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MRCP PART 1 · PSYCHIATRY

Psychiatry questions
for MRCP Part 1.

Clinora has 217 psychiatry single best answer questions covering 195 topics. Every question explains all five options, separates the key clue from what it means and what to do next, and links to its source. Try the 5 sample questions below, then practise more for free.

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FREE SAMPLE QUESTIONS

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Question 1Bipolar disorder/maniaMedium

A 30-year-old man with no current psychiatric medication presents with a one-week history of elevated mood, decreased need for sleep, grandiosity and impulsive spending, consistent with acute mania. What is the most appropriate first-line pharmacological approach?

  1. ANo medication, psychotherapy alone
  2. BA selective serotonin reuptake inhibitor as monotherapy
  3. CAn antipsychotic such as olanzapine, quetiapine, risperidone or haloperidol
  4. DHigh-dose benzodiazepine as sole definitive treatment
  5. EImmediate electroconvulsive therapy as first-line
Show answer and explanation

Answer: C An antipsychotic such as olanzapine, quetiapine, risperidone or haloperidol

A week of elevated mood, reduced need for sleep, grandiosity and impulsive spending meets the criteria for a manic episode. For a person not already taking an antipsychotic or mood stabiliser, NICE CG185 recommends offering an antipsychotic first: haloperidol, olanzapine, quetiapine or risperidone, chosen with the person, taking side effects and their preferences into account. If the first antipsychotic is poorly tolerated or ineffective at an adequate dose, offer a different one, then consider adding lithium (or valproate, avoided in women of childbearing potential). Any antidepressant should be stopped, because antidepressants can drive or prolong mania. A benzodiazepine can be used short term for agitation or sleep, but it is not the definitive treatment. Check physical health baselines before starting, such as weight, glucose, lipids, ECG where indicated and prolactin.

Key clue
Acute mania in a previously unmedicated patient
What it means
First presentation of acute mania
What to do
Start an antipsychotic per NICE guidance, assess safety and admission needs, and arrange specialist psychiatric follow-up

Why the other options are less appropriate

  • A Psychological therapy alone does not control acute mania. Medication is needed to treat the episode safely.
  • B SSRIs can trigger or worsen mania and are stopped, not started, in an acute manic episode.
  • D Benzodiazepines help with agitation and sleep in the short term, but they do not treat the manic episode.
  • E ECT is reserved for severe, life-threatening or treatment-resistant episodes, not as first-line treatment.

Source: NICE CG185 Bipolar disorder: assessment and management

Question 2Alcohol withdrawalMedium

A patient with long-standing alcohol dependence is admitted after stopping drinking two days ago. He is tremulous, anxious, tachycardic and reports visual hallucinations, and is assessed to be at high risk of severe withdrawal. What is the most appropriate management?

  1. AStart disulfiram immediately during active withdrawal
  2. BDischarge with advice to reduce alcohol intake gradually at home
  3. CNo pharmacological treatment, only reassurance
  4. DAdmit for medically assisted alcohol withdrawal with a benzodiazepine reducing regimen and thiamine replacement
  5. EGive high-dose glucose infusion before any thiamine
Show answer and explanation

Answer: D Admit for medically assisted alcohol withdrawal with a benzodiazepine reducing regimen and thiamine replacement

Tremor, anxiety, tachycardia and visual hallucinations two days after stopping drinking indicate significant alcohol withdrawal. Symptoms usually begin 6–12 hours after the last drink, seizures peak at around 24–48 hours, and delirium tremens typically develops at 48–72 hours. NICE CG100 recommends admission for medically assisted withdrawal in people at high risk, including those with hallucinations, previous withdrawal seizures or delirium tremens, or significant comorbidity. Use a benzodiazepine, usually chlordiazepoxide or diazepam, given as a fixed-dose reducing regimen or symptom-triggered using a validated scale such as CIWA-Ar. For delirium tremens, offer oral lorazepam first line, with parenteral lorazepam or haloperidol if symptoms persist or oral medicine is declined. Give parenteral thiamine, such as Pabrinex, to people with suspected Wernicke's encephalopathy or at high risk of it, and oral thiamine to others at risk. Correct magnesium, potassium and phosphate, and plan relapse-prevention treatment once withdrawal is complete.

