Psychiatry

A forensic psychiatrist is reviewing the medical file of a female inmate being evaluated for transfer to a long-term psychiatric facility. Comprehensive longitudinal medical records indicate that her psychiatric illness began exactly 10 years ago with the insidious onset of auditory hallucinations, persecutory delusions, and severe avolition. Over this entire 10-year period, these psychotic symptoms have been continuously present on a daily basis without any periods of remission. The records also reveal that 8 years ago, she suffered a distinct 6-month period of profound anhedonia, hypersomnia, and feelings of worthlessness. Four years ago, she had a 3-month episode characterized by pressured speech, grandiosity, and a decreased need for sleep. There are no other documented mood episodes throughout her lifespan. Toxicology screens and medical evaluations have been consistently unremarkable throughout her incarceration and previous hospitalizations. Based on the patient's longitudinal history, which of the following is the most appropriate DSM-5 diagnosis?

Match each patient's comprehensive clinical vignette to the most accurate psychiatric diagnosis.

Match each clinical presentation with the most appropriate psychiatric diagnosis.

A 54-year-old man with a severe alcohol use disorder is brought to the emergency department by emergency medical services due to confusion and unsteadiness. He was found wandering in the street. His last alcoholic drink was approximately 24 hours ago. On presentation, he is diaphoretic, tachycardic (heart rate 118/min), and visibly tremulous. Neurologic examination reveals bilateral horizontal nystagmus, a wide-based ataxic gait, and profound global confusion. Point-of-care blood glucose testing shows 58 mg/dL (3.2 mmol/L). The patient is admitted to the hospital.

Arrange the following management steps in the most appropriate chronological sequence for this patient, from immediate acute stabilization to pre-discharge planning.

A 21-year-old female university student presents to the student health center accompanied by a residence hall advisor. The patient is visibly distraught, weeping uncontrollably, and stating that her life is 'completely empty' after a three-week romantic relationship ended abruptly the previous night. Physical examination reveals several superficial, linear scratches on her left volar forearm. She admits to making these marks with a safety pin, stating, 'I just needed to feel something.' The advisor mentions that the patient has a history of intense, unstable friendships, often idolizing peers before suddenly turning against them. The patient's medical history includes a diagnosis of 'atypical depression,' for which she currently takes phenelzine. During the interview, she mentions that last night she briefly suspected the campus security was tracking her phone, but she now realizes this was an irrational thought. She denies any current suicidal ideation or plan. Which of the following are appropriate next steps in the ongoing management of this patient? (Select all that apply.)

A $19$-year-old man is brought to the emergency department by his friends due to severe agitation, confusion, and muscle twitching. The friends report they were at an electronic music festival where the patient consumed an unknown pill approximately $4$ hours ago. His medical history is significant for major depressive disorder, for which he has been taking sertraline for the past $6$ months.

Temperature is $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$), blood pressure is $168/102 \text{ mm Hg}$, pulse is $132/\text{min}$, and respirations are $24/\text{min}$.

On examination, the patient is disoriented, markedly diaphoretic, and has mydriasis. Neurologic examination reveals shivering, hyperreflexia in the lower extremities, and sustained bilateral ankle clonus.

Laboratory studies reveal:

Urine toxicology screen is positive for amphetamines.

Which of the following is the most likely underlying mechanism for this patient's acute presentation?

A $19$-year-old male collegiate wrestler is brought to the student health center due to profound fatigue, dizziness, and muscle cramps over the past two weeks. He has been intensely focused on "making weight" for the upcoming wrestling season. His BMI is $21.5 \text{ kg/m}^2$. Vital signs show temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), pulse $112$/min, respirations $12$/min, and blood pressure $96/60 \text{ mm Hg}$. Physical examination reveals dry mucous membranes, bilateral parotid gland swelling, and calluses on the dorsum of his right hand. The lungs are clear to auscultation, and the heart has a regular rhythm with no murmurs.

Laboratory studies show:
Sodium: $138 \text{ mEq/L}$
Potassium: $2.6 \text{ mEq/L}$
Chloride: $86 \text{ mEq/L}$
Bicarbonate: $36 \text{ mEq/L}$
Thyroid-stimulating hormone (TSH): $1.2 \text{ }\mu\text{U/mL}$ (normal $0.4$-$4.0$)
Free T4: $0.7 \text{ ng/dL}$ (normal $0.9$-$2.4$)

An arterial blood gas on room air shows pH $7.52$ and PaCO2 $48 \text{ mm Hg}$. An ECG reveals sinus tachycardia with flattened T waves and prominent U waves.

Which of the following is the most accurate statement regarding this patient's condition?

An outpatient psychiatric consultation is requested for a 42-year-old female patient experiencing debilitating, multi-domain worry. Over the last 7 months, she has been unable to control her persistent apprehension regarding her career stability, household finances, and the well-being of her children. These pervasive concerns are accompanied by chronic cervical muscle tension, poor concentration, and prominent fatigue. She denies any prior manic or hypomanic episodes.

