Psychiatry

A 35-year-old patient is diagnosed with severe Major Depressive Disorder without psychotic features. Arrange the following interventions in the standard sequential order of a stepped-care approach for this patient, progressing from the initial evaluation and management to interventions for highly treatment-resistant disease. Assume an inadequate clinical response to each preceding step.

A 28-year-old woman is diagnosed with major depressive disorder and prescribed an oral selective serotonin reuptake inhibitor (SSRI). Arrange the following clinical events and milestones in the typical chronological order in which they are expected to occur during her treatment course, from the initial days of therapy to long-term management.

During morning rounds and surgical consultations, the consultation-liaison psychiatry team is asked to evaluate five different patients who are complicating their own medical care through deeply ingrained, inflexible behavioral patterns. Evaluate the interpersonal dynamics and defense mechanisms presented in each scenario, and pair each patient with the most accurate underlying psychiatric diagnosis.

A 34-year-old woman is admitted to the inpatient psychiatric unit due to a 4-week history of severe depressed mood, hypersomnia, profound fatigue, and passive suicidal ideation. Her psychiatric history is significant for a severe manic episode at age 26 that required a 2-week hospitalization, establishing a diagnosis of bipolar I disorder. She discontinued her prescribed maintenance lithium two years ago due to weight gain. For the past month, she has been taking daily over-the-counter St. John's wort and 5-hydroxytryptophan (5-HTP) supplements. Her past medical history includes a non-functioning pituitary microadenoma diagnosed incidentally last year, for which she currently takes no medications.

Physical examination reveals a flat affect, psychomotor retardation, and delayed deep tendon reflexes.

Laboratory studies show:

Comprehensive metabolic panel and complete blood count are within normal limits.

Which of the following are appropriate management steps for this patient? (Select all that apply)

A 24-year-old woman is evaluated in the psychiatric clinic for worsening mood. For the past two months, she has experienced pervasive sadness, anhedonia, hypersomnia (sleeping 12 to 14 hours a day), and a 6-kg (13-lb) weight gain. She describes her arms and legs as feeling "heavy like lead," though she notes her mood brightens temporarily when her sister comes to visit. Three years ago, she was hospitalized for a one-week episode during which she slept only two hours a night, spoke extremely rapidly, and spent her entire savings. During that admission, she heard a voice telling her she was a prophet, but this hallucination resolved completely within 5 days alongside her other symptoms after she received acute treatment. She is currently taking fluoxetine, which was prescribed by her primary care physician three weeks ago, but she reports no improvement.

Which of the following is the most appropriate next step in management?

A medical student is reviewing the pharmacological management of bipolar disorder. Match each medication to its most appropriate baseline screening and monitoring requirement prior to initiation.

A 27-year-old man is referred to a psychiatrist for an evaluation requested by his employer. Over the past four years, his coworkers have complained that he behaves oddly, often wearing heavy winter clothing in the middle of summer and muttering to himself in the breakroom. During the interview, the patient makes poor eye contact and displays a constricted affect. He explains that he avoids social gatherings because he feels "out of sync" with others. When discussing his lack of friends, he utilizes fantasy as a defense mechanism, explaining that he does not need physical companions because he maintains strong telepathic connections with others on an "astral plane." He denies ever hearing external voices, seeing things that are not there, or feeling that his thoughts are being controlled by outside forces. His thought processes, while highly eccentric, remain logical. These traits have been stable since his late teens. Which of the following is the most likely diagnosis?

A 35-year-old woman is evaluated in the psychiatric clinic for severe anxiety and intrusive memories. Six months ago, she was the victim of a violent home invasion. Since the event, she has experienced frequent nightmares about the attack, avoids leaving her house, and remains excessively vigilant. She also reports a 3-week history of depressed mood, severe fatigue, and anhedonia. Her past psychiatric history is significant for two hospitalizations in her early twenties for episodes characterized by a markedly decreased need for sleep, rapid speech, and grandiose delusions. Her only current medication is phenelzine, an MAOI, which was started by a different physician two months ago for depression. Which of the following statements regarding the appropriate diagnosis and management of this patient are correct?

