Psychiatry

A 32-year-old woman is evaluated in the outpatient psychiatric clinic for chronic relationship difficulties. She recently separated from her husband of three years. She states, 'I did everything he asked. I moved to a city I hated, quit my job so I could be home when he wanted, and even stopped talking to my friends because he thought they were a bad influence. I just wanted him to make the decisions so I wouldn't mess things up.' Despite her concessions, her husband filed for divorce. Since the separation, she has felt 'lost and completely helpless.' She immediately moved in with her older sister and has been pleading with her sister to help her find a new job, decide what clothes to wear, and manage her finances. When asked how she coped when her husband first mentioned divorce, she says, 'I begged him to stay and promised I would change whatever he wanted. I just panicked and clung to him tighter.' She denies ever making suicide attempts, engaging in self-injurious behavior, or experiencing sudden angry outbursts toward her husband. She has no history of substance use disorder.

Which of the following clinical features most accurately distinguishes this patient's personality pathology from borderline personality disorder?

A 28-year-old male veteran presents to an outpatient clinic reporting a 5-month history of severe sleep disturbances, hypervigilance, and intrusive memories of a combat engagement. He avoids crowded places and frequently scans his environment for threats. During the interview, he appears visibly tense. He also reports a recent onset of profound fatigue, constipation, and feeling cold all the time over the past 4 weeks.

His psychiatric history is significant for a severe episode of grandiosity, pressured speech, and lack of sleep that required inpatient hospitalization at age 22. He is currently taking isocarboxazid, a monoamine oxidase inhibitor (MAOI), prescribed two years ago for treatment-resistant depression, but he reports it is no longer effective and finds the dietary restrictions burdensome.

Vital signs are within normal limits. Laboratory testing reveals:
- Thyroid-stimulating hormone (TSH): $0.1 \text{ \mu U/mL}$ (Normal: $0.5 - 5.0 \text{ \mu U/mL}$)
- Free thyroxine (T4): $0.6 \text{ ng/dL}$ (Normal: $0.9 - 1.7 \text{ ng/dL}$)

The physician decides to restructure his psychiatric and medical management.

Which of the following are the most appropriate next steps in management? (Choose two correct answers)

Match each classic clinical presentation with its most appropriate DSM-5 diagnostic category.

A 28-year-old woman presents to the outpatient clinic 3 months postpartum reporting an overwhelmingly sad mood, profound hypersomnia, hyperphagia, and a sensation of extreme heaviness in her arms and legs. She reports significant functional impairment, noting difficulty getting out of bed to care for her infant. To avoid common clinical pitfalls and ensure standard-of-care management, arrange the following steps in the correct chronological sequence, from the immediate diagnostic evaluation to the management of potential treatment refractoriness.

Match each patient's clinical presentation of major depressive disorder with the most appropriate initial pharmacological treatment based on their specific comorbidities and symptom profiles.

A 45-year-old night-shift security guard is evaluated at a primary care clinic for a routine employment physical. The patient reports that he lives entirely alone and spends his off-hours building intricate model ships. When the physician asks about his social support system, the patient states that he has no close friends and prefers it that way, noting that interacting with others is exhausting and uninteresting to him. He expresses no desire for romantic or sexual relationships. During the interview, he appears indifferent to the physician's attempts to build rapport and displays a flattened, detached affect. He denies experiencing any hallucinations, paranoia, or periods of depressed mood. Which of the following is the most likely diagnosis?

An emergency medical team brings a 20-year-old female university student to the hospital after she fainted during a lecture. Her friends report she has been severely restricting her food intake and exercising excessively for the past 8 months. On arrival, she is lethargic but arousable. Her body mass index is calculated at $13.0\text{ kg/m}^2$. Vital signs indicate profound bradycardia ($38\text{ /min}$) and hypotension ($78/48\text{ mm Hg}$). Arrange the following interventions in the most appropriate chronological sequence for managing this patient's condition, progressing from immediate acute care to definitive long-term therapy.

