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All of the following are true regarding dementia except A. Alzheimer’s is more common than vascular dementia in Asia.

['B. One-fifth of patients with Alzheimer’s have cerebral vascular lesions.', 'C. Following a stroke, about one in four patients develops dementia.', 'D. Hypertension in early life is a risk factor for dementia.', 'E. Cigarette smoking in early life is a risk factor for dementia.']

Answer: C. The patient has all the signs and symptoms suggestive of PTSD and since the symptoms have lasted for more than 3 months, it is chronic. In acute stress disorder, the symptoms last for less than 4 weeks. The patient does not meet the criteria for diagnosis of major depressive disorder or panic disorder.

Which of the following is true regarding late-onset psychosis?

['A. First-rank symptoms must be present.', 'B. There is no enlargement of the ventricles.', 'C. Delusions are more common than hallucinations.', 'D. Twenty percent of cases have a family history of schizophrenia.', 'E. Patients usually have a good premorbid personality.']

Answer: D. Ego strength is not elevated in acute PTSD. If anything, it is likely to be decreased in comparison with that of the normal population.

All of the following are true regarding first onset of depression in the elderly except

['A. Somatic delusions are common.', 'B. The condition responds to treatment with antidepressants.', 'C. Life expectancy is reduced.', 'D. The condition rarely results in suicide.', 'E. There is less likely to be a genetic predisposition.']

Answer: A. The modern concept of PTSD was developed after the Vietnam war; before this, it was known as shell shock, soldier’s heart, irritable heart, and by other names. The lifetime prevalence in general population is about 8%, and an additional 5 to 15% of the population has subclinical forms; the most important risk factors are severity, duration, and proximity of a person’s exposure to the trauma.

Which of the following is the characteristic neuroimaging change seen in Alzheimer’s?

['A. Deep white matter changes on CT scan B. Frontotemporal deficits on SPECT', 'C. Reduced ventricular size', 'D. Lateral temporal lobe hypertrophy', 'E. Periventricular hyperintensities on MRI 21. Which of the following is true regarding psychodynamic therapy in the elderly?', 'A. It is not appropriate in patients on antipsychotics.', 'B. It is contraindicated in patients with dementia.', 'C. Older patients make positive changes more rapidly.', 'D. Psychodynamic therapy is less effective in the elderly.', 'E. Sexuality should not be addressed in those over 70.']

Answer: C. Very little is known about the prevalence or the prognosis of mixed anxiety disorder because of confusion about the diagnosis and the common comorbidity of depressive and anxiety symptoms. Venlafaxine has been approved by FDA for the treatment of both depression and generalized anxiety disorder and is considered to be the drug of choice although most of the SSRIs are also effective.

In the psychometric testing of older people, all of the following are true except

['A. The tests take longer.', 'B. Performance may be affected by hearing or visual loss.', 'C. A fixed battery of tests is recommended.', 'D. More extensive procedures can be used in early dementia.', 'E. Tests have shown good reliability.']

Answer: D. Patients with factitious disorder have low tolerance for frustration; some of the other features of these patients are normal or above average intelligence quotient, poor sexual adjustment, and elevation of almost all clinical scales on MMPI-2.

All of the following are true regarding late-onset psychosis in women except A. Associated with deafness

['B. Characterized by visual hallucinations C. More prevalent in lower socioeconomic classes D. Family history of schizophrenia may be present E. Antipsychotic drugs are ineffective 24. All of the following are features of late-onset psychosis except A. May precede dementia B. Good response to antipsychotics', 'C. Positive findings shown on CT scan', 'D. Runs a chronic course', 'E. More common in men than in women']

Answer: A. The existence of the condition called Ganser syndrome is very controversial and many think it to be a variant of malingering. It is typically associated with prison inmates and is characterized by approximate answers. It is thought to be more common in men, and severe personality disorder is a predisposing factor.

Which of the following is a response to change of sleep patterns in the elderly?

['A. Decreased number of REM episodes', 'B. Reduced total REM sleep', 'C. Increased amplitude of delta waves', 'D. Decreased stages 1 and 2 sleep', 'E. Concentration of REM sleep in the latter part of night']

Answer: B. In malingering, there is an obvious, recognizable goal in producing signs and symptoms. Both conditions are characterized by signs and symptoms that are produced intentionally, but the goal in patients with factitious disorder is to assume a sick role. Confrontation usually is not helpful in factitious disorder, and in malingering the patient just goes to a different hospital.

Which of the following is not a feature of sleep terror disorder?

['A. Occurrence in NREM sleep', 'B. Increased muscle tone', 'C. Episode duration of 30–40 minutes', 'D. Vivid memories of a dream’s content 2. Rett syndrome is characterized by all of the following except A. A genetic basis', 'B. Hyperammonemia in some patients', 'C. History of PCP abuse in mothers of children who develop the disorder', 'D. Stereotypic hand-wringing movements 3. In what percentage of persons with schizophrenia is the onset before the age of 10 years?', 'A. Less than 10%', 'B. Less than 7%', 'C. Less than 3%', 'D. Less than 1%']

Answer: E. Validation of traumatic experience and cognitive reframing of the traumatic experiences will help in the treatment of this condition. Family therapy and interventions may also be of help. Treating preexisting psychopathology and applying general techniques used in treating posttraumatic stress disorder and dissociative disorders are also helpful.

An 18-month-old-old girl is separated from her parents for about 1 month following a natural calamity. The child develops severe depression following this episode. What is the name of this phenomenon?

['A. Vulnerable child syndrome', 'B. Anaclitic depression', 'C. Separation anxiety disorder', 'D. None of the above']

Answer: A. People with body dysmorphic disorder may be so distressed that about one-fifth attempt suicide. Many of these patients go from surgeon to surgeon for corrective surgery and are not satisfied with the surgical outcomes.

Which of the following is characteristic of encopresis?

['A. The child is at least 4 years old.', 'B. The episodes of incontinence occur at least once a month for 3', 'C. The child repeatedly passes feces in inappropriate places.', 'D. All of the above']

Answer: E. Denial is not one of the defenses used in body dysmorphic disorder. Psychodynamic theory views this condition as the displacement of a sexual or emotional conflict onto an unrelated body part.

Which of the following is not correct regarding enuresis in children?

['A. Episodes of urinary incontinence occur at a frequency of twice a week for at least 3 months or they lead to clinically significant distress.', 'B. The child is at least 5 years old.', 'C. It is more common among boys.', 'D. All of the above']

Answer: C. Although the exact incidence of chronic fatigue syndrome is unknown, it is estimated at 1 per 1,000. Prevalence in women is twice as common at 0.52%.

Which of the following has been found useful in the treatment of enuresis in children?

['A. Desmopressin', 'B. Bell and pad method of conditioning C. Imipramine', 'D. All of the above']

Answer: D. Sublimation is a mature defense mechanism in which unacceptable aggressive ideas or wishes are rechanneled into another form that are accepted and appreciated by the society.

In children with depression, a decrease in growth hormone secretion has been found after challenge with which of the following substances?