A 72-year-old woman is brought to the emergency department by her husband due to a progressive physical decline over the past week. She has a history of persistent depressive disorder since her late 40s and was diagnosed with a superimposed major depressive episode 6 months ago following her husband's stroke. During the current episode, she sequentially failed 8-week trials of sertraline and venlafaxine at maximum tolerated doses. Four weeks ago, her psychiatrist initiated a combination of fluoxetine 40 mg and bupropion 150 mg daily. Over the past 7 days, she has entirely refused to eat or drink, stating that her "stomach has been replaced by a block of ice" and that eating is a sin. On examination, she is mute, exhibits severe psychomotor retardation, and avoids eye contact. Her temperature is 37.0°C (98.6°F), pulse is 110/min, and blood pressure is 105/65 mm Hg. Her mucous membranes are extremely dry, and skin turgor is poor. Laboratory results show a blood urea nitrogen (BUN) of 48 mg/dL and a serum creatinine of 1.9 mg/dL (baseline 4 weeks ago was 0.8 mg/dL). Which of the following is the most appropriate next step in management?

Paramedics bring a 30-year-old primigravid woman at 32 weeks gestation to the emergency department. She called 911 reporting sudden, overwhelming chest tightness, diaphoresis, and a sensation of smothering. Upon arrival in the ED, the patient is tremulous and states, "I thought I was having a heart attack and going to die." She reports the symptoms began while she was watching television and peaked within five minutes. She admits to having three similar episodes over the past four weeks. Consequently, she has stopped driving and refuses to go to the supermarket out of fear that a similar event might occur in public.

Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, heart rate is 118/min, and respiratory rate is 26/min. Pulse oximetry is 99% on room air. Lungs are clear to auscultation bilaterally. Cardiac examination reveals a regular rhythm with a grade 2/6 early systolic murmur at the left upper sternal border. No lower extremity edema is present. An electrocardiogram demonstrates sinus tachycardia. Arterial blood gas on room air shows a pH of 7.50, $pCO_2$ of 27 mm Hg, and $pO_2$ of 104 mm Hg. A plasma D-dimer level is 0.7 mg/L (normal non-pregnant $\leq$ 0.5 mg/L).

Which of the following is the most appropriate next step in management?

A 29-year-old woman presents to the outpatient gynecology clinic for a routine wellness examination and contraception counseling. During the initial interview, she is exceptionally complimentary, telling the physician, "You are the only doctor I have ever met who truly listens. My last gynecologist was completely incompetent, ignored my concerns, and practically ruined my health." Toward the end of the appointment, she asks for the physician's personal cell phone number, stating she needs it "just in case I have a medical emergency after hours." When the physician politely declines and explains the clinic's standard answering service and on-call procedures, the patient's demeanor changes abruptly. She becomes visibly furious, yells that the physician is "just as cold and heartless as the rest of them," and threatens to leave without undergoing the physical examination. The patient has no history of mania, psychosis, or substance use disorder. Which of the following is the most appropriate next step in the management of this patient?

A 22-year-old college student is referred to the university psychiatric clinic by his academic advisor due to social isolation and eccentric behavior. For the past three years, the patient has had no close friends and spends most of his weekends extensively researching clairvoyance, telepathy, and astral projection. He tells the physician that he can frequently "feel the vibrational energy" of other people in the room, which makes him highly uncomfortable in crowds. He wears a heavy trench coat adorned with multiple mismatched scarves, regardless of the weather. His speech is vague and highly circumstantial, often drifting into tangential discussions about "cosmic alignments," but his thought process remains goal-directed without frank disorganization. He explicitly denies auditory or visual hallucinations, and there is no evidence of major depressive or manic episodes. He occasionally takes citalopram, which was prescribed by his primary care physician for mild generalized anxiety. Which of the following statements regarding the diagnosis and management of this patient's condition are accurate? (Select 2)

