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MCQ exam (Paper 2): Answer Key History, mental state exam and psychopathology 1. Which of the following is the BEST example of inattention? A. The patient interrupts the conversation to ask when he will be discharged. B. The patient is oriented and aware of his recent medical problems but falls asleep during the conversation. C. The patient suddenly bursts into tears when you are discussing his recent amputation. D. The patient watches a fly buzzing on the ceiling while you are discussing the prognosis for his lung cancer, then falls asleep. E. The patient cannot remember what you have told him 3 minutes ago. Then he tries to make up the answer. The best answer is D. A. Impulsive interruptions may or may not indicate inattentiveness. B. Falling asleep may indicate inattentiveness, but further information would be needed to rule out other explanations such as recent administration of a sedating medication. C. Sudden bursts of affect have a significant differential beyond inattention. D. This patient seems distracted despite discussion of an issue of vital personal importance to him. In the context also of apparent drowsiness, the clinician should suspect the presence of delirium. E. The patient may suffer from dementia and cannot register the information. Author: Roger Ho 2. A 30-year-old man firmly believes that the alien has put an implant in his body and he feels there is a pushing sensation on his aorta. Which types of hallucinations BEST suited his description? A. B. C. D. E. Auditory Cenesthetic Gustatory Kinesthetic Visual. Year: 2013. The answer is B. Explanation: Cenesthetic hallucinations are unfounded sensations of altered states in bodily organs. Examples of cenesthetic hallucinations are a burning sensation in the brain, a pushing sensation in the blood vessels, and a cutting sensation in the bone marrow. Bodily distortion may also occur. Author: Roger Ho Year: 2013. This is an advanced-level question. 3. Perseveration is MOST commonly seen in which of the following disorders? A. Autism The answer is D. Explanation: Perseveration is a persisting response to a previous B. C. D. E. Attention deficit and hyperactivity disorder Bipolar disorder Frontal lobe dementia Obsessive compulsive disorder. stimulus after a new stimulus has been presented; it is often associated with frontal lobe lesion. Author: Roger Ho Year: 2013 4. A patient presents with persistence, perfectionism and body image distortion. Which of the following disorders is MOST likely to be associated with the above clinical features? A. B. C. D. E. Anorexia nervosa Borderline personality disorder Delusional disorder Hypochondriasis Somatization disorder. The answer is A. Explanation: Persistence and perfectionism are associated with obsessive-compulsive personality traits and disorders, along with body image distortion occurring in many patients with anorexia nervosa. Author: Roger Ho Year: 2013 Cognitive assessment 5. Which of the following statement is FALSE about Mini-mental state examination (MMSE)? A. A total score of 5 indicates severe dementia. B. Assessment of orientation to time and place is part of the MMSE. C. The MMSE can be administered in Chinese or English. D. The MMSE can be used to monitor treatment progress after initiation of acetylcholinesterase inhibitors (AChEIs). E. The MMSE is the gold standard in establishing the diagnosis of dementia. The answer is E. Explanation: MMSE is a screening test and there is no gold standard to establish the diagnosis of dementia in clinical practice. Clinical assessment by a psychiatrist or geriatrician is more important than MMSE in establishing diagnosis of dementia. Author: Roger Ho Year: 2013 Psychiatric epidemiology 6. Which of the following settings have the HIGHEST prevalence of delirium? A. B. C. D. E. Accident and emergency department Cardiac surgery ward General surgery ward Hospice with palliative advanced cancer patients Nursing home looking after dementia patients. The answer is D. Explanation: General surgical patients: 10-15%; Cardiac surgery patients: 30%; Hip fractures: 50%; Age >65 admitted to ICU: 70%; Palliative advanced cancer patients: 88%. Author: Roger Ho 7. The worldwide point prevalence of schizophrenia is BEST estimated as: A. 1% Year: 2013. The answer is A. Explanation: The worldwide point prevalence is 1% and Singapore is B. C. D. E. 2.5% 5% 7.5% 10%. 0.6%. Author: Roger Ho Year: 2013 Psychiatric aetiology, diagnosis and classification 8. Advanced paternal age is a well- established risk factor for which of the following psychiatry illnesses? A. B. C. D. E. Alcoholism Major depressive disorder Obsessive compulsive disorder Generalized anxiety disorder Schizophrenia. 