['A. Clonidine', 'B. Levodopa', 'C. Desmethylimipramine', 'D. All of the above']

Answer: A. Brain-imaging studies in panic disorder point to pathological involvement of the temporal lobes, particularly the hippocampus. One MRI study reported cortical atrophy in the temporal areas on the right side.

Which of the following is a characteristic feature of Kleine-Levin syndrome?

['A. Hyperphagia', 'B. Hypersomnia', 'C. Loss of sexual inhibitions', 'D. Higher incidence in boys', 'E. All of the above']

Answer: C. At any given time, 10–15% of the elderly population suffers from depression as opposed to 5% with dementia.

A 32-year-old mother brings her 7-year-old son to a hospital’s emergency department. The child is found to be restless and displaying stereotyped hand movements. The mother reports that he was “normal” until 1 year ago and had achieved childhood developmental milestones at the appropriate times. For the past year, the child has shown progressive deterioration in social interactions and communication abilities and recently has lost control over the bowel training that he had attained earlier. Which of the following is the most appropriate diagnosis?

['A. Rett syndrome', 'B. Heller syndrome', 'C. Asperger syndrome', 'D. Minimal brain damage']

Answer: C. The prevalence of delusions, hallucinations, and misidentifica-tion syndromes in dementia are 20–50%, 17–36%, and 11–36% respectively.

According to his schoolteacher, an 11-year-old boy doesn’t interact with his peers and prefers to be left alone. He is considered to be a whiz kid with numbers. He does not get excited by any of his achievements. His parents also report that he is aloof at home and does not respond to affection from his parents or siblings. He does not have any impairment in language or cognitive functions. What is the most likely diagnosis?

['A. Rett syndrome', 'B. Pervasive developmental disorder', 'C. Asperger syndrome', 'D. Selective mutism']

Answer: B. Atypical presentations of depressive disorder are relatively common in the elderly. These include pseudodementia, agitation, and paranoid symptoms. Hypochondriacal symptoms and other illness behavior, pseudo personality disorder, and mixed personality disorder are quite common. Readjustment of social circumstances alone is not sufficient, and in patients with established depression, pharmacotherapy and, on occasions, ECT may be required.

Which of the following medications can exacerbate tics in Tourette syndrome?

['A. Pimozide', 'B. Pemoline', 'C. Clonidine', 'D. Naltrexone']

Answer: A. The elderly may deny symptoms of depression and may soma-tize instead. They find it more difficult to express their feelings than the younger population. Wishing to die is not always a result of depression, as this association has not been found in 20% of suicides and 10% of parasuicides.

Which of the following medications should not be used to treat Tourette syndrome?

['A. Clonidine', 'B. Zoloft', 'C. Wellbutrin', 'D. Naltrexone']

Answer: C. Minor depression, if left untreated, can progress to major depression. Antidepressants may not be required in all cases of depression in the elderly. Treatment should be tailored to meet individual needs. It should be directed at predisposing, precipitating, and perpetuating factors on social, psychological, and biological axes. Where possible, correctable factors should be rectified or adjusted. DSM-IV should be used to make a diagnosis before commencing pharmacologic treatment. Supportive psychotherapy, formal counseling, CBT, and group psychotherapy are effective. Depression in the elderly is frequently undertreated.

Which of the following tricyclic antidepressants used in treatment of ADHD

['A. Imipramine', 'B. Nortriptyline', 'C. Desipramine', 'D. Maprotiline']

Answer: D. The dexamethasone suppression test is positive in depression; however, it is also positive in a number of other conditions and is not specific to depression.

Which of the following is not true for Tourette syndrome?

['A. Has an onset before age 18', 'B. Is more prevalent in boys', 'C. Has obsessive-compulsive features in 40% of cases D. Can be caused by postviral encephalitis 16. Which of the following tests can be used to measure the intellectual ability of children aged 3–7 years?', 'A. Wechsler Intelligence Scale for Children, 3rd Edition B. Stanford-Binet Test', 'C. Wechsler Preschool and Primary Scale of Intelligence–Revised D. Bayley Scales of Infant Development E. None of the above']

Answer: E. Physical illnesses predispose the elderly to develop depression. Up to 50% of medically ill elderly patients suffer from depression. Occult malignancies and drugs like corticosteroids can cause depression. Other factors include anxiety tendencies and avoidant and dependent personality, adverse life events, bereavement, female sex, and feeling lonely (but not necessarily living alone).

Guanfacine is used in the treatment of ADHD in children. How does it act?

['A. By stimulating the release of dopamine from presynaptic vesicles B. By inhibiting the reuptake of dopamine in the brain C. By acting as an agonist at presynaptic alpha-2 receptors D. None of the above 18. Which of the following stimulants used in the treatment of ADHD requires monitoring of liver enzymes?', 'A. Methylphenidate', 'B. Amphetamine', 'C. Pemoline', 'D. None of the above']

Answer: A. The prognosis of depression in the elderly is mired in contro-versy. Post (1962) suggested that with treatment most patients had a good outcome, although only 26% showed full recovery at follow-up and 12% were continually ill. Murphy (1983) found only 35% well at 1-year follow-up; 29% were continually ill and 14% dead at 1-year follow-up. There was a 15% risk of developing dementia.

A 17-year-old girl presents to the ER with her parents. Her parents report that she has been behaving very unusually in the last 6 months. She has started expressing strange beliefs and has become very suspicious of family members and friends, claiming for example that her high school teachers are actually members of a radical group who are enemies of the country. Her physical examination shows a minimal resting tremor and a grayish green ring around the edges of the cornea that is most marked at the superior and inferior pole. The abnormality for this disease condition is located in which chromosome?

['A. Chromosome 6', 'B. Chromosome 13', 'C. Chromosome 12', 'D. Chromosome 6']

Answer: C. Dementia is more common in those in care. Cognitive impairment resulting from depression is called depressive pseudodementia. Treatment of depression corrects the cognitive impairment. Dementia itself can lead to depression in the earlier stages, when insight is fully or partially preserved. This insight usually is absent in late dementia.

Which of the following features can be seen in children exposed to toxic levels of lead?

['A. Intellectual impairment', 'B. Behavior disorder', 'C. Seizures', 'D. Decrease in heme production', 'E. All of the above']

Answer: B. A fluctuating level of consciousness suggests delirium rather than dementia. The symptoms of dementia include recent memory impairment, agnosia, dyspraxia, dysphasia, and loss of judgment, self-control, and planning ability. Insight and emotions decline only gradually. Depression is present in 20–40% of early cases. Anxiety, paranoid symptoms, social withdrawal, hoarding of possessions, and change of personality may occur.

At what age do children develop the concept of death as permanent?

['A. 2–3 years', 'B. 3–4 years', 'C. 7–8 years', 'D. 4–5 years']

Answer: C. Pseudodementia is the cognitive changes occurring in depression. It can be differentiated from depression by rapid onset and progression, the manner in which the patient answers questions, a past history of depression, depressed mood, diurnal variation in mood, biological symptoms, islands of normality, and exaggerated presentation of symptoms. The cognitive functions usually return to normal with successful treatment of depression.