An established patient presents to the outpatient psychiatry clinic accompanied by her sister. The 29-year-old woman reports feeling profoundly 'empty' and exhausted for the past three weeks. During this time, she has struggled with significant hypersomnia, hyperphagia, and pervasive feelings of guilt. Her sister notes that two years prior, the patient experienced a highly uncharacteristic 10-day period during which she was exceptionally 'wired,' slept merely two hours per night, spoke incessantly, and had grandiose delusions of being a secret government agent. She was subsequently placed on phenelzine for presumed unipolar depression by a different provider, but she independently stopped taking this medication 3 days ago due to a lack of perceived efficacy. Current laboratory results, including a complete thyroid panel (TSH and free T4), are within normal limits. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 38-year-old freelance artist is accompanied to a primary care appointment by her older sister. The patient is wearing heavily layered, mismatched clothing adorned with various metallic charms that she claims "deflect negative electromagnetic frequencies." During the interview, she speaks in a circumstantial and overly abstract manner, describing her health as being "out of alignment with the lunar cycles." She avoids eye contact, appearing highly uncomfortable, and mentions that she rarely leaves her apartment because she is overwhelmed by the "intense auras" of other people. Her sister expresses frustration, stating that this behavior has persisted since the patient's early twenties, and requests that the physician "prescribe medication to stop these delusions." The patient denies hearing voices or believing that others are trying to harm her. She is fully oriented and correctly answers questions about her medical history. Which of the following is the most appropriate action by the physician?

A 38-year-old man is hospitalized for intravenous antibiotic therapy for severe lower extremity cellulitis. Over the past 48 hours, the nursing staff reports escalating behavioral difficulties. The patient exhibits rapid, unpredictable shifts in affect, ranging from profound tearfulness to intense, sarcastic outbursts. He recently told the attending physician, "You are the only competent doctor in this hospital; the morning nurses are maliciously ignoring my needs." Following a minor delay in receiving his morning meal tray, he became extremely distressed and reported briefly hearing a voice telling him he is "worthless." This perceptual disturbance completely resolved within two hours after a supportive conversation with the clinical social worker. His medical record indicates a history of recurrent impulsive medication overdoses, chronic feelings of emptiness, and tumultuous interpersonal relationships. His home medications include phenelzine for a history of treatment-resistant depression. The patient is currently demanding that the team "do something to fix my severe depression right now."

Which 3 of the following interventions are appropriate components of this patient's comprehensive management plan during this admission?

A 34-year-old man comes to the clinic seeking a second opinion regarding his "chronic fatigue and workplace stress." He brings a 5-page typed document detailing his symptoms, previous doctors' visits, and a list of medical literature he has reviewed. He states that he is constantly exhausted because he works 80 hours a week as a software developer. He explains, "I have to do everything myself because my colleagues are incompetent and careless. If I delegate, the code will be messy, and I refuse to release anything less than perfect." Because of this rigid standard, he frequently misses project deadlines, which recently led to a formal reprimand from his manager. The patient expresses anger at his manager's "inability to appreciate true quality." He denies any repetitive rituals or intrusive thoughts that cause him distress. He reports no periods of elevated mood, impulsivity, or decreased need for sleep. He has no close friends because he finds socializing to be "an inefficient use of time." Which of the following is the most likely diagnosis?

A 31-year-old woman comes to the clinic with her husband due to a 4-week history of profound sadness, frequent crying spells, and a feeling of being "completely overwhelmed." She delivered her first child 2 months ago via an uncomplicated vaginal delivery. She states that she sleeps heavily when the infant sleeps but still feels exhausted throughout the day. She has a poor appetite and expresses immense guilt over being a "terrible mother." She denies any thoughts of harming herself or the infant. Her medical history is unremarkable. Vital signs are normal. Laboratory testing shows a thyroid-stimulating hormone (TSH) level of $4.2 \mu U/mL$ (normal: $0.5-5.0 \mu U/mL$) and a free T4 of $1.1 ng/dL$ (normal: $0.8-2.8 ng/dL$). During the interview, her husband mentions that during her second trimester of pregnancy, she experienced a 3-week period where she "barely slept for days," rapidly renovated their entire house single-handedly, and spoke so quickly that he struggled to follow her train of thought. He had assumed this was a severe case of "pregnancy nesting." Which of the following is the most appropriate next step in pharmacological management?

A 72-year-old woman is brought to the clinic by her daughter due to a 1-year history of progressive memory loss, misplacing items, and getting lost in familiar neighborhoods. Arrange the following steps in the most appropriate chronological order for the initial diagnostic evaluation of this patient's progressive cognitive decline.