Key clue
High-risk features of alcohol withdrawal including hallucinations and autonomic instability
What it means
High-risk alcohol withdrawal requiring inpatient management
What to do
Admit for medically assisted withdrawal with a benzodiazepine regimen and prompt thiamine replacement before or with glucose

Why the other options are less appropriate

  • A Disulfiram is for relapse prevention once the patient is abstinent and stable. It has no role during active withdrawal.
  • B Hallucinations and autonomic features mean a high risk of seizures and delirium tremens. He needs inpatient assisted withdrawal.
  • C Untreated severe withdrawal risks seizures and delirium tremens. A benzodiazepine regimen is needed, not reassurance alone.
  • E Glucose before thiamine may precipitate Wernicke's encephalopathy in a thiamine-deficient patient. Thiamine should be given first or together.

Source: NICE CG100 Alcohol-use disorders: diagnosis and management of physical complications

Question 3Less severe depressionMedium

A 28-year-old man has a six-week less severe depressive episode without suicidal intent, psychosis or major self-neglect. He prefers a non-drug approach and can engage reliably. What should be offered first?

  1. AOffer an SSRI routinely despite his preference for non-drug treatment
  2. BOffer a supervised group exercise programme as the only acceptable option
  3. COffer an antidepressant combined with individual CBT
  4. DGuided self-help using structured behavioural activation or CBT principles
  5. EUse active monitoring alone without arranging review or active treatment
Show answer and explanation

Answer: D Guided self-help using structured behavioural activation or CBT principles

His episode is less severe (in NICE terms, a PHQ-9 score below 16), he is not at risk, he is engaged, and he prefers not to take medication. NICE NG222 says to discuss the treatment options with him and to match the choice to his needs and preferences. It lists the options for less severe depression in a table, ordered by clinical and cost-effectiveness. Guided self-help comes first: structured CBT or behavioural activation materials, supported by a trained practitioner who reviews progress. Group CBT, group behavioural activation, individual CBT or behavioural activation, group exercise, and mindfulness or meditation follow. NG222 says antidepressants should not routinely be offered first line for less severe depression, unless that is the person's preference. Active monitoring is mainly for people who do not want treatment or think their symptoms will settle without it. Assess his suicide risk at every contact. If he does not improve, review the plan and consider a more intensive psychological therapy, or medication if he chooses it.

Key clue
Less severe depression, low immediate risk, and preference for non-drug care
What it means
A low-intensity evidence-based psychological intervention is proportionate and acceptable
What to do
Guided self-help using structured behavioural activation or CBT principles

Why the other options are less appropriate

  • A NICE advises against offering antidepressants routinely first line for less severe depression, and this would go against his informed preference.
  • B Group exercise is one of the NICE options, but it should be chosen with him, not presented as the only acceptable treatment.
  • C Combined treatment is for more severe depression, and an antidepressant goes against his preference for a non-drug approach.
  • E Active monitoring suits people who do not want treatment. He wants treatment and can engage, so an active intervention should be offered.

Source: NICE NG222: Depression in adults — recommendations

Question 4Inadequate clozapine responseHard

A 38-year-old man with schizophrenia remains distressed by voices after six months of clozapine. What is the most appropriate step before adding another antipsychotic?