A 4-year-old child whose development was normal until around 31/2 years develops difficulty comprehending speech. The child psychiatrist who assessed him believes that he has a severe deficit in comprehension that is new in onset. After 2 months, the patient is found in his bed unresponsive and is found to have passed urine in the bed. He is seen by a neurologist, who orders an EEG; the EEG shows abnormalities in both temporal areas.

['By now the patient is often found to be irritable, inattentive, and depressed.', 'A. Gerstmann syndrome', 'B. Rett syndrome', 'C. Heller syndrome', 'D. Landau-Kleffner syndrome']

Answer: E. Depression is associated in up to 80% of suicides. Duration of depression varies from 6 to 12 months. Twenty-five to thirty percent of suicides occur in the first episode of depression. Suicide is more common among men than women. It is associated with bereavement and with living alone whether widowed, single, or divorced. Alcohol or substance abuse is present in up to 44% of cases. The prevalence of schizophrenia and paraphrenia is about 6–17%. Mild dementia is a risk factor. Physical illness is present in up to 65% cases. Hypochondriasis may also be present. The elderly are more likely to succeed in their attempts at suicide, and the intent is usually quite high.

The age of incidence of fragile X syndrome decreases in succeeding generations. What is this phenomenon called?

['A. Anticipation', 'B. Assimilation', 'C. Both of the above', 'D. None of the above']

Answer: D. Financial worries are not associated with suicide in the elderly.

Which of the following is not considered among the causes of school phobia?

['A. Fear of a strict teacher', 'B. Fear of being bullied by another student C. Separation anxiety on the parent’s part D. Separation anxiety on the child’s part E. None of the above']

Answer: B. Menopause is associated with hot flashes, depression, vaginal dryness, shrinkage of the labia, dyspareunia, cystocele, urinary frequency/incontinence, and genital tract atrophy.

According to Thomas and Chess, which of the following is not a category of temperament?

['A. Adaptability', 'B. Intensity', 'C. Quality of mood', 'D. Rhythmicity', 'E. None of the above']

Answer: B. With tricyclics in the elderly, all of the following are increased: plasma half-life, steady-state levels, volume of distribution, incidence of postural hypotension, and susceptibility to antimuscuranic side effects.

Which of the following is not true regarding gender identity?

['A. Gender identity is the child’s perception of self as male or female.', 'B. In the majority of children, formation of gender identity starts at age 3–4 years and is complete by age 5–7 years.', 'C. Gender identity forms earlier in girls.', 'D. Homosexual play in early childhood is indicative of adult sexual orientation.', 'E. None of the above']

Answer: B. Age is the only definitive risk factor for dementia. Other risk factors include family history in first-degree relatives, Down syndrome, infections, autoimmune conditions, head injury, aluminum, previous history of depression, advanced age of mother at birth, and thyroid disease.

Who first described autism?

['A. Kanner', 'B. Asperger', 'C. Chess', 'D. Benham', 'E. None of the above']

Answer: A. Alzheimer’s is more common than vascular dementia in the Western world, where it accounts for more than 50% of cases. In Asia, vascular dementia is more common. Hypertension, cigarette smoking, Oriental diet, male sex, increasing age, heart disease, and hyperlipidemia are the other risk factors for vascular dementia.

Which of the following is not true regarding Lesch-Nyhan syndrome?

['A. It is due to a deficiency in HGPRT.', 'B. Patients show self-mutilating behavior.', 'C. Patients have mild to moderate mental retardation.', 'D. There is a decrease in uric acid levels.', 'E. There is an accumulation of uric acid.']

Answer: C. Typical first-rank symptoms are found in only 30% of cases. A CT scan of the brain may show evidence of organic changes, but the significance is unknown. Delusions are usually persecutory, grandiose, or erotic. Hallucinations are usually auditory. The risk of paraphrenia in first-degree relatives of late paraphrenics is about half that found in first-degree relatives of younger schizophrenics.

Which of the following is not true regarding tuberous sclerosis?

['A. Patients show hyperactivity and impulsivity.', 'B. It is an autosomal dominant disorder.', 'C. CT scan of the brain shows calcified hamartomas.', 'D. Patients develop epilepsy.', 'E. It is an autosomal recessive disorder.']

Answer: D. Hypochondriacal delusions and somatization are common presentations in the elderly. The condition responds well to antidepressants and usually SSRIs, NARI, and reversible MAOIs are better tolerated than tricyclics. Murphy et al. found that mortality is increased in this population. Fifty to eighty percent of patients who complete suicide have a depressive illness.

Which of the following is true about persons with oppositional defiant disorder?

['A. They often lose their tempers.', 'B. They deliberately annoy others.', 'C. They blame others for their mistakes.', 'D. Their symptoms last more than 6 months.', 'E. All of the above']

Answer: E. Periventricular hyperintensities are seen on the MRIs of patients with Alzheimer’s disease.

Who proposed the concept of a “holding environment” in the development of children?

['A. Winnicott', 'B. Michael Balint', 'C. Margaret Mahler', 'D. Melanie Klein', 'E. None of the above']

Answer: C. Psychodynamic therapy may be used on patients who are on antipsychotics as long as the patient is not actively psychotic. It’s unlikely to be of benefit in moderate to severe dementia. There is no age limit for addressing issues related to sexuality.

Which of the following should raise suspicions of child abuse?

['A. Bucket-handle fractures', 'B. Inflammatory hair loss', 'C. Bilateral black eyes', 'D. Retinal hemorrhages', 'E. All of the above']

Answer: C. Various scales have been developed to provide an accurate assessment of psychological functioning in the elderly. Psychometric tests quantify the level and range of ability. Serial measures can be used to measure the effect of interventions or to measure the progression of the illness over time. These tests have shown good reliability.

What percentage of intracranial injuries found in children in the first year of life are due to physical abuse?

['A. <10%', 'B. <50%', 'C. <60%', 'D. >50%', 'E. >90%.']

Answer: A. The common associations of late-onset psychosis are female sex, family history, personality, sensory deprivation (deafness, blindness), social isolation, significant life events, and organic brain changes. Hallucinations are most commonly auditory. In 10–20% of cases, only delusions are present. Symptoms do respond to antipsychotic treatment.

Which of the following features should raise the suspicion of sexual abuse in children?

['A. Anal dilatation with loss of rectal tone B. Incidence of sexually transmitted diseases C. Flattened rectal rugae', 'D. Inappropriate sexual behavior by children E. All of the above']

Answer: E. The female to male ratio is 9:1. Antipsychotics are effective, and long-term treatment is necessary. A CT scan of the brain shows organic changes.

Which is the only SSRI authorized by the FDA for the treatment of depression in children?

['A. Fluvoxamine', 'B. Fluoxetine', 'C. Paroxetine', 'D. Sertraline', 'E. Escitalopram']

Answer: B. REM sleep duration is reduced in the elderly.

Which of the following is true regarding obsessive-compulsive disorder in children?