A 24-year-old graduate student presents to the clinic reporting that she has felt "down and empty" for the past 6 weeks. She describes poor appetite, waking up multiple times during the night, low energy, and an inability to enjoy her usual hobbies. She feels guilty about her recently declining academic performance. She has no significant past medical history and takes no medications. Her physical examination is unremarkable. The physician determines that she meets the criteria for a major depressive episode and considers initiating pharmacotherapy with an antidepressant. Which of the following is the most appropriate next step in the psychiatric evaluation prior to prescribing this medication?

A 31-year-old male architect visits a new psychiatrist seeking help for severe, debilitating anxiety. He describes being overwhelmed by intrusive, horrific images of his house catching fire. To neutralize these thoughts, he feels driven to check the stove and electrical outlets exactly twelve times before leaving for work. This ritual consumes over two hours daily, threatening his employment. He also reports experiencing a profoundly depressed mood, fatigue, and anhedonia for the past six weeks. His medical record reveals a prior psychiatric admission three years ago for an episode of grandiosity, pressured speech, and zero sleep requirement that lasted 10 days. The patient is currently taking tranylcypromine, prescribed by a previous provider, but finds it ineffective for his checking rituals. He requests to switch to a different class of medication, specifically a selective serotonin reuptake inhibitor (SSRI), starting today.

Which of the following actions represent appropriate steps in the comprehensive management of this patient's psychiatric conditions? (Select all that apply)

Match each clinical vignette with the most likely personality disorder diagnosis.

A 42-year-old male marketing executive presents to the clinic for a two-month history of pervasive anhedonia, early morning awakening, and an unintentional 5-kg (11-lb) weight loss. He reports that his symptoms have severely impaired his concentration, leading to a recent formal reprimand at work. He is seeking pharmacologic treatment. Assuming this patient will eventually develop treatment-resistant depression over the next year, arrange the following clinical management steps in the standard chronological sequence according to evidence-based stepped-care guidelines.

Match each patient's clinical vignette with the most appropriate personality disorder diagnosis.

A 27-year-old primigravida at 16 weeks gestation is brought to the clinic by her partner due to worsening mood. Over the last four weeks, she has felt profoundly sad, lacks energy, and sleeps up to 14 hours a day. She expresses deep guilt and says she feels "empty." Her partner notes that during her second year of college, she experienced a distinct two-week period where she slept only three hours a night, spoke at an unusually rapid pace, and started three different business ventures that rapidly failed. That prior episode resolved without hospitalization. She currently takes a daily prenatal vitamin and an over-the-counter dextromethorphan syrup for a chronic post-viral cough. Vital signs are within normal limits. Recent laboratory testing shows a thyroid-stimulating hormone (TSH) level of 1.1 mU/L. Which of the following is the most appropriate next step in pharmacologic management?

A 28-year-old man presents to the outpatient psychiatric clinic complaining of severe "panic attacks" and insomnia. For the past 8 months, he has experienced sudden surges of intense fear accompanied by tachycardia, diaphoresis, and a feeling of impending doom. These episodes are frequently triggered by loud noises or when he attempts to fall asleep. During these episodes, he reports "zoning out" and vividly hearing the screeching of tires and feeling the impact of a vehicle, reliving a severe car accident he survived 8 months ago in which his fiancée was killed. He has since refused to ride in any motor vehicles, walking 3 miles to work every day. He notes that 3 years ago, he experienced a distinct 4-week period where he required only 2 hours of sleep per night, believed he had been chosen by God to solve world hunger, and maxed out multiple credit cards to start a charity. This behavior led to a brief psychiatric hospitalization, but he stopped taking his prescribed medications shortly after discharge. He is currently taking no medications. Vital signs, physical examination, and laboratory studies are unremarkable. Which of the following is the most appropriate next step in management?

Match each depressive disorder or specifier with its most characteristic clinical presentation.