9. Which of the following social factors is MOST LIKELY to be associated with relapse of schizophrenia after hospitalization? A. Discrimination B. Financial problems C. Homelessness D. Increased expressed emotion E. Isolation and absence of family member. The answer is E. Explanation: Advanced paternal age is a risk factor for schizophrenia. Author: Roger Ho Year: 2013. The answer is D. High levels of expressed emotion (EE) in the families of patients with schizophrenia predicted relapse following hospital discharge. Psychoeducational family therapy aims at helping the family reduce the factors that constitute expressed emotion. The therapist also educates the family about schizophrenia and the need to continue antipsychotic medication indefinitely. Author: Roger Ho 10. Individuals with which one of the following genes have the HIGHEST risk of developing Alzheimer’s disease? A. B. C. D. E. Homozygous apolipoproteins (APO) E2/E2 Homozygous APO E4/E4 Homozygous APO E6/E6 Heterozygous APO E2/E4 Heterozygous APO E2/E6. Year: 2013. The answer is B. Explanation: Homozygous APO E4/E4 increases the risk of developing Alzhimer’s disease by 8 times. Author: Roger Ho Year: 2013. General adult psychiatry 11. A 40-year-old man suffered from a heart attack under general anaesthesia. The doctors in the operation theatre successfully resuscitated him. After recovery, he wants to sue the hospital for causing him post-traumatic stress disorder (PTSD). He claims the resuscitation process was extremely traumatic. Which of the following is the MOST IMPORTANT feature to exclude the The answer is D. Explanation: In the new diagnostic criteria, it is possible for a PTSD patient not to directly witness a traumatic event and learn about it from others after the accident. The most crucial feature is whether diagnosis of PTSD? A. He does not have past history of PTSD. B. He has hidden agenda of suing the hospital and tries to seek compensation. C. He was under general anaesthesia and he was not conscious during resuscitation. D. The process of resuscitation is not considered to be traumatic in general and doctor resuscitated him in his best interest. E. He did not seek treatment from a psychiatrist after the operation. 12. Common symptoms of panic attacks include the all of following EXCEPT: A. B. C. D. E. Fear of dying Fear of losing control Fear of going crazy Palpitations Suicidal thoughts. 13. Which of the following schizophrenia patients has the HIGHEST suicide risk? A. An adolescent with prodromal symptoms and vague paranoid idea. B. An elderly retired man with late onset schizophrenia. C. A middle-aged man with negative symptoms. D. A middle-aged woman who suffers from simple schizophrenia. E. A young male university student who once had high expectations. 14. Which of the following is NOT a recognized alteration of sleep disturbance associated with major depressive disorder? A. Difficulty in falling asleep B. Increase in nocturnal awakening C. Increase in density of Rapid Eye Movement (REM) sleep D. Increase in the latency of Rapid Eye Movement (REM) sleep E. Reduction of total sleep time. 15. A 40-year-old woman is staying with her godbrother. She was rejected by her family and she felt helpless in the past. She needs her godbrother to make decision for her and her godbrother asks her to be the housekeeper in return. One day, her god-brother needs to go to Vietnam for 1 week and she feels extremely uncomfortable. Which of the following resuscitation itself is not a traumatic process and it is necessary for doctors to save patients’ life by resuscitation. Author: Roger Ho Year: 2013 This is an advanced – level question. The answer is E. Explanation: Suicidal thought is not common symptom of panic attack. Author: Rathi Mahendran Year: 2013. The answer is E. Explanation: The profile of the patient at greatest risk is a young man who once had high expectations, declined from a higher level of functioning, realizes that his dreams are not likely to come true, and has lost faith in the effectiveness of treatment. Author: Roger Ho Year: 2013. The answer is D. Explanation: It should be reduction of latency of REM sleep. Author: Roger Ho Year: 2013. This is an advanced level question. The answer is B. Explanation: She is best described to suffer from dependent personality because she cannot make decision on her own, uncomfortable when left alone and subordination to her god- personality traits BEST describes this person? A. B. C. D. E. Borderline personality Dependent personality Histrionic personality Schizoid personality Schizotypal personality. brother’s need (e.g. to be a housekeeper). Author: Roger Ho Year: 2013 16. A 30-year-old man comes to see you and he worries about premature ejaculation. The MOST appropriate time frame to meet the diagnosis of premature ejaculation is: A. Ejaculation occurs within 60 seconds following vaginal penetration. B. Ejaculation occurs within 90 seconds following vaginal penetration. C. Ejaculation occurs within 120 seconds following vaginal penetration. D. Ejaculation occurs within 150 seconds following vaginal penetration. E. Ejaculation occurs within 180 seconds following vaginal penetration. The answer is A. 17. A 30-year-old man suffered from eight episodes of The answer is D. mood disturbances within a single year. These mood episodes met the diagnostic criteria for major depression, mania and hypomania. These episodes were separated by remission. Which of the following is the MOST likely diagnosis? A. B. C. D. E. Cyclothymic disorder Emotionally unstable personality disorder Mixed affective disorder Rapid cycling bipolar disorder Schizoaffective disorder. Explanation: Premature ejaculation is defined as ejaculation occurs within 60 second following vaginal penetration and the patient wishes it. Author: Roger Ho Year: 2013 Explanation: This patient has more than 4 episodes of mania and depressive disorder in 1 year. He is too severe for cyclothymic disorder. Author: Roger Ho Year: 2013 Old age psychiatry 18. Which of the following is NOT a predisposing The answer is D. factor for depression in the elderly? A. B. C. D. E. Cerebrovascular accident Poly-pharmacy Looking after a spouse with chronic illness Male gender Widowhood. Explanation: Women have longer life span compared to men. As a result, women are more likely to be a widow and correspond to option E. Author: Roger Ho Year: 2013. 19. Dementia in general is BEST described as: The answer is E. A. Behavioural disturbance B. Global impairment C. Impaired memory for personal events (e.g. marriage, past occupation) D. Personality change Explanation: dementia is a progressive deterioration of cognition, including memory and/or one of four other cognitive symptoms (aphasia, apraxia, agnosia, impaired executive E. Progressive deterioration. functioning) but it may not be a global impairment. Impairment memory for recent events is more common than personal events. Author: Roger Ho 20. A 65-year-old man presents with memory loss, which of the following is the LEAST important indication for a computerized tomography (CT) scan for his brain: Year: 2013. The answer is C. Explanation: The other factors suggest an organic cause. A. A sudden decrease in cognitive function over a onemonth period B. Gait abnormalities C. His age D. Urinary incontinence E. Use of anticoagulants. Author: Roger Ho 21. For anxiety disorders in the elderly, which of the The answer is D Year: 2013. following statements is TRUE? A. Prevalence increases with age. B. Prevalence rates are lower in women. C. Common primary diagnoses in hospital population. D. Highest rates are found in the community. E. Most anxiety disorders have onset in late life. Explanation: Majority of anxiety disorders in elderly has their onset in young adult and middle age and are mainly managed by primary healthcare providers in the community. In the hospital setting, are usually comorbid conditions and are uncommonly primary diagnoses in the hospital population. Author: Tan Lay Ling Date of submission: 27 Feb 2013 This is an advanced-level question Child and adolescent psychiatry 22. Which of the following is THE MOST IMPORTANT predictor of bipolar disorder in adolescent depression? A. B. C. D. E. Diurnal variation of mood Hypomanic symptoms after taking antidepressants Hypersomnia Increased weight Multiple suicide attempts. 23. The MOST COMMON reason for children with autism are brought to medical attention by their parents is: The answer is B. Explanation: Antidepressant is the most common cause of hypomania and hypomania is part of the bipolar disorder. Author: Roger Ho Year: 2013. The answer is A. Explanation: Language delay is the most obvious sign and most disturbing A. B. C. D. E. Language delays Lack of toilet control Odd play School difficulties Stereotyped behaviour. to parents when they discover their children are lacking behind in language development compared to other children. Author: Roger Ho 24. Which of the following statements is FALSE regarding separation anxiety disorder? A. It involves recurrent distress when separate from attachment figures. B. Separation anxiety disorder does not occur in adolescents. C. Separation anxiety disorder is associated with school refusal. D. The child has difficulty falling asleep at night. E. The child may complain of somatic symptoms. 