skip to main content

Late-Onset Mania Investigation — MRCPsych Paper B MCQ

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

HardMood DisordersLate-Onset Mania InvestigationMRCPsych Paper B

A 68-year-old woman presents with her first episode of persistently elevated and irritable mood, markedly reduced need for sleep, pressured speech, excessive spending and grandiose delusions. She has no previous psychiatric history, and medication review, substance screening and baseline blood investigations reveal no cause. Her family describes 9 months of progressive executive dysfunction and personality change. Examination identifies subtle left-sided hyperreflexia without fever, fluctuating consciousness or recent seizures. Which investigation is most appropriate next?

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

Reveal the answer and explanation

Correct answer: E — MRI of the brain

The correct answer is E. A first manic episode in later life requires careful assessment for secondary causes. Here, progressive executive and personality change together with unilateral hyperreflexia specifically raises concern about frontal or other structural cerebral pathology, making brain MRI the most appropriate next investigation. NICE does not recommend routine neuroimaging for every first psychotic presentation, but supports selective imaging when clinical features increase the likelihood of an organic structural cause. No further investigation would therefore be unsafe. Lumbar puncture would be considered if infection, inflammation or autoimmune encephalitis were suspected, particularly with an acute confusional state, seizures or systemic features. EEG is primarily indicated when epilepsy or non-convulsive seizure activity is suspected. A chest radiograph would not evaluate the most likely pathology described.

Reference: National Institute for Health and Care Excellence. Structural neuroimaging in first-episode psychosis, TA136, section 4.3.6: selective neuroimaging where presentation suggests an underlying organic cause. 2008. https://www.nice.org.uk/guidance/ta136/chapter/evidence-and-interpretation