  1. AIncrease clozapine immediately to the maximum dose without measuring a level
  2. BAdd aripiprazole now for a fixed ten-week augmentation trial
  3. CSwitch from clozapine to another antipsychotic because any residual voice proves failure
  4. DReview diagnosis, adherence, clozapine level, dose, duration and psychological treatment
  5. ERefer for electroconvulsive therapy before reviewing clozapine exposure or formulation
Show answer and explanation

Answer: D Review diagnosis, adherence, clozapine level, dose, duration and psychological treatment

Persistent voices after six months of clozapine look like clozapine resistance, but much apparent failure is really inadequate exposure or a wrong formulation of the problem. NICE CG178 advises that, before adding a second antipsychotic, you review the diagnosis, check adherence, confirm the dose and duration are adequate, measure a clozapine level, and look at substance use, other medicines and whether the person has been offered psychological treatment such as CBT for psychosis. A trough plasma level of at least about 0.35 mg/L is commonly used as the threshold for an adequate trial. Levels vary widely: smoking induces CYP1A2 and lowers them, so stopping smoking can raise them sharply, while fluvoxamine and some infections raise them too. If the illness still does not respond to optimised clozapine, NICE suggests augmentation with a second antipsychotic that does not compound clozapine's side effects, with an adequate trial that may need 8–10 weeks. Aripiprazole is a common choice because it can also offset weight gain.

Key clue
Persistent symptoms during clozapine without documented exposure, adherence or optimisation
What it means
True clozapine resistance cannot be concluded until the trial and competing explanations are reviewed
What to do
Review diagnosis, adherence, clozapine level, dose, duration and psychological treatment

Why the other options are less appropriate

  • A Raising the dose blindly risks seizures, sedation and other concentration-related toxicity. A level guides whether more clozapine is needed at all.
  • B Augmentation may come later, but it is premature before adherence, levels and diagnosis confirm that optimised clozapine has truly failed.
  • C Some residual symptoms do not prove failure. Clozapine is the most effective option for resistant schizophrenia and should be optimised, not abandoned.
  • E ECT is reserved for selected situations and does not replace checking whether clozapine exposure and the diagnosis have been properly reviewed.

Source: NICE CG178: Psychosis and schizophrenia in adults — clozapine recommendations

Question 5Generalised anxiety disorderEasy

A 40-year-old man with generalised anxiety disorder remains symptomatic after education and active monitoring. Symptoms are distressing but do not cause marked functional impairment. Which intervention should be offered next?

  1. ABegin an SSRI after discussing activation and withdrawal effects
  2. BOffer individual high-intensity CBT delivered by a trained therapist
  3. COffer applied relaxation as a high-intensity psychological intervention
  4. DCBT-based guided self-help, non-facilitated self-help or psychoeducation
  5. EUse a benzodiazepine briefly despite the absence of an acute crisis
Show answer and explanation

Answer: D CBT-based guided self-help, non-facilitated self-help or psychoeducation

The key clues are that education and active monitoring (step 1) have not been enough, and that symptoms are distressing but do not cause marked functional impairment. NICE CG113 uses a stepped-care model, and this places him at step 2: a low-intensity psychological intervention chosen according to his preference. The options are individual non-facilitated self-help (CBT-based written or electronic material, usually over about 6 weeks), individual guided self-help (CBT-based material supported by a trained practitioner over about 5–7 sessions), or a psychoeducational group (CBT-based, usually 6 weekly sessions). Step 3 is for marked functional impairment or no improvement after step 2. There, people are offered either a high-intensity psychological intervention (CBT or applied relaxation) or drug treatment. If a drug is chosen, NICE recommends sertraline first. Review within 2 weeks of starting. Benzodiazepines should not be offered for GAD in primary or secondary care except as short-term treatment in a crisis.

Key clue
Persistent GAD after education and monitoring without marked functional impairment
What it means
The patient is at the low-intensity step of the GAD pathway
What to do
CBT-based guided self-help, non-facilitated self-help or psychoeducation

Why the other options are less appropriate

  • A An SSRI is a step 3 option, for marked functional impairment or failure of low-intensity treatment. Neither applies yet.
  • B High-intensity CBT is effective but is a step 3 treatment. Low-intensity treatment should be offered first in this situation.
  • C Applied relaxation is a high-intensity step 3 intervention, so it comes after low-intensity options have been tried.
  • E Benzodiazepines are not recommended for GAD except briefly in a crisis, and there is no crisis here.

