Psychiatry

A $34$-year-old man comes to the clinic requesting assistance with smoking cessation. He has smoked one and a half packs of cigarettes daily for the past $15$ years. His past medical history is significant for bipolar I disorder. His last manic episode occurred $4$ years ago, and he is currently stable on valproate monotherapy without any recent depressive or manic symptoms. The patient states, 'I tried using nicotine patches and nicotine gum together last year, but the cravings were too strong and I went back to smoking within a week.' He is highly motivated to quit and asks for an oral prescription medication to help reduce his cravings. Physical examination and vital signs are within normal limits. Which of the following is the most appropriate pharmacotherapy for this patient?

A 27-year-old woman is brought to the psychiatric clinic by her husband due to bizarre behavior. She gave birth to her first child 9 weeks ago via an uncomplicated vaginal delivery. Her husband reports that exactly 2 weeks after the delivery, the patient began claiming that the television was transmitting coded messages from a secret government agency regarding her infant's "chosen destiny." Shortly thereafter, she started hearing two unfamiliar men's voices debating whether she is a suitable mother. These symptoms have been present consistently every day since they started. The patient has no prior psychiatric history and takes no medications. Her husband has taken over all infant care, as the patient is frequently preoccupied with the voices and appears emotionally detached. During the interview, the patient's affect is blunted and she avoids eye contact. She denies feeling sad, hopeless, or overly energetic. Her husband confirms her sleep and appetite have remained normal throughout this period. Medical workup, including a comprehensive metabolic panel and thyroid-stimulating hormone, is unremarkable. Urine toxicology screen is negative. Which of the following is the most likely diagnosis?

Match each clinical vignette involving a legal or ethical dilemma in a psychiatric setting with the most appropriate next step in management or mandated action.

Match each patient's clinical presentation with the most likely corresponding substance intoxication or withdrawal syndrome.

An unmedicated 28-year-old male graphic designer comes to the physician seeking help for debilitating 'panic spells'. He states that over the last four months, he has suffered six unexpected episodes of overwhelming fear, pounding heart, diaphoresis, and a feeling that he might die. These episodes reach maximum intensity within a few minutes. He has become increasingly fearful of experiencing another attack and now refuses to ride the city bus to his office.

Physical examination, electrocardiography, and laboratory studies (including thyroid function) show no abnormalities.

During the clinical interview, the patient discloses a history of severe depression in his early twenties. Furthermore, at age 24, he experienced a distinct three-week period characterized by a markedly decreased need for sleep, pressured speech, and grandiose delusions that he was a famous inventor, which resulted in a psychiatric hospitalization. He has not taken any prescribed medications for the past two years.

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

Match each clinical presentation to the most accurate sleep-wake disorder diagnosis.

Match each pharmacotherapy used in the treatment of substance-related and addictive disorders to its primary mechanism of action, key clinical consideration, or contraindication.

A psychiatry care team is reviewing the management plans for four distinct patients presenting with psychotic spectrum symptoms. Match each patient's specific clinical scenario to the most appropriate next step in pharmacological management.

A 37-year-old man comes to the psychiatrist complaining of feeling "completely empty" for the past 2 months. He reports that he has lost interest in his architectural work, which he usually loves, and struggles to get out of bed before noon. His appetite has decreased, leading to an 8-lb (3.6-kg) weight loss. He expresses intense guilt over a minor calculation mistake he made on a project a year ago. A review of his past medical records reveals an emergency department visit 3 years ago for acute agitation. During that visit, he was speaking so quickly he was difficult to understand, claimed he had discovered the secret to limitless energy, and had not slept in 5 days. He was stabilized on a medication that he subsequently stopped taking because he felt it blunted his creativity. His vital signs and physical examination today are unremarkable. Which of the following is the most appropriate next step in the pharmacologic management of this patient's current symptoms?

Campus security brings a 19-year-old male university student to the emergency department after he was found destroying furniture in his dormitory. The student's friends report that he went to an off-campus warehouse party three days ago and has been awake ever since. He has been barricaded in his room, loudly claiming that hidden cameras are broadcasting his thoughts. Vital signs show a temperature of 38.6°C (101.5°F), blood pressure of 172/105 mmHg, and heart rate of 138/min. Physical examination reveals profound diaphoresis, mydriasis, and psychomotor agitation. There is no horizontal or vertical nystagmus, and muscle tone is normal. Routine urine drug immunoassay is negative for all tested substances. The patient requires multiple doses of chemical restraints over the next four days to manage ongoing severe combativeness and hallucinations. Which of the following is the most likely diagnosis?

