 on MoCA. There is no heavy alcohol history. His father developed dementia in his early 50s and died at 58. (i) Define young-onset dementia and outline the major aetiologic differential. (ii) Detail history, examination, and investigation priorities including genetics. (iii) Discuss risk, capacity, employment, and driving. (iv) Propose a management plan including when cholinesterase inhibitors are appropriate and limits of antipsychotics. (v) Address family genetic counselling principles. (20 marks)

Open

Domain

Addiction psychiatry — behavioural addictions

2

Gambling disorder — criteria, risk, CBT, and naltrexone (MEQ)

A 42-year-old man is referred after his partner discovered $180,000 of concealed online sports-betting losses and a second mortgage. He gambles daily, chases losses, lies about sessions, has failed repeated cut-down attempts, and is restless when he tries to stop. He drinks 8–10 standard drinks most evenings, has passive suicidal ideation without plan since the financial disclosure, and LFTs show ALT 62 U/L. He asks for 'a tablet that will kill the urge' and refuses psychology. (i) Apply DSM-5-TR diagnostic and severity framing. (ii) Outline acute risk and dual-diagnosis assessment priorities. (iii) Construct a first-line psychosocial and harm-reduction plan with named therapy elements. (iv) Discuss naltrexone evidence, off-label status, dosing/monitoring framing, and counselling points given his LFTs and alcohol use. (v) List two classic differential traps relevant to this presentation. (20 marks)

Open

Gaming and internet addiction — ICD-11, CBT, and comorbidity (MEQ)

A 17-year-old boy is referred after failing Year 11. He plays online multiplayer games 8–12 hours most days, sleeps 03:00–11:00, has been violent twice when parents cut the Wi-Fi, conceals session length, and continues despite academic collapse. He screens positive for ADHD traits, has low mood without clear melancholic features, spends approximately $200/month on loot boxes, and has passive suicidal ideation after the latest family fight. Parents demand 'a detox admission and a tablet.' (i) Apply ICD-11 gaming disorder framing and contrast DSM-5-TR IGD research status. (ii) Outline assessment priorities including risk and differential. (iii) Construct a first-line psychosocial plan with named elements. (iv) Counsel on pharmacotherapy expectations including bupropion evidence context. (v) List two classic pitfalls. (20 marks)

Open

Domain

Specialty psychiatry — gender diversity ethics and systems

1

Gender diversity — minority stress, ethics, and systems care (MEQ)

A 19-year-old non-binary person (they/them) is referred after an intentional overdose. They describe years of family misgendering, workplace harassment, and avoidance of GPs after a prior clinician deadnamed them and asked voyeuristic genital questions. They do not want hormones. PHQ-9 is 18; they have ongoing passive death wish without plan after means removal. One parent demands 'conversion counselling' before any further mental health contact. (i) Distinguish gender diversity from gender dysphoria and state why identity is not a mental disorder. (ii) Explain minority stress mechanisms relevant to this presentation. (iii) Outline acute risk management and affirming communication. (iv) Discuss ethical response to conversion demands and privacy. (v) Propose a longitudinal plan targeting protective factors and comorbidity without forced medicalisation. (20 marks)

Open

Domain

Specialty psychiatry — gender and sexuality

1

Gender dysphoria — assessment, risk, and affirming pathway (MEQ)

A 17-year-old assigned female at birth is referred after school refusal and self-harm. For 2 years they have used he/him pronouns privately, worn a chest binder, and describe intense distress at menses and breast development. They request testosterone. History includes social anxiety, possible autistic traits (literal communication, sensory sensitivity), and one prior overdose after family rejection of their identity. No current psychotic symptoms. Parents disagree: one parent is supportive; the other demands 'conversion counselling'. PHQ-9 is 16; there is passive death wish without plan today. (i) Define gender dysphoria and discriminate from BDD and temporary identity exploration. (ii) Outline comprehensive assessment including risk and comorbidity. (iii) Explain affirmative care principles and why conversion efforts are inappropriate. (iv) Discuss capacity/consent developmental issues for hormones. (v) Propose a multidisciplinary management plan. (20 marks)

Open

Domain

General adult psychiatry — anxiety disorders

6

Generalised anxiety disorder — assessment and stepped management (MEQ)

A 36-year-old accountant is referred with 10 months of difficult-to-control worry about work performance, finances, family health and minor daily matters, occurring most days. She reports restlessness, muscle tension, irritability, poor concentration and initial insomnia. She denies discrete unexpected panic attacks. She drinks three strong coffees and two glasses of wine most evenings. PHQ-9 is 12; GAD-7 is 15; she has passive thoughts that 'family would be better if I were less of a burden' without a plan. TSH last year was normal. No prior mania is volunteered. (i) Outline assessment priorities including risk, substances, organic exclusion and scales. (ii) State working diagnosis and key differentials with discriminators. (iii) Outline a stepped management plan including CBT ingredients and a named first-line medication with dose and monitoring. (iv) Discuss the role and limits of benzodiazepines and where pregabalin or buspirone might fit. (v) State how comorbidity with depression changes risk and follow-up. (20 marks)

Open

Panic disorder and agoraphobia — assessment and stepped management (MEQ)

A 29-year-old woman is referred after six months of recurrent unexpected episodes of palpitations, dyspnoea, derealisation and fear of dying that peak within minutes. Between episodes she worries daily about the next attack and has stopped using buses and shopping alone. She visits ED twice monthly; prior ECGs and troponins were normal. She drinks four coffees daily and uses alprazolam from a relative when distressed. PHQ-9 is 14; she reports passive death wishes without plan. (i) Outline assessment priorities including medical exclusion, substances, risk and differential. (ii) State working diagnoses using DSM-5-TR logic. (iii) Detail a first-line psychological treatment plan with active ingredients. (iv) Propose a named first-line antidepressant with starting dose, titration and monitoring, and state the place of benzodiazepines. (v) Outline maintenance and relapse-prevention planning. (20 marks)

Open

Selective mutism — school silence and stepped care (MEQ)

A 6-year-old girl has said no words to teachers for 5 months despite speaking freely at home in full sentences. She freezes and stares at the floor when called on. Peers and the teacher answer for her. Parents say she is 'shy but fine' and request 'a tablet to force her to talk by next week' while refusing school visits. Hearing has never been checked. She is bilingual at home; classroom language is English, which she understands on testing but rarely practices with non-family adults. PHQ-style mood screen is negative for depression. (i) Outline assessment priorities including criteria, collateral, and key exclusions. (ii) State working diagnosis and differentials with discriminators. (iii) Detail first-line psychological/school plan including accommodation targets. (iv) Discuss medication role with a named agent, dose, route, and monitoring. (v) Address parental requests for forced speech and disposition. (20 marks)

Open

Separation anxiety disorder — school refusal and adult under-recognition (MEQ)

A 10-year-old girl has missed 7 weeks of school with morning abdominal pain, insists on sleeping in her parents' bed, and becomes frantic if her mother leaves the house. Symptoms began after her father was hospitalised 4 months ago and have lasted continuously since. Her 38-year-old mother separately confides that for 2 years she cannot let her husband travel for work, checks his location constantly, and has panic-like episodes only when home alone — she was never assessed for anxiety as a child. PHQ-9 on the mother is 14 with passive death wishes when she imagines 'something happening to my family and me being alone forever'. (i) Outline assessment priorities for child and mother including risk, criteria, and differentials. (ii) State working diagnoses with discriminators. (iii) Detail first-line psychological plans including family accommodation targets. (iv) Discuss medication options with named agents, doses, routes, and monitoring, including CAMS-informed paediatric framing. (v) Address disposition, school liaison, and adult under-recognition. (20 marks)

Open

Social anxiety disorder — assessment and stepped management (MEQ)

A 22-year-old university student is referred with 4 years of intense fear of seminars, tutorials and parties. He blushes, sweats and trembles when speaking, believes peers will judge him as incompetent, avoids presentations (risking course failure), and drinks 4–6 standard drinks before any social event. He denies unexpected panic attacks. He has passive thoughts that 'everyone would be better off without my awkwardness' without a plan. PHQ-9 is 14; SPIN is high. No mania is volunteered. TSH last year was normal. (i) Outline assessment priorities including risk, substances, organic exclusion and scales. (ii) State working diagnosis and key differentials with discriminators. (iii) Outline a stepped management plan including CBT ingredients and a named first-line medication with dose and monitoring. (iv) Discuss alcohol as a safety behaviour and limits of benzodiazepines. (v) State how comorbid depression changes risk and follow-up. (20 marks)

Open

Specific phobia — assessment and exposure-first management (MEQ)

A 31-year-old teacher is referred after collapsing during a routine blood test. She has avoided injections and dental care for 12 years, cancelled a recommended colonoscopy, and becomes dizzy and nauseated at the sight of blood. She also refuses commercial flights after a turbulent landing 8 years ago, using only ground transport even when it costs her promotions. She denies unexpected panic attacks, multi-domain public transport fear, or fear of scrutiny at work. PHQ-9 is 11 with passive death wishes without plan when she thinks about 'being a burden if I get cancer and cannot have tests'. (i) Outline assessment priorities including risk, type specifiers, organic/syncope issues and differentials. (ii) State working diagnoses with discriminators. (iii) Detail a first-line psychological plan including hierarchy principles and, where relevant, one-session treatment and applied tension. (iv) State the limited role of medication with a named short-term option and cautions. (v) Address healthcare avoidance and depression risk. (20 marks)

Open

Domain

Addiction psychiatry — hallucinogen-related disorders

1

Hallucinogen-related disorders — bad trip, HPPD, and PAT interface (MEQ)

A 24-year-old man is brought from a multi-day music festival after ingesting blotter sold as LSD plus cannabis. HR 108, BP 138/84, temperature 37.2°C, glucose normal. He is oriented, mydriatic, terrified that the stage lights are scanning his thoughts, and tries to run toward a road. Friends report this is his third lifetime psychedelic use; no prior psychiatric admissions; maternal uncle has schizophrenia. Effects peak over several hours then settle with talk-down and a single oral lorazepam 1 mg. Two months later he re-presents with constant visual trailing and geometric patterns while abstinent, with occupational impairment and secondary anxiety. He asks whether microdosing will fix his 'depression' after reading about psilocybin trials. (i) Outline acute assessment and management priorities for the festival presentation. (ii) Formulate psychosis risk and dual formulation issues given the family history. (iii) Define HPPD and initial management. (iv) Explain the evidence interface with psychedelic-assisted therapy and why unsupervised microdosing is not appropriate. (v) List disposition and harm-reduction advice. (20 marks)

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Domain

Addiction psychiatry — public health and systems

1

Harm reduction package for an open drug scene (MEQ)

You are the addiction psychiatry consultant advising a metropolitan health district. Over 18 months, ambulance-attended opioid overdoses have risen, HIV diagnoses among people who inject drugs have increased, and local businesses report public injecting. A community coalition demands a supervised consumption service; a council faction argues this will 'send the wrong message' and wants abstinence-only detox expansion instead. A 32-year-old man who injects heroin daily, shares equipment when 'stuck', survived an overdose last month, and declined methadone previously after being discharged from a clinic for one positive benzodiazepine urine, is presented as a case study. (i) Define harm reduction and contrast it with abstinence-only gatekeeping. (ii) Propose a multi-component public-health package with named interventions and evidence. (iii) Outline individual care for the case patient including naloxone, NSP, and OAT re-engagement. (iv) Address stigma and the 'wrong message' objection in examiner-ready language. (v) Name high-risk transition points for overdose prevention planning. (20 marks)

Open

Domain

Specialty psychiatry — clinical paraphilic disorders

1

Help-seeking pedophilic disorder with occupational access risk (MEQ)

A 34-year-old man self-refers to psychiatry in profound shame. He reports a multi-year preferential sexual interest in prepubescent children, increasing use of illegal child exploitation material online (disclosed spontaneously), and fear he will 'act in real life.' He denies contact offences. He works as a swimming coach for children and lives with his partner who does not know. He drinks heavily on weekends. PHQ-9 is 18 with passive death wishes after contemplating police discovery. (i) Formulate diagnoses and key differentials. (ii) Outline assessment priorities including risk and confidentiality limits. (iii) Propose a management plan spanning protection, psychology, and pharmacology principles. (iv) State treatment goals and prognosis framing. (v) Link to WFSBP/ICD-11 teaching with evidence. (20 marks)

Open

Domain

Forensic psychiatry — homicide and mental disorder

1

Homicide during untreated first-episode psychosis (MEQ)

You are the forensic psychiatry registrar. A 22-year-old man with no prior psychiatric admissions is charged with the stabbing death of his mother. Neighbours describe three months of social withdrawal, sleeplessness, and talk that she was 'poisoning his thoughts'. He was not under mental health care. Toxicology at arrest is negative for stimulants; low-level alcohol only. In custody he remains preoccupied that she was an imposter and he is intermittently suicidal. Counsel raises mental impairment and asks about future risk. (i) Summarise the epidemiological context examiners expect (absolute vs relative risk; FEP). (ii) Outline multi-source reconstruction of mental state at the offence and how you would approach criminal responsibility without equating diagnosis with defence. (iii) Separate fitness and future-risk questions from responsibility. (iv) Immediate management priorities including suicide risk. (v) Longer-term pathway principles and prevention lessons. Do not invent statute section numbers. (20 marks)