Source: NICE CG113: Generalised anxiety disorder and panic disorder in adults — recommendations

That is 5 of 217. Carry on with psychiatry in the practice bank, with progress tracking, flashcards and timed sessions.

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Topics covered

Show all 195 psychiatry topics
  • A personalised bipolar relapse plan
  • A score must not decide discharge
  • Abrupt stop or early withdrawal?
  • Acute dystonia treatment
  • Acute mania
  • ADHD differential
  • ADHD medication safety
  • Adjustment disorder timeframe
  • Adult ADHD
  • Adult anorexia when initial psychological therapy is ineffective
  • Adult autism assessment
  • Alcohol dependence
  • Alcohol dependence relapse prevention
  • Alcohol level and psychosocial assessment
  • Alcohol relapse prevention
  • Alcohol withdrawal
  • Alcohol withdrawal seizure
  • Anorexia nervosa
  • Anorexia nervosa complications
  • Anorexia nervosa medical risk
  • Antidepressant discontinuation syndrome
  • Antidepressant withdrawal
  • Antidepressant-associated mania
  • Antipsychotic baseline monitoring
  • Antipsychotic hyperprolactinaemia
  • Antipsychotic selection
  • Antipsychotic-associated fever and rigidity
  • Antipsychotic-induced akathisia
  • Antipsychotic-induced diabetes monitoring
  • Antipsychotics in pregnancy
  • At-risk mental state
  • Avoidant-restrictive food intake disorder
  • Avoiding over-frequent routine DXA in anorexia
  • Benzodiazepine withdrawal
  • Binge-eating disorder
  • Binge-eating disorder after ineffective guided self-help
  • Bipolar depression
  • Bipolar disorder
  • Bipolar disorder/mania
  • Bipolar relapse prevention
  • Body dysmorphic disorder
  • Bone-density assessment after prolonged adult underweight
  • Borderline personality disorder
  • Borderline personality disorder crisis
  • Bulimia nervosa
  • Bupropion seizure caution
  • Capacity assessment principle
  • Capgras delusion
  • Clomethiazole outside hospital
  • Clozapine adverse effects
  • Clozapine myocarditis presentation
  • Clozapine neutropenia
  • Clozapine-induced gastrointestinal hypomotility
  • Cocaine dependence
  • Community monitoring frequency
  • Continuing specialist support when severe anorexia treatment is declined
  • Cotard syndrome
  • Cyclothymia recognition
  • Delayed sleep-wake phase disorder
  • Delirium precipitant review
  • Delirium versus dementia
  • Delusional perception
  • Dementia
  • Dementia with Lewy bodies
  • Dental protection after recurrent vomiting
  • Depersonalisation-derealisation disorder
  • Depression
  • Depression follow-up
  • Depression with seasonal pattern
  • Depressive episode assessment
  • Depressive illness with delusions
  • Diagnostic overshadowing
  • Dispensing a community withdrawal course
  • Dissociative flashback
  • Disulfiram before the last drink has cleared
  • Dual alcohol and benzodiazepine dependence
  • Early aftercare after self-harm
  • Early post-traumatic symptoms
  • Eating disorder
  • Eating disorder with type 1 diabetes
  • ECG before an antipsychotic in an inpatient manic episode
  • Electroconvulsive therapy
  • Electrolyte replacement route in stable eating-disorder care
  • Erotomanic delusion
  • Established post-traumatic stress disorder
  • Ethics
  • First-episode psychosis
  • Fregoli delusion
  • Functional cognitive disorder clue
  • Functional seizures
  • Gambling-related harms
  • Gamma-hydroxybutyrate withdrawal
  • Ganser syndrome
  • Generalised anxiety disorder
  • Higher lithium target in selected relapse prevention
  • Hoarding disorder
  • Hypoactive delirium
