Psychiatry

During a routine primary care visit, a 31-year-old architect describes feeling 'drained of all energy' for the past month. She reports sleeping up to 13 hours daily, a 4-kg (8.8-lb) weight gain, and profound sadness. She states, 'I cannot concentrate on my blueprints anymore.' The patient has no prior medical conditions and takes no daily medications. Upon further questioning, she recalls a period in her early 20s when she felt 'on top of the world' for about a week. During that time, she slept only 2 hours a night, spent her entire savings on luxury clothes, and felt her thoughts were racing, which ultimately led to a brief inpatient admission. Currently, she appears lethargic and speaks with a flat affect. She reports that for the past 2 days, she has occasionally heard a voice calling her name when she is alone in her apartment. Laboratory studies show a TSH of $1.5 \mu U/mL$ (normal: $0.5-5.0 \mu U/mL$) and free T4 of $1.2 ng/dL$ (normal: $0.9-1.7 ng/dL$). Which of the following is the most appropriate next step in pharmacologic management?

Match each patient's presentation of a depressive disorder or related mood disturbance with the most appropriate therapeutic intervention.

A 33-year-old woman comes to the clinic reporting sudden-onset episodes of chest tightness, palpitations, and sweating. These episodes started 3 weeks ago after she survived a severe multi-car collision. The episodes are triggered whenever she attempts to get into a vehicle. She reports having recurrent nightmares about the crash, avoids driving completely, and feels detached from her husband and children. Physical examination and an electrocardiogram are unremarkable. Which of the following is the most likely diagnosis?

A 38-year-old woman presents to the outpatient psychiatry clinic seeking help for severe distress. Ten months ago, she was the victim of a violent home invasion. Since then, she experiences recurrent, intrusive nightmares of the event, avoids being alone in her house, and feels constantly "on guard." She states she feels emotionally detached from her husband. Her past psychiatric history includes a hospitalization at age 22 for a week-long period of decreased need for sleep, rapid speech, and grandiose delusions, followed by a severe depressive crash. Three weeks ago, a primary care physician started her on phenelzine for her low mood. She read online that paroxetine is effective for trauma survivors and asks if she can start taking it today to help with her nightmares. Which of the following are the most appropriate actions in the management of this patient's current presentation? (Select 2)

A 38-year-old woman with no prior medical or psychiatric history is evaluated in the outpatient clinic after her employer mandated a medical leave of absence. According to her husband, the patient has spent the last 4 months obsessively dismantling the home smoke detectors and covering all the windows with heavy blankets. She claims that a coordinated surveillance team is transmitting voices directly into her ears, warning her of an impending abduction. The husband notes that her personal hygiene has deteriorated significantly during this timeframe, and she rarely leaves her bedroom. Physical examination, routine laboratory studies, and a comprehensive urine toxicology screen are all within normal limits. Which of the following is the most appropriate diagnosis?

A 34-year-old woman is admitted to the hospital for intravenous antibiotic treatment of acute pyelonephritis. Over the past 48 hours, she has been exceptionally demanding and critical of the nursing staff. She frequently states that she is a "VIP in the corporate world" and insists that only the attending physician is qualified to draw her blood or assess her vital signs. She threatens to sue the hospital over a 15-minute delay in her meal delivery, claiming that her time is "far more valuable than anyone else's in this mediocre facility." When the attending physician explains that her serum creatinine is slightly elevated, she becomes furious, accusing the medical team of incompetence and demanding an immediate transfer to a "world-class hospital." She displays no signs of hallucinations or disorganized thought, and her mood is euthymic as long as her demands are accommodated. Her past medical history is notable for multiple cosmetic surgeries. Which of the following is the most appropriate approach for the physician to take in managing this patient?

A 45-year-old man is brought to the emergency department with severe agitation, diaphoresis, visual hallucinations, and tachycardia. His last alcoholic drink was 48 hours ago. He expresses a strong desire to stop drinking permanently. Arrange the following management steps in the most appropriate chronological order, from immediate emergency care to long-term maintenance.

Match each clinical vignette describing a patient with a bipolar spectrum illness to the most appropriate next best step in management or pharmacologic rationale.

Review the clinical vignettes below and match each patient presentation to the most accurate subtype of delusional disorder.