Open

Domain

General adult psychiatry — somatic symptom and related

1

Illness anxiety disorder — assessment and stepped management (MEQ)

A 38-year-old teacher is referred by her GP after 14 months of fear that she has 'undiagnosed leukaemia.' She has mild fatigue only. Full blood counts and chemistry panels have been normal three times. She spends 2–3 hours daily checking for bruises and reading online cancer forums, has attended ED twice, and requests another bone-marrow biopsy 'for peace of mind.' PHQ-9 is 16; she has passive death wishes without plan. She takes sertraline 50 mg for 3 weeks. (i) Define IAD and discriminate from SSD, OCD, and delusional disorder. (ii) Map legacy hypochondriasis to DSM-5-TR. (iii) Outline the CBT maintaining model and specialised psychological treatment. (iv) Optimise pharmacotherapy with agent and trial concept. (v) Describe the CL / primary-care collaborative plan and risk issues. (20 marks)

Open

Domain

Addiction psychiatry — inhalant-related disorders

1

Inhalant-related disorders — chroming, sudden sniffing death, and N2O myeloneuropathy (MEQ)

A 15-year-old is brought to ED after collapsing while running from police; friends report he had been chroming spray paint from a bag for 30 minutes. He smells strongly of paint, HR 118, BP 98/60, ECG sinus tachycardia, GCS 14, paint stains on hands. Overnight he is irritable with craving to chrome again. Two weeks later his 19-year-old cousin presents with progressive gait ataxia and numbness in the feet after daily nitrous oxide balloons for three months; serum B12 is borderline. (i) Outline immediate medical priorities for the 15-year-old and explain sudden sniffing death. (ii) Describe assessment of adolescent inhalant use and key comorbidities. (iii) Outline ongoing management for volatile substance misuse, including the evidence position on pharmacotherapy. (iv) Formulate the cousin's presentation and acute treatment steps. (v) List harm-reduction and disposition principles for both presentations. (20 marks)

Open

Domain

Psychopharmacology — long-acting injectable antipsychotics

1

Initiating a long-acting injectable antipsychotic (MEQ)

A 23-year-old man with first-episode schizophrenia had two early relapses after missing oral aripiprazole. He accepts that tablets are hard to remember, is metabolically healthy, and is not treatment-resistant. (i) Justify offering an LAI early, citing key evidence. (ii) Outline pre-start assessment including oral tolerability. (iii) Describe an aripiprazole monohydrate initiation plan including oral overlap principles. (iv) Explain monitoring and missed-dose planning. (v) State when LAI would not replace clozapine. (20 marks)

Open

Domain

Psychopharmacology — monoamine oxidase inhibitors

1

Initiating an irreversible MAOI safely in treatment-resistant depression (MEQ)

A 48-year-old man with recurrent unipolar MDD has not remitted after adequate trials of sertraline, venlafaxine XR and lithium augmentation. He has atypical features (mood reactivity, hypersomnia, leaden paralysis). No bipolar history. He drinks occasionally and uses OTC cold remedies in winter. The consultant proposes phenelzine. (i) Justify MAOI consideration and name one landmark evidence thread for atypical depression and one for late TRD. (ii) List baseline assessment and counselling points including diet. (iii) State washout rules from his current regimen and forbidden combinations. (iv) Outline starting dose, titration targets, monitoring and two common non-crisis adverse effects. (v) Distinguish tyramine hypertensive crisis from serotonin toxicity and give first-line emergency principles for each. (20 marks)

Open

Domain

Psychopharmacology — lithium

1

Initiating and monitoring lithium in bipolar I with suicide risk (MEQ)

A 28-year-old woman with bipolar I disorder had a manic episode six weeks ago (now settling on olanzapine). Two prior depressive episodes, one serious suicide attempt last year. eGFR 95, TSH normal, not pregnant, takes PRN ibuprofen for migraine. She asks whether lithium is 'too dangerous' compared with valproate. (i) Justify offering lithium for maintenance and anti-suicide rationale with named evidence. (ii) List pre-start investigations and consent points including sick-day rules. (iii) Outline initiation, 12-hour trough targeting, and a monitoring calendar for levels and organs. (iv) Counsel on ibuprofen and other level-raising interactions. (v) Describe recognition and first-line hospital management of toxicity including when EXTRIP applies. (20 marks)

Open

Domain

Psychopharmacology — cognitive enhancers

1

Initiating and reviewing cognitive enhancers in Alzheimer disease (MEQ)

A 78-year-old woman with probable mild–moderate Alzheimer disease (insidious amnestic onset, gradual decline, MMSE 21) lives with her daughter. Pulse 68, eGFR 72, no heart block. She takes oxybutynin for urgency and occasional ibuprofen. Daughter asks for 'the dementia cure tablet' and whether memantine should be started now. (i) Explain what cognitive enhancers can and cannot do, with named evidence for AChEI benefit. (ii) Outline pre-treatment assessment, drug review, and counselling points including cardiac/GI risks. (iii) Propose a donepezil initiation and titration plan with review schedule. (iv) State when you would add or switch to memantine and cite key combination/continuation trials. (v) Advise on MCI versus dementia indications and on stopping rules including DOMINO-AD logic. (20 marks)

Open

Domain

Psychopharmacology — clozapine

1

Initiating clozapine in treatment-resistant schizophrenia (MEQ)

A 26-year-old man with schizophrenia has failed two adequate adherent antipsychotic trials (olanzapine then aripiprazole). Persistent positive symptoms, BMI 29, smokes 20 cigarettes/day, no cardiac history. He and his family are anxious about 'the dangerous blood drug'. (i) Define TRRIP-style treatment resistance and justify offering clozapine. (ii) List pre-start investigations and service prerequisites. (iii) Outline a slow titration plan and first-month safety monitoring including myocarditis vigilance. (iv) Explain smoking/CYP1A2 counselling and a plasma-level approach if non-response. (v) State how you would prevent and recognise life-threatening constipation. (20 marks)

Open

Domain

Psychopharmacology — ketamine and esketamine

1

Initiating ketamine/esketamine for treatment-resistant depression (MEQ)

A 42-year-old woman with recurrent MDD has failed adequate trials of sertraline, venlafaxine, and augmentation with quetiapine. Persistent MADRS 34, intermittent passive suicidal ideation without plan, BP 128/78, no aneurysm history, no substance misuse. She asks about 'the ketamine nasal spray' and whether it is safer than ECT. (i) Define TRD entry and justify considering esketamine or IV ketamine. (ii) Outline pre-treatment assessment and absolute/major cardiovascular red flags. (iii) Describe a supervised esketamine induction plan including dose scaffold, observation, oral antidepressant, and driving advice. (iv) Explain expected session adverse effects and how you monitor them. (v) Compare with ECT using ELEKT-D-level nuance and shared decision points. (20 marks)

Open

Domain

Psychopharmacology — stimulants and ADHD medications

1

Initiating, monitoring and switching ADHD pharmacotherapy (MEQ)

A 28-year-old software engineer is newly diagnosed with adult ADHD (combined presentation) after multi-informant assessment. PHQ-9 6, no hypomania history, BMI 24, BP 118/74, HR 72. He binge-drinks on weekends and previously shared a roommate's IR dexamfetamine during university exams. He needs morning-to-evening focus for work and driving. (i) Justify first-line pharmacologic class and name one long-acting agent with a starting dose and titration plan. (ii) List baseline and early monitoring parameters including cardiovascular and diversion safeguards. (iii) Summarise Cortese 2018 NMA relevance to adult choice. (iv) If he fails optimised methylphenidate, outline two next evidence-based medication strategies with doses. (v) Counsel on substance use and the Wilens-era message about stimulant treatment and later SUD risk. (20 marks)

Open

Domain

intellectual disability psychiatry

1

Intellectual disability — assessment, classification and aetiological workup (MEQ)

A 9-year-old girl is referred because of persistent academic failure, concrete thinking, and difficulty with money, time and peer relationships. Pregnancy was uncomplicated; she walked at 18 months and used phrases at age 3. Hearing and vision screens are normal. School psychology testing shows full-scale IQ approximately 62 (confidence interval spans the mild range). Parents say she needs help with dressing choices, cannot safely cross roads alone, and is socially naive. (i) State the DSM-5-TR criteria structure for intellectual developmental disorder and how severity is rated. (ii) Name the three adaptive domains and how you would measure adaptive function. (iii) Outline first-line aetiological investigations and when you would escalate genetic testing. (iv) List key differentials from specific learning disorder, ASD, GDD and borderline intellectual functioning with discriminators. (v) Describe multiagency supports and one systems evidence point about premature mortality. (20 marks)

Open

Domain

General adult psychiatry — impulse control

2

Intermittent explosive disorder — ED assault and dual diagnosis (MEQ)

A 27-year-old man is brought to ED after smashing his partner's phone and punching a wall during an argument about washing dishes. He has had similar outbursts several times per week for 4 months (yelling, throwing objects) and three episodes in the past year that caused property damage. Attacks last under 30 minutes; he is remorseful afterward. He drinks heavily most evenings but says many attacks occur when sober. No manic syndrome, no psychosis, no childhood conduct disorder. Partner is frightened. (i) State working diagnosis with DSM-5-TR operational criteria. (ii) Give four critical differentials with one discriminator each. (iii) Outline acute risk management including partner safety. (iv) Propose a medium-term treatment plan including one psychological approach with evidence and one pharmacological option with dose, route, and monitoring. (20 marks)

Open

Kleptomania and pyromania — retail arrest and arson differential (MEQ)

A 32-year-old woman is diverted to psychiatry after a third shoplifting arrest. She steals inexpensive items she does not need, feels mounting tension in stores, relief while stealing, then crushing shame. She denies mania symptoms and says many episodes occur when sober. Separately, the consultant asks you to outline how you would approach a man charged with two fires: one after an argument with a neighbour (revenge) and one while intoxicated. (i) Operationalise DSM-5-TR kleptomania for the woman and list four differentials with discriminators. (ii) Outline medium-term treatment including CBT elements and one pharmacological option with dose, route, monitoring, and safety checks. (iii) Explain why neither fire meets pyromania and what multi-agency steps you prioritise for arson risk. (20 marks)

Open

Domain

Professional — working with interpreters and CALD communities

1

Interpreter-mediated assessment after overdose in a CALD woman (MEQ)

You are the psychiatry registrar in a metropolitan ED. A 39-year-old woman who prefers Mandarin is medically cleared after a deliberate overdose. Her English is limited to short social phrases. Her teenage son offers to interpret. Nursing staff say a face-to-face interpreter will take two hours; telephone professional interpreting is available now. (i) Define professional vs ad hoc interpreting and state the preferred standard. (ii) Outline your immediate communication and risk-assessment plan. (iii) Describe briefing, seating, and MSE pitfalls with interpreters. (iv) Discuss confidentiality issues in small linguistic communities and forced-migrant contexts if relevant. (v) Name key evidence anchors (language barriers/access; interpretation errors; psychiatric care quality). (20 marks)

Open

Domain

Forensic psychiatry — mental health law

1

Involuntary admission vs capacity pathway and CTO decision (MEQ)

A 27-year-old man with first-episode psychosis is brought to ED by police after three days of refusing food, accusing neighbours of poisoning him, and threatening to 'stop them first'. He has capacity for simple financial decisions on bedside testing but does not appreciate that he is ill or that treatment may reduce risk. He refuses voluntary admission. Family demand he be 'sectioned under section 3 of the Mental Health Act' (they are unsure which jurisdiction's Act). (i) Distinguish capacity assessment from Mental Health Act compulsory criteria as constructs. (ii) Outline your least restrictive management options and what you would document. (iii) Summarise the evidence base relevant to later use of a community treatment order at discharge. (iv) Explain human-rights and process elements you must address if compulsion is used. (v) State how you handle the family's request for a specific section number. (20 marks)

Open

Domain

Psychopharmacology — lamotrigine

1

Lamotrigine initiation with valproate and OCP counselling (MEQ)

A 28-year-old woman with bipolar I disorder has depression-predominant recurrences. Mania was recently stabilised on sodium valproate. She takes a combined ethinylestradiol oral contraceptive. You plan to add lamotrigine. (i) Justify lamotrigine for her polarity pattern with named evidence. (ii) Write a safe oral titration plan accounting for valproate. (iii) Explain the OCP–lamotrigine interaction and counselling points when she starts or later stops the pill. (iv) List rash red flags and immediate actions. (v) State one pregnancy-related counselling point if she later plans conception. (20 marks)

Open

Domain

Old age psychiatry — anxiety disorders

1

Late-life anxiety disorders — assessment and management (MEQ)