['A. Functional imaging studies show increased glucose metabolism in the orbital frontal and prefrontal cortex, right caudate nucleus, and anterior cingulated gyrus.', 'B. There is an increased incidence of neurological signs in children with OCD.', 'C. Lifetime prevalence of OCD in children is 2–4%.', 'D. Encephalitis, head trauma, and epilepsy can lead to the development of OCD.', 'E. All of the above']

Answer: D. Sleep terror is characterized by repeated episodes of sleep disturbances, manifested mainly as repeated awakening from sleep with a terrified cry. These episodes usually occur in the first third of sleep during NREM sleep and each lasts for approximately 1–10 minutes. Upon awakening, the child is unresponsive and thereafter is confused and disoriented. The child usually is not able to remember the content of the dream in detail.

Which of the following presentations is common in patients with pediatric autoimmune neuropsychiatry disorder associated with streptococcal infection?

['A. Depression', 'B. Hallucinations', 'C. Apathy', 'D. Alexithymia', 'E. OCD']

Answer: C. The characteristic feature of Rett syndrome is the development of numerous deficits after an initial period of normal functioning following birth. The child has a deceleration of head growth between the ages of 5 and 48 months. The child shows a loss of previously acquired hand skills and subsequently develops stereotyped hand movements like hand wringing. The child also develops deficits in expressive and receptive language.

Which of the following is not true regarding pervasive developmental disorder (PDD)?

['A. There is a higher incidence in males.', 'B. The prevalence of PDD is 4–5 per 10,000.', 'C. Persons with PDD fail to develop peer relationships.', 'D. Naltrexone helps in improving social interactions.', 'E. Persons with PDD exhibit stereotyped and repetitive motor patterns.']

Answer: D. The onset of schizophrenia is most common from 17 to 27 years of age in males and in the late 20s to early 30s in females. The incidence of childhood-onset schizophrenia is very low, less than 1%. Four percent of cases occur before 15 years of age.

Which of the following antidepressants has been most implicated with increased rate of suicide in children and adolescents?

['A. Sertraline', 'B. Citalopram', 'C. Venlafaxine', 'D. Fluvoxamine', 'E. None of the above']

Answer: B. Anaclitic depression occurs primarily in infants (6–30 months) who have lost or been separated from their mothers or primary caretakers. The condition was described by Rene Spitz.

Which of the following is true regarding suicide in children?

['A. Suicide is the fourth leading cause of death in children.', 'B. Suicide is the third leading cause of death in adolescents.', 'C. Less than 25% of the adolescents had expressed suicidal thoughts before committing suicide.', 'D. Hanging is the most commonly used method of completed suicides in children.', 'E. Adolescent females are more likely to commit suicide by jumping from a high place or taking an overdose of medications.']

Answer: D. Encopresis is characterized by repeated passage of feces in inappropriate places. This can be both voluntary and involuntary. According to DSM-IV this should occur at least once a month for at least 3 months. The child should be at least 4 years of age. Prevalence is about 1% in 5-year-olds and decreases with increasing age.

Which of the following is considered a cause in the etiology of reactive attachment disorder in children?

['A. Total disregard for the child’s emotional needs B. Total disregard for the child’s basic physical needs C. Inconsistent caregivers', 'D. Mental retardation in parents', 'E. All of the above']

Answer: D. Enuresis is characterized by repeated voiding of urine during the day or at night into bed or clothes. Most of the time it is involuntary, but sometimes it can be intentional. For a diagnosis according to DSM-IV, the voiding of urine should occur at least twice per week for at least 3 months. The chronologic age of the child should be at least 5 years.

Which of the following modalities can be used in the treatment of encopresis?

['A. An educational approach', 'B. Investigating for a medical cause of encopresis C. Daily timed intervals on the toilet D. Psychotherapy in children with concomitant behavioral problems E. All of the above']

Answer: D. Any medical causes that can lead to enuresis should be eliminated. It should also be determined whether the enuresis is a direct physiologic consequence of any medication such as laxatives. It should be explained to the child and parents that this is a common condition and the child is not to be blamed. In addition to the bell and pad conditioning method, imipramine and desmopressin have been found useful in treatment.

Which of the following is true regarding pica?

['A. It entails persistent eating of nonnutritional substances.', 'B. The name was introduced by the French physician Ambroise Pare.', 'C. The behavior is not culturally appropriate.', 'D. Economic deprivation, poor parental support, and disorganized family situations can lead to the development of pica.', 'E. All of the above']

Answer: D. Children with depression show a decrease growth hormone secretion when challenged by the following medications: levodopa, clonidine, and desmethylimipramine.

Which of the following is not true regarding rumination disorder?

['A. It is characterized by repeated regurgitation and rechewing of food.', 'B. Symptoms last at least 3 months.', 'C. The disorder is most common in the first year of life.', 'D. A disturbed caregiver-infant relationship can lead to the development of rumination disorder.', 'E. None of the above']

Answer: E. Kleine-Levin syndrome is characterized by hypersomnia and hyperphagia, sexual disinhibition, and sometimes psychosis. It has a 3:1 male preponderance. The onset of symptoms usually occurs in adolescence. It is hypothesized that symptoms are related to hypothalamic dysfunction.

What percentage of children diagnosed with conduct disorder go on to develop antisocial personality disorder?

['A. 80%', 'B. 50%', 'C. 5%', 'D. 40%', 'E. 25%']

Answer: B. Childhood disintegrative disorder, known as Heller syndrome, is characterized by a clinically significant loss in previously acquired skills in at least two of the following areas: expressive or receptive language, social skills, bowel or bladder control, play, and motor skills. For a diagnosis according to DSM-IV, the child should have had normal development for at least the first 2 years of life.

Which of the following is a feature of residual attention-deficit hyperactivity disorder in adults?

['A. Short temper associated with explosive outbursts B. Affective lability', 'C. Drug and alcohol use', 'D. Marital instability', 'E. All of the above']

Answer: C. Asperger syndrome is characterized by significant deficits in social skills, preoccupation with one or more interests, and a lack of significant impairment in language and cognitive function.

What is the mechanism of action of atomoxetine (Strattera)?

['A. Serotonin reuptake inhibition', 'B. Norepinephrine reuptake inhibition', 'C. Dopamine reuptake inhibition', 'D. Increased release of norepinephrine E. Increased release of dopamine']

Answer: B. Pimozide, clonidine, and naltrexone can be used in the treatment of tics. But pemoline is a stimulant that is used in the treatment of ADHD and can exacerbate tics.

Which of the following is true regarding ADHD in children?

['A. ADHD is more prevalent in girls.', 'B. The symptoms should persist for at least 3 months for a diagnosis of ADHD.', 'C. Depression is the most common comorbid condition associated with ADHD.', 'D. Oppositional defiant disorder and conduct disorder are the most common comorbid conditions associated with ADHD.', 'E. Low-dose atypical antipsychotic medications are the treatment of choice for ADHD.']

Answer: C. Wellbutrin, which works by the reuptake inhibition of dopamine, can lead to an exacerbation of tics.

