Master CPS - Psychiatry/Neurology
for MSRA

What the MSRA Tests in CPS - Psychiatry/Neurology

The MSRA CPS - Psychiatry/Neurology component tests clinical decision-making in common presentations such as psychosis, depression, anxiety, dementia, epilepsy, headache, stroke, and movement disorders. Candidates must apply DSM-5/ICD-10 diagnostic criteria, choose first-line pharmacological and non-pharmacological treatments per NICE guidelines, and interpret key investigations (e.g., EEG, CT head, lumbar puncture). Emphasis is on safe prescribing (e.g., antipsychotic monitoring, antidepressant doses), risk assessment (suicide, self-harm, falls), and recognising red flags (e.g., cauda equina syndrome, meningism, neuroleptic malignant syndrome). Questions often present a clinical scenario requiring prioritisation of next steps—immediate management vs. referral vs. further tests.

High-Yield Concepts

• Depression – First-line and Augmentation: First-line for moderate-severe depression: SSRIs (sertraline 50 mg od, citalopram 20 mg od) or SNRIs. Augmentation strategies include adding a second antidepressant (e.g., mirtazapine 15-30 mg nocte) or an atypical antipsychotic (e.g., aripiprazole 2.5-10 mg). NICE recommends at least 2 years of maintenance therapy after recurrent episodes. Avoid venlafaxine in uncontrolled hypertension.
• Psychosis – Antipsychotic Choice and Monitoring: First-line for first-episode psychosis: oral atypical antipsychotic (e.g., olanzapine 10 mg od, risperidone 2-6 mg od). Baseline and regular monitoring: FBC, U&Es, LFTs, prolactin, fasting glucose/lipids, ECG (QTc <450 ms men, <470 ms women). Clozapine reserved for treatment-resistant schizophrenia (2 adequate trials of different antipsychotics); requires weekly FBC for 18 weeks, then fortnightly.
• Epilepsy – Classification and First-line AEDs: Focal seizures: lamotrigine or levetiracetam first-line. Generalised tonic-clonic: sodium valproate (avoid in women of childbearing potential due to teratogenicity; use lamotrigine or levetiracetam instead). Absence seizures: ethosuximide first-line. Status epilepticus: lorazepam 4 mg IV (or buccal midazolam 10 mg) then phenytoin 18 mg/kg IV or levetiracetam 60 mg/kg IV.
• Stroke – Thrombolysis and Secondary Prevention: Thrombolysis with alteplase within 4.5 hours of symptom onset for ischaemic stroke (exclude haemorrhage on CT). Contraindications: recent major surgery, INR >1.7, platelets <100,000, BP >185/110 mmHg. Secondary prevention: clopidogrel 75 mg od (or aspirin 75 mg + dipyridamole MR 200 mg bd if intolerant), atorvastatin 80 mg od, antihypertensives (target <130/80 mmHg).
• Dementia – Diagnosis and Cholinesterase Inhibitors: Alzheimer’s disease: first-line donepezil 5 mg od (titrate to 10 mg), rivastigmine, or galantamine. NICE criteria: MMSE score 10-26 (mild-moderate). Vascular dementia: no specific drug licensed; manage vascular risk factors. Lewy body dementia: rivastigmine first-line; avoid antipsychotics (severe sensitivity reactions). Frontotemporal dementia: no drug treatment; behavioural management.
• Headache – Red Flags and Migraine Management: Red flags (SNOOP4): Systemic symptoms (fever, weight loss), Neurological signs, Onset sudden (thunderclap), Older age (>50), Previous headache history change, Papilloedema, Positional/Precipitated by Valsalva, Progressive. Acute migraine: triptan (e.g., sumatriptan 50-100 mg po) + NSAID (e.g., naproxen 500 mg). Prophylaxis: propranolol 40-80 mg bd, topiramate 25-50 mg bd, or amitriptyline 10-50 mg nocte.
• Anxiety Disorders – First-line Pharmacotherapy: GAD: first-line SSRI (sertraline 50 mg od) or SNRI (duloxetine 60 mg od). Panic disorder: SSRI (citalopram 20 mg od) with short-term benzodiazepine (e.g., diazepam 2 mg tds for max 2-4 weeks) to avoid dependence. Social anxiety: sertraline or escitalopram first-line. CBT is recommended alongside medication. Avoid benzodiazepines as monotherapy beyond acute crises.
• Movement Disorders – Parkinson’s Disease Management: First-line for motor symptoms: levodopa/carbidopa (co-careldopa) 100/25 mg tds, or dopamine agonist (e.g., ropinirole 0.25 mg tds) in younger patients (<60). Monitor for dyskinesias and impulse control disorders. For tremor-dominant: anticholinergics (e.g., procyclidine 5 mg tds) but avoid in elderly. NMS: hyperthermia, rigidity, autonomic instability, raised CK – stop antipsychotic, support in ICU, give dantrolene or bromocriptine.

Common Traps in CPS - Psychiatry/Neurology Questions

• Confusing first-line treatment for acute mania (e.g., lithium or valproate) with maintenance therapy (lithium remains first-line for bipolar I).
• Ordering CT head for all first seizures in adults – NICE advises routine CT only if focal neurology, head injury, or anticoagulation; otherwise MRI is preferred.
• Using benzodiazepines as first-line for GAD or panic disorder beyond 2-4 weeks – leads to dependence; SSRIs/SNRIs are first-line.
• Missing the diagnosis of normal pressure hydrocephalus (gait apraxia, urinary incontinence, cognitive decline) in elderly patients with dementia – treatable with VP shunt.
• Forgetting to check serum sodium within 2 weeks of starting an SSRI (especially citalopram/escitalopram) – risk of hyponatraemia in elderly.
• Assuming all antipsychotics are equally safe in dementia – haloperidol and typical antipsychotics increase stroke risk and mortality in elderly with dementia; risperidone/olanzapine only for severe symptoms.

How to Revise CPS - Psychiatry/Neurology for the MSRA

Prioritise common, guideline-driven scenarios: depression with suicidality, first-episode psychosis, acute stroke management, migraine red flags, and epilepsy classification. Questions are framed as 'What is the next best step?' or 'Which drug is most appropriate?'—focus on safety, NICE pathways, and contraindications. Practise applying DSM-5 criteria (e.g., major depressive episode: 5 of 9 symptoms for 2 weeks) and distinguishing similar conditions (e.g., delirium vs. dementia). Memorise key thresholds: QTc cut-offs, BP targets, MMSE ranges, and time windows for thrombolysis. Review adverse effects of psychotropics (e.g., serotonin syndrome, agranulocytosis with clozapine, weight gain with olanzapine).

Practise it: MedLumen has 50 CPS - Psychiatry/Neurology questions for the MSRA, each with a full explanation and references.