A 76-year-old woman is referred from her GP with nine months of daily uncontrollable worry about her heart, her daughter's marriage, and falling. She has cut shopping trips, checks her pulse repeatedly, sleeps poorly, and feels 'on edge'. She scores 15 on the GAD-7. She denies pervasive low mood but admits passive thoughts that 'the family would be better off without my fretting'. She takes hydrochlorothiazide for hypertension and has used diazepam 5 mg at night for four years. eGFR is 58 mL/min. (i) Formulate the likely diagnosis and key differentials including medical/substance factors. (ii) Outline assessment priorities including risk. (iii) Propose a non-drug and drug management plan with named agents, dosing philosophy, and monitoring. (iv) Address benzodiazepine management. (v) Outline follow-up and disposition. (20 marks)

Open

Domain

Old age psychiatry — mood disorders

2

Late-life bipolar disorder — assessment and management (MEQ)

A 71-year-old woman is brought by her daughter with ten days of decreased sleep (3 hours/night), irritable expansiveness, pressured speech, grandiose plans to remortgage the family home for a 'global wellness empire', and spending of AUD 18,000. She has bipolar I disorder since age 28, long-term lithium carbonate 250 mg twice daily (last level 0.72 mmol/L six months ago), hypertension on a thiazide, and recent ibuprofen for osteoarthritis. eGFR was 52 mL/min three months ago. She denies suicidal ideation but owns a firearm for 'farm security'. MoCA is 22/30 with inattention. (i) Formulate early- vs late-onset context and differential including secondary factors and delirium. (ii) Outline acute risk and medical priorities including lithium toxicity. (iii) Propose acute mania management with named agents, doses/levels philosophy, and monitoring. (iv) Address suicide/means and disposition. (v) Outline long-term lithium maintenance plan in older age. (20 marks)

Open

Late-life depression — assessment and management (MEQ)

A 76-year-old widower is referred from primary care with three months of low mood, anhedonia, early waking, 6 kg weight loss, impaired concentration, and passive death wishes. He has hypertension and type 2 diabetes. His wife died eight months ago. He lives alone, owns a firearm for 'farm pest control', and takes a thiazide diuretic. He scores 14 on the GDS and says 'my memory is gone — I think I have dementia.' There is no prior manic history volunteered. (i) Outline assessment priorities including risk, cognition, and medical exclusion. (ii) Discuss working diagnosis and differentials including vascular depression, bereavement, and dementia. (iii) Propose an initial management plan with a named antidepressant, dose, monitoring (including sodium), and psychosocial interventions. (iv) State when you would escalate to ECT. (v) Outline maintenance planning after remission. (20 marks)

Open

Domain

Old age psychiatry — psychosis

1

Late-onset psychosis — assessment and management (MEQ)

A 76-year-old woman living alone is referred after police were called by neighbours who she accused of pumping gas through the walls. Over four months she has developed persecutory delusions, third-person auditory hallucinations, and progressive self-neglect. She has moderate hearing loss, no prior psychiatric admissions, and scores 24/30 on a MoCA done in the emergency department while distressed. Vital signs are stable. (i) Define LOS and VLOSLP and outline working diagnosis versus key differentials including dementia and delirium. (ii) Detail organic and risk assessment including investigations. (iii) Propose non-drug and drug management with a named antipsychotic, starting dose, monitoring, and dementia-related cautions. (iv) Outline prognosis and follow-up including cognitive surveillance. (20 marks)

Open

Domain

Foundations — behavioural science

1

Learning theory applied to panic and avoidance (MEQ)

A 29-year-old woman has panic attacks in crowded shops. She leaves immediately when heart racing begins, feels better within minutes, and now avoids malls unless her partner comes and she carries diazepam she never takes. (i) Define classical and operant processes maintaining this presentation, including two-factor avoidance. (ii) Explain extinction using Bouton’s framework and name three relapse phenomena relevant to her treatment. (iii) Outline an inhibitory-learning exposure plan (Craske), including how you handle safety behaviours. (iv) Contrast this with a pure 'habituation until SUDS drops' approach. (v) State two situations where you would defer elective exposure. (20 marks)

Open

Domain

Consultation-liaison — transplant and ICU psychiatry

1

Liver transplant candidate with depression and prior alcohol use (MEQ)

You are the C-L psychiatry registrar. A 48-year-old man with decompensated alcohol-associated cirrhosis is referred for pre-listing psychosocial evaluation. He reports 11 months abstinence, attends a community alcohol programme fortnightly, and has a partner who does not drink. He has moderate major depression with anhedonia and intermittent passive death wishes without plan, PHQ-9 in the moderately severe range, and two clinic DNAs in the past year attributed to low energy. Surgeons ask whether he is a 'psychiatric contraindication.' (i) Outline the domains of a structured pre-transplant psychosocial evaluation (ISHLT-style/SIPAT constructs). (ii) How would you assess substance-related risk and adherence risk? (iii) Discuss absolute vs relative psychosocial barriers at principle level. (iv) Formulate a management plan before listing MDT. (v) Name two evidence anchors (e.g. named tools or meta-analyses) relevant to evaluation or outcomes. (20 marks)

Open

Domain

General adult psychiatry — mood disorders

5

Major depressive disorder — assessment and stepped management (MEQ)

A 38-year-old teacher is referred after 3 months of low mood, anhedonia, early morning waking, reduced appetite with 4 kg weight loss, impaired concentration, and passive death wishes without a plan. She has had one similar episode 6 years ago that remitted with an unknown SSRI stopped after 3 months. She drinks a bottle of wine most nights. No prior mania is volunteered. PHQ-9 is 19; item 9 is positive for passive ideation several days per week. Observations are normal. (i) Outline your assessment priorities including risk, bipolar screen and organic exclusion. (ii) State working diagnosis and key differentials with discriminators. (iii) Outline an initial management plan including a named first-line antidepressant with starting dose, monitoring, and a psychological intervention. (iv) Explain how STAR*D informs sequential treatment if she does not remit. (v) State when you would escalate to ECT. (20 marks)

Open

Melancholic vs atypical features — diagnosis and treatment (MEQ)

A 42-year-old nurse presents with a 10-week major depressive episode. Case A (same day clinic): near-total anhedonia, no mood lift to family visits, early waking, 7 kg weight loss, marked psychomotor retardation, excessive guilt. Case B (same clinic list): mood brightens briefly when friends visit, hypersomnia, 5 kg weight gain, leaden heaviness in limbs, lifelong interpersonal rejection sensitivity impairing work. Neither has psychosis. Bipolar screen negative so far. (i) Assign the correct DSM-5-TR feature specifier to each case and list the mandatory hinge criterion that separates them. (ii) List three priority differentials for Case B with discriminators. (iii) Outline first-line management for Case A including when you would choose ECT, with named evidence framing. (iv) Outline stepped pharmacotherapy and psychotherapy for Case B, including historical MAOI evidence and one concrete safety rule if phenelzine is later used. (v) State two common examiner pitfalls when coding or treating these specifiers. (20 marks)

Open

Psychotic depression — acute management and evidence (MEQ)

A 54-year-old teacher is admitted with a 6-week major depressive episode (early waking, anhedonia, 8 kg weight loss, profound guilt). He believes he has bankrupted his family and that police will arrest him for secret crimes (no evidence). He hears a voice saying he deserves to die. He has stockpiled tablets at home. No prior mania. TSH normal. UDS negative. (i) State the working diagnosis including specifier language and list three priority differentials with discriminators. (ii) Outline acute risk management and legal/capacity principles (no invented statute numbers). (iii) Propose a first-line pharmacological plan with named agents, doses/routes, and monitoring, citing landmark trial logic. (iv) State when you would choose ECT first-line instead. (v) After remission on combination therapy, outline continuation decisions informed by STOP-PD II. (20 marks)

Open

Seasonal and atypical depression — assessment and management (MEQ)

A 34-year-old indoor office worker in Melbourne describes three consecutive winters of low mood, anhedonia, hypersomnia, carbohydrate craving with 5 kg weight gain, and passive death wishes without plan, with full remission each October. This May she is well and asks how to stop 'next winter happening again'. Last winter she partially improved with a borrowed light box used irregularly at night. There is no volunteered mania. PHQ-9 in winter peaks was 18. (i) State working diagnosis with DSM-5-TR seasonal pattern logic and list key differentials. (ii) Outline assessment priorities including bipolar screen, risk and light-therapy suitability. (iii) Give an acute winter management plan including light therapy parameters and a named antidepressant option with dose. (iv) Design a preventive plan for the coming high-risk season including bupropion XL timing and an alternative psychological strategy. (v) List pitfalls that would lose marks. (20 marks)

Open

Treatment-resistant depression — sequential management (MEQ)

A 44-year-old accountant is referred as 'TRD'. She has had 8 months of severe unipolar-appearing depression (PHQ-9 22) with early waking, anhedonia, guilt, and intermittent passive death wishes without a plan. Records show sertraline 50 mg for 12 days then stopped for nausea; venlafaxine XR 75 mg for 3 weeks with partial benefit then lost to follow-up; and quetiapine 25 mg at night for sleep. She drinks a bottle of wine most nights. No structured bipolar screen is documented. TSH is normal. (i) Critique the TRD label and list pseudo-resistance factors present. (ii) Outline your reassessment priorities including risk and bipolar exclusion. (iii) Define an adequate antidepressant trial and propose a measurement-based next pharmacological plan with a named agent, dose, and monitoring. (iv) State when you would augment with lithium (including monitoring) versus escalate to ECT. (v) Outline the role of psychotherapy and STAR*D implications if she remains non-remitted after two true adequate trials. (20 marks)

Open

Domain

Foundations — attachment

1

MEQ: Attachment theory — Strange Situation, AAI, RAD/DSED, and clinical application

You are the psychiatry registrar in a child and adolescent clinic. A 5-year-old boy is referred by foster carers after three placement breakdowns. He experienced severe early neglect and institutional care until age 2. Carers report he rarely seeks comfort when hurt, shows limited positive affect, and at school approaches unfamiliar adults without checking back. His current carer asks whether he has 'attachment disorder', whether this means she is a bad parent, and whether holding therapy would help. (i) Define attachment and distinguish secure base from safe haven (3). (ii) Outline Strange Situation patterns A/B/C/D and what Adult Attachment Interview states of mind capture (5). (iii) Distinguish attachment styles from RAD and DSED, applying both phenotypes to this child (6). (iv) Outline assessment priorities, evidence-aligned management (including what to refuse), and one developmental evidence anchor (6). (20 marks)

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Domain

Professional — formulation

1

MEQ: BPS and 4P formulation for first-episode psychosis with cannabis

You are the psychiatry registrar in an early intervention clinic. A 19-year-old university student is referred with 6 weeks of persecutory delusions, auditory hallucinations commenting on his actions, marked social withdrawal, and declining self-care. He has smoked high-potency cannabis daily for 8 months, sleeps 3–4 hours during exam week, and has a mother treated for schizophrenia. He lives with parents who argue loudly about 'whether he is lazy or sick'. His older sister is supportive and brings him to appointments. He is unsure whether spirits or 'the university system' are targeting him. (i) Define psychiatric formulation and distinguish it from diagnosis (3). (ii) Construct a biopsychosocial × 4P (predisposing/precipitating/perpetuating/protective) formulation for this young man (8). (iii) Outline a management plan that maps explicitly onto your formulation, including risk and cultural/illness-meaning elements (6). (iv) Name two evidence anchors relevant to formulation or cultural assessment (3). (20 marks)

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Domain

Psychotherapy — trauma-focused CBT and EMDR

1

MEQ: Choosing and planning trauma-focused therapy after assault

You are the psychiatry registrar in a community clinic. A 28-year-old nurse was sexually assaulted 9 months ago. She has daily intrusive images, nightmares, avoidance of night shifts and hospital car parks, self-blame ('I should have fought harder'), hypervigilance, and irritability. PCL-5 is 52. She drinks 4–5 standard drinks most nights 'to sleep'. She is not currently suicidal but feels hopeless. She asks whether she needs 'tablets or hypnosis' and is frightened of 'reliving it'. (i) Outline the Ehlers–Clark maintaining model applied to this case (5). (ii) Name two first-line trauma-focused psychological options and one key technique from each (5). (iii) Describe readiness, risk, and how you would explain PE or EMDR and obtain informed consent including temporary distress (5). (iv) Discuss alcohol, pharmacotherapy interface, and what you would do if she does not improve after an adequate TF trial (5). (20 marks)

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Domain

Psychotherapy — combined treatment

1

MEQ: Designing combined treatment for chronic depression with partial SSRI response