A 22-year-old man visits a community health clinic reporting a 3-week period of severely depressed mood, hypersomnia, and intense feelings of worthlessness. During the psychiatric history, the physician learns that one year ago, the patient experienced a distinct 10-day period where he felt 'invincible,' required only 3 hours of sleep per night to feel fully rested, and engaged in impulsive, high-risk financial investments. He currently takes no medications and has no other medical conditions. Which of the following represent appropriate initial management steps for this patient's current condition? (Select all that apply)

A 19-year-old female college student is evaluated at the student health center due to significant weight loss and academic decline. For the past eight months, she has experienced overwhelming anxiety when eating in the campus dining hall, constantly fearing that other students are intensely watching and negatively judging her table manners. To avoid this distress, she has been skipping meals, resulting in a 5-kg (11-lb) weight loss. She denies any fear of gaining weight or distorted body image. She also strictly avoids raising her hand or speaking in seminars. Her medical history is significant for a recent methicillin-resistant *Staphylococcus aureus* (MRSA) skin abscess, for which she was started on oral linezolid three days ago. Her psychiatric history includes an episode at age 17 characterized by severe depression, which was followed by a distinct two-week period of euphoric mood, decreased need for sleep, and hypersexuality.

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

A 21-year-old man is brought to the emergency department by his friends due to severe agitation and confusion. His friends report that they were at an electronic music festival when he suddenly became profusely sweaty, disoriented, and collapsed. His medical history is significant for major depressive disorder, for which he takes fluoxetine daily. His temperature is 39.4°C (102.9°F), blood pressure is 170/105 mm Hg, pulse is 128/min, and respirations are 22/min. Physical examination shows diffuse diaphoresis, bilateral mydriasis, and tremors. Neurologic examination reveals prominent hyperreflexia and sustained clonus in the lower extremities. Which of the following illicit substances did this patient most likely consume?

A 31-year-old man presents to the psychiatry clinic deeply distressed. For the past 3 weeks, since the birth of his daughter, he has been experiencing recurrent, intrusive images of himself dropping the infant down the stairs. He states, "I love her more than anything and would never hurt her, but these terrifying thoughts keep popping into my head." To neutralize his anxiety, he mentally recites the alphabet backward exactly three times every time the image occurs. This cycle repeats dozens of times a day. He has refused to hold the baby, placing significant strain on his marriage.

His medical history is notable for congenital long QT syndrome. His psychiatric history includes a severe manic episode with psychotic features at age 24, for which he was hospitalized and successfully treated. However, he discontinued all psychiatric medications two years ago and has been euthymic since. An electrocardiogram today shows a QTc interval of $490 \text{ ms}$.

Which of the following are the most appropriate steps in the clinical management of this patient? (Select exactly 2)

A $28$-year-old male architect is brought to the outpatient psychiatric clinic by his husband. The patient reports a $4$-week history of feeling "profoundly empty," sleeping $14$ hours a day, gaining $7$ kg ($15$ lbs), and experiencing an inability to concentrate on his design projects. His husband notes that $3$ years ago, the patient had a distinct $2$-week period where he slept only $2$ hours a night, maxed out several credit cards investing in cryptocurrency, and firmly believed he was communicating telepathically with extraterrestrials. That episode resulted in a $10$-day psychiatric hospitalization. The patient's only current medication is daily omeprazole. His vital signs and physical examination are unremarkable. Which of the following statements regarding the appropriate pharmacological management for this patient are correct? (Select all that apply)

A 34-year-old female software engineer presents to the clinic with a 6-week history of profound fatigue, sleeping 12 to 14 hours a day, significant weight gain, and an inability to focus on her work. She reports feeling hopeless and admits to passive thoughts of death, though she denies active suicidal ideation or any specific plan. She has no significant past medical history. A review of her medical records indicates that three years ago she was brought to the emergency department by her family for severe agitation, grandiosity, and going four consecutive days without sleep. She was hospitalized, diagnosed with a psychiatric condition, and prescribed medication, which she discontinued shortly after discharge. Vital signs are within normal limits. Physical examination is unremarkable. Laboratory evaluation reveals a thyroid-stimulating hormone (TSH) level of $1.8 \mu\text{U/mL}$ (normal: $0.4-4.0 \mu\text{U/mL}$) and a free T4 level of $1.2 \text{ ng/dL}$ (normal: $0.9-2.4 \text{ ng/dL}$). Which of the following is the most appropriate pharmacological management for this patient?

A 29-year-old man comes to the clinic reporting severe anxiety, poor sleep, and frequent nightmares for the past 3 weeks. Three weeks ago, he was the driver of a commercial truck that was involved in a fatal collision with a pedestrian. Although he was not physically injured, he witnessed the aftermath. Since the incident, he has experienced intense intrusive memories of the event, refuses to drive or be near large vehicles, feels emotionally numb, and is constantly hypervigilant. His medical history is significant for bipolar I disorder, diagnosed at age 22, and chronic lower back pain. He discontinued his maintenance lithium 6 months ago because he felt well, and he currently takes no psychiatric medications. He takes tramadol as needed for his back pain. He expresses intense distress about his symptoms. Which of the following is the most appropriate next step in management?