A 71-year-old retired architect is brought to the neurologist by his daughter due to a 9-month history of progressive cognitive decline. Initially, he began having difficulty organizing his finances and interpreting architectural blueprints. Six months ago, he started experiencing vivid episodes during sleep where he thrashes around and shouts, sometimes injuring his wife. Over the last 3 months, he has reported seeing silent, unfamiliar children playing in his living room, though he is generally not distressed by them. He has a history of major depressive disorder treated with sertraline. Two weeks ago, his primary care physician suspected an underlying bipolar diathesis but ultimately only increased his sertraline dose. A few days later, he was prescribed linezolid at an urgent care clinic for a suspected skin infection. A thyroid panel obtained last week showed a TSH of 0.1 μU/mL (normal: 0.4-4.0 μU/mL) and a free T4 of 0.6 ng/dL (normal: 0.9-1.7 ng/dL). On physical examination today, his temperature is 37.1°C (98.8°F), blood pressure is 128/82 mmHg, and heart rate is 76/min. He has a mask-like facies and increased resting muscle tone with a catch-and-release pattern in both arms. Deep tendon reflexes are 2+ bilaterally without clonus. His Mini-Mental State Examination score is 21/30. Which of the following is the most likely diagnosis?

A 32-year-old man is brought to the outpatient psychiatry clinic by his parents due to chronic behavioral changes. They report that their son has been behaving abnormally for the past 3 years. It began when he started claiming that national television news anchors were communicating with him through coded hand gestures. He also frequently converses with voices that no one else can hear. According to the parents, these beliefs and hallucinations have been continuously present since their onset. During this 3-year period, the patient experienced three distinct episodes of profound sadness, anhedonia, hypersomnia, and feelings of worthlessness. Each of these episodes lasted approximately 2 months and resolved spontaneously, with him returning to a normal mood. He is currently displaying a flat affect and reports that the news anchors are still sending him messages, but he denies any current sadness or changes in sleep, appetite, or energy. His medical history is unremarkable, and a urine toxicology screen is negative. Which of the following is the most likely diagnosis?

A 27-year-old male civil engineer is brought to the psychiatric emergency service by his roommate. The patient has been isolating in his bedroom for the past month, sleeping over 14 hours a day, and neglecting his personal hygiene. During the interview, he exhibits profound psychomotor retardation and admits to active suicidal ideation with a plan to ingest household chemicals. His medical history is unremarkable. Upon review of his psychiatric history, his roommate reports that three years ago, the patient experienced a distinct three-week period during which he slept only two hours per night, spoke so rapidly he was nearly incomprehensible, and frantically wrote a 500-page manifesto believing he had independently solved major problems in quantum physics. The patient was hospitalized at that time but subsequently lost to follow-up. Vital signs and routine laboratory studies are within normal limits. Which of the following pharmacological interventions are appropriate for this patient's current presentation? (Select all that apply)

A 26-year-old woman comes to the outpatient psychiatric clinic reporting severe anxiety, insomnia, and nightmares. Exactly three weeks ago, she was sexually assaulted by an acquaintance at a party. She has not disclosed the assault to anyone else and explicitly asks the physician not to notify law enforcement, stating she is not ready for an investigation. Since the incident, she has avoided social gatherings, feels constantly 'on edge,' and experiences distressing flashbacks. Her past medical history is significant for bipolar I disorder. Her current medications include lithium and tranylcypromine, the latter having been added two months ago for depressive symptoms. She asks if a medication like sertraline could be prescribed, as she has heard it is effective for trauma. Vital signs are within normal limits. Which of the following is the most appropriate next step in management?

A 78-year-old man with an 8-year history of Parkinson disease is brought to the geriatrics clinic by his daughter. Over the past 6 months, he has exhibited progressive memory loss, difficulty paying bills, and fluctuating attention. During the last 2 weeks, he has developed vivid, terrifying visual hallucinations of strangers in his bedroom, leading to severe agitation. His vital signs and physical examination are unchanged from his baseline. His current medications include carbidopa-levodopa, pramipexole, trihexyphenidyl, and omeprazole. The physician determines that a stepwise approach is required to manage his neuropsychiatric symptoms while attempting to preserve motor function.

Arrange the following management steps in the most appropriate sequential order, from the initial most necessary action to the final therapy of last resort.

A 19-year-old college student is evaluated in the university health center. His roommate brought him in because he has been "acting strange" for the past two hours. The roommate notes that the patient has been laughing inappropriately, speaking slowly, and eating unusually large amounts of snack foods. The patient has no past medical history and takes no medications. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 115/75 mm Hg, pulse of 118/min, and respirations of 14/min. Physical examination shows prominent conjunctival injection and a dry oral mucosa. Pupils are equal and reactive to light. Neurologic examination is unremarkable, and there is no nystagmus. Which of the following is the most likely cause of this patient's current condition?