You are the psychiatry registrar in an outpatient clinic. A 44-year-old accountant has persistent depressive disorder with superimposed major depressive episodes for 6 years. He takes sertraline 150 mg oral daily for 5 months with partial improvement (PHQ-9 fell from 22 to 14). He still lies in bed until late morning, ruminates that he is a failure, avoids friends, and has ongoing interpersonal conflicts at work. He asks whether he should ‘stop tablets and start proper therapy instead,’ or ‘just add another tablet.’ Past CBT was three unstructured sessions with no homework. No mania, psychosis, or active suicidal plan; intermittent passive death wishes when ashamed after work criticism. (i) Define concurrent vs sequential combined treatment and state which model(s) fit this case (5). (ii) Outline the evidence for combination or adjunctive psychotherapy in chronic/partial-response depression, naming key trials/syntheses (5). (iii) Propose a practical combined care plan including medication decision, therapy targets, measures, and split-care communication if used (5). (iv) List red flags and pitfalls (false dichotomy, pseudo-CBT, risk) (5). (20 marks)

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Domain

Foundations — history of psychiatry

1

MEQ: History of psychiatry — landmarks, reform, and modern practice

You are preparing a teaching session for psychiatry registrars on the history of the specialty. (i) Outline the emergence of psychiatry as a medical specialty and define moral treatment with key figures (4). (ii) Summarise the psychopharmacological revolution using lithium, chlorpromazine, and ECT as landmarks, with dates and clinical significance (6). (iii) Explain deinstitutionalisation as a multi-causal process and its failure modes (5). (iv) Discuss DSM-III’s historical significance and the Rosenhan debate (including critiques), linking both to modern dual-system practice and diagnostic humility (5). (20 marks)

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Domain

Psychopharmacology — metabolic syndrome and psychotropic monitoring

1

Metabolic syndrome risk, monitoring and metformin after olanzapine (MEQ)

A 26-year-old man with first-episode schizophrenia starts olanzapine 10 mg at night. Baseline: weight 78 kg, BMI 25, waist 88 cm, BP 118/76, fasting glucose 5.1 mmol/L, lipids normal. At 8 weeks he has gained 6.5 kg, waist 96 cm, fasting glucose 6.4 mmol/L, triglycerides raised. Positive symptoms are improved. (i) Define metabolic syndrome components relevant to this case. (ii) Place olanzapine on the metabolic risk hierarchy and name mechanisms. (iii) State the ADA/APA-style monitoring schedule he should have received. (iv) Outline immediate management options including lifestyle, switch and metformin with practical dosing principles. (v) Explain how your plan would differ if he required clozapine for true treatment resistance. (20 marks)

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Domain

Psychopharmacology — atypical and multimodal antidepressants

1

Mirtazapine vs bupropion phenotype matching and combination literacy (MEQ)

A 41-year-old with recurrent unipolar MDD has residual anergia and SSRI-induced anorgasmia on escitalopram 20 mg. BMI is 22; no seizure history; smokes 15 cigarettes/day. A colleague suggests 'just add mirtazapine and venlafaxine tonight as rocket fuel.' (i) Justify a preferred next pharmacological step with agent, oral dose framework and monitoring, including smoking considerations. (ii) Explain when mirtazapine would have been the better phenotype match instead. (iii) Critique the rocket-fuel suggestion using STAR*D Level 4 and CO-MED evidence. (iv) List three absolute/relative bupropion red flags you already excluded or must still document. (20 marks)

Open

Domain

Psychopharmacology — mood stabilisers

1

Mood stabiliser choice, lithium monitoring and pregnancy hierarchy (MEQ)

A 29-year-old woman with bipolar I disorder is recovering from a second manic episode treated with olanzapine. She wishes to plan pregnancy in 12–18 months, currently uses inconsistent contraception, eGFR 92, TFT normal, BMI 29. She asks whether valproate is 'stronger' than lithium for staying well. (i) Justify your preferred long-term mood stabiliser strategy with trial evidence (BALANCE and related). (ii) Detail lithium baseline tests, target trough concept, and early monitoring if lithium is chosen. (iii) Explain why valproate is not appropriate as her routine maintenance and what counselling is required if any anticonvulsant is discussed. (iv) Outline lamotrigine’s niche and titration caveats. (v) List three drug interactions that raise lithium and how you would manage an intercurrent dehydration illness. (20 marks)

Open

Domain

Professional practice — psychological therapies

1

Motivational interviewing in dual diagnosis engagement (MEQ)

A 34-year-old man with schizophrenia (stable on paliperidone palmitate) drinks 10–14 standard drinks most days, misses depot clinics, and says 'I will cut down when life is less stressful.' His partner wants you to 'make him stop.' LFTs are mildly elevated. He declines residential rehab 'because I'm not an alcoholic.' (i) Define MI and contrast it with brief advice and with CBT. (ii) Outline the spirit (PACE) and OARS, with one example utterance each for this case. (iii) Identify change talk vs sustain talk in his presentation and how you would respond to each. (iv) Summarise key trial/meta-analytic evidence (MATCH, UKATT, Cochrane) relevant to counselling this patient. (v) State two situations in which pure MI would be deferred or subordinated to other actions. (20 marks)

Open

Domain

Addiction psychiatry — psychosocial interventions

1

Mutual-help linkage and contingency management for stimulant relapse (MEQ)

You are the addiction psychiatry registrar in a community clinic. A 29-year-old man completed 7-day residential detox for methamphetamine three weeks ago. He has relapsed to daily smoking of methamphetamine, dropped out of CBT after two sessions, and says he 'hates religion' so refused AA. He is not opioid-dependent. His partner asks whether 'paying him to stay clean' is unethical. Urine testing is available thrice weekly. (i) Define mutual-help and contingency management and distinguish TSF from AA. (ii) Propose an integrated 12-week plan including CM protocol elements and secular mutual-help. (iii) Answer the partner’s ethics concern with evidence. (iv) List pitfalls that would make CM fail. (v) State disposition if he develops suicidal ideation during early abstinence. (20 marks)

Open

Domain

General adult psychiatry — psychosis

2

Negative and cognitive symptoms of schizophrenia — primary vs secondary and treatment honesty (MEQ)

A 29-year-old man with schizophrenia is referred for 'untreatable negative symptoms'. He spends most days in bed, speaks little, has poor hygiene, and has not worked for three years. Current medicines: risperidone 6 mg orally daily, benztropine 2 mg orally twice daily, and quetiapine 300 mg at night 'for sleep'. He has bilateral cogwheel rigidity and a shuffling gait. Family say he still hears muffled voices occasionally and has seemed low in mood with passive death wishes. He cannot follow multi-step instructions at a supported-employment trial. (i) Separate primary from secondary negative contributors present. (ii) Outline your bedside assessment including scales/domains and risk. (iii) Propose a stepwise management plan including medication optimisation and psychosocial/cognitive interventions with evidence anchors. (iv) State careful nuances for cariprazine and clozapine in this context. (v) List exam pitfalls. (20 marks)

Open

Treatment-resistant schizophrenia — TRRIP and clozapine pathway (MEQ)

A 28-year-old man with schizophrenia is referred as 'treatment-resistant'. Records show olanzapine 5 mg for 10 days then stopped for sedation; risperidone 2 mg for 3 weeks with partial benefit then lost to follow-up; and quetiapine 25 mg at night for sleep. He misses most clinic appointments and family report tablets are often left in the blister pack. He smokes heavily and uses high-potency cannabis most days. PANSS-equivalent clinical impression shows persistent persecutory delusions and auditory hallucinations. No plasma levels or LAI trial are documented. (i) Critique the TRS label and list pseudo-resistance factors present. (ii) Outline your reassessment priorities including risk and organic/substance exclusion. (iii) Define an adequate antipsychotic trial and propose a measurement-based plan including the role of LAI before clozapine. (iv) State TRRIP criteria in operational terms and when you would offer clozapine (including monitoring non-negotiables). (v) Outline ultra-treatment resistance steps if he later fails an adequate clozapine trial, including ECT evidence. (20 marks)

Open

Domain

Addiction psychiatry — neonatal abstinence

1

Neonatal abstinence syndrome — assessment and dyad care (MEQ)

A 28-year-old woman on methadone 80 mg daily delivers a term infant at 39 weeks. She has been stable in OAT for 6 months, is hepatitis C antibody positive (RNA pending), HIV-negative, and smokes 10 cigarettes/day. She used diazepam irregularly in the third trimester. Social work is concerned because of a prior child-protection file for an older child (now with grandmother). The neonate is rooming-in. At 36 hours of life Finnegan scores are rising; the infant feeds poorly, is inconsolable at times, has loose stools, but is afebrile with normal glucose. Mother asks whether this means methadone ‘damaged the baby’ and whether she should stop OAT and formula-feed only. (i) Define NAS/NOWS and the likely exposure contributors. (ii) Outline assessment including differential diagnoses you must not miss. (iii) Give a stepwise management plan (non-pharmacologic and thresholds for opioids/adjuncts). (iv) Counsel on breastfeeding, methadone continuation, and child-protection framing. (v) Name key evidence you would cite (MOTHER/Suarez/ESC). (20 marks)

Open

Domain

foundations — neuroscience for fellowship psychiatry

1

Neural circuits localisation MEQ (psychosis and frontal change)

A 28-year-old is admitted with first-episode psychosis: auditory hallucinations, persecutory delusions, and ideas of reference after escalating methamphetamine use. Collateral also describes three years of progressive tactlessness and poor work planning after a severe orbitofrontal TBI at age 25. (i) Map positive psychotic symptoms to a dopamine pathway model (Howes–Kapur) and name the other three major DA pathways with one clinical association each. (ii) Localise the personality/behavioural change to a prefrontal syndrome and contrast it with DLPFC and medial frontal syndromes. (iii) Place the presentation in a large-scale network frame (Menon triple network). (iv) List organic red flags and first-line investigations you would still pursue. (v) State two pitfalls of over-localisation. (20 marks)

Open

Domain

Addiction psychiatry — nicotine and behavioural addictions

1

Nicotine, varenicline, and dual diagnosis smoking — MEQ

A 36-year-old man with schizophrenia (stable on clozapine 400 mg nightly) smokes 30 cigarettes/day, first cigarette within 5 minutes of waking. He has failed three unassisted quit attempts and one patch-only course. He is admitted to a smoke-free ward after a psychotic relapse that has now largely settled. Nursing staff report escalating irritability since admission. He asks whether varenicline will 'make me suicidal' and whether he should 'just detox cold turkey'. Separately, his partner discloses he has been gambling online sports bets and hiding a $40,000 debt; he denies suicidal ideation on brief screen. (i) Interpret nicotine dependence severity and the ward irritability. (ii) Propose a pharmacotherapy and behavioural plan with named agents, doses/titration principles, and monitoring — including clozapine interaction issues. (iii) Address EAGLES-era safety counselling for varenicline in psychiatric illness. (iv) Outline assessment and management priorities for the gambling disclosure. (v) List disposition and harm-reduction steps for discharge. (20 marks)

Open

Domain

Intellectual disability — forensic dual disability

1

Offending and intellectual disability (MEQ)

You are the psychiatry registrar in a dual-disability clinic. A 26-year-old man with mild intellectual disability and limited literacy is charged with sexual assault of a co-resident. Staff say he 'always agrees with police'. There is no guardianship order. He has prior property offences, cannabis use, and a history of being bullied. Solicitors request opinions on fitness to stand trial, risk, and management. (i) Summarise key epidemiology teaching points and method traps for offending in ID. (ii) Outline interview vulnerability (suggestibility) and assessment of fitness. (iii) Describe multi-source offence and risk assessment principles including limits of risk tools. (iv) Propose an RNR-adapted management plan including dual-diagnosis and victimisation considerations. (v) Discuss diversion/custody disposition principles without inventing statute section numbers. (20 marks)

Open

Domain

Addiction psychiatry — substance use disorders

2

Opioid substitution and withdrawal — induction, COWS, pregnancy (MEQ)

A 31-year-old woman is 18 weeks pregnant. She injects heroin 3–4 times daily, last use 14 hours ago. COWS is 15. She had a non-fatal overdose 2 months ago. Partner demands 'detox in 5 days so the baby is clean.' She has QTc 430 ms, HCV antibody positive (RNA pending), and sometimes takes street diazepam. (i) Interpret COWS and outline immediate withdrawal care options. (ii) Justify OAT choice and induction plan with named doses. (iii) Address pregnancy, NAS counselling, and partner pressure. (iv) Cover naloxone/harm reduction, HCV, and benzodiazepines. (v) Explain the mortality evidence against detox-only care. (20 marks)

Open

Opioid use disorder — assessment, overdose, and OAT (MEQ)

A 34-year-old man is brought to ED after being found unresponsive with respiratory rate 5/min and miosis. Bystanders gave one dose of intranasal naloxone; he is now sweating, yawning, and restless with COWS 16. He injects heroin daily, has had two prior overdoses, is hepatitis C antibody positive, and left methadone treatment 3 months ago (last known dose 70 mg). He also takes irregular diazepam. Partner is pregnant. (i) Outline immediate overdose and post-naloxone management. (ii) Interpret his withdrawal state and risks of buprenorphine vs methadone restart. (iii) Propose an OAT plan with named agent, induction/monitoring, and harm reduction. (iv) Address HCV, benzodiazepines, and partner/pregnancy safeguarding issues. (v) Explain the mortality evidence you would use if he requests 'just a detox and done'. (20 marks)

