Psychiatry

A 34-year-old woman with a history of severe opioid use disorder has been receiving methadone maintenance therapy at a specialized clinic for the past two years. Her current daily dose is 80 mg, and she has maintained abstinence from illicit opioids. Due to a recent job offer in a rural area without access to a methadone clinic, she requests to transition to office-based buprenorphine/naloxone therapy. Arrange the following steps in the most appropriate chronological sequence for safely transitioning this patient from methadone to buprenorphine therapy.

A 72-year-old woman is brought to the outpatient geriatric psychiatry clinic by her son due to a 6-month history of significant cognitive decline. He reports that she has become increasingly withdrawn, spends most of the day in bed, and has stopped managing her household finances. During the interview, she makes poor eye contact, exhibits psychomotor retardation, and frequently answers "I don't know" rather than attempting to answer orientation or memory questions. Her Montreal Cognitive Assessment (MoCA) score is 19/30. Medical history is significant for bipolar I disorder that was well-controlled on lithium for two decades; however, she discontinued all medications 14 months ago following the death of her husband. Her son notes she has not had any periods of elevated mood, decreased need for sleep, or rapid speech since stopping her medication. Vital signs and physical examination are normal. Laboratory studies, including complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, and vitamin B12 levels, are within normal limits. The physician determines that her cognitive deficits are secondary to a severe mood episode rather than a primary neurodegenerative process. Which of the following is the most appropriate initial pharmacological intervention for this patient?

A 35-year-old man is diagnosed with major depressive disorder in the outpatient clinic. Over the next year, he experiences persistent symptoms despite good medication adherence, requiring a progressive escalation of his treatment plan. Arrange the following management steps in the standard chronological order for escalating treatment of major depressive disorder, proceeding from initial pharmacological therapy to the management of highly refractory disease.

A 32-year-old woman is evaluated in the psychiatric clinic for severe, persistent anxiety and intrusive thoughts. Over the past 6 months, she has been consumed by an overwhelming fear that her hands are contaminated with deadly environmental bacteria. This has led her to wash her hands up to 50 times a day, with her daily washing routines occupying nearly 4 hours. She has a past psychiatric history of bipolar I disorder, which has been stable on valproate for the last 3 years. Recently, she was diagnosed with a complex skin and soft tissue infection and was started on a 14-day course of oral linezolid 3 days ago. She is deeply distressed by her psychiatric symptoms and is requesting immediate treatment. Vital signs are within normal limits, and physical examination is unremarkable except for dry, cracked skin on her hands. Which of the following is the most appropriate next step in the management of this patient's psychiatric symptoms?

A 26-year-old man is brought to the outpatient psychiatric clinic by his sister due to severe depressive symptoms for the past 3 weeks. He reports sleeping 14 hours a day, profound fatigue, and an inability to experience pleasure. Two years ago, he had a distinct episode of severe grandiosity, racing thoughts, decreased need for sleep, and auditory hallucinations commanding him to "lead the world." This prior episode lasted for exactly 3 weeks before remitting completely. He was recently prescribed selegiline for his low mood by a different provider, but he stopped taking it 2 days ago because he felt it was not working. His vital signs are within normal limits. Mental status examination reveals psychomotor retardation and a blunted affect, but no current psychosis. Laboratory studies show a TSH of 2.8 µU/mL (normal: 0.4-4.0 µU/mL) and a normal free T4. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 70-year-old man is brought to the clinic by his son due to memory issues that began 2 months ago, shortly after the sudden death of his wife. The patient frequently complains about his memory, stating, "My brain is just broken; I can't remember anything." During cognitive testing, he puts forth poor effort and frequently answers "I don't know" to questions, though he can often provide the correct answers when gently prompted. He also reports early morning awakenings, decreased appetite, and a 4-kg (8.8-lb) weight loss over this period. His physical and neurological examinations are unremarkable. Which of the following is the most likely diagnosis?

A 24-year-old woman is brought to the clinic by her husband due to severe sadness and social withdrawal for the past 6 weeks. She has been sleeping 12 to 14 hours a day, has poor appetite, and struggles to concentrate on daily tasks. She frequently complains of feeling cold. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 1.5 µU/mL and a normal free T4 level. Her husband notes that two years ago, she had a 3-week period where she barely slept, spoke so rapidly it was hard to interrupt her, and recklessly spent thousands of dollars on unneeded home renovations. The patient is currently not taking any medications. Which of the following is the most appropriate next step in management?

A 22-year-old man presents to the psychiatry clinic complaining of profound fatigue, poor concentration, and severe sleep disturbances. Five weeks ago, he was held at gunpoint during a convenience store robbery. Since the incident, he has experienced recurrent nightmares about the event, actively avoids the neighborhood where the store is located, and feels constantly "on edge." He also describes distressing periods where he feels as though he is floating outside of his own body. His past medical history is significant for a major depressive episode at age 19. At that time, he was prescribed fluoxetine; however, within two weeks of starting the medication, he developed a severe episode of elated mood, pressured speech, and a decreased need for sleep that lasted for eight days. The fluoxetine was discontinued, and he subsequently stabilized. He also reports a separate episode two years ago during which he heard voices telling him he was special; this lasted for three weeks and resolved entirely without treatment. The patient admits that due to his recent severe distress, he restarted taking leftover fluoxetine from his old prescription three days ago. He is requesting additional medication to help him cope. Which of the following is the most appropriate next step in the management of this patient's current condition?