Which of the following is true regarding nightmares?

['A. Patient awakens with detailed recall of frightening dreams.', 'B. After awakening, the patient rapidly becomes oriented and alert.', 'C. Nightmares occur during REM.', 'D. All of the above']

Answer: C. Tricyclic antidepressants have been used for the treatment of depression and occasionally ADHD. Among the tricyclic antidepressants, it is desmopressin that has been associated with mortality in children.

Which of the following is not true regarding Hallervorden-Spatz syndrome?

['A. Onset is usually in childhood or early adolescence.', 'B. The disease is transmitted in an autosomal recessive fashion.', 'C. CT scan shows increased density in the globus pallidus, indicating iron deposition.', 'D. Dystonia is a late feature.', 'E. The patient shows choreoathetoid movement.']

Answer: D. Tourette syndrome is characterized by multiple motor tics and a few vocal tics. The onset of the disease is usually before 18 years of age, with the average age of onset being around 7 years. This is more common in males. For a diagnosis according to DSM-IV, the tics should have been present for at least 1 year and there should not have been a tic-free period of more than 3 months during that year.

What is the most common cause of hyperthyroidism?

['A. Hashimoto’s thyroiditis', 'B. Grave’s disease', 'C. Administration of exogenous thyroid D. TSH-secreting pituitary adenoma', 'E. Hydatidiform mole']

Answer: C. Wechsler Preschool and Primary Scale of Intelligence–Revised can be used to measure intelligence in children aged 3–7 years. Bayley Scales of Infant Development can be used in the age group 1–42 months. Stanford-Binet Intelligence Test, 4th edition, can be used in the age range from 2.5 years to adult. Wechsler Intelligence Scale for Children-III can be used in the age range 6–16 years.

Which of the following is not the role of the psychiatry liaison consultant?

['A. Comprehensive assessment of the patient B. Accurate note keeping', 'C. Detailed psychodynamic formulation', 'D. Documentation of plans for follow-up 3. Which of the following is true regarding mental disorders in patients with epilepsy?', 'A. Ictal psychosis is more common than interictal psychosis.', 'B. Violence is common during a seizure.', 'C. Rates of attempted suicide are increased in people with epilepsy.', 'D. Mood symptoms are more common than schizophrenia-like symptoms.']

Answer: C. Guanfacine is a presynaptic alpha-2 adrenergic receptor agonist that leads to decreased release of norepinephrine. It has been used in the treatment of ADHD and is less sedating and has a longer half-life than clonidine.

In which of the following regions of the brain is a tumor most likely to cause psychiatric symptoms?

['A. Frontal', 'B. Parietal', 'C. Temporal', 'D. Occipital']

Answer: C. Pemoline belongs to the class of stimulants and has been used in the treatment of ADHD.

What is the most common reason for psychiatric consultation in rehabilitation medicine?

['A. Anxiety', 'B. Pain', 'C. Depression', 'D. Psychosis']

Answer: B. This patient has Wilson’s disease, which is an autosomal recessive disorder of copper metabolism, which can present with movement disorder, personality changes, and psychosis. It usually presents in the first through third decades of life. The genetic defect, which is localized to chromosome 13, leads to a defect in copper-transporting adenosine triphosphatase in the liver, which in turn leads to accumulation of copper in the liver, brain, cornea, and kidney.

What is the most common psychiatric manifestation of Cushing syndrome?

['A. Mania', 'B. Psychosis', 'C. Depression', 'D. Panic attacks', 'E. Anxiety']

Answer: E. There is no pathognomonic sign of lead toxicity. Children exposed to toxic levels of lead for prolonged periods develop the following features: irritability, sleeplessness, lethargy, poor appetite, headaches, abdominal pain, vomiting, and constipation. In children exposure to toxic levels of lead can also lead to seizure, intellectual impairment, and decreased heme production.

With which of the following is exogenous administration of steroids most commonly associated?

['A. Mania', 'B. Psychosis', 'C. Depression', 'D. Panic attacks', 'E. Anxiety']

Answer: D. Children don’t develop the concept of permanence of death until around 4 or 5 years of age.

What is the most common psychiatric condition seen in patients with hyperparathyroidism?

['A. Mania', 'B. Depression', 'C. Psychosis', 'D. Anxiety', 'E. Panic attacks']

Answer: D. Landau-Kleffner syndrome (LKS) is a rare form of childhood epilepsy that results in a severe language disorder. The cause of the condition is unknown. All children with LKS have abnormal electrical activity in one and sometimes both temporal lobes, the area of the brain responsible for processing language. This epileptiform activity shows up on an EEG, particularly when the child is asleep. About two-thirds of children with LKS have seizures. Expressive language (the ability to speak) is often seriously affected; some children lose their speech completely. Behavioral problems are common, especially hyperactivity, poor attention, depression, and irritability.

Which of the following is not true regarding diabetes mellitus?

['A. Dementia is less common.', 'B. There is a negative correlation between depression and good diabetic control.', 'C. In ketoacidotic coma, the level of consciousness correlates with plasma osmolality.', 'D. MAOIs potentiate the effect of oral hypoglycemic drugs.']

Answer: A. The phenomenon of the decreasing age of incidence of the disease with each successive generation is known as anticipation. This phenomenon is seen in fragile X syndrome and Huntington’s disease.

Which of the following is not a psychiatric manifestation of hyperthyroidism?

['A. Depression', 'B. Anxiety', 'C. Schizophrenia-like symptoms', 'D. Opiate dependence', 'E. Cognitive impairment']

Answer: E. School phobia mostly occurs when the child starts going to a school. It can occur as a result of separation anxiety of the child and also as a result of the separation anxiety on the part of the parent. It can be due to a legitimate cause such as a very strict teacher or bullying by other students.

All of the following are associated with psychiatric illness with steroid treatment except

['A. Male sex', 'B. Higher dose', 'C. Longer duration of therapy', 'D. Previous psychiatric illness', 'E. Depressed mood']

Answer: E. Stella Chess and Alexander Thomas in their New York longitudinal study found that temperamental traits could be identified from infancy. The nine traits identified by Chess and Thomas are activity level, dis-tractibility, adaptability, attention span, intensity, threshold of responsiveness, quality of mood, rhythmicity, and approach/withdrawal. They postulated that temperament has a genetic base and these traits could also be altered by environmental factors.

Which of the following is true regarding SSRIs used in treatment of premenstrual dysphoric disorder?

['A. They cannot be combined with hormonal treatments.', 'B. They are poorly tolerated.', 'C. They inhibit ovulation.', 'D. They can be used exclusively in the luteal phase.', 'E. They have few side effects.']

Answer: D. Gender identity is the child’s perception of self as male or female. For majority of children, formation of gender identity starts at the age of 3–4 and is complete by 5–7. Gender identity occurs earlier in girls. Homosexual play in early adulthood is not indicative of adult sexual orientation.

Which of the following is true regarding pituitary disease?

