A 79-year-old man with moderate Alzheimer disease on donepezil lives with his son. Over the last two days he has become drowsy, with lucid spells, then agitated at night; he pulled out his catheter and does not recognise his son. Three days ago a urologist started oxybutynin for urge incontinence. Temperature is 37.0 C, there are no focal signs and he has not fallen. What is the next best step?

Stop oxybutynin and look for other precipitants

Start regular haloperidol at night

Record this as progression of his dementia

Child psychiatry, dementia, delirium and Mental Healthcare Act

10 NEET-PG practice questions on Child psychiatry, dementia, delirium and Mental Healthcare Act, part of Psychiatry. The first 10 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Easy
A 30-year-old man in a village in Assam is brought at night in acute panic, holding his penis with a string tied to it. He is convinced it is shrinking into his abdomen and that he will die when it disappears. Several men in neighbouring villages had similar episodes that week. What is the most likely diagnosis?
1. ACouvade syndrome
2. BKoro
3. CLatah
4. DDhat syndrome
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Answer: B · Koro
Acute fear that the penis (or in women the breasts or vulva) is retracting into the body and will cause death is koro, a genital retraction syndrome. It may occur in epidemics, and outbreaks have been reported in north-east India. It is treated with reassurance, education and short-term anxiolysis. Exclude a true penile problem with a calm examination.
- A: Couvade syndrome is a husband's pregnancy-like symptoms during his partner's pregnancy.
- C: Latah is an exaggerated startle with echolalia and echopraxia.
- D: Dhat syndrome is worry about semen loss, not acute genital retraction.
Question 2 · Hard
A psychiatry resident in a district mental health establishment reviews treatment rules under the Mental Healthcare Act 2017. Consider these statements: 1. Sterilisation may be done as a treatment for mental illness if the family consents. 2. ECT without anaesthesia and muscle relaxants is prohibited. 3. A person with mental illness must not be chained in any form. 4. ECT may be given to a minor only with the guardian's informed consent and prior permission of the Mental Health Review Board. Which statements are correct?
1. A2 and 3 only
2. B2, 3 and 4 only
3. C1, 2, 3 and 4
4. D1, 3 and 4 only
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Answer: B · 2, 3 and 4 only
Statements 2, 3 and 4 are correct. The Act lists prohibited procedures: ECT without muscle relaxants and anaesthesia, ECT for minors (except as below), sterilisation as a treatment for mental illness, and chaining in any manner. If a psychiatrist judges ECT necessary for a minor, it may be given with the guardian's informed consent and the prior permission of the Mental Health Review Board. Statement 1 is false because family consent cannot make sterilisation a permitted treatment.
- A: Omits statement 4, the conditional exception for ECT in minors.
- C: Includes sterilisation, which the Act prohibits as treatment.
- D: Includes sterilisation and omits the ban on unmodified ECT.
Question 3 · Hard
A 79-year-old man with moderate Alzheimer disease on donepezil lives with his son. Over the last two days he has become drowsy, with lucid spells, then agitated at night; he pulled out his catheter and does not recognise his son. Three days ago a urologist started oxybutynin for urge incontinence. Temperature is 37.0 C, there are no focal signs and he has not fallen. What is the next best step?
1. AStop oxybutynin and look for other precipitants
2. BIncrease the donepezil dose
3. CStart regular haloperidol at night
4. DRecord this as progression of his dementia
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Answer: A · Stop oxybutynin and look for other precipitants
An acute change over days, with fluctuating alertness, inattention and night-time agitation, is delirium superimposed on dementia, not progression of dementia, which is slow. Oxybutynin is an anticholinergic that crosses the blood-brain barrier and opposes donepezil, and patients with dementia are very vulnerable to such drugs. The offending drug is stopped and other causes (infection, retention, electrolytes, hypoxia, pain) are looked for. Antipsychotics are kept for severe distress or danger, in the lowest dose for the shortest time.
- B: Increasing donepezil does not remove the anticholinergic cause of the delirium.
- C: Antipsychotics are not first-line and do not treat the cause.
- D: Dementia progresses over months; a change over two days is delirium until proved otherwise.
Question 4 · Medium
An 8-year-old boy in Class 3 is brought because for a year he has been unable to sit through lessons, blurts out answers, loses his books and runs about at home and school. His teacher's report confirms this. Hearing, vision and IQ are normal and there is no tic. Parent training has started. Which drug is first-line?
1. AMethylphenidate
2. BFluoxetine
3. CRisperidone
4. DHaloperidol
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Answer: A · Methylphenidate