A 37-year-old man is brought to the clinic by his sister due to a 6-week history of profound fatigue, hypersomnia, and a 4-kg (9-lb) weight gain. He states he feels completely devoid of energy, struggles to get out of bed, and expresses unwarranted guilt over taking time off from his job as an accountant. His sister notes that three years ago, the patient experienced a highly unusual two-week period during which he slept only three hours a night, exhibited pressured speech, and impulsively emptied his savings account to invest in unproven cryptocurrency. He has no other medical history and takes no medications. Vital signs are within normal limits. Laboratory evaluation shows a thyroid-stimulating hormone (TSH) level of 2.1 µU/mL (normal: 0.5-5.0 µU/mL) and a normal free T4 level. Which of the following is the most appropriate initial pharmacotherapy for this patient?

An 18-year-old male is brought to the emergency department by his older sister because he has been unable to stand up from the couch for the past two hours. Over the last $3$ weeks, his sister notes he has been increasingly withdrawn, occasionally talking to people who are not present, and failing to show up for his part-time job. His medical history includes major depressive disorder, for which he has been taking fluoxetine for the past year.

On physical examination, the patient is lethargic but arousable. An erythematous, flaky rash is noted around his mouth and nares. Lungs are clear to auscultation. Heart rate is $105/\text{min}$, blood pressure is $112/70\text{ mm Hg}$, and respiratory rate is $24/\text{min}$. Neurologic examination reveals symmetric $2/5$ muscle strength in the lower extremities bilaterally, with absent patellar reflexes.

Laboratory results:
$Na^+$: $140\text{ mEq/L}$
$K^+$: $1.8\text{ mEq/L}$
$Cl^-$: $115\text{ mEq/L}$
$HCO_3^-$: $14\text{ mEq/L}$
$BUN$: $10\text{ mg/dL}$
$Cr$: $0.7\text{ mg/dL}$
$TSH$: $1.8\text{ }\mu\text{U/mL}$
Urine toxicology screen: Negative for opioids, amphetamines, cocaine, PCP, and cannabis.

Arterial blood gas on room air:
pH: $7.22$
$P_{a}CO_2$: $36\text{ mm Hg}$
$P_{a}O_2$: $85\text{ mm Hg}$

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

A 68-year-old man is brought to the geriatric psychiatry clinic by his son for evaluation of worsening memory. The son reports that his father has been increasingly forgetful over the past 4 months, frequently missing appointments and neglecting to pay bills. The patient's wife passed away unexpectedly 6 months ago. Since her death, the patient has lost 5 kg (11 lbs), complains of waking up at 3:00 AM every morning and being unable to return to sleep, and has lost interest in his usual hobby of gardening. During the interview, the patient makes poor eye contact and appears apathetic. When asked about recent news events to test his memory, he immediately sighs and responds, "I just don't know, my memory is terrible." With significant encouragement and prompting, he is able to recall 2 out of 3 words after 5 minutes and correctly draw a clock. His physical and neurological examinations are unremarkable. Which of the following clinical features most strongly supports a diagnosis of major depressive disorder with cognitive impairment (pseudodementia) rather than Alzheimer disease in this patient?

A 19-year-old female is evaluated in the emergency department for severe generalized weakness and muscle cramps. Her roommate reports that the patient is heavily preoccupied with her body image and frequently goes to the bathroom immediately after meals. Vital signs show a blood pressure of 100/60 mm Hg and a heart rate of 98/min. Physical examination reveals bilateral parotid gland enlargement, dry mucous membranes, and calluses on the dorsum of her right hand. Which of the following sets of laboratory abnormalities is most likely to be found in this patient?

A $68$-year-old man is brought to the geriatric clinic by his daughter for a follow-up evaluation. For the past $3$ months, he has experienced profound sadness, anhedonia, early morning awakenings, and a $6$-kg ($13$-lb) weight loss. Three weeks ago, he began stating that his "stomach has turned to dust" and now frequently refuses to eat.

Three weeks ago, his primary care physician diagnosed a major depressive episode and prescribed citalopram. The patient took it for $14$ days but stopped it entirely $7$ days ago because "it wasn't doing anything." His past medical history includes severe osteoarthritis, for which he takes daily tramadol.

His daughter privately reports that when the patient was $32$ years old, he had a distinct $6$-week period where he slept only $2$ hours a night, exhibited pressured speech, and impulsively bought two boats, which led to a brief psychiatric hospitalization.

Vital signs are within normal limits. Physical examination is unremarkable.
Laboratory results show:
- Thyroid-stimulating hormone (TSH): $1.2$ $\mu$ U/mL (normal: $0.4$–$4.0$ $\mu$ U/mL)
- Free thyroxine (T4): $0.5$ ng/dL (normal: $0.9$–$2.4$ ng/dL)

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