Open

Domain

general-adult

1

OSFED — atypical anorexia and residual ED assessment (MEQ)

A 17-year-old girl is referred after losing 18 kg over 8 months through extreme restriction and compulsive exercise. Premorbid BMI was 28; current BMI is 22.4. She has intense fear of weight regain, body-checking, and secondary amenorrhoea for 4 months. Heart rate is 42 bpm sitting; orthostatic pulse rise is 30 bpm. Potassium is 3.6 mmol/L; phosphate is low-normal. She denies objective binge eating and purges by vomiting about twice weekly. PHQ-9 is 14 with passive death wishes. Parents were told by a coach she is 'finally at a healthy weight.' (i) State the most appropriate DSM-5-TR diagnostic framing and discriminate from full AN, BN, and ARFID. (ii) Outline medical and psychiatric assessment priorities with risk formulation. (iii) Propose acute and definitive management including psychological model and monitoring. (iv) Disposition, family work, and safety-netting. (20 marks)

Open

Domain

General adult psychiatry — perinatal

2

Perinatal mood and anxiety disorders — assessment and emergency pathway (MEQ)

A 28-year-old primiparous woman is brought to the emergency department on day 6 postpartum. Her partner reports 48 hours of almost no sleep, rapid speech, belief that the infant is 'not hers' and that she must 'send it back', and an attempt to leave the house barefoot at 3 a.m. She has no prior psychiatric admissions but her mother has bipolar disorder. She is breastfeeding. Observations: HR 104, BP 128/78, temperature 36.8°C, capillary glucose normal. (i) State your working diagnosis and key differentials with discriminators. (ii) Outline immediate risk assessment for mother and infant and initial setting decisions including mother-baby unit considerations. (iii) Outline an acute management plan including pharmacological principles (named classes/agents and monitoring concepts) and when you would consider ECT. (iv) Discuss longer-term prognosis counselling regarding recurrence and preconception planning. (20 marks)

Open

Postpartum psychosis — emergency assessment and treatment (MEQ)

A 29-year-old primiparous woman is brought to ED on day 7 postpartum. Her partner reports 72 hours of almost no sleep, rapid speech, belief that the infant is 'not hers' and must be 'returned to the hospital,' and an attempt to leave home barefoot at 2 a.m. She has no prior psychiatric admissions; her sister has bipolar disorder. She has been breastfeeding. Observations: HR 102, BP 126/76, temperature 36.7°C, capillary glucose normal. (i) State your working diagnosis and key differentials with discriminators. (ii) Outline dual risk assessment and setting decisions including mother-baby unit considerations. (iii) Detail an acute pharmacological and physical treatment plan with named agents, monitoring, lactation principles, and ECT threshold. (iv) Counsel regarding prognosis and prevention for a subsequent pregnancy. (20 marks)

Open

Domain

Psychopharmacology — pregnancy and lactation

1

Perinatal psychopharmacology risk–benefit and class hierarchy (MEQ)

A 32-year-old woman with bipolar I disorder, two prior manias, presents at 6 weeks’ unplanned pregnancy. Medications: sodium valproate 1000 mg daily and quetiapine 200 mg nocte. She is currently euthymic, no substance use, good partner support. She asks whether she should 'stop everything today'. (i) Frame untreated bipolar illness risks in pregnancy and postpartum with named evidence. (ii) Explain the valproate teratogenicity hierarchy (MCM and neurodevelopment) and your immediate plan for valproate. (iii) Outline lithium’s modern cardiac risk framing if offered as alternative and monitoring concepts. (iv) State late-pregnancy antidepressant/neonatal issues that still apply if depression emerges. (v) Give lactation principles if she wishes to breastfeed on a psychotropic. (20 marks)

Open

Domain

Foundations — personality science

1

Personality theory in formulation and nosology (MEQ)

A 27-year-old woman has recurrent depression, chaotic relationships, identity instability, and chronic emptiness. She scores high on neuroticism and antagonism facets, low on conscientiousness, and shows marked impairment in self-direction and intimacy. She asks whether she has 'multiple personality disorders' listed in a previous letter (borderline, histrionic, and dependent). (i) Define personality, traits, and the disorder threshold. (ii) Map her presentation to FFM domains and to AMPD Criteria A and B. (iii) Explain how ICD-11 would organise the diagnosis differently from stacked DSM categorical labels. (iv) Outline a 4P formulation using personality theory. (v) State two clinical pitfalls (state–trait; stigma/care denial) and how you avoid them. (20 marks)

Open

Domain

Psychopharmacology — pharmacogenomics

1

Pharmacogenomics in psychiatry (MEQ)

A 35-year-old woman of Vietnamese ancestry with bipolar I disorder is planned for carbamazepine after partial response to lithium. Separately, her brother with MDD brings a commercial multi-gene PGx report marking sertraline 'red' and recommending a switch based on SLC6A4. (i) Explain the HLA gene–drug pairs relevant to carbamazepine and how ancestry informs testing. (ii) Outline immediate actions if she were HLA-B*15:02 positive and drug-naive. (iii) Critically appraise using the commercial report's SLC6A4 result to choose his antidepressant. (iv) Name two CYP enzymes with CPIC-level antidepressant guidance and one trial (GUIDED or PRIME Care) with a key limitation. (v) State how TDM and phenoconversion complement genotype. (20 marks)

Open

Domain

foundations — philosophy of mind

1

Philosophy of mind, multilevel explanation, and capacity (MEQ)

You are teaching a first-year registrar after a ward round. A 34-year-old with first-episode psychosis says 'either my brain chemicals are broken or I am morally weak.' Family ask whether a brain scan will prove free will is absent so that legal responsibility disappears. The team has written a biopsychosocial formulation that lists 'bio / psycho / social' with no hypotheses. (i) Define philosophy of mind versus descriptive psychopathology for clinical work. (ii) Contrast substance dualism, physicalism, and functionalism in exam-usable sentences. (iii) Outline Kendler's multilevel / pluralist approach and the 'dappled causes' idea. (iv) Defend a non-empty biopsychosocial method against Ghaemi's critique. (v) Respond to the free-will and responsibility claim and outline capacity abilities if treatment consent is contested. (20 marks)

Open

Domain

Psychopharmacology — ECT and neurostimulation

1

Planning ECT for severe depression and discussing neurostimulation tiers (MEQ)

A 58-year-old with recurrent unipolar major depression presents with melancholic features, psychotic guilt, marked weight loss, and high suicide intent. Two adequate antidepressant trials (including one with lithium augmentation) failed. She fears 'memory wipe' from ECT. ECG is normal; she has mild GORD; medications include diazepam 10 mg nocte and sodium valproate 500 mg BD started last year for 'mood stability' without a bipolar diagnosis. (i) Justify ECT as the preferred acute somatic treatment and list essential pre-ECT assessments. (ii) Explain capacity/consent principles and how you address cognitive risk honestly. (iii) Propose electrode placement, pulse-width and dosing strategy with rationale. (iv) Outline anaesthesia essentials the psychiatrist must coordinate and peri-ECT medication issues. (v) Detail the continuation plan after index response and when you would consider rTMS, VNS or DBS instead of or after ECT. (20 marks)

Open

Domain

General adult psychiatry — mood disorders / women's mental health

1

Premenstrual dysphoric disorder — assessment and management (MEQ)

A 29-year-old teacher with regular 28-day cycles describes 10 days of intense irritability, tearfulness, anxiety and hopelessness before each period for four years, with near-complete resolution by day 4 of menses. Relationships and classroom performance collapse in that window; she has passive death wishes for three days each cycle without plan. Mid-follicular PHQ-9 is 3. She wants to know whether 'hormone tablets', 'the depression tablet only half the month', or 'having my ovaries out' is best. She may want pregnancy in two years. (i) State working diagnosis with DSM-5-TR logic and key differentials. (ii) Outline assessment including diary, risk and bipolar screen. (iii) Give a first-line plan including a named SSRI with dose and a dosing schedule choice, plus a psychological option. (iv) Discuss COC and surgical pathways with selection criteria and cautions. (v) List pitfalls that would lose marks. (20 marks)

Open

Domain

Old age psychiatry — psychopharmacology

1

Prescribing psychotropics in older adults — safety and deprescribing (MEQ)

An 82-year-old woman in residential care has Alzheimer disease, hypertension, and prior falls. Her chart shows: risperidone 1 mg twice daily (started 8 months ago for 'agitation' with no review date), temazepam 20 mg at night, oxybutynin, and a thiazide. Staff request 'something stronger' because she still calls out. A daughter asks about starting an antidepressant because Mum 'seems flat.' (i) Critically review the current regimen using Beers and STOPP/START concepts. (ii) Outline age-related PK/PD factors relevant to her risk. (iii) Discuss antipsychotic use in dementia including black-box mortality/stroke framing, CATIE-AD limitations, and a deprescribing plan. (iv) State how you would approach possible depression and sodium risk if an SSRI is considered. (v) Address QTc and falls as integrated safety constraints. (20 marks)

Open

Domain

Foundations — prevention and early intervention

1

Prevention and early intervention — district design MEQ

You are the psychiatry registrar advising a Primary Health Network. Youth wait-lists are long. Politicians want either (A) only more acute inpatient beds or (B) a single whole-school wellbeing day for all secondary students. A local early psychosis team reports median DUP of 12 months. GPs see many adolescents with subthreshold depression. (i) Define Gordon universal, selective, and indicated prevention with one mental-health example each. (ii) Explain Rose's population strategy and the prevention paradox in this planning dispute. (iii) Outline an indicated approach for subthreshold depression and for clinical high-risk (UHR) presentations, including what you would not do by default. (iv) List core elements of a multi-element early intervention service for first-episode psychosis and why shortening DUP matters. (v) Name two implementation risks that could make the plan fail. (20 marks)

Open

Domain

Forensic psychiatry — prison mental health

1

Prison mental health — reception crisis and care pathway (MEQ)

You are the psychiatry registrar covering a remand prison. A 28-year-old man arrives at 01:00 after arrest for alleged assault. Custody notes: first night in custody, recent crystal methamphetamine use, tearful, saying 'I might as well end it', old forearm scars, community notes (arrived late) show untreated schizophrenia with last LAI three months ago, and methadone 60 mg daily until two days ago. Wing staff want him in a single segregation cell 'for his own good'. (i) Outline reception priorities in the first hours. (ii) How would you assess and manage suicide and self-harm risk tonight? (iii) Address substance withdrawal and dual diagnosis. (iv) Respond to the segregation proposal and outline stepped care including transfer principles. (v) List release-transition risks and planning principles even though release is not imminent. (20 marks)

Open

Domain

Foundations — psychiatric genetics and epigenetics

1

Psychiatric genetics and epigenetics — family counselling MEQ

You are the psychiatry registrar reviewing a 19-year-old with first-episode schizophrenia. His mother asks three questions: (1) 'Is this 80% genetic so treatment is pointless?' (2) 'What is the chance his younger sister will get the same illness?' (3) 'Should the whole family buy an online polygenic risk test?' Separately, the medical team notes repaired tetralogy of Fallot, intermittent hypocalcaemia, and nasal speech. (i) Define heritability and correct the mother's first misunderstanding with twin-study evidence. (ii) Outline how you would structure empiric recurrence-risk counselling for the sister. (iii) Explain what GWAS and polygenic scores add — and their current clinical limits. (iv) Interpret the medical clues and outline genetic investigation and care principles if 22q11.2 deletion is confirmed. (v) State three ethical principles guiding psychiatric genetic testing and counselling. (20 marks)

Open

Domain

Psychotherapy — psychoeducation and family interventions

1

Psychoeducation and family psychoeducation after first-episode psychosis (MEQ)

A 22-year-old man is discharged after a first episode of schizophrenia. He lives with his parents. Mother is highly anxious, speaks over him, and has quit work 'to watch him 24/7.' Father is critical ('he's lazy and weak'). The patient wants a quiet life and is ambivalent about olanzapine 10 mg orally at night because of weight gain. No IPV. Capacity intact. (i) Define psychoeducation and family psychoeducation and contrast both with systemic family therapy. (ii) Define expressed emotion and its components; relate them to this family. (iii) Outline a structured FPE plan (dose, content modules, format options including MFG). (iv) Summarise key evidence (EE meta-analysis, Hogarty/Falloon/McFarlane, Cochrane PE/family intervention, Rodolico NMA). (v) State three professional pitfalls or safety limits in delivering PE/FPE. (20 marks)

