Psychiatry Prometric exam questions with answers

1. Question 1Foundations: Neuroscience, Basic Psychology, Psychiatric Assessment & Classificationeasy

   A 55-year-old man asked what brought him to clinic gives a long account with many unnecessary details about his journey and his neighbour, but eventually returns to answer the question. Which formal thought disorder does this describe?

   1. ATangentiality
   2. BCircumstantiality
   3. CFlight of ideas
   4. DLoosening of associations
   Show answer and explanation▾

   Answer: B. Circumstantiality

   Circumstantiality is over-inclusive, detailed speech that is delayed in reaching the goal but eventually gets there. In tangentiality the speaker departs from the question and never returns to the original point. Flight of ideas involves rapid, pressured shifts between ideas with understandable links, typical of mania, whereas loosening of associations involves shifts with no logical connection.

2. Question 2Schizophrenia Spectrum & Other Psychotic Disordershard

   A 32-year-old man with treatment-resistant schizophrenia is stable on clozapine 400 mg daily and smokes 25 cigarettes a day. He is admitted to a smoke-free medical ward for 2 weeks and uses nicotine patches. Which change is most likely to occur?

   1. AClozapine levels fall because nicotine induces CYP1A2
   2. BClozapine levels are unchanged because smoking does not affect its metabolism
   3. CClozapine levels fall because gastric absorption is reduced
   4. DClozapine levels rise, risking toxicity, so dose reduction should be considered
   Show answer and explanation▾

   Answer: D. Clozapine levels rise, risking toxicity, so dose reduction should be considered

   Polycyclic aromatic hydrocarbons in tobacco smoke, not nicotine, induce CYP1A2, the main enzyme metabolising clozapine; stopping smoking removes this induction and clozapine levels can rise substantially within days to weeks, risking sedation, hypotension and seizures. Nicotine replacement does not induce CYP1A2 and so does not prevent the rise. Plasma level monitoring and a planned dose reduction are recommended, with the reverse adjustment if smoking resumes.

3. Question 3Depressive, Bipolar & Related Disordersmedium

   A 29-year-old woman with bipolar I disorder, not currently taking any medication, presents with a major depressive episode of moderate severity without psychotic features. Which is the most appropriate first-line pharmacological treatment?

   1. AQuetiapine monotherapy
   2. BSertraline monotherapy
   3. CVenlafaxine monotherapy
   4. DRisperidone monotherapy
   Show answer and explanation▾

   Answer: A. Quetiapine monotherapy

   Quetiapine has robust evidence in acute bipolar depression and is a first-line option in major guidelines, alongside agents such as lurasidone, cariprazine, lithium and lamotrigine. Antidepressant monotherapy is not recommended in bipolar I disorder because it is often ineffective and may induce mania or rapid cycling, with a greater risk for venlafaxine than for SSRIs. Risperidone is effective for mania but not for bipolar depression.

4. Question 4Anxiety, Obsessive-Compulsive & Related, Trauma- and Stressor-Related & Dissociative Disordersmedium

   A 34-year-old woman has nightmares, intrusive memories, avoidance and hypervigilance 6 months after a violent assault, with marked impairment at work. She is not depressed or suicidal and wants treatment. Which is the most appropriate first-line intervention?

   1. AA benzodiazepine for sleep and hyperarousal
   2. BA single session of psychological debriefing
   3. CTrauma-focused psychological therapy such as trauma-focused CBT or EMDR
   4. DSupportive counselling without trauma-focused work
   Show answer and explanation▾

   Answer: C. Trauma-focused psychological therapy such as trauma-focused CBT or EMDR

   Trauma-focused psychological therapies, including trauma-focused CBT, cognitive processing therapy, prolonged exposure and EMDR, have the strongest evidence and are recommended first-line for PTSD in adults. Benzodiazepines are not recommended because they do not treat core symptoms and may impair recovery. Single-session psychological debriefing is ineffective and may be harmful, and non-trauma-focused counselling is less effective.

5. Question 5Personality, Impulse-Control, Feeding & Eating, Sleep-Wake, Sexual & Reproductive Psychiatrymedium

   A 23-year-old woman with borderline personality disorder has recurrent self-harm by cutting, chronic emptiness and intense, unstable relationships. She asks what treatment is most likely to help. Which is the most appropriate recommendation?

   1. ALong-term mood stabiliser therapy as the main treatment
   2. BDialectical behaviour therapy
   3. CLow-dose antipsychotic maintenance
   4. DShort-term admission whenever self-harm occurs
   Show answer and explanation▾

   Answer: B. Dialectical behaviour therapy

   Structured psychological therapies are the treatment of choice for borderline personality disorder, and dialectical behaviour therapy has the strongest evidence for reducing self-harm, particularly in women with recurrent self-harm; mentalisation-based therapy is another option. Guidelines advise against medication as the primary treatment because no drug has proven benefit for the core disorder, reserving short-term use for comorbid conditions or crises. Repeated admissions can reinforce dependence and are not therapeutic.