A 28-year-old woman presents to the emergency department reporting a sudden onset of intense chest pain, palpitations, shortness of breath, and a feeling of impending doom that began 20 minutes ago while she was resting at home. She states, "I thought I was having a heart attack and going to die." This is her fourth similar episode this month. She is now terrified of having another attack and has stopped driving to work out of fear of losing control. Her medical history is notable for a severe depressive episode two years ago. At that time, she was started on citalopram, but within days she developed racing thoughts, a decreased need for sleep, and impulsive spending, which led to her hospitalization. She currently takes no medications. Her temperature is 37.0°C (98.6°F), blood pressure is 128/82 mm Hg, pulse is 110/min, and respirations are 22/min. Physical examination, ECG, and serial cardiac troponins are unremarkable. The patient's acute symptoms resolve completely after reassurance in the emergency department. Which of the following is the most appropriate long-term management strategy for this patient's current psychiatric condition?

A 32-year-old architect is evaluated in the clinic for worsening sadness and inability to concentrate at work over the past month. He reports sleeping up to 14 hours a day and feeling completely drained of energy. He has a history of an emergency department visit 4 years ago when he was brought in by his family for not sleeping for 6 days, talking rapidly, and spending a large portion of his savings on impulsive online purchases while claiming he had a foolproof plan to become a billionaire. He was hospitalized and stabilized at that time but stopped all medications 2 years ago. His vital signs are within normal limits. Physical examination shows no focal neurologic deficits and normal thyroid gland palpation. Mental status examination reveals a man with slumped posture, psychomotor retardation, and a depressed, congruent affect. He denies active suicidal ideation or auditory hallucinations. Which of the following is the most appropriate next step in management?

A 28-year-old woman is brought to the psychiatric outpatient clinic by her husband due to profound sadness, hypersomnia, and a 4.5-kg (10-lb) weight gain over the past 4 weeks. She reports feeling "slowed down" and states that she has begun hearing a voice repeatedly telling her she is worthless. Review of her medical history reveals that 2 years ago, she experienced a distinct 2-week period where she slept only 2 hours a night without feeling fatigued, spent their entire savings on luxury vehicles, and claimed she could communicate directly with angels; this episode required hospitalization. Her current medications include isocarboxazid, which was prescribed 2 weeks ago by a different physician for her depression. Vital signs are within normal limits. Physical examination shows a depressed affect and psychomotor retardation. Laboratory studies show a free thyroxine (T4) level of 0.5 ng/dL (normal: 0.9–1.7 ng/dL) and a thyroid-stimulating hormone (TSH) level of 1.5 µU/mL (normal: 0.5–5.0 µU/mL). Which of the following statements is most accurate regarding this patient's diagnosis and management?

A 28-year-old woman is brought to the outpatient psychiatric clinic by her partner due to a one-month history of worsening depression. The patient reports profound sadness, anhedonia, extreme fatigue, and sleeping up to 14 hours a day. She has gained 4 kg (8.8 lb) over the past month. She mentions feeling completely worthless but denies any active suicidal plans. Two years ago, the patient was hospitalized for 3 weeks after an episode characterized by a decreased need for sleep, pressured speech, and grandiose delusions of being a divine messenger. She was treated with medication at that time but discontinued it a year ago because she felt her symptoms were cured. Vital signs are within normal limits. Mental status examination reveals a depressed mood, flat affect, and psychomotor retardation. Her laboratory results, including a comprehensive metabolic panel, thyroid-stimulating hormone, and complete blood count, are within normal limits. Which of the following is the most appropriate next step in management?

A 24-year-old woman is brought to the emergency department by her husband due to worsening depressive symptoms over the past 3 weeks. She reports feeling profoundly sad, sleeping up to 14 hours a day, and experiencing significant psychomotor retardation. For the past 2 weeks, she has been hearing a persistent voice telling her that she is "worthless and should die," and she admits to having a specific plan to overdose on her medications. Her husband reports that 3 years ago, she had a distinct 1-week period where she barely slept, exhibited grandiose behavior, and engaged in impulsive spending that resulted in severe financial debt. Three days ago, her primary care provider diagnosed her with major depressive disorder and started her on fluoxetine. Laboratory studies reveal a thyroid-stimulating hormone (TSH) level of $0.2 \text{ mU/L}$ (normal: $0.5-5.0 \text{ mU/L}$) and a free T4 of $0.6 \text{ ng/dL}$ (normal: $0.9-1.7 \text{ ng/dL}$). Which of the following is the most appropriate next step in management?