Open

Domain

Foundations — psychoneuroendocrinology and psychoimmunology

1

Psychoneuroendocrinology and psychoimmunology — MEQ

You are teaching a psychiatry registrar. (i) Define psychoneuroendocrinology and psychoimmunology and outline the HPA cascade with GR/MR feedback and allostatic load. (ii) Contrast Holsboer's GR hypothesis and Gold–Chrousos melancholic versus atypical stress-system framing. (iii) Explain sickness behaviour, major immune-to-brain routes, and one human cytokine model of depression. (iv) State the contemporary role of the DST and of CRP/IL-6 in psychiatric diagnosis, and outline assessment of antipsychotic hyperprolactinaemia. (v) Apply these concepts to formulation and management of a medically ill depressed patient without overclaiming biomarkers. (20 marks)

Open

Domain

General adult psychiatry — psychosis rehabilitation

1

Psychosocial rehabilitation in psychosis — multi-component package (MEQ)

A 28-year-old man with schizophrenia has residual auditory commentary, mild negative symptoms and clear cognitive slowing. Positive symptoms improved on aripiprazole 15 mg orally daily but he remains unemployed, isolated and living with high-EE parents who criticise him daily. He has had three admissions in 18 months with poor clinic attendance between episodes. He wants competitive work in retail. The community team offers a weekly art group and says he is 'not ready' for work. (i) Define clinical, functional and personal recovery and apply CHIME. (ii) Map disability drivers and secondary causes to check. (iii) Design an evidence-based multi-component psychosocial rehabilitation package with named models and evidence anchors. (iv) Address intensity of community care and family work. (v) List exam pitfalls including recovery-language abuses. (20 marks)

Open

Domain

Forensic psychiatry — arson and fire-setting

1

Psychotic arson of the family home (MEQ)

You are the forensic psychiatry registrar. A 24-year-old man with no prior admissions is charged with arson after setting fire to his parents' house at night. Neighbours report three months of social withdrawal and talk that the house was 'wired by intelligence agencies'. Toxicology at arrest shows low-level cannabis only. In custody he remains convinced the fire 'freed the wires' and is intermittently suicidal. Counsel raises mental impairment and asks about future fire risk and whether he has pyromania. (i) Define the firesetting / arson / pyromania triad and apply it here. (ii) Place the case in epidemiological context (community fire-setting, pyromania rarity, psychosis–arson association). (iii) Outline multi-source reconstruction of mental state at the offence and criminal-responsibility approach without equating diagnosis with defence. (iv) Separate fitness and future fire-risk questions; list immediate safety priorities. (v) Longer-term treatment and risk-management principles including specialist fire-specific work. Do not invent statute section numbers. (20 marks)

Open

Domain

General adult psychiatry — secondary / organic psychosis

1

Psychotic disorder due to another medical condition — assessment to management (MEQ)

A 51-year-old previously well man is brought after 4 weeks of believing his neighbours are poisoning him and hearing a critical second-person voice. He has lost 8 kg, feels heat-intolerant, and his resting heart rate is 112 bpm. He is oriented to person and place, attention is preserved, afebrile, no focal neurology. (i) State the working differential with discriminators for primary vs secondary psychosis vs delirium. (ii) List Tier-1 investigations and two directed Tier-2 tests justified by this stem. (iii) When would you image and when would you consider LP/EEG/autoantibodies? (iv) Outline acute management including a named low-dose antipsychotic with monitoring, and the primary disease-modifying priority. (v) Name two autoimmune encephalitis red flags that are absent here but would change the package. (20 marks)

Open

Domain

Psychopharmacology — renal and hepatic disease

1

Psychotropics in CKD and cirrhosis (MEQ)

A 62-year-old man with bipolar I disorder has been stable for 8 years on lithium carbonate (current 12-hour trough 0.72 mmol/L). eGFR has fallen from 78 to 48 mL/min/1.73 m² over 4 years. He also has Child–Pugh B cirrhosis from prior alcohol use (now abstinent 2 years), takes ramipril and intermittent ibuprofen for knee pain, and has new major depression with passive death wishes. (i) Interpret the lithium–renal trajectory and immediate drug-interaction risks. (ii) Outline investigations and monitoring adjustments. (iii) Discuss antidepressant choices in light of CAST/ERBP evidence and his dual organ impairment. (iv) Explain benzodiazepine policy for insomnia given cirrhosis. (v) State when EXTRIP-level care would apply if he presented with lithium toxicity. (20 marks)

Open

Domain

Psychopharmacology — fitness to drive

1

Psychotropics, sedation and driving (MEQ)

A 68-year-old man with generalised anxiety and chronic insomnia drives a private car to work at 06:30. He has taken diazepam 5 mg three times daily for 4 years and zopiclone 7.5 mg most nights. His GP recently added sertraline 50 mg daily. He reports two near-misses in the past month and occasional wine with dinner. He asks if he is 'fine to drive because the sleeping tablet is not a benzodiazepine.' (i) Interpret his crash-risk profile using epidemiological evidence. (ii) Explain residual hypnotic impairment and the role of SDLP science. (iii) Outline immediate driving advice and medication review priorities. (iv) State how concurrent BZD + antidepressant risk applies in older drivers. (v) Document the key elements of a fitness-to-drive counselling note including licence-class caveats. (20 marks)

Open

Domain

Public-community — quality improvement and patient safety

1

Quality improvement and patient safety in psychiatry (MEQ)

You are the psychiatry registrar on an acute adult inpatient unit. In the past quarter: (A) two near-miss wrong long-acting injectable draws; (B) rising seclusion hours; (C) one patient died by suicide five days after discharge with no recorded follow-up plan; (D) staff report they are afraid to submit incident forms after a previous punitive review. (i) Classify each problem (A–D) using safety/quality language (near miss, outcome, culture). (ii) For problem C, propose a Model for Improvement aim with one outcome, one process, and one balancing measure. (iii) Explain Swiss-cheese/systems thinking for problem A (latent vs active failures). (iv) Outline a just-culture response to problem D. (v) Name one evidence-linked ward package for conflict/containment and one population-level service-design pearl linking recommendation implementation to suicide rates. (20 marks)

Open

Domain

General adult psychiatry — reactive attachment and disinhibited social engagement

1

Reactive attachment and DSED — nosology, residual adult risk and caregiving-first care (MEQ)

A 19-year-old is referred to adult community mental health after leaving out-of-home care. Early records document prolonged institutional care abroad until age 3, then serial foster placements. As a child he was described as 'too friendly with strangers' and once left a shopping centre with an unfamiliar adult. Current presentation: mild–moderate depression (PHQ-9 14), residual indiscriminate trust with two recent financial exploitation incidents, and no psychosis. Adoptive carers ask whether he 'still has RAD' and whether holding therapy would help. A legal aid letter asks if 'adult reactive attachment disorder' explains a recent impulsive theft. (i) Outline diagnostic formulation distinguishing childhood RAD/DSED criteria from residual adult presentation. (ii) Detail differentials with discriminators (ASD, ADHD, complex trauma/personality, ordinary insecurity). (iii) Outline risk priorities including exploitation and safeguarding. (iv) Give a stepped management plan rejecting coercive therapies and addressing comorbidity with a named antidepressant example if indicated. (v) Cite key evidence bases (AACAP, APSAC, BEIP, ERA young adult). (20 marks)

Open

Domain

Public-community — military and veteran psychiatry

1

Recently transitioned combat veteran with nightmares, alcohol use, and passive death wishes (MEQ)

You are the psychiatry registrar in a community mental health team. A 32-year-old man discharged from the Army 8 months ago is referred after his partner reports nightmares, explosive anger, heavy evening drinking, avoidance of crowded places, and saying 'maybe everyone would be better off without me.' He completed two combat deployments. He keeps a licensed firearm at home for 'security.' He declines that he has PTSD because 'I am not weak.' (i) Outline a service-context formulation including PTSD versus moral injury. (ii) Structure assessment today including risk, weapons, MST enquiry principles, and measures. (iii) Summarise key epidemiology anchors (Hoge, Fear, Seal/Fulton). (iv) Outline stepped management including PE/CPT evidence, an SSRI plan with dose and monitoring, and prazosin equipoise. (v) List pitfalls and disposition. (20 marks)

Open

Domain

Consultation-liaison — hepatic encephalopathy and advanced transplant psychiatry

1

Recurrent HE and liver transplant listing psychosocial evaluation (MEQ)

You are the C-L psychiatry registrar. A 52-year-old man with decompensated alcohol-associated cirrhosis has had three admissions for overt hepatic encephalopathy in six months. Asterixis is present on day 1; he improves with lactulose. Hepatology is considering transplant evaluation. He reports 8 months self-reported abstinence, attends mutual-help groups irregularly, has moderate depression with passive death wishes, and two clinic DNAs. Surgeons ask if he is a 'psychiatric contraindication.' (i) Define and classify HE relevant to this stem (West Haven / covert–overt / type). (ii) List key precipitants and acute management principles including one evidence-based secondary prevention agent. (iii) Outline structured pre-transplant psychosocial domains (SIPAT/ISHLT-style). (iv) Discuss absolute vs relative psychosocial barriers and a management plan before MDT. (v) Name two evidence anchors (named trials/meta-analyses/guidelines). (20 marks)

Open

Domain

Public and community psychiatry — rural and remote

1

Rural and remote psychiatry — service design MEQ

You are the psychiatry registrar advising a regional health board. A very remote shire (MMM6–7) has no resident psychiatrist. The nearest regional inpatient unit is 5 hours by road. Local GPs report rising crisis presentations, two farmer suicides in 18 months, and difficulty obtaining timely specialist review. Broadband is uneven. An Aboriginal Community Controlled Health Organisation (ACCHO) provides primary care for many residents. The board proposes either (A) a pure video telepsychiatry clinic from the capital with no local redesign, or (B) building a 20-bed remote inpatient unit staffed by FIFO nurses without GP integration. (i) Define rural/remote psychiatry and name two geographic classification systems used in Australia. (ii) Outline the epidemiology of rural suicide risk and treatment gap relevant to this shire. (iii) Critique options A and B. (iv) Propose a multi-component service model including telepsychiatry standards, collaborative care, cultural safety, crisis/retrieval, and workforce. (v) List monitoring and prescribing safeguards for high-risk medications. (20 marks)

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Domain

Public and community psychiatry — school and workplace mental health

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School and workplace mental health — multi-tier design and RTW (MEQ)

A regional education department and a large employer both ask you, as consultant psychiatrist, to advise on mental health strategy. The education department reports rising student self-harm referrals and patchy counsellor coverage. The employer has high sick leave for depression and runs only a one-day resilience workshop yearly. (i) Define multi-tiered school mental health and name core Tier 1–3 components. (ii) Summarise SEYLE findings including which arm improved primary suicide outcomes. (iii) List work-related psychosocial risks for common mental disorders and outline a mentally healthy workplace framework. (iv) Describe evidence-informed return-to-work principles for depression. (v) State red flags that require crisis care rather than programme enrolment. (20 marks)

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Domain

Child and adolescent psychiatry — school refusal and school anxiety

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School refusal and school anxiety — functional analysis, CBT and return-to-school (MEQ)

A 13-year-old girl has attended only 12 full days this term. She develops nausea and panic-like symptoms on school mornings that resolve if she stays home streaming shows. She fears class presentations and eating in the canteen. Parents cancelled school repeatedly 'to settle her nerves' and now struggle to get her out of bed. Teachers report she is bright but avoids oral work; no clear bullying. MSE: tense when school is discussed, no psychosis, intermittent passive death wishes without plan when thinking about failing year. (i) Define school refusal and give key differentials including truancy. (ii) Perform a Kearney functional analysis for this case. (iii) Outline assessment priorities including risk. (iv) Describe first-line psychological and school interventions. (v) Discuss when and how you would use medication, citing Melvin and CAMS-level evidence, with monitoring. (20 marks)

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Domain

Public-community psychiatry — restrictive practices

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Seclusion decision, least-restrictive ladder and reduction frameworks (MEQ)

A 29-year-old man with relapsed schizophrenia is on a locked acute ward. He has smashed a chair, threatened a co-patient, and is advancing on nursing staff after refusing oral olanzapine. Verbal de-escalation by one lead nurse has failed; weapons have been removed from the day area. The shift coordinator asks you to 'just seclude him for the night so the ward can settle' and to chart IM sedation 'as chemical restraint'. (i) Define seclusion and distinguish it from voluntary quiet room use and from environmental ward lock. (ii) Outline your least-restrictive immediate management sequence, including when physical intervention or seclusion would become proportionate. (iii) Summarise key harms evidence (name at least one systematic review) and positional safety rules if restraint is used. (iv) Explain Six Core Strategies and Safewards as reduction frameworks and what you would do after the episode. (v) How do you respond to the request for overnight seclusion and the label 'chemical restraint'? (20 marks)

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Domain

Psychopharmacology — rTMS, VNS and DBS

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Selecting and consenting rTMS, VNS or DBS for TRD (MEQ)