Four weeks ago, the patient began taking phenelzine for refractory atypical depression. While her mood has significantly brightened, her anxiety symptoms have remained unchanged. At age 20, she experienced a discrete 14-day period characterized by intense auditory hallucinations and paranoid delusions, which resolved entirely without long-term sequelae.

Midway through the consultation, the clinic's front desk forwards a phone call from the patient's supervisor. The supervisor wishes to verify that the patient is receiving medical care so that her paid leave can be formally approved. The patient has not completed any release of information forms.

Recent laboratory investigations reveal:
Thyroid-stimulating hormone (TSH): 2.4 µU/mL (normal: 0.5-5.0 µU/mL)
Free thyroxine (T4): 0.5 ng/dL (normal: 0.9-1.7 ng/dL)

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

An emergency medical team brings a 35-year-old woman to the hospital due to the acute onset of confusion, severe agitation, and muscle twitching. The patient's husband reports that she has a long-standing history of treatment-resistant depression that has been managed with phenelzine for the past year. Four days ago, she consulted a different clinician for persistent low mood and was started on an additional psychiatric medication. Her vital signs show a temperature of 39.4°C (102.9°F), pulse of 124/min, respirations of 20/min, and blood pressure of 165/95 mm Hg. Physical examination reveals profuse diaphoresis, dilated pupils, a bilateral resting tremor, and pronounced hyperreflexia with spontaneous clonus in the lower extremities. The addition of which of the following medications most likely precipitated this patient's current condition?

During a routine home-visit evaluation, a geriatric psychiatrist examines a 73-year-old man whose daughter reports a 9-month history of progressive cognitive decline and unusual behaviors. The daughter emphasizes that his mental clarity fluctuates dramatically; he can be highly alert in the morning but profoundly lethargic and disorganized by the afternoon. Over the past 3 months, he has started seeing "strangers sitting on the living room couch," which causes him significant distress and agitation. For the past 4 years, he has exhibited violent thrashing and shouting movements during sleep. His medical history is significant for major depressive disorder, for which he has taken fluoxetine continuously for the last 5 years. Vital signs are within normal limits. Neurologic examination demonstrates bilateral cogwheel rigidity and a mild resting tremor in the left upper extremity. His Montreal Cognitive Assessment score is 20/30, featuring prominent deficits in visuospatial construction. The physician discusses management options with the daughter to address the patient's distressing visual hallucinations. Which of the following is the most appropriate next step in the pharmacologic management of this patient's condition?

Match each clinical vignette with the most appropriate psychiatric diagnosis from the somatic symptom and related disorders spectrum.

An accompanying friend brings a $23$-year-old female ballet dancer to the emergency department after the patient experienced an episode of syncope during a rehearsal. The friend notes that the patient has been increasingly obsessed with her weight, often skipping meals and expressing intense fear of becoming overweight despite appearing remarkably thin. Her current body mass index is $17.1 \text{ kg/m}^2$.

On physical examination, blood pressure is $86/52 \text{ mmHg}$ and heart rate is $114/\text{min}$. Tapping over the facial nerve elicits a twitch of the nose and lips.

Initial laboratory studies reveal:

Arterial blood gas (room air):

Random urine studies:

Which of the following is the most likely etiology of this patient's laboratory abnormalities?

Emergency medical responders transport a 48-year-old male to the trauma bay after he was found obtunded in his apartment. According to his live-in girlfriend, the patient has a history of treatment-resistant depression managed with phenelzine. She notes that over the past two days, he consumed multiple bottles of over-the-counter dextromethorphan for an upper respiratory infection. Vital signs upon arrival include a temperature of $39.9^\circ\text{C}$ ($103.8^\circ\text{F}$), heart rate of $132/\text{min}$, blood pressure of $170/105\text{ mm Hg}$, and respiratory rate of $24/\text{min}$. Physical examination is remarkable for profuse diaphoresis, hyperactive bowel sounds, and pronounced hyperreflexia with bilateral ankle clonus. The patient is stuporous and unable to communicate. A review of the electronic medical record reveals a legally executed advance directive designating the patient's sister as his sole healthcare proxy. Reached by telephone, the sister unequivocally requests that all life-sustaining and necessary medical treatments be provided. However, the girlfriend, who is present at the bedside, demands that no interventions be initiated, claiming the patient recently expressed a desire to 'die naturally without medical interference.' Which of the following is the most appropriate next step in the management of this patient?