['A. There is an increased rate of mania in hypopituitarism.', 'B. Libido is increased in acromegaly.', 'C. Psychosis is common in acromegaly.', 'D. Increased energy and activity are seen in hypopituitarism.', 'E. Symptoms of hypopituitarism fully resolve with treatment.']

Answer: A. Leo Kanner first described features of autism. Anne Benham developed the scale for Infant and Toddler Mental Status Exam. Chess and Thomas described the nine temperamental traits. It was Hans Asperger who first described the Asperger syndrome.

All of the following are associated with vitamin B12 deficiency except A. Macrocytic anemia

['B. Depression', 'C. Polyneuropathy', 'D. Dementia', 'E. Memory impairment']

Answer: D. Lesch-Nyhan syndrome is caused by a deficiency of hypoxanthine-guanine phosphoribosyl transferase (HPRT). It is genetic in origin, with the pathology located at Xq26–27. It leads to an accumulation of uric acid. Patients show self-mutilating behavior like biting or chewing on their bodies.

All of the following are symptoms of Wilson’s disease except A. Cognitive impairment

['B. Visual symptoms', 'C. Epilepsy', 'D. Changes in personality', 'E. Rigidity and dystonia']

Answer: E. Tuberous sclerosis is a neurocutaneous syndrome characterized by hamartomas in the brain, kidney, heart, and skin. The hamartomas in the brain are seen as subepindymal calcified nodule on CT and MRI. Persons with tuberous sclerosis also have mental retardation, show features of aggression and impulsivity, and develop seizures. This is inherited as an autosomal dominant disorder.

All of the following are symptoms of premenstrual dysphoric disorder except

['A. Pelvic discomfort', 'B. Irritability', 'C. Occurrence of the disorder soon after menstruation D. Carbohydrate craving', 'E. Occurrence of the disorder for 2 consecutive months 17. Which of the following is true about premenstrual dysphoric disorder?', 'A. It is seen in 10% to 20% of women.', 'B. It indicates abnormal ovarian function.', 'C. Symptoms are more severe in a middle-aged woman.', 'D. It is linked to abnormal central serotonergic function.', 'E. It is not associated with sexual abuse.']

Answer: E. According to DSM-IV, the pattern of negativistic, hostile, and defiant behavior should last for at least 6 months. Children with ODD often lose their temper, argue with adults, actively defy or refuse to comply with adults’ rules, deliberately annoy people, and are often angry and spiteful.

All of the following are true of porphyria except A. Peripheral neuropathy may be seen.

['B. Elevated ceruloplasmin is seen.', 'C. Benzodiazepines may be used.', 'D. Symptoms may resemble schizophrenia.', 'E. Acute intermittent porphyria is the most common form.']

Answer: A. Donald Winnicott described the concept of a “holding environment,” the psychic space created by the mother between herself and the infant that makes it possible for the child to develop his or her awareness as a separate person. Margaret Mahler described the evolution of object relations and described the concept of separation and individuation. Melanie Klein developed a theory of internal object relations and used “play therapy” to learn about the internal fantasies of children. Klein also described the paranoid-schizoid position and depressive position. Balint described the concept of “basic fault” in the development of child.

Which of the following inborn errors of metabolism can not be treated by diet?

['A. Homocystinuria', 'B. Lesch-Nyhan syndrome', 'C. Phenylketonuria', 'D. Galactosemia']

Answer: E. Physical abuse of a child is something for which psychiatrists should have a low threshold of suspicion. Impressions of the human hand on the skin, old and new bruises, immersion burns, intracranial injuries, bilateral black eye, inflammatory hair loss, subgaleal hematomas, and bucket-handle or corner fractures are some of the features that should raise the suspicion of physical abuse if seen in children.

Which of the following is true about prion diseases?

['A. It is more common in men.', 'B. Patients usually have a normal EEG.', 'C. There is a reduced risk with E4 apolipoprotein allele.', 'D. It is encoded on chromosome 10.', 'E. The familial form is autosomal recessive.']

Answer: E. Ninety-five percent or more of the intracranial injuries seen in children younger than 1 year are due to physical abuse. Physical abuse can include violent shaking or slamming. This can lead to subdural bleeding. It can also lead to retinal hemorrhage.

Which of the following is not true regarding affective disorder in patients on renal dialysis?

['A. Adjustment disorder can lead to behavioral problems.', 'B. Major depression is the most common psychiatric diagnosis.', 'C. Adjustment disorders can influence physical outcome.', 'D. Adjustment disorders may become chronic.', 'E. Lack of energy and insomnia are less indicative of depression than in patients who are not on dialysis.']

Answer: E. The following physical findings should raise suspicions of sexual abuse: labial and perineal tears, anal dilatation with loss of rectal tone, flattened rectal rugae, and occurrence of sexually transmitted diseases. Age-inappropriate sexual behavior is also indicative of sexual abuse.

Which of the following is not true regarding cognitive therapy in liaison settings?

['A. It teaches techniques to deal with future problems.', 'B. It can modify negative automatic thoughts about physical illness.', 'C. It helps patients regain control of their illness.', 'D. It is supported by evidence in liaison settings.', 'E. It is directed by therapists’ perception of the patient’s problems.']

Answer: B. Although all SSRIs are used in the treatment of depression in children, only fluoxetine has FDA authorization. Paroxetine and venlafaxine have been found to cause increased agitation in children and therefore contribute to increased suicidal thoughts and attempts.

Which of the following is true regarding denial in patients on renal dialysis?

['A. It is rarely present.', 'B. It may cause problems with compliance.', 'C. It is always pathological.', 'D. If denial is low, less mood dysfunction occurs.', 'E. High denial results in rapid readjustment.']

Answer: E. Childhood OCD has a prevalence of 2–4%. Onset of OCD can follow encephalitis, head trauma, and epilepsy, which supports a neurobio-logical etiology of OCD. PET studies show increased glucose metabolism in the orbitofrontal region of the brain, prefrontal cortex, caudate nucleus, and anterior cingulated gyrus. Children with OCD have a higher incidence of neurological soft signs.

Which of the following is not useful in diagnosing depression in the patient on a medical inpatient unit?

['A. Hopelessness', 'B. Morning depression', 'C. Depressed mood', 'D. Sleep disturbance', 'E. Suicidal thoughts']

Answer: E. Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection is characterized by the presence of OCD and tics. It develops as a sequela to group A-beta hemolytic streptococcal infection.

Which of the following is true about the treatment of depression in diabetes mellitus?

['A. Fluoxetine is the preferred drug.', 'B. Tricyclic antidepressants can cause hypoglycemic episodes.', 'C. Tricyclic antidepressants should be avoided even in well-controlled diabetes mellitus.', 'D. Sodium valproate can give false-positive urine tests for glucose.', 'E. Amitriptyline is contraindicated in diabetic neuropathy.']

Answer: E. Pervasive developmental disorder is characterized by delay and deviation in social and communication skills. PDD has a prevalence of 4–5 per 10,000 births. PDD is more prevalent among boys. Naltrexone helps in reducing the hyperactivity and inattention associated with PDD but does not have any effect on social interactions.