During a routine wellness visit, the parents of a 9-year-old boy express deep concern regarding his increasingly difficult behavior. For the past 9 months, he has consistently refused to follow household rules and argues excessively with adults. The parents note that he deliberately annoys his younger sister and quickly blames her whenever he gets into trouble. A written report from his third-grade teacher describes identical defiant behavior during class, noting that he often loses his temper when asked to transition between activities. Despite these challenges, he has never engaged in physical fights, property destruction, or theft. His sleep patterns and appetite are normal, and he maintains friendships with a small group of neighborhood peers. His physical examination is unremarkable. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation of a psychotropic adverse effect with the medication most likely responsible.

A 35-year-old male construction worker is brought to the emergency department by his wife due to sudden-onset severe agitation, fever, and muscle stiffness. His medical history is significant for major depressive disorder, for which he has been taking sertraline for the past 2 years. Two days ago, the patient underwent a complex root canal procedure and was prescribed a short course of a centrally acting analgesic. On physical examination, his temperature is 39.4°C (102.9°F), blood pressure is 165/100 mmHg, and heart rate is 118/min. He is diaphoretic, flushed, and noticeably disoriented. Neurologic examination reveals bilateral ankle clonus, marked shivering, and generalized hyperreflexia that is most prominent in the lower extremities. Which of the following describes the mechanism of action of the analgesic that most likely precipitated this patient's current condition?

A 26-year-old woman presents to the psychiatric clinic accompanied by her husband. She gave birth to her first child 3 months ago. Over the past month, she has been experiencing recurrent, terrifying mental images of deliberately dropping her infant down the staircase. She finds these images deeply disturbing and recognizes them as products of her own mind. She has no desire to harm her child. To cope, she absolutely refuses to carry the infant near any stairs and repeatedly asks her husband to confirm she is a capable mother, occupying several hours of their day. Her psychiatric history is significant for bipolar II disorder, currently well-controlled on lithium. At age 21, following a severe stressor, she experienced auditory hallucinations that lasted for 2 weeks and resolved completely without long-term medication. Currently, in addition to lithium, she takes over-the-counter St. John's wort for mild fatigue. Which of the following is the most appropriate next step in management?

Match each patient's clinical scenario and specific medication requirement with the most appropriate second-generation antipsychotic.

Pair the following acute clinical presentations with their most likely underlying substance-related diagnosis.

Select the most appropriate initial pharmacological or procedural intervention for each of the following patients presenting with distinct clinical features of major depressive disorder.

Match each patient's clinical presentation of an adverse drug reaction to the psychotropic medication most likely responsible for their symptoms.

A 22-year-old woman is brought to the emergency department by her roommate due to increasingly bizarre behavior. The roommate reports that for the past 3 weeks, the patient has been locking herself in her room, claiming that foreign intelligence agents are transmitting messages into her brain through the electrical outlets. She has also been observed whispering to unseen entities and has stopped attending her college classes. The patient was previously healthy and highly functional until she experienced a sudden, traumatic breakup with her fiancé one month ago. She has no prior psychiatric or medical history. Vital signs are within normal limits, and a comprehensive physical examination is unremarkable. Urine toxicology screening is negative for illicit substances. The patient is admitted to the psychiatric unit and started on oral risperidone. Four days later, her psychotic symptoms completely resolve, and she is discharged with a full return to her baseline level of functioning. Which of the following is the most likely diagnosis?

A 24-year-old woman comes to the outpatient psychiatric clinic due to a 4-week history of feeling severely depressed, lacking energy, and sleeping 12 to 14 hours a day. She reports a loss of interest in her usual hobbies and a 5-kg (11-lb) weight gain over this period. The patient has no significant past medical history. Upon further questioning, the patient's roommate states that 8 months ago, the patient had a 10-day episode where she was extremely energetic, required only 3 hours of sleep per night, and spoke so rapidly it was difficult to interrupt her. During that time, she spontaneously booked an expensive, non-refundable trip to Europe that she could not afford. She was not hospitalized and eventually returned to her baseline. Which of the following is the most appropriate pharmacotherapy for this patient's current condition?