25. Which of the following symptoms is MOST LIKELY to persist when a young person suffers from Attention Deficit and Hyperactivity Disorder (ADHD) becoming an adult? A. B. C. D. E. Accident risk Hyperactivity Impulsivity Inattention Learning difficulties. Year: 2013. The answer is B. Explanation: Separation anxiety disorder is more common in children and it can occur in adolescents. Author: Roger Ho Year: 2013. The answer is D. Answer: Although symptoms of hyperactivity and impulsivity often improve as the child grows older, inattentive symptoms are likely to persist. Author: Roger Ho 26. A baby is born with low birth weight, microcephaly, small eyes, upturned nose and a smooth, undeveloped philtrum. He fails to thrive and develops seizures. Which of the following was he MOST likely exposed to during pregnancy? A. Alcohol B. Cocaine C. LSD D. Methamphetamine E. Inhalants. Year: 2013 The answer is A. Explanation: This is a classical description of the facial features of foetal alcohol syndrome Author: Roger Ho Year: 2013. Substance abuse 27. The term which BEST describes an altered physiological state and neuro- adaptation caused by repeated administration of a drug is: A. B. C. D. E. Addiction Dependence Misuse Withdrawal Tolerance. The answer is B. Explanation: The term dependence indicates physiological changes. Misuse refers to use of any drug, usually by self-administration, in a manner that deviates from approved social or medical patterns. Addiction is non-specific and ignores the concept of substance dependence is a medical condition. Author: Roger Ho 28. While driving, a 40-year-old man with no previous history refused to stop for the traffic police. He was subsequently brought into the accident and emergency department (AED) by them. You are the resident working in the AED. When you assess him, he states that he was hearing voices in clear consciousness. He admits to a history of alcohol use. What is the most appropriate diagnosis? A. B. C. D. E. Alcoholic hallucinosis Delirium tremens Korsakoff psychosis Schizophrenia Wernicke’s encephalopathy. 29. Which of the following BEST describes the mechanism of action with naltrexone in the treatment of alcohol dependence? A. Naltrexone acts on the benzodiazepine receptor and prevents alcohol withdrawal. B. Naltrexone blocks opioid receptors to decrease alcohol craving. C. Naltrexone inhibits aldehyde dehydrogenase to decrease alcohol craving. D. Naltrexone is a GABA agonist and decreases alcohol craving. E. Naltrexone is a glutamate antagonist and decreases alcohol craving. 30. Which of the following complications is LEAST likely to occur in cocaine abusers? A. Arrhythmia B. Hyperthermia C. Myocardial infarction D. Phlebitis E. Seizure. Year: 2013. The answer is A. Explanation: Auditory hallucinosis is usually composed of auditory hallucination. Sensorium is clear and it is different from delirium tremens. There are not enough symptoms to conclude that he suffers from schizophrenia. Author: Roger Ho Year: 2013. The answer is B. Explanation: Option A refers to benzodiazepine. Option C refers to the action of disulfiram. Option D and E refer to the action of acamprosate. Author: Roger Ho Year: 2013. The answer is D. Explanation: Cocaine is least likely to be injected via IV route. As a result, phlebitis is relatively less likely to occur in patients misusing cocaine. Author: Roger Ho Year: 2013 This is an advanced-level question. 31. The primary neurotransmitter involved with Lysergic acid diethylamide (LSD) is: a. Acetylcholine b. Dopamine c. γ-Aminobutyric acid d. Norepinephrine The answer is E. Explanation: LSD increases the level of serotonin and overdose of LSD is associated with serotonin syndrome. e. Serotonin. Author Roger Ho Year: 2013. 32. All of the following are true about alcohol A. B. C. D. E. withdrawal EXCEPT: Central nervous system hyperexcitability Onset 12 to 24 hours after last drink Peak intensity at 24 to 48 hours Sympathetic hypoactivity Triggered by abrupt cessation of intake in dependent persons. Psychopharmacology 33. Monoamine oxidase inhibitor (MAOI) is LEAST useful in treating which of the following disorders? A. B. C. D. Atypical depression Obsessive compulsive disorder Panic disorder Severe depressive disorder not responding to selective serotonin reuptake inhibitor E. Severe depressive disorder with hyponatraemia The answer is D. Explanation: It should be sympathetic hyperactivity. Author: Rathi Mahendran Year: 2013. The answer is B. Explanation: MAOI is least useful to treat OCD. Author: Roger Ho Year: 2013. This is an advanced-level question. 