6. Question 6Personality, Impulse-Control, Feeding & Eating, Sleep-Wake, Sexual & Reproductive Psychiatryeasy

   A 46-year-old man has had difficulty maintaining sleep on most nights for 8 months, with daytime fatigue. There is no sleep apnoea, depression or substance use. Which is the recommended first-line treatment for his chronic insomnia?

   1. AZolpidem nightly for 3 months
   2. BA sedating antihistamine as needed
   3. CTrazodone 50 mg at night
   4. DCognitive behavioural therapy for insomnia
   Show answer and explanation▾

   Answer: D. Cognitive behavioural therapy for insomnia

   Cognitive behavioural therapy for insomnia, combining stimulus control, sleep restriction, cognitive restructuring and sleep hygiene, is recommended first-line for chronic insomnia in adults and has durable benefits. Hypnotics such as zolpidem may be used short term but carry risks of tolerance, falls and complex sleep behaviours. Sedating antihistamines and low-dose trazodone lack good evidence for chronic insomnia.

7. Question 7Substance-Related & Addictive Disordersmedium

   A 30-year-old man with opioid use disorder who injects heroin wishes to start buprenorphine. His last use was 6 hours ago and his Clinical Opiate Withdrawal Scale (COWS) score is 4. What is the most appropriate action?

   1. ADelay the first dose until objective withdrawal is at least moderate
   2. BGive buprenorphine 8 mg now to prevent withdrawal developing
   3. CGive naloxone to confirm opioid dependence before starting
   4. DStart methadone 60 mg today instead of buprenorphine
   Show answer and explanation▾

   Answer: A. Delay the first dose until objective withdrawal is at least moderate

   Buprenorphine is a high-affinity partial agonist that displaces full agonists, so giving it before withdrawal is established can precipitate withdrawal; induction usually starts when objective withdrawal is at least moderate (often a COWS score of about 8 to 12 or more), typically 12 hours or more after short-acting opioids. A COWS of 4 indicates only mild withdrawal. A naloxone challenge is unnecessary and distressing, and a starting methadone dose of 60 mg is unsafe because of overdose risk.

8. Question 8Substance-Related & Addictive Disordershard

   A 52-year-old man with alcohol use disorder has completed withdrawal and wants medication to prevent relapse. He has chronic kidney disease with an eGFR of 25 mL/min/1.73 m2, normal liver function and stable ischaemic heart disease, and takes no opioids. Which medication is most appropriate?

   1. AAcamprosate
   2. BDisulfiram
   3. CNaltrexone
   4. DGabapentin at standard doses
   Show answer and explanation▾

   Answer: C. Naltrexone

   Acamprosate is renally excreted and contraindicated when creatinine clearance is 30 mL/min or less, and disulfiram is contraindicated in ischaemic heart disease because the alcohol-disulfiram reaction can cause hypotension and arrhythmia. Naltrexone is mainly metabolised by the liver, is suitable with normal liver function in a patient not taking opioids, and can be used with caution in renal impairment. Gabapentin accumulates in renal impairment and would need substantial dose reduction.

9. Question 9Psychopharmacology & Somatic Therapies (ECT and Neuromodulation)easy

   A 60-year-old woman has been stable on lithium for 10 years. Her family doctor plans to start a new medication for hypertension. Which drug is most likely to raise her lithium level into the toxic range?

   1. AAmlodipine
   2. BHydrochlorothiazide
   3. CDoxazosin
   4. DHydralazine
   Show answer and explanation▾

   Answer: B. Hydrochlorothiazide

   Thiazide diuretics reduce renal lithium clearance by increasing proximal tubular reabsorption of sodium and lithium, raising lithium levels substantially; ACE inhibitors, angiotensin receptor blockers and NSAIDs have similar effects. If a thiazide is unavoidable, the lithium dose should be reduced and levels monitored closely. Amlodipine, doxazosin and hydralazine have no clinically important effect on lithium levels.

10. Question 10Psychopharmacology & Somatic Therapies (ECT and Neuromodulation)hard

    A 68-year-old woman with severe psychotic depression starts ECT. Her medications are sertraline 100 mg, olanzapine 10 mg, levothyroxine and lorazepam 2 mg three times daily. At the first session an adequate seizure cannot be induced despite stimulus titration to high energy. Which medication change is most likely to improve seizure induction?

    1. AStop sertraline before the next session
    2. BStop olanzapine before the next session
    3. CStop levothyroxine before the next session
    4. DReduce and taper lorazepam before further sessions
    Show answer and explanation▾

    Answer: D. Reduce and taper lorazepam before further sessions

    Benzodiazepines raise the seizure threshold and shorten seizures, so high doses can prevent adequate seizure induction and reduce ECT efficacy; they should be tapered where possible, or their effect briefly reversed with flumazenil under anaesthetic supervision. SSRIs and antipsychotics such as olanzapine do not impair seizure induction and are usually continued. Levothyroxine has no relevant effect on the seizure threshold.

11. Question 11Consultation-Liaison (Psychosomatic) Psychiatry, Somatic Symptom & Neurocognitive Disordersmedium

    A 31-year-old woman has 3 weeks of right leg weakness. Hip extension is weak when tested directly but becomes normal when she flexes the opposite hip against resistance. Reflexes and MRI are normal. Which statement about the diagnosis is most accurate?