Inattention, hyperactivity and impulsivity present in two settings for more than six months, starting in childhood, are attention-deficit hyperactivity disorder. In school-age children a stimulant, methylphenidate, is first-line alongside behavioural parent training and classroom support. It blocks dopamine and noradrenaline reuptake. Appetite, growth and sleep should be monitored; atomoxetine is a non-stimulant alternative.
- B: Fluoxetine treats depression and anxiety, not core ADHD symptoms.
- C: Risperidone is used for aggression or irritability, not as first-line for ADHD.
- D: Haloperidol is used for tics or psychosis, not ADHD.
Question 5 · Medium
A 35-year-old man has long resented his younger brother, who was their parents' favourite. In family gatherings he is excessively affectionate towards the brother, praises him loudly and insists on paying for everything for him. Which defence mechanism is he using?
1. ADisplacement
2. BSublimation
3. CProjection
4. DReaction formation
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Answer: D · Reaction formation
Reaction formation turns an unacceptable impulse into its opposite, often in an exaggerated way, so hidden hostility appears as excessive affection. It is an unconscious, neurotic-level defence. The exaggeration is a clue that the visible feeling is not the true one. It is common in obsessional personality traits.
- A: Displacement shifts feelings onto a safer target, such as shouting at a spouse after a scolding by the boss.
- B: Sublimation channels an impulse into a socially valued activity, such as aggression into sport.
- C: Projection attributes one's own unacceptable feelings to someone else.
Question 6 · Medium
A 72-year-old retired teacher has had 18 months of fluctuating confusion, with good and bad days. He sees children sitting in his room, acts out his dreams at night and has a shuffling gait. Two days after a doctor gave haloperidol for the visual hallucinations he became severely rigid and drowsy. What is the most likely diagnosis?
1. ADementia with Lewy bodies
2. BAlzheimer disease
3. CFrontotemporal dementia
4. DVascular dementia
Answer and explanation in LearnFree account
Question 7 · Easy
A 22-year-old unmarried man from a village in Uttar Pradesh complains of weakness, fatigue and poor concentration, which he blames on losing semen in his urine. He worries this will make him unfit for marriage. Examination and urinalysis are normal. What is the most likely diagnosis?
1. AKoro
2. BDhat syndrome
3. CAmok
4. DBrain fag syndrome
Answer and explanation in LearnFree account
Question 8 · Medium
A 70-year-old woman has had two years of slowly worsening memory: she repeats questions, misplaces her keys and recently got lost in her own colony. MMSE is 19/30 and MRI shows bilateral hippocampal atrophy. Her psychiatrist starts donepezil. How does this drug act?
1. AReversible inhibition of brain acetylcholinesterase
2. BAgonism at muscarinic M1 receptors
3. CReduction of amyloid plaque load
4. DBlockade of NMDA glutamate receptors
Answer and explanation in LearnFree account
Question 9 · Medium
A 23-year-old college student is brought to casualty after swallowing rat poison following a breakup. After she is stabilised, a police constable says she must be charged for attempting suicide. How does the Mental Healthcare Act 2017 deal with her attempt?
1. AShe must be detained in a mental health establishment
2. BShe can be treated only with a magistrate's order
3. CShe must be prosecuted for the attempt once she is medically fit
4. DShe is presumed to have severe stress and must be given care
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Question 10 · Medium
A 30-month-old boy is brought to the paediatric OPD because he has no words. He does not respond to his name, makes poor eye contact, does not point to show his mother things, lines up his toy cars for hours and flaps his hands when excited. Brainstem evoked response audiometry is normal. What is the most likely diagnosis?
1. AAttention-deficit hyperactivity disorder
2. BAutism spectrum disorder
3. CSelective mutism
4. DExpressive language disorder
Answer and explanation in LearnFree account

Child psychiatry, dementia, delirium and Mental Healthcare Act

A 35-year-old man has long resented his younger brother, who was their parents' favourite. In family gatherings he is excessively affectionate towards the brother, praises him loudly and insists on paying for everything for him. Which defence mechanism is he using?

A 22-year-old unmarried man from a village in Uttar Pradesh complains of weakness, fatigue and poor concentration, which he blames on losing semen in his urine. He worries this will make him unfit for marriage. Examination and urinalysis are normal. What is the most likely diagnosis?

A 70-year-old woman has had two years of slowly worsening memory: she repeats questions, misplaces her keys and recently got lost in her own colony. MMSE is 19/30 and MRI shows bilateral hippocampal atrophy. Her psychiatrist starts donepezil. How does this drug act?

A 23-year-old college student is brought to casualty after swallowing rat poison following a breakup. After she is stabilised, a police constable says she must be charged for attempting suicide. How does the Mental Healthcare Act 2017 deal with her attempt?