A 24-year-old woman comes to the primary care clinic reporting feeling "constantly on edge" for the past 3 months. She states she has been worrying excessively about her academic performance, her finances, and her parents' health. The patient reports experiencing restlessness, muscle tension in her neck and shoulders, and difficulty concentrating on her studies. These symptoms began 3 months ago when she moved to a new city to start a rigorous graduate program. She acknowledges that the transition has been very stressful, and her academic performance has declined because she is so distracted by her worries. She denies any history of trauma, panic attacks, or periods of elevated mood. Her physical examination and laboratory studies, including thyroid-stimulating hormone, are within normal limits. Which of the following is the most likely diagnosis?

A 32-year-old woman presents to the outpatient clinic with a 2-month history of severely depressed mood. She reports sleeping up to 14 hours a day, an increased appetite with a 5-kg (11-lb) weight gain, and a frequent sensation that her arms and legs are "made of lead." She states that she briefly feels better when her friends visit, but her low mood quickly returns. She has no prior psychiatric history and has never been treated for depression. She tearfully requests an antidepressant medication so she can return to her job as an accountant. Her vital signs and physical examination are unremarkable. Laboratory studies reveal a thyroid-stimulating hormone (TSH) level of 1.5 mU/L (normal: 0.4-4.0 mU/L) and a free T4 at the lower limit of normal. A urine toxicology screen is negative. The physician diagnoses a major depressive episode with atypical features and considers initiating pharmacotherapy. Which of the following is the most appropriate next step in management?

A 38-year-old man, a self-employed clock repairman, presents to a primary care clinic for a physical examination required to renew his commercial driver's license. He has not interacted with the healthcare system in over a decade. During the interview, the patient is guarded and reluctant to answer questions regarding his medical history. When asked about his living situation, he becomes irritable, demanding to know why the physician is "prying into my personal life" and questioning whether the clinic intends to share his information with government agencies to revoke his license. The patient's brother, who is in the waiting room, privately informs the nurse that the patient has always been "highly suspicious" of others since his early twenties. The brother notes that the patient frequently accuses his clients of trying to defraud him and has completely cut off contact with several family members because he suspects they are secretly plotting to ruin his business. The patient has never experienced hallucinations, his speech is goal-directed and organized, and he does not hold magical or bizarre beliefs. Which of the following is the most likely diagnosis?

A primary care physician is evaluating a 71-year-old retired mechanic who is accompanied by his son. The son reports that over the past 14 months, his father has exhibited progressive short-term memory loss, missed several bill payments, and recently struggled to recall the names of his grandchildren. The patient feels he is "doing just fine" and is mildly annoyed by the visit. Vital signs are normal, and the neurological examination is nonfocal. Arrange the following diagnostic and management steps in the most appropriate chronological sequence for evaluating and managing this patient's suspected major neurocognitive disorder, from initial clinical assessment to definitive management.

A 24-year-old woman is evaluated in the outpatient psychiatry clinic. She reports a 4-week history of severe sadness, loss of interest in her usual activities, hypersomnia, and low energy. She is diagnosed with major depressive disorder and prescribed escitalopram. The physician counsels her extensively on what to expect during the course of her treatment. Arrange the following clinical events in the typical chronological order of their occurrence after initiating this pharmacotherapy, from earliest to latest.

A $26\text{-year-old}$ female graduate student presents to the outpatient psychiatry clinic accompanied by her roommate due to worsening isolation and depression. For the past $3 \text{ weeks}$, the patient has stayed in her room, slept up to $14 \text{ hours}$ a day, and consumed large amounts of junk food, leading to a $4 \text{ kg}$ ($8.8 \text{ lb}$) weight gain. She tells the physician, "I am a failure and I hear a voice whispering that I should just give up." Her roommate mentions that the patient has been taking an over-the-counter herbal supplement, St. John's wort, for the past $2 \text{ months}$ to "help with her mood," but it has not provided any relief.

Review of her psychiatric history reveals that $2 \text{ years}$ ago, she had a distinct $6\text{-day}$ period where she felt "incredibly energized," slept only $3 \text{ hours}$ per night, and simultaneously wrote three term papers while serving as the president of a student club. She did not require hospitalization during that time, and her overall functioning was arguably enhanced.

Her vital signs and physical examination are normal. Laboratory studies, including a TSH of $4.5 \text{ \mu U/mL}$ (normal: $0.5 - 5.0 \text{ \mu U/mL}$) and a free T4 of $0.9 \text{ ng/dL}$ (normal: $0.8 - 1.8 \text{ ng/dL}$), are unremarkable.

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

A 16-year-old girl is hospitalized for severe malnutrition secondary to anorexia nervosa, restricting subtype. Her body mass index (BMI) is $13.2 \text{ kg/m}^2$. The medical team plans to initiate careful nutritional rehabilitation but is acutely concerned about a potentially fatal metabolic complication characterized by severe electrolyte derangements. Arrange the following pathophysiological steps of this syndrome in the correct chronological sequence, starting from the initial dietary trigger to the ultimate clinical manifestations.