34. Which of the following antidepressants is LEAST The answer is A. likely to contribute to the development of serotonin syndrome? Explanation: Bupoprion works on dopamine and norepinephrine. As a A. Bupropion result, it is least likely to cause B. Fluoxetine serotonin syndrome. C. Moclobemide D. Paroxetine Answer: Roger Ho E. Venlafaxine. Year: 2013. This is an advanced-level question. 35. Which of the following antipsychotics exhibit a novel mechanism as a partial antagonist? A. B. C. D. E. Aripiprazole Clozapine Olanzapine Quetiapine Ziprasidone. The answer is A. Explanation: Aripiprazole exhibits a novel mechanism by definition while other antipsychotics listed do not have this property. Author: Roger Ho Year: 2013. 36. Regarding lamotrigine, which of the following The answer is C. statements is FALSE? A. It acts at voltage-sensitive sodium channels. Explanation: Double-blind, placebo- B. It inhibits the release of excitatory amino acid neurotransmitters. C. It is not effective in the treatment of bipolar depression. D. Its use can lead to toxic epidermal necrolysis. E. There is no need to monitor lamotrigine blood levels during treatment. controlled trials have shown that it has acute and prophylactic antidepressant effects. It can lead to severe dermatological condition such as Steven Johnson syndrome/ toxic epidermal necrolysis. In Singapore, there is no blood test to check its level. Author: Roger Ho Year: 2013 This is an advanced-level question. 37. Anticholinergic side effects include all of The answer is A. the following EXCEPT: A. B. C. D. E. Bradycardia Constipation Dry mouth Exacerbation of open-angle glaucoma Urinary retention. 38. In a schizophrenia patient without history of asthma, the BEST treatment for chronic akathisia is: A. B. C. D. E. Alprazolam Benzhexol Clonazepam Propranolol Vitamin E. Explanation: Anticholinergic side effect include tachycardia. Author: Roger Ho Year: 2013. The answer is D. Explanation: Propranolol (beta blocker) is the best treatment in this patient without history of asthma as it does not cause dependence as in Option A and C. Beta blockers can reduce restlessness and tremor. Option B is more useful for pseudoparkinsonism. Author: Roger Ho 39. Which of the following psychotropic medications is MOST EFFECTIVE in preventing relapse in rapid cycling bipolar disorder? A. B. C. D. E. Haloperidol Lithium Olanzapine Valproate Risperidone. Year: 2013. The answer is D. Explanation: Lithium is less effective in preventing relapse in rapid cycling bipolar disorder. Valproate and carbamazepine are preferred over lithium. Author: Roger Ho 2013 40. Common side-effects of clozapine include the The answer is E. following EXCEPT: A. B. C. D. E. 41. A. B. C. D. E. Explanation: Clozapine and olanzapine are well-known in causing weight gain and metabolic syndrome. Anticholinergic side-effects Agranulocytosis Sedation Seizures Weight loss. Author: Rathi Mahendran Modified by Roger Ho 2013 Common indications for ECT include all of the The answer is E. following EXCEPT: Contraindications to medication Explanation: Strong suicide ideation Medication failure rather than repeated self-harm is a Previous good response common indication for ECT. Psychotic depression Repeated self-harm. Author: Rathi Mahendran 2013 Psychotherapy 42. In conducting psychotherapy with individuals who have experienced a traumatic event and suffer from post-traumatic stress disorder (PTSD), the following are all recommended techniques EXCEPT: The answer is A. A. B. C. D. E. Encouraging avoidance of emotion Examining feelings of guilt Examining the patient’s response to the trauma Offering consolation Overcoming avoidance or phobia related to the trauma. Author: Roger Ho 43. A 30-year-old woman with panic disorder does not respond to an initial treatment with an selective serotonin reuptake inhibitor (SSRI). Which of the following treatment is considered the best approach? The answer is B. A. B. C. D. E. Year 2013. Explanation: The effect of CBT is as efficacious as SSRI. Author: Roger Ho Benzodiazepine Cognitive behaviour therapy Serotonin-noradrenaline reuptake inhibitor Olanzapine Psychodynamic psychotherapy. 