A 35-year-old man is brought to the clinic by his husband for couples counseling. The husband complains that the patient is "suffocatingly rigid." For example, the patient insists on packing the dishwasher in a highly specific configuration and will unpack and repack it entirely if the husband does it "incorrectly." The patient recently received a formal warning at his accounting firm because he missed a major filing deadline; he spent three weeks formatting the spreadsheets to look "flawless" rather than submitting the adequate, finalized data on time. He refuses to delegate tasks to junior accountants, stating, "They are careless, and I am the only one who can do it exactly right." He frequently skips social events to organize his home office and refuses to throw away old, broken electronics, claiming they "might be useful someday." During the interview, the patient appears frustrated and says, "My husband is overreacting. I just have high standards. Is it a crime to want things done properly?" He denies any repetitive, intrusive thoughts or sudden urges that cause him distress. Mental status examination reveals a constricted affect and overly formal speech. Which of the following is the most likely diagnosis?

A 32-year-old woman comes to the outpatient clinic 4 months postpartum for a follow-up evaluation of depressive symptoms. Two weeks ago, she presented with a 4-week history of profound despondency, early morning awakenings, anorexia with a 3-kg (6.6-lb) weight loss, and feeling worse in the morning. She reported that these symptoms made it exceedingly difficult to get out of bed and properly care for her infant. At that time, she was diagnosed with major depressive disorder and started on escitalopram 10 mg daily. Today, she states, "The medication isn't working. I still feel incredibly depressed, but now I also feel extremely restless, jittery, and my thoughts are racing." Vital signs are within normal limits. On examination, the patient appears visibly agitated, is pacing the room, and exhibits rapid speech. Upon detailed psychiatric review, she mentions that during her second year of college, she experienced a spontaneous 6-day period where she felt "incredibly energized," slept only 3 hours per night without fatigue, and impulsively maxed out two credit cards on unnecessary clothing. That episode resolved without medical intervention. Which of the following is the most appropriate next step in pharmacotherapy?

A 28-year-old man is evaluated on the inpatient medical floor where he is being treated for a severe asthma exacerbation. The nursing staff reports that his behavior has been highly disruptive. During the morning shift, he told his assigned nurse that she is "the most compassionate and skilled caregiver in this entire hospital." However, later in the afternoon, he became enraged with a different nurse, yelling that she is "cruel, incompetent, and intentionally ignoring me." When the attending physician informs the patient that his respiratory status has improved and he will be discharged the following day, the patient becomes visibly furious. He threatens to stop taking all his asthma medications and walk into oncoming traffic if he is forced to leave. His past medical history is significant for multiple superficial, self-inflicted forearm lacerations and a pattern of intense, unstable romantic relationships. Which of the following are appropriate management steps for this patient? (Select all that apply)

A 54-year-old male architect is evaluated for a first episode of pervasive sadness, early morning awakening, and severe anhedonia. Over the subsequent 14 months, his clinical course is characterized by progressive treatment resistance, ultimately culminating in an inpatient psychiatric admission for life-threatening symptoms. According to evidence-based stepped-care guidelines for Major Depressive Disorder, arrange the following management steps in the most appropriate chronological order, corresponding to his clinical evolution from initial presentation to severe, refractory illness.

A 34-year-old woman presents to the clinic accompanied by her sister due to a 4-week history of recurrent, unexpected episodes of intense fear, palpitations, sweating, and chest pain. Each episode peaks within 10 minutes. Because of these attacks, she has stopped going to work and refuses to leave her house, fearing she will be unable to escape if an attack occurs. She has a history of bipolar I disorder, diagnosed after a severe manic episode at age 24, but discontinued her lithium 3 years ago. For the past month, she has also felt profoundly sad, with low energy and hypersomnia. She recently saw another physician who prescribed phenelzine two weeks ago. In the waiting room, the sister pulls the physician aside and asks, 'Is she developing schizophrenia like our mother? I need to know her exact diagnosis.' Vital signs are temperature 37.0°C (98.6°F), blood pressure 128/82 mm Hg, and pulse 108/min. Physical examination is unremarkable. Which of the following are appropriate next steps in this patient's management? (Select all that apply)

A 45-year-old male executive presents to the primary care clinic reporting a two-month history of having "zero energy." He describes experiencing a persistently low mood, an inability to enjoy his usual hobbies, and a sensation that his arms and legs are unusually heavy. The patient reports sleeping 12 to 14 hours a day and has gained 7 kg (15.4 lb) over this period. Medical history is notable for migraine headaches, for which he takes sumatriptan as needed; he has used it twice in the past week. Four years ago, the patient experienced a distinct six-day period during which he slept only two hours a night but felt completely rested. During that time, he was highly talkative, unusually confident, and impulsively invested a large amount of money into a risky startup. This caused significant marital friction but did not require hospitalization. Vital signs are within normal limits. Mental status examination reveals psychomotor retardation and a blunted affect, but no delusions or suicidal ideation. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 1.8 µU/mL (normal: 0.5–5.0 µU/mL) and free T4 of 1.1 ng/dL (normal: 0.8–1.8 ng/dL). Which of the following is the most appropriate next step in pharmacotherapy for this patient?

Match each clinical presentation to the most likely underlying neurocognitive etiology.