1. Answer: B. Graves’ disease is the most common cause of hyperthyroidism. Hashimoto’s disease causes hypothyroidism and not hyperthyroidism. A hyperthyroid state resulting from excess administration of exogenous thyroid hormone preparation is not uncommon. TSH-secreting pituitary adenoma is very rare.

2. Answer: C. Studies have found that depression is very common in patients who are in rehabilitation, and it is also one of the most common reasons for psychiatric consultation. Depression in rehabilitation patients is associated with longer duration of stay as well as delay in resumption of premorbid social and occupational activities.

3. Answer: E. The most common psychiatric manifestation in patients with Cushing’s syndrome is depression. Cushing’s syndrome refers to a diverse symptom complex resulting from excess steroid hormone production by the adrenal cortex or excessive administration of exogenous glucocorticoids. Depression is very common and is seen in up to 50% of patients with Cushing’s syndrome. Some patients also have symptoms of mania and psychosis.

4. Answer: B. Hyperparathyroidism is characterized by hypercalcemia. Depression is common in patients with hypercalcemia. Symptoms become worse as the hypercalcemia levels increase. At calcium levels of more than 50 mg/dL, delirium, psychosis, and cognitive impairment are seen.

5. Answer: B. About 30% to 70% of patients with diabetes mellitus have psychiatric disorders including anxiety, depression, and substance use.

6. Answer: D. Hyperthyroidism is associated with a wide variety of psychiatric manifestations including anxiety, depression, psychosis, and cognitive impairment. The majority of patients who present with depression and anxiety secondary to hyperthyroidism will experience a resolution of symptoms once hyperthyroidism is treated. Although subjects with anxiety disorders and other psychiatric disorders often abuse opiates, opiate dependence is not known to be associated with hyperthyroidism.

7. Answer: A. Psychiatric disorders with steroid use are more likely to be associated with female gender, high doses of steroids, longer treatment duration, previous history of any psychiatric illness, and depressed mood.

8. Answer: D. Most SSRIs have been shown to be effective in the treatment of PMDD. Some SSRIs, given in the latter half of the cycle, have been found to be as effective as continuous daily dosing. Many of the SSRIs can be combined with other hormonal treatments, and the side effects of SSRIs in PMDD are not different from side effects noticed when SSRIs are used to treat depression or anxiety. SSRIs are not found to inhibit ovulation.

9. Answer: B. Vitamin B12 deficiency can cause macrocytosis, polyneuropathy, dementia, and memory impairment. Its association with depression is not established.

10. Answer: B. Wilson’s disease is a rare autosomal recessive disorder. It is characterized by the excessive deposition of copper in the tissues, mainly in the liver and brain. The neurological features are related to basal ganglia dysfunction and include resting, postural, or kinetic tremor as well as rigidity and dystonia of the bulbar musculature with dysarthria and dysphagia. Psychiatric features include behavioral and personality changes and emotional problems. The pathognomonic sign is the golden-brown or orange Kayser-Fleischer ring in the cornea caused by copper deposition in Descemet’s membrane.

11. Answer: C. The DSM-IV criteria for diagnosing PMDD include prospective documentation of physical and behavioral symptoms (using diaries) being present for most of the preceding year. Five or more of the following symptoms must have been present during the week prior to menses, resolving within a few days after menses starts. At least one of the five symptoms must be one of the first four on this list: (1) feeling sad, hopeless, or selfdeprecating; (2) feeling tense, anxious, or “on edge”; (3) marked lability of mood interspersed with frequent tearfulness; (4) persistent irritability, anger, and increased interpersonal conflicts; (5) decreased interest in usual activities, which may be associated with withdrawal from social relationships; (6) difficulty concentrating; (7) feeling fatigued, lethargic, or lacking in energy; (8) marked changes in appetite, which may be associated with binge eating or craving certain foods; (9) hypersomnia or insomnia; (10) a subjective feeling of being overwhelmed or out of control; and (11) other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of bloating, and weight gain.

12. Answer: D. A number of studies have shown an association between serotonin dysfunction and PMDD. Estimates of prevalence of PMDD vary between 4% to 7%. The presence of PMDD does not indicate abnormal ovarian function, and women with PMDD show no consistent differences in basal levels of ovarian hormones. Younger age and low education levels have been associated with more severe symptoms of PMDD. Past sexual abuse is reported by a significant proportion of woman seeking treatment for PMDD.