A 48-year-old man with recurrent unipolar MDD has failed adequate trials of sertraline, venlafaxine XR, and augmentation with lithium. MADRS 32, no psychosis, no catatonia, intermittent passive SI without plan, able to attend daily outpatient sessions. He asks whether 'the magnet treatment', 'the vagus implant', or 'brain electrodes' would cure him, and whether he can skip ECT forever. (i) Position rTMS/iTBS, VNS and DBS on the evidence/invasiveness ladder and justify first device consideration. (ii) Outline an acute left DLPFC rTMS or iTBS protocol scaffold and pre-treatment safety checks. (iii) Summarise VNS evidence with honest acute vs long-term reading. (iv) Summarise DBS depression evidence including negative pivotal RCTs. (v) Explain when you would still prioritise ECT. (20 marks)

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Domain

Emergency psychiatry — self-harm and crisis

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Self-harm presentation — psychosocial assessment and crisis aftercare (MEQ)

A 22-year-old woman is brought to ED 3 hours after taking 30 × paracetamol 500 mg tablets and cutting her forearm superficially after an argument with her partner. She is receiving N-acetylcysteine and is haemodynamically stable. She says she 'didn’t really want to die' but 'couldn’t stand the feelings'. She has cut monthly for 2 years to calm down when distressed, has never had a high-lethality attempt before, lives with flatmates, and drinks heavily on weekends. (i) Define self-harm, NSSI, and suicide attempt and place this presentation on the intent continuum. (ii) Outline your psychosocial assessment once she can engage. (iii) Detail a Stanley-Brown-style safety plan and means restriction. (iv) Summarise evidence for brief contact interventions and structured psychological therapies relevant to aftercare. (v) Justify disposition and follow-up intensity, including why hospital-treated self-harm elevates longer-term risk. (20 marks)

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Domain

Consultation-liaison — burns and critical illness psychiatry

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Self-inflicted burns with depression and evolving PTSD risk (MEQ)

You are the C-L psychiatry registrar. A 31-year-old is admitted with 28% TBSA accelerant self-inflicted burns. They report two weeks of severe anhedonia and active suicidal intent at the time of injury, now partially reduced but with intermittent passive death wishes. Nightmares of fire began on day 5. Pain is under-treated overnight. Surgeons request 'psych clearance' before grafting tomorrow. (i) Outline your acute psychiatric assessment domains. (ii) How would you assess suicide risk and intentional injury context? (iii) Discuss delirium vs trauma symptoms vs depression in this setting. (iv) Formulate a management plan including capacity for grafting. (v) Name two evidence anchors (named papers or guidelines) relevant to burns psychiatry or critical-illness mental health. (20 marks)

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Domain

Specialty psychiatry — sexual dysfunction and paraphilias

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Sexual dysfunction and paraphilic risk — assessment and management (MEQ)

A 38-year-old man is referred by his GP. Six months after sertraline was increased to 150 mg for recurrent depression (now remitted), he has marked delayed ejaculation and reduced desire causing relationship conflict. He also discloses, with shame, long-standing exhibitionistic urges; he has exposed himself twice in the past year in a park at night but was not caught. He denies sexual interest in children. PHQ-9 is 4; he has passive death wishes when imagining police involvement but no plan. (i) Formulate the sexual dysfunction and the paraphilic presentation with disorder thresholds. (ii) Outline assessment priorities including risk and confidentiality limits. (iii) Manage the antidepressant-related sexual dysfunction. (iv) Outline management of exhibitionistic disorder and risk. (v) Safety-net and disposition. (20 marks)

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Domain

Forensic psychiatry — sexual offending

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Sexual offending — assessment, risk, and treatment principles (MEQ)

A 38-year-old man is referred for a forensic psychiatry report before possible community step-down. Index offence: sexual assault of an adult acquaintance after heavy alcohol use three years ago. Prior non-sexual assaults and one conviction for possession of child sexual exploitation material two years earlier. He minimises the contact offence, acknowledges ongoing alcohol craving, and denies current pedophilic interest. Static actuarial ranking for sexual recidivism is elevated. He has completed part of an offence-focused CBT programme and has stable supported housing with no unsupervised child contact. (i) Distinguish sexual offence, paraphilia, and paraphilic disorder in this case. (ii) Outline multi-source assessment and key risk domains (static, dynamic, protective). (iii) Apply a motivation–facilitation formulation. (iv) Propose an RNR-informed management plan including when pharmacotherapy would and would not be appropriate. (v) List essential report elements and reassessment triggers. (20 marks)

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Domain

Psychopharmacology — anxiolytics and hypnotics

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Short-term anxiolytic choice, interactions and taper planning (MEQ)

A 52-year-old man with new moderate-severe GAD has started sertraline 50 mg 10 days ago. He is highly aroused, not sleeping, and requests 'something strong like Xanax'. He takes oxycodone 10 mg twice daily for chronic back pain. No prior seizures. Liver enzymes normal. (i) Outline evidence-based durable treatment for GAD and the place of short-term benzodiazepines. (ii) State the key interaction risk with his opioid and counselling points. (iii) If a short GABAergic bridge is used, give an example agent/dose pattern, duration limit, and exit plan. (iv) Name two non-GABAergic pharmacologic alternatives with mechanism and a dosing orientation. (v) If he were already on alprazolam for 18 months, outline taper principles. (20 marks)

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Domain

Psychopharmacology — SNRIs and NRIs

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SNRIs after SSRI failure — dosing, dual action and safety (MEQ)

A 41-year-old teacher with recurrent unipolar MDD has PHQ-9 18 after 8 weeks of adherent sertraline 150 mg. No hypomania history. BP 128/78, HR 72, Na 139, LFTs normal. She has residual anhedonia, morning dread and tension headaches. She fears 'withdrawal' because a relative stopped venlafaxine abruptly. (i) Justify a switch including whether venlafaxine-XR is reasonable and cite STAR*D Level-2 logic. (ii) Give a venlafaxine-XR start and titration plan with the dose band where dual SERT+NET action is more expected, citing mechanism evidence. (iii) List baseline and follow-up monitoring specific to SNRIs. (iv) Counsel on discontinuation risk and taper principles. (v) Name one alternative SNRI if pain becomes dominant and one reason reboxetine is no longer a casual default. (20 marks)

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Domain

Foundations — social determinants of mental health

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Social determinants of mental health — multi-level MEQ

You are the psychiatry registrar in a community team. A 34-year-old sole parent with recurrent major depression is 'non-adherent' with sertraline, has three DNA letters, lives in overcrowded temporary housing after eviction, reports food insecurity, and describes workplace racism before job loss. The consultant asks for a social-determinants formulation and plan. (i) Define social determinants of mental health and distinguish structural from intermediate determinants, with examples from this case. (ii) Explain the social gradient and why this patient's risk is not only an 'individual failure'. (iii) Outline life-course and bidirectional mechanisms linking adversity, poverty, and depression. (iv) Using Rose and Gordon frameworks, propose a multi-level prevention and care package for this patient and for the local population. (v) List three pitfalls to avoid in documentation and discharge planning. (20 marks)

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Domain

Foundations — social psychology

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Social psychology applied to family EE, teams, and stigma (MEQ)

A 24-year-old man is discharged after a first episode of psychosis. His mother says he is 'bone idle and choosing not to wash.' He delayed presentation for months because he feared work would 'find out I'm crazy.' On the ward, several staff noticed early agitation before an assault but each assumed someone else would escalate. (i) Define high expressed emotion and link the mother's comments to attribution theory. (ii) Explain conformity vs obedience vs bystander diffusion using the ward scenario. (iii) Outline an anti-stigma and family-intervention plan grounded in evidence. (iv) State two ethical limits when applying classic obedience research to clinical hierarchy. (20 marks)

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Domain

General adult psychiatry — somatic symptom and related disorders

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Somatic symptom disorder — criteria, assessment and stepped care (MEQ)

A 39-year-old woman is referred by her GP after 18 months of multi-system pain, fatigue, palpitations, and abdominal discomfort. Multiple specialist reviews and investigations have been unrevealing for progressive disease. She spends hours daily body-checking and searching symptoms online, attends ED fortnightly, and has stopped working. PHQ-15 is high; PHQ-9 is 16 with passive death wishes. She becomes angry when told 'tests are normal.' (i) Define SSD and state the key DSM-5 change vs DSM-IV somatoform logic. (ii) Discriminate from illness anxiety disorder, FND, factitious disorder, and malingering. (iii) Outline bedside assessment including scales and risk. (iv) Propose stepped collaborative management including psychological care and how you avoid iatrogenic harm. (v) Discuss the role and limits of medication with at least one agent, dose concept, and monitoring. (20 marks)

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Domain

Child and adolescent psychiatry — specific learning disorder

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Specific learning disorder — domains, identification and multiagency plan (MEQ)

A 9-year-old boy is referred by his school because he remains two years behind peers in reading despite two terms of small-group literacy support. Teachers report slow decoding, refusal to read aloud and incomplete written work; maths is nearer age level. Parents say his uncle 'never learned to read properly.' Hearing and vision screens are normal. Conversation is age-appropriate; he appears demoralised and calls himself 'dumb.' Parents ask whether he needs tablets to fix dyslexia and whether a low IQ is required for the diagnosis. (i) Define SLD and map domain/severity specification relevant to this presentation. (ii) Outline assessment including instructional response and key differentials. (iii) Summarise dyslexia science (phonological / multiple-deficit / language) at exam level. (iv) Construct a multiagency management plan including what you say about medication. (20 marks)

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Domain

Professional — spirituality and religion in psychiatry

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Spiritual assessment and boundaries after first-episode psychosis with religious content (MEQ)

You are the psychiatry registrar in an early psychosis service. A 19-year-old student is recovering from a first episode of psychosis. He remains on risperidone oral 2 mg at night with good adherence and partial insight. He says God speaks to him during prayer; his parents say this is new and frightening. He asks you to pray with him and to stop the tablet because illness is a spiritual test. (i) Define spirituality vs religion and outline why both may be clinically relevant. (ii) How would you structure a respectful spiritual assessment (include HOPE or FICA)? (iii) Discriminate supportive faith experience from psychosis content and list risk priorities. (iv) Discuss professional boundaries regarding prayer and proselytising, and how you would involve spiritual care. (v) Name key evidence anchors (WPA position; Huguelet spiritual assessment RCT; coping literature). (20 marks)

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Domain

Psychopharmacology — SSRIs

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SSRI selection, black box, QTc and discontinuation (MEQ)

A 22-year-old university student with moderate–severe unipolar MDD (PHQ-9 = 19), no bipolar history, and no prior antidepressants is referred for pharmacological treatment. They also have panic attacks. (i) Justify an SSRI choice with an adult oral starting dose and titration plan, including early review structure. (ii) Explain the black-box warning in plain language appropriate for consent. (iii) Contrast citalopram/escitalopram QTc dosing rules with sertraline. (iv) Three months later they stop paroxetine abruptly after a community switch and develop dizziness and electric-shock sensations — diagnose and manage. (20 marks)

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Domain

Forensic psychiatry — stalking and harassment

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Stalking and harassment — assessment and multi-domain management (MEQ)

A 34-year-old man is referred by community mental health after his third breach of a protection order. He and his former partner share a 6-year-old child. Since separation 10 months ago he has sent hundreds of messages, appeared at her workplace twice, and last week texted that 'if I cannot have my family no one will'. He drinks heavily on contact days. He denies intent to harm, says he only wants reconciliation, and asks you to 'make her see reason'. MSE shows no frank psychosis; he is irritable, minimising, and tearful when discussing the separation. The victim reports severe hypervigilance, sleep loss, and workplace fear. (i) Define stalking and classify this presentation using Mullen typology and relationship context. (ii) Outline multi-source assessment and multi-domain risks. (iii) Formulate key drivers and violence scenarios. (iv) Propose an integrated management plan for victim safety and stalker treatment. (v) State documentation and duty-to-protect considerations without inventing statutes. (20 marks)

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Domain

Professional — stigma, recovery and rights-based care

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Stigma, recovery and rights-based care (MEQ)

You are a psychiatry registrar. A 25-year-old with first-episode psychosis delayed presentation for 9 months due to shame. His parents conceal the diagnosis from relatives. He declines a long-acting injectable because he does not want to 'look like a mental patient' at his apprenticeship, despite partial adherence to oral medication. He says people with his diagnosis never work. The ward culture uses labels such as 'non-compliant' in the notes. (i) Map public, self, structural and courtesy stigma in this case. (ii) Outline a personal recovery plan using CHIME. (iii) Describe how you would use shared decision-making for oral versus LAI medication. (iv) State two rights-based principles relevant if compulsory treatment is later considered, without inventing statute numbers. (v) Name two evidence anchors for anti-stigma or recovery practice. (20 marks)

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Domain

Addiction psychiatry — stimulant and methamphetamine use

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Stimulant and methamphetamine use — acute MAP to definitive care (MEQ)