44. Which of the following statements INCORRECT about Interpersonal therapy? Explanation: A is the answer. Affect or emotion should not be avoided in psychotherapy. Year: 2013. is A. Has been shown to be efficacious in adult outpatients suffering from depression. B. Is more efficacious than psychodynamic psychotherapy C. Works as quickly as antidepressant medication. D. Works best in mild to moderate depression. E. Works best in people facing problems in role transition. The answer is C. Explanation: Interpersonal therapy is slower than the effect of antidepressant because the therapist needs time to assess the patient and formulate strategies (e.g. interpersonal inventory and role play). Author: Roger Ho 45. A 23-year-old student is seen in the University counselling centre because of relationship problems. She has had one serious relationship with her boyfriend that lasted about six months. She terminated the relationship because she discovered that her boyfriend was seeing someone else. During psychotherapy, she mentions that ‘All men just can’t be trusted.’ Which of the following BEST describes this thinking error? Year: 2013. The answer is D. Explanation: This patient demonstrates overgenearlization because she believes in and follows a general rule on the basis of limited examples. Author: Roger Ho Year: 2013. A. B. C. D. E. Arbitrary inference Dichotomous thinking Magnification Overgeneralization Selective abstraction. Ethics and laws 46. All medical students are required to study psychiatry so that they are qualified to assess and manage common psychiatric disorders after graduation. The compulsory psychiatric training is BEST described by which of the following ethical principles? A. B. C. D. E. Autonomy Beneficence Morality Justice Fiduciary duty. The answer is B. Explanation: With competent psychiatric knowledge, the future doctors can provide benefits to patients when making decision on diagnosis and management. The other concept that is relevant is dereliction. Fiduciary duty refers to the duty that the doctor must act in the patient’s best interest and it is not as relevant as beneficence in this case. Author: Roger Ho Year: 2013 Liaison and neuropsychiatry 47. You are a medical resident. A 40-year-old The answer is B. schizophrenia patient was admitted as a result of polydipsia. Which of the following statements Explanation: Psychogenic polydispsia regarding polydipsia in schizophrenia is NOT true? is a common condition for chronic schizophrenia. The estimates of A. It is associated with low urine osmolality. prevalence range from 5 to 20%. The B. It is associated with high sodium in urine. patient drinks excess water and C. It is associated with low serum sodium. results in diluted urine. The body tries D. Patients should be investigated for Syndrome of to preserve sodium and results in low Inappropriate Secretion of Anti-Diuretic Hormone urine sodium. The serum is diluted. (SIADH). SIADH should be considered for DDX. E. Polydipsia occurs in between 5 to 20% of patients suffering from chronic schizophrenia. Author: Roger Ho Year: 2013. This is an advanced-level question. 48. A 40-year-old British man is admitted to the The answer is B. medical ward. He tries to run away from the ward. He is very aggressive and the security guards have Explanation: He suffers from delirium difficulty to stop him. He claims that he is tremens. Intramuscular diazepam has currently working in the office. The medical poor absorption. Option C and D are records show that he has been drinking half of a not available in Singapore. Option E is bottle of whisky every night. You need to order a a depot antipsychotics and it is not medication to sedate him. He refuses to take any useful in acute setting. oral medication. Which of the following medications is the BEST alternative in Singapore? Author: Roger Ho A. B. C. D. E. Intramuscular diazepam Intramuscular lorazepam Intramuscular olanzapine Intramuscular quetiapine Intramuscular risperidone. Year: 2013 49. You are the resident working for the liver The answer is B. transplant team. The MOST common psychiatric disorder in patients with liver cancer in the week Explanation: Delirium is the most before and after transplantation is: common disorder and it can be caused by systemic infection, side A. Adjustment disorder effect of immunosuppressant, B. Delirium impairment of liver function, hepatic C. Generalized anxiety disorder encephalopathy. D. Major depressive disorder E. Somatoform pain disorder. Author: Roger Ho Year: 2013. 50. You are the resident working in the obstetrics The answer is B. department. Which of the following is the BEST treatment strategies to treat hyperemesis during Explanation: Benzodiazepine may pregnancy? cause cleft palate in the first trimester. Psychoanalysis is not for A. Benzodiazepines e.g. alprazolam symptomatic relief. SSRI like B. Relaxation therapy fluvoxamine is associated with nausea C. Psychoanalysis side effect. Hyperemesis is not D. Selective serotonin reuptake inhibitor e.g. associated with stimulus. Relaxation fluvoxamine therapy is the best treatment. E. Stimulus deprivation. Author: Roger Ho Year: 2013. Vetted by: Dr. Lai YM (2013)