13. Answer: B. intermittent porphyria is the most common form of this disorder. It is an autosomal dominant condition. Many drugs including barbiturates, carbamazepine, tricyclic antidepressants, phenytoin and valproic acid may precipitate the attacks. Patients present with abdominal pain, autonomic and peripheral neuropathy, seizures, and psychosis. Benzodiazepines are generally considered to be safe for use in porphyria, and elevated ceruloplasmin levels are associated with Wilson’s disease.

14. Answer: A. Prion disorders, also known as subacute spongiform encephalopathies, are associated with the accumulation in the brain of abnormal partially protease-resistant glycoprotein known as prion protein. The human prion diseases can be inherited, sporadic, and acquired forms.

CJD is a rapidly progressive dementia with myoclonus. It usually affects people 45 to 75 years of age. The clinical progression typically occurs over weeks, progressing to akinetic mutism and death within about 2 to 3 months. Patients with progressive dementia and two or more of the symptoms of myoclonus, cortical blindness, pyramidal, cerebellar, or extrapyramidal signs or akinetic mutism, in the setting of an EEG finding of pseudoperiodic sharp wave activity nearly always have CJD.

The familial form of prion disease, called Gerstmann-Sträussler-Scheinker disease, has an onset in the third and fourth decades of life and is characterized by cerebellar ataxia with pyramidal features and dementia. It is an autosomal dominant disorder.

15. Answer: B. The most common psychiatric diagnoses in patients with ESRD and undergoing dialysis are adjustment disorders (30%), mood disorders (24%), and organic mental disorders. Symptoms useful in identifying major depressive disorders are low mood, reduced interest in usual activities, worthlessness, hopelessness, excess guilt, anorexia, weight-loss, and psychomotor retardation. Symptoms that are not found to be helpful in making a diagnosis of depression are lack of energy, insomnia, and reduced libido as these are very common in patients with ESRD.

16. Answer: D. Cognitive therapy can be used to treat psychological problems related to physical illness in hospital settings. Studies have shown that as patients perceive themselves as having no control in a situation, it is more likely they will be depressed. One of the important requirements is that the therapist should be empathetic and understand patients’ perception of problems. Cognitive therapy aims to improve patients’ sense of control over their physical state and educate them in techniques that can be used to deal with future problems. Cognitive therapy focuses more on “here and now” rather than exploring psychodynamic issues.

17. Answer: D. Depression is sometimes difficult to diagnose in patients with physical illness. Depressed mood, hopelessness, inappropriate guilt feelings, and suicidal thoughts are more suggestive of depression. Other symptoms such as sleep disturbances, anorexia, lethargy, and psychomotor retardation, although common in depression, can also be the result of physical illness.

18. Answer: B. Psychiatric disorders are common in patients with diabetes mellitus, and treatment of comorbid psychiatric conditions leads to better outcomes. There are reports of SSRIs sometimes causing hypoglycemia and not hyperglycemia. All the other statements are true.

19. Answer: B. The majority of the psychotropic medications are metabolized in the liver, and therefore, psychiatric treatment in patients with hepatic failure presents with unique challenges. Fluoxetine and paroxetine cause significant inhibition of CYP 450 2D6 enzymes and both are cleared by hepatic enzymes. The other SSRIs (citalopram, sertraline, and escitalopram) cause relatively less inhibition of hepatic CYP 450 enzymes. For drugs that are metabolized by the liver, the half-lives are increased and not decreased. Lithium is often considered as the mood stabilizer of choice in patients with hepatic failure because it is cleared almost entirely by the kidneys.

20. Answer: D. Delirium is characterized by waxing and waning of consciousness. Impaired attention is considered to be the core cognitive disturbance. In addition, most patients experience disturbances of memory, orientation, language, mood, thinking, perception, motor behavior, and the sleep-wake cycle. Although individual delirium symptoms are nonspecific, their pattern is highly characteristic with acute onset, fluctuant course, and transient nature. Delirium is common in general hospital settings with a point prevalence of 10% to 30%. It is more frequent in older patients and those with pre-existing cognitive impairment and medical or surgical problems.