  • ICD-11 personality disorder formulation
  • ICD-11 schizoaffective disorder
  • Illness anxiety disorder
  • Inadequate clozapine response
  • Korsakoff syndrome cognitive profile
  • Lamotrigine is not an acute mania drug
  • Law
  • Laxative misuse and calorie absorption
  • Less severe depression
  • Life-threatening prolonged mania despite treatment
  • Lithium continuation with declining renal function
  • Lithium in the postnatal period
  • Lithium monitoring
  • Lithium monitoring after the first year at a higher level
  • Liver impairment changes the withdrawal medicine
  • Long-acting injectable antipsychotics
  • Malignant catatonia rather than behavioural disturbance
  • Mania after two adequate antipsychotic trials
  • Mania duration
  • Mental Health Act section 2
  • Mirtazapine adverse-effect selection
  • Mixed affective symptoms during an acute episode
  • Monitoring after disulfiram initiation
  • Monitoring after starting depression treatment
  • More severe depression
  • Naloxone titration
  • Naltrexone and future analgesia
  • Neuroleptic malignant syndrome
  • Neuropsychiatry
  • Neurotoxicity despite a laboratory therapeutic lithium result
  • Obsessive-compulsive disorder
  • OCD
  • Older-person self-harm
  • Opioid dependence
  • Opioid detoxification
  • Opioid maintenance
  • Organic
  • Othello syndrome
  • Overdose toxicity shapes antidepressant choice
  • Panic attack in emergency care
  • Panic attack physiology
  • Panic disorder
  • Past overactivity discovered during depression assessment
  • Perinatal
  • Persistent depressive disorder
  • Persistent drinking despite acamprosate
  • Persistent electrolyte abnormalities need reassessment
  • Persistent negative symptoms
  • Personality
  • Personality disorder is not an exclusion
  • Physical health surveillance in bipolar disorder
  • Planned withdrawal of lamotrigine in stable bipolar care
  • Poor tolerance of the first antipsychotic for mania
  • Positive diagnosis of functional weakness
  • Post-traumatic stress disorder
  • Postpartum obsessive intrusive thoughts
  • Postpartum psychosis
  • Pregnancy after anorexia remission
  • Premenstrual dysphoric disorder pattern
  • Prolonged grief disorder
  • Pseudodementia historical clue
  • Psychological treatment for persisting inter-episode bipolar symptoms
  • Psychopharmacology
  • Psychosis with substance misuse
  • Psychotic depression
  • PTSD
  • Rapid tranquillisation
  • Relapse monitoring after long-term bipolar medication is stopped
  • Relapse prevention when stopping lithium
  • REM sleep behaviour disorder
  • Renal and thyroid surveillance for lithium
  • Repeated presentations despite a care plan
  • Restrictive dieting perpetuating binge eating during therapy
  • Risk
  • Risk assessment beyond suicide in mania
  • Routine valproate concentrations in stable bipolar treatment
  • Schizophrenia
  • Schizophrenia/first episode
  • Self-harm
  • Self-harm assessment
  • Self-harm/capacity
  • Serotonin syndrome
  • Shared psychotic disorder principle
  • Sleep
  • Smoking cessation in severe mental illness
  • Social anxiety disorder
  • Somatic symptom disorder
  • Substance misuse does not automatically exclude eating-disorder treatment
  • Suicide-risk enquiry
  • Tardive dyskinesia
  • Tourette syndrome recognition
  • Treating an other specified eating disorder
  • Treatment review after mania resolves
  • Treatment-resistant OCD
  • Treatment-resistant schizophrenia
  • Trichotillomania
  • Wernicke encephalopathy prevention
  • Where symptom-triggered withdrawal dosing belongs

Other MRCP Part 1 specialties