skip to main content

Acute Mania — MRCPsych Paper B MCQ

Instant feedback + full explanation. One question, done properly.

HardMood DisordersAcute ManiaMRCPsych Paper B

A 25-year-old woman is brought to A&E after being found running through traffic because she believes she can fly. She is grandiose, disinhibited and hostile, with pressured speech, and has not slept for 4 days. De-escalation has failed and she continues to pose an immediate risk of serious harm. She refuses all oral medication and is detained under Section 2 of the Mental Health Act. There is no evidence of alcohol or drug intoxication. She has never received an antipsychotic, and an ECG cannot safely be obtained before urgent sedation. What is the most appropriate initial pharmacological intervention?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Intramuscular lorazepam

The correct answer is **A, intramuscular lorazepam**. She has severe mania with immediate dangerous behavioural disturbance, oral treatment is impossible, and urgent rapid tranquillisation is required. NICE NG10 permits either intramuscular lorazepam or intramuscular haloperidol with promethazine, but specifically recommends lorazepam when the patient has not previously received antipsychotics or when no ECG has been obtained. Haloperidol with promethazine is therefore not the preferred initial intervention here because parenteral haloperidol carries QT-related risk and a baseline ECG is recommended. Quetiapine is an appropriate ongoing antimanic treatment but cannot provide urgent control when oral medication is refused. Lithium has a delayed onset and requires physical investigations and monitoring. Sodium valproate is neither rapid tranquillisation nor an appropriate routine choice for a 25-year-old woman under current UK valproate restrictions.

Reference: National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings (NG10), recommendations 1.4.37–1.4.39, 2015. https://www.nice.org.uk/guidance/ng10/chapter/Recommendations