Which of the following is true regarding the treatment of depression in hepatic disease?

['A. Tricyclic antidepressants are safe in the presence of liver disease.', 'B. Lithium is the mood stabilizer of choice in the presence of liver disease.', 'C. SSRIs are contraindicated in liver disease.', 'D. MAOIs are safe in hepatitis B.', 'E. Half-lives of drugs are reduced in liver disease.']

Answer: E. Paroxetine has been implicated in an increased incidence of suicide rates in children and adolescents. Some countries have issued warnings regarding the use of paroxetine in that age group. Recently venlafaxine was also barred from use in children. On September 17, 2004, an FDA panel voted to advise the agency to require a “black box” warning to highlight the potential risk to depressed pediatric patients. The safety concerns applied to Prozac, Paxil, Wellbutrin, Zoloft, Celexa, Effescor, Luvox, Remeron, and Serzone.

Which of the following is true regarding delirium?

['A. It rarely involves mood symptoms.', 'B. It includes a narrow range of psychiatric symptoms.', 'C. Clouding of consciousness is sufficient for the diagnosis.', 'D. Attention disturbance is the core cognitive disturbance.', 'E. Sleep–wake cycle is preserved.']

Answer: C. Suicide is the fourth leading cause of death in children and the third leading cause in adolescents. Hanging is the most commonly used method in younger children, while hanging and firearms are used with equal frequency in adolescents. More than 65% of the adolescents who complete suicide had expressed suicidal thoughts beforehand.

Which of the following is true of hypoactive delirium?

['A. Psychotic symptoms are rare.', 'B. It responds poorly to antipsychotics.', 'C. It is frequently missed in practice.', 'D. It has a better prognosis than agitated delirium.', 'E. Patient is commonly unarousable.']

Answer: E. Reactive attachment disorder (RAD) is described by DSM-IV as “markedly disturbed and developmentally inappropriate social relatedness in most contexts.” RAD begins before the age of 5 years and is typified by deviant social characteristics like being excessively inhibited, hypervigilant, or ambivalent. The disorder can be precipitated by abuse as well as neglect. Lack of a consistent caregiver, mental retardation, and poor parenting skills can lead to the development of RAD.

Which of the following is true regarding the management of delirium?

['A. Iatrogenic causes are rare.', 'B. Involvement of the patient in management should be discouraged.', 'C. Antipsychotics are effective due to their sedative actions.', 'D. Reduction of risk factors can prevent further episodes.']

Answer: E. The first approach in treating encopresis is education. The parents (or other caregiver) and the child should both be educated about the nature of the condition, and it should be stressed to both the child and parents that the condition is not the child’s or parents’ fault. The child should be investigated for possible medical causes of the encopresis. Daily timed intervals at the toilet are an effective method of treatment. Pharmacotherapy is not very well studied, nor has it been found effective. Behavioral management is still the mainstay of treatment.

Wernicke’s syndrome can cause all of the following except A. Ataxia

['B. Diplopia', 'C. Peripheral neuropathy', 'D. Dysphasia', 'E. Confusion']

Answer: E. Pica is characterized by the persistent eating of nonnutritious substances. Economic deprivation, poor parental support, and disorganized family situations can lead to the development of pica. Among the substances ingested by children with this condition are dirt, paint, hair, sand pebbles, uncooked rice, and paper. Ingesting these substances can lead to infections as well as intestinal obstructions. The treatment is mainly behavioral and includes physical restraints, aversive behavioral therapy, and time-outs.

Which of the following is true of Korsakoff syndrome?

['A. It can be caused by continuous vomiting.', 'B. Confabulation is always present.', 'C. Disorientation is usually present.', 'D. Clouding of consciousness is characteristic.', 'E. Immediate memory is affected.']

Answer: B. Rumination disorder is characterized by repeated regurgitation and rechewing of the regurgitated food. For a diagnosis according to DSM-IV, the disorder should be present for 1 month.

HIV can manifest as all of the following except A. Hypomania

['B. Alzheimer’s dementia', 'C. Depression', 'D. Transient panic attacks', 'E. Schizophreniform psychosis']

Answer: D. Approximately 40% of children diagnosed with conduct disorder will go on to have a diagnosis of antisocial personality disorder in adulthood. There is not much evidence that conduct disorder is treatable.

Which of the following is true concerning AIDS encephalitis?

['A. The EEG is normal in the early stages.', 'B. Frank dysphoria is common.', 'C. Insight is preserved until late.', 'D. Memory is usually preserved.', 'E. Treatment does not alter course of disease.']

Answer: E. ADHD can persist into adulthood. There is not much data on the prevalence of ADHD in adults, but it is estimated that ADHD traits persist in 10–50% of adults who had ADHD as children. The characteristics of adult ADHD are motor hyperactivity, attention deficits, affective lability, short temper, explosive outbursts, loss of control, emotional overreactivity, disorganized behavior, inability to complete tasks, impulsivity, marital instability, and alcohol and drug use.

Which of the following is true about suicide in medically ill patients?

['A. Most terminally ill patients develop a psychiatric disorder.', 'B. Most terminally ill patients are at risk of suicide.', 'C. Anger is an important factor in suicide.', 'D. Mental illness is not common in patients who commit suicide.']

Answer: B. Atomoxetine works by inhibiting the reuptake of norepinephrine. It is used for treatment of ADHD. It should not be taken along with an MAOI or within 2 weeks of stopping an MAOI. Growth should be monitored during treatment with atomoxetine.

What is the risk of completed suicide in a person who has made a previous suicide attempt?

['A. 2 times', 'B. 25 times', 'C. 50 times', 'D. 100 times']

Answer: D. ADHD is more prevalent among boys. The symptoms must be present for at least 6 months to meet the criteria for a diagnosis of ADHD according to DSM-IV. ODD and conduct disorder are the most common comorbid conditions associated with ADHD. The treatment of choice for ADHD in children is behavioral management along with a stimulant like methylphenidate, dexamphetamine, or pemoline. More recently approved by the FDA is treatment with the nonstimulant medication atomoxetine, a selective norepinephrine reuptake inhibitor. Alpha-2 agonists like clonidine and guanfacine.

All of the following are exceptions to confidentiality between psychiatrist and the patient except

['A. Child abuse', 'B. Danger to self or others', 'C. Intent to commit a crime', 'D. Communication with other physicians not involved in the care of the patient', 'E. Competency procedures']

Answer: D. Nightmares are frightening dreams that occur during REM sleep. The child having a nightmare awakens from the dream frightened. The child remembers the content of the dream unlike in night terror. Ten to fifty percent of children in the age range 3–6 years have occasional nightmares. The child rapidly becomes oriented and alert after waking up from sleep.

Which of the following is true regarding competency?

['A. Most depressed patients are mentally incompetent.', 'B. Cognitively impaired patients do not have the capacity to make decisions.', 'C. Competency is a clinical determination.', 'D. Capacity and competency are the same.', 'E. Capacity to consent is specific to the issue and the situation.']