A 31-year-old man is brought by police after smashing a neighbour's window. He has smoked crystal methamphetamine for 72 hours. He is tachycardic and hypertensive but afebrile and oriented. He believes the neighbour is beaming laser surveillance into his flat and hears a third-person commentary. CK is mildly elevated; ECG shows sinus tachycardia without ischaemic ST change. (i) Define MAP and contrast it with primary psychotic disorder using timeline discriminators. (ii) Outline immediate medical and behavioural priorities. (iii) Describe the expected methamphetamine withdrawal time course and a key psychiatric risk in the crash. (iv) Give an evidence-based definitive treatment package for stimulant use disorder, naming the strongest psychosocial modality and accurately stating one limited pharmacotherapy option with dose if offered. (v) State dual-diagnosis and disposition principles. (20 marks)

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Domain

Addiction psychiatry — acute stimulant syndromes

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Stimulant intoxication and withdrawal — MAP, toxicity, and anti-craving vacuum (MEQ)

A 32-year-old man is brought to ED after a 5-day crystal methamphetamine binge. HR 142, BP 178/102, temperature 38.9°C, CK 3200 U/L, troponin borderline, ECG sinus tachycardia without ST elevation. He believes neighbours are laser-mapping his flat and hears third-person commentary; consciousness is clear and he is oriented. Last use 8 hours ago. Partner reports he has been awake almost continuously. He has no prior psychiatric admissions. On day 2 he becomes hypersomnolent then tearful with passive suicidal ideation and intense craving. (i) Outline immediate medical and behavioural priorities for intoxication/toxicity. (ii) Formulate MAP versus primary psychosis at this stage and acute MAP management. (iii) Describe the expected withdrawal/crash course and suicide risk plan. (iv) Explain to the examiner why there is no approved anti-craving/substitution standard and what first-line ongoing treatment you would recommend. (v) List disposition and harm-reduction steps before discharge. (20 marks)

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Domain

Professional skills — mental state examination

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Structure and interpret a complete Mental State Examination (MEQ)

You are the psychiatry registrar. A 24-year-old is brought to ED after neighbours reported shouting at night. On interview he is dishevelled, pacing, speaks rapidly with topic shifts that lose logical connection, believes intelligence services implanted a chip in his tooth, and describes second-person voices telling him not to trust doctors. He says 'nothing is wrong with me' but accepts a sandwich and a quiet room. Orientation to person and place is intact; attention is impaired on serial testing. (i) List the core MSE domains you will document and distinguish mood from affect and thought form from content. (ii) Write a concise domain-structured MSE consistent with this presentation. (iii) Outline organic red flags and when MMSE/MoCA are appropriate adjuncts. (iv) Assess insight using a multidimensional model and relate it (without equating) to capacity. (v) Name two evidence anchors relevant to thought disorder terminology or first-rank symptom status. (20 marks)

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Domain

Addiction psychiatry — substance-induced mood and anxiety disorders

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Substance-induced mood and anxiety — timing, alcohol and dual care (MEQ)

A 46-year-old man with 10 years of heavy daily alcohol use is admitted for detox. For 4 weeks while drinking he has had anhedonia, early morning waking, guilt and passive suicidal ideation. He has no prior depressive episodes during two previous 3-month sober periods. CIWA is moderate; he is medically stable after thiamine and a reducing diazepam protocol. (i) Define substance/medication-induced depressive disorder and state key discriminators from independent MDD and delirium. (ii) Outline assessment priorities including suicide risk and investigations. (iii) Give a definitive dual management plan including when you would watch-and-wait versus start a named antidepressant with dose, plus one AUD medicine with dose. (iv) Counsel on prognosis using named evidence. (20 marks)

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Domain

General adult psychiatry — substance/medication-induced psychosis

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Substance-induced psychosis — timeline, conversion and dual care (MEQ)

A 21-year-old man is brought to ED after 4 days of believing neighbours are spying through his phone and hearing a third-person commentary. He smokes high-THC cannabis daily and last used 18 hours ago. He is afebrile, alert, BP 128/78, glucose normal. Urine drug screen is positive for cannabis only. Parents report good premorbid function until 6 months of escalating cannabis use. Insight is partial. (i) Define substance/medication-induced psychotic disorder and state the key discriminators from primary psychosis and delirium. (ii) Outline assessment priorities including risk and investigations before medication. (iii) Give a named acute management plan including one oral antipsychotic with dose and monitoring. (iv) Counsel on conversion risk using named evidence and plan dual-diagnosis follow-up. (20 marks)

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Domain

Emergency psychiatry — suicide risk

1

Suicide risk assessment and safety planning after overdose (MEQ)

A 28-year-old woman is brought to ED 6 hours after taking 40 × paracetamol 500 mg tablets and half a bottle of wine following a relationship breakdown. She is medically stabilising after N-acetylcysteine. She says she wanted to die at the time but now feels embarrassed and minimises risk. She has one prior overdose 2 years ago. She lives alone, has untreated recurrent depression, and keeps her mother’s leftover amitriptyline at home. (i) Outline your structured suicide risk assessment. (ii) Formulate static, dynamic, and protective factors. (iii) Detail a Stanley-Brown-style safety plan and means restriction steps. (iv) Justify disposition options and the evidence for elevated risk after self-harm and after psychiatric admission. (v) Name one medication with anti-suicide evidence relevant if bipolar spectrum emerges, and one for schizophrenia-spectrum suicidality. (20 marks)

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Domain

Professional — teaching and supervision skills

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Teaching and supervision skills for psychiatrists (MEQ)

You are the educational supervisor for a second-year psychiatry registrar. Over eight weeks, nursing staff report incomplete risk documentation after self-harm assessments, and a mini-CEX shows a disorganised MSE. The registrar is likeable, works hard, and previous supervisors rated them as 'satisfactory' without written concerns. Tomorrow they are rostered to cover the emergency psychiatry list independently overnight. (i) Distinguish educational supervision, clinical (case) supervision, and clinical teaching, and name the three Proctor-style supervision functions. (ii) Map the concerns to Miller's pyramid and outline how you would use workplace-based assessment educationally. (iii) Outline a feedback conversation using Ende principles and/or R2C2. (iv) State your immediate plan for overnight cover and for remediation if needed, including failure-to-fail risks. (v) Name four landmark literature anchors relevant to supervision, feedback, assessment, or remediation. (20 marks)

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Domain

Public and community psychiatry — telepsychiatry

1

Telepsychiatry — service design and safe practice MEQ

You are the psychiatry registrar advising a regional health service. A rural catchment has no resident psychiatrist. The board proposes a pure home-video telepsychiatry clinic from the capital three days per week, with no local emergency protocol redesign and no GP care-manager funding. Broadband is uneven; many older patients lack private devices. ED presentations for crisis are rising. (i) Define telepsychiatry and list four delivery modalities. (ii) Summarise key effectiveness and process-standard evidence candidates should name. (iii) Critique the board proposal. (iv) Design a safer multi-component telepsychiatry model including emergency standards, primary-care integration, equity measures, and monitoring logistics. (v) Outline ethical and jurisdictional issues for cross-site practice. (20 marks)

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Domain

Forensic psychiatry — therapeutic security

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Therapeutic security — placement and step-down (MEQ)

You are the forensic psychiatry registrar. A 34-year-old man with schizophrenia is referred from prison after alleged serious assault on a cellmate during a psychotic relapse. He has one prior conviction for wounding when unwell, intermittent crystal methamphetamine use, and three absconds from open wards years ago. Prison staff report he is currently settled on olanzapine but remains guarded. The referring team asks whether he needs 'high secure' versus medium or low secure hospital. Separately, a different patient has been in medium secure care for six years with completed programmes, successful unescorted leave, and low dynamic risk, but no step-down plan. (i) Define therapeutic security and its three domains. (ii) Outline how you would assess the level of secure care needed for the prison referral. (iii) State principle-level differences between high, medium, and low secure care. (iv) Address the long-stay medium secure patient and step-down principles. (v) List pitfalls and aftercare points relevant to discharge from secure care. (20 marks)

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Domain

Child and adolescent psychiatry — service interface

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Transition from CAMHS to adult services — managed transition plan (MEQ)

A 17-year-old with childhood combined ADHD and recurrent major depression has been under CAMHS for five years. He remains on long-acting methylphenidate (product-specific morning dosing titrated to response) and sertraline 100 mg oral daily. Residual organisational failure threatens final-year school completion; he has weekend cannabis use and two self-harm episodes in the past year without current suicidal intent. CAMHS upper age limit is in five months. Adult community mental health teams in the region typically accept only severe and enduring illness. Parents want 'everything transferred next week'. (i) Distinguish transfer from transition and explain why an immediate administrative transfer is inadequate. (ii) Outline risk and need assessment priorities for pathway mapping. (iii) Propose a managed transition plan with medication continuity and adult options if AMHS declines. (iv) Address capacity, information-sharing with parents, and cannabis. (v) Name key evidence anchors (TRACK/MILESTONE or equivalent) that justify structured transition. (20 marks)

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Domain

General adult psychiatry — OCRD / BFRB

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Trichotillomania and excoriation disorder — assessment and management (MEQ)

A 24-year-old design student is referred after dermatology excluded alopecia areata. She has irregular scalp patches with broken hairs of varying lengths, sparse left eyebrow, and spends 2–3 hours daily pulling while studying online lectures (often without full awareness). She also picks at facial bumps until scabbed. She swallows some hair roots. PHQ-9 is 11; she denies active suicidal plan. She had sertraline 50 mg for 6 weeks for 'OCD' without change in pulling. (i) Define TTM and SPD and place them nosologically. (ii) Discriminate from alopecia areata, OCD, and BDD. (iii) Outline assessment including styles and medical risks. (iv) Propose first-line psychological treatment. (v) Discuss pharmacologic options including NAC adult evidence and paediatric caveats, and next steps. (20 marks)

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Domain

Forensic psychiatry — victimology

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Victimology and trauma in forensic settings — secondary victimisation and IPV pathway (MEQ)

You are the psychiatry registrar on call. A 29-year-old woman is brought by police after reporting sexual assault by her partner of four years. She has bruises, is tremulous, minimises risk, and says she must return home 'or he will take the children.' She declines a full forensic medical examination 'because last time the doctors made me feel dirty.' (i) Define secondary victimisation and explain how it may already be operating. (ii) Outline immediate risk and safety assessment priorities (adult and child). (iii) Map likely psychiatric outcomes using ASD/PTSD/ICD-11 complex PTSD thresholds. (iv) Describe stepped acute-to-definitive management including trauma-focused therapy and one evidence-based SSRI with dose range and monitoring. (v) List three exam pitfalls specific to victim care in forensic settings. (20 marks)

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Domain

Emergency psychiatry — violence risk

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Violence risk assessment after named threats in first-episode psychosis (MEQ)

A 24-year-old man is brought to ED by police after threatening to kill his flatmate whom he believes is implanting thoughts via the television. He has used methamphetamine intermittently for 6 months. There is no prior contact with mental health services. He has a kitchen knife in his bag. He denies intent now but remains guarded and restless. Collateral from the flatmate confirms three days of escalating persecutory talk and one prior punch to a wall. (i) Outline your structured violence risk assessment. (ii) Formulate static, dynamic, and protective factors. (iii) Explain the mental illness–violence relationship in non-stigmatising terms relevant to this case. (iv) Detail an immediate safety and risk management plan including least-restrictive principles. (v) Name the role of imminent vs longer-horizon tools and what you will document. (20 marks)

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Domain

Forensic psychiatry — young offenders

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Young offenders — detention reception and multi-system plan (MEQ)

You are the psychiatry registrar covering a youth detention centre. A 15-year-old boy arrives at 22:30 on first remand after alleged street assault. Notes: school exclusion, longstanding hyperactivity and impulsivity, daily cannabis, old forearm scars, tearful saying 'I might as well die in here', mother with untreated depression, father imprisoned. Wing staff want him in isolation overnight 'so he can't copy the cutters'. Community ADHD medication was stopped two days ago after arrest. (i) Outline reception priorities in the first hours. (ii) How would you assess suicide/self-harm and violence risk? (iii) Formulate using a developmental pathway framework and key comorbidities. (iv) Respond to the isolation proposal and outline stepped care including named psychosocial interventions. (v) List transition/throughcare principles even if release is not imminent. (20 marks)

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Domain

Child and adolescent psychiatry — youth self-harm and suicide

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Youth self-harm — assessment, safety planning, family/school, and disposition (MEQ)

A 15-year-old is brought to ED 2 hours after an impulsive overdose of a parent's sertraline (low tablet count) and superficial forearm cutting after a school bullying episode and argument with parents. Medically stable. They say they 'just wanted the feelings to stop', deny clear intent to die now, but have cut weekly for 8 months. Parents call it 'attention-seeking' and want immediate discharge. Household medications remain accessible. The young person does not want school involved. (i) Define NSSI, suicide attempt, and mixed intent and place this presentation on the continuum. (ii) Outline your assessment structure including private interview, confidentiality limits, and collateral. (iii) Detail a youth-adapted safety plan and means restriction. (iv) Summarise key therapy evidence (DBT-A, family approaches, Cochrane/Ougrin). (v) Justify disposition and aftercare, including why hospital-treated youth self-harm is not trivial. (20 marks)

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