    1. AFunctional neurological disorder is diagnosed on positive signs of incompatibility
    2. BA recent psychological stressor must be identified to make the diagnosis
    3. CFeigning must first be excluded by covert observation
    4. DThe diagnosis can only be made after all other tests are normal
    Show answer and explanation▾

    Answer: A. Functional neurological disorder is diagnosed on positive signs of incompatibility

    In DSM-5-TR, functional neurological symptom disorder is diagnosed on clinical findings showing incompatibility with recognised neurological disease, such as a positive Hoover sign, rather than purely by exclusion. A psychological stressor is not required, although it may be specified if present. The disorder is distinguished from factitious disorder and malingering, but these do not have to be excluded by surveillance.

12. Question 12Geriatric, Public/Community & Cross-Cultural Psychiatrymedium

    A 76-year-old man has fluctuating cognition, recurrent well-formed visual hallucinations of children in the room, REM sleep behaviour disorder and mild parkinsonism. The hallucinations are distressing. Which is the most appropriate first-line pharmacological treatment?

    1. AHaloperidol 0.5 mg twice daily
    2. BRisperidone 0.5 mg at night
    3. CA cholinesterase inhibitor such as rivastigmine or donepezil
    4. DIncreasing levodopa to improve parkinsonism
    Show answer and explanation▾

    Answer: C. A cholinesterase inhibitor such as rivastigmine or donepezil

    These features meet criteria for dementia with Lewy bodies, in which cholinesterase inhibitors improve cognition, can reduce hallucinations and are recommended first-line. Patients with DLB have marked sensitivity to antipsychotics, and haloperidol and risperidone can cause severe, sometimes fatal, reactions with worsening parkinsonism; if an antipsychotic is unavoidable, low-dose quetiapine or clozapine is used cautiously. Dopaminergic therapy tends to worsen hallucinations.

13. Question 13Child & Adolescent Psychiatry and Neurodevelopmental Disordersmedium

    An 8-year-old boy is to start methylphenidate for ADHD. He has no personal or family history of cardiac disease, syncope or sudden death, and his cardiovascular examination is normal. Which baseline assessment is routinely required before starting treatment?

    1. AA 12-lead ECG and echocardiogram
    2. BHeart rate, blood pressure, height and weight
    3. CAn EEG to exclude subclinical seizures
    4. DThyroid function tests and a full blood count
    Show answer and explanation▾

    Answer: B. Heart rate, blood pressure, height and weight

    Before starting stimulant medication, guidelines require a cardiovascular history, heart rate and blood pressure plotted on a centile chart, and height and weight, which are then monitored during treatment because stimulants can raise blood pressure and suppress appetite and growth. An ECG is needed only with a relevant cardiac history, a family history of sudden death or abnormal findings. EEG and blood tests are not routinely indicated.

14. Question 14Emergency Psychiatry, Risk Assessment & Crisis Managementhard

    A 40-year-old man is acutely agitated and violent on an inpatient unit despite de-escalation, and has refused oral medication. He has no known medical history, has never taken antipsychotics and no ECG is available. Which is the most appropriate intramuscular medication for rapid tranquillisation?

    1. ALorazepam
    2. BHaloperidol alone
    3. CHaloperidol with promethazine
    4. DOlanzapine given together with lorazepam
    Show answer and explanation▾

    Answer: A. Lorazepam

    When there is insufficient information about cardiac status or previous antipsychotic exposure, intramuscular lorazepam is preferred for rapid tranquillisation. Haloperidol carries risks of QT prolongation, arrhythmia and acute dystonia, so it should not be used without an ECG and is avoided in antipsychotic-naive patients; adding promethazine does not remove the need for an ECG. Intramuscular olanzapine and parenteral benzodiazepines should not be given together because of the risk of hypotension and respiratory depression.

15. Question 15Forensic Psychiatry, Mental Health Law, Ethics, Professionalism & Patient Safetyeasy

    During a session, a 35-year-old man with paranoid delusions states credibly that he will kill his named neighbour this weekend and has bought a knife. He refuses admission. Which action best fulfils the psychiatrist's duty?

    1. AMaintain confidentiality and increase outpatient appointments
    2. BRecord the threat and discuss it at the next team meeting
    3. CAsk the patient to promise not to act on his threat
    4. DTake reasonable steps to protect the neighbour, including breaching confidentiality
    Show answer and explanation▾

    Answer: D. Take reasonable steps to protect the neighbour, including breaching confidentiality

    When a patient poses a serious and imminent threat of violence to an identifiable person, the duty to protect, recognised since the Tarasoff decisions and in professional codes, justifies a proportionate breach of confidentiality, for example warning the potential victim, informing police and considering detention under mental health legislation. Delayed discussion or more frequent appointments do not address the imminent risk. No-harm promises have no protective value.

Last reviewed September 2026. Questions are original and written to the published exam blueprint; they are not taken from any real paper.