Answer: D. Hallervorden-Spatz disease is a hereditary disease with genetic pathology located at chromosome 20 p. The onset of the disease is usually in childhood or early adolescence. Initial features include dystonia, rigidity, difficulty with gait and speech. Seizures and retinitis pigmentosa are also seen. A CT scan of the brain shows iron deposition in the brain, especially in the globus pallidus.

Which of the following is true regarding advance directives?

['A. Advance directives are a means for people to indicate their wishes and decisions about future healthcare in the event of their incompetency.', 'B. Power of attorney is valid even if the person becomes incompetent.', 'C. Durable power of attorney empowers an agent to make only business decisions on behalf of the patient.', 'D. The determination of a patient’s competence is specified in a durable power of attorney and healthcare proxy statutes.']

Answer: B. Hyperthyroidism is the condition resulting from the effect of excessive amounts of thyroid hormone on body tissues. Grave’s disease is the most common cause of hyperthyroidism. Hashimoto’s thyroiditis causes hypothyroidism. Excess ingestion of thyroid hormone is relatively common when patients are given higher doses than that necessary to maintain a euthyroid state. TSH-secreting pituitary adenoma is very rare.

The use of seclusion and restraint is contraindicated for all of the following except

['A. To prevent harm to the patient or others B. To assist the staff during staff shortages C. To assist in treatment', 'D. To prevent significant disruption to a treatment program E. To decrease sensory stimulation']

Answer: C. A detailed psychodynamic formulation is not appropriate in the consultation liaison setting. Suggestions about managing troublesome and disruptive behaviors are helpful.

Which of the following is characteristic of depression associated with medical illness?

['A. Earlier age of onset', 'B. Increased rate of family history of depression C. Decreased rate of alcoholism in family members D. Greater likelihood of suicide', 'E. Poor response to ECT']

Answer: C. Interictal psychotic states are more common than ictal psychosis. An estimated 10–30% of all patients with complex partial epilepsy have psychotic symptoms. Risk factors are female gender, lefthandedness, onset of seizures during puberty, and a left-sided lesion. Mood symptoms like depression and mania are seen less often than schizophrenia-like symptoms. There is an increased incidence of attempted suicide in patients with epilepsy.

Which of the following is true regarding psychiatric illness in cancer patients?

['A. Twenty-five percent of patients with cancer develop a psychiatric illness.', 'B. Depression is the most common psychiatric diagnosis.', 'C. Suicide is rare among patients with cancer.', 'D. Patients with pancreatic cancer are at highest risk of suicide.']

Answer: A. Approximately 50% of patients with brain tumors experience psychiatric symptoms. In approximately 80%, the tumors are located in the frontal or limbic region. Meningiomas are likely to cause focal symptoms by compressing a limited region of the cortex, whereas gliomas are likely to cause diffuse symptoms.

Which of the following is the most common course of mania in patients with cancer?

['A. Bipolar I disorder', 'B. Cerebral metastasis', 'C. Diencephalic tumors', 'D. Corticosteroid use', 'E. Bipolar II disorder']

Answer: C. Depression is the most frequent reason for psychiatric consultation in rehabilitation medicine. It is associated with longer duration of inpatient rehabilitation, deficient self-care, and delay in resumption of premorbid social activities.

Depression following stroke is associated with lesion in which of the following regions of the brain?

['A. Left occipital', 'B. Left temporal', 'C. Left frontal', 'D. Right parietal', 'E. Right frontal']

Answer: C. The most common psychiatric manifestation of Cushing syndrome is depression. Cushing syndrome refers to a diverse symptom complex due to excess steroid hormone production by the adrenal cortex or sustained administration of glucocorticoids. The depressive symptoms are moderate to severe in 50% of patients. Many patients also experience psychotic features. In patients who demonstrate depression, it may be necessary to institute therapy for the depression itself while awaiting the eventual resolution of the manifestation of Cushing syndrome.

Which type of dementia is typically seen in patients with HIV?

['A. Alzheimer’s dementia', 'B. Subcortical dementia', 'C. Lewy body dementia', 'D. Infectious dementia', 'E. Vascular dementia']

Answer: A. Exogenous administration of steroids is most commonly associated with mania. It can also cause psychosis, depression, panic attacks, or anxiety.

What is the most common neuropsychiatric complication in hospitalized patients with AIDS?

['A. Depression', 'B. Dementia', 'C. Psychosis', 'D. Mania', 'E. Delirium']

Answer: B. Depression is common in patients with hypercalcemia. The severity of symptoms intensifies as the level of hypercalcemia increases. Delirium, psychosis, and cognitive impairment are more commonly seen in patients who have calcium levels more than 50 mg per dl. Depressive symptoms, but not cognitive symptoms, tend to resolve with treatment. Cognitive symptoms may improve; however, residual symptoms may remain.

Which of the following is commonly seen in AIDS dementia complex?

['A. Psychosis', 'B. Aphasia', 'C. Agnosia', 'D. Word-finding difficulties']

Answer: A. Dementia is more common in persons with diabetes mellitus. There is a negative correlation between emotional symptoms and diabetic control. Patients exhibiting persistent psychiatric symptoms who receive psychiatric intervention may have less disease morbidity. Between one-third and two-third of patients with diabetes mellitus have some kind of psychiatric disorder, ranging from anxiety and depression to substance abuse.

Which of the following is associated with high HIV risk behaviors?

['A. Marijuana', 'B. Alcohol', 'C. LSD', 'D. Crack cocaine']

Answer: D. Hyperthyroidism is associated with a variety of psychiatric manifestations including anxiety, depression, psychosis, and cognitive impairment. More than 90% of patients presenting with depression and anxiety who do not have a preexisting psychiatric condition will experience resolution of the symptoms during the course of treatment for hyperthyroidism. Opiate dependence is not known to be associated with hyperthyroidism.

What proportion of people with chronic pain also have an axis I psychiatric disorder?

['A. 5%', 'B. 10%', 'C. 25%', 'D. 50%', 'E. 75%']

Answer: A. Psychiatric illness with steroid use is associated with female sex, high doses of steroids, longer duration of treatment, previous history of psychiatric illness, and depressed mood.

Which of the following is true about ECT?

['A. It can be administered to patients with epilepsy.', 'B. It is contraindicated in patients with Parkinson’s disease.', 'C. Seizures are the most common cause of death in patients given ECT.', 'D. The use of bilateral electrodes reduces the risk of cognitive deficits.', 'E. ECT should be used after medication failure in catatonia.']

Answer: D. Most serotonin-enhancing antidepressants have been shown to be effective in the treatment of premenstrual dysphoric disorder in comparison with placebo. Some SSRIs given in the latter half of the cycle can be as effective as continuous daily doses. In the case of citalopram, half-cycle dosing was found to be better than daily dosing. It has been postulated that some woman may have reduced serotonergic activity across the menstrual cycle as a trait, and during the luteal phase, further abnormalities of serotonergic function may occur. The beneficial effects of SSRIs on dysphoric symptoms are evident soon after initiation of treatment. They are generally well tolerated and do not interfere with ovulation.