Psychiatry

A 45-year-old man comes to the clinic seeking help to stop drinking alcohol. He states, "I have been drinking half a liter of vodka daily for the past two years, but my wife says she will leave me if I don't quit." The patient's last drink was 5 days ago, and he successfully completed a supervised inpatient alcohol detoxification program yesterday. He feels "very depressed" about his marital problems and asks for a medication to help his mood as well as his alcohol cravings. His medical history is significant for bipolar I disorder, for which he has not taken any medications for several years, and severe osteoarthritis of the right knee. Current medications include a fentanyl transdermal patch for chronic pain. Vital signs are within normal limits. Physical examination reveals a palpable liver edge 3 cm below the right costal margin. Laboratory studies show an aspartate aminotransferase (AST) of 115 U/L, an alanine aminotransferase (ALT) of 52 U/L, and a serum creatinine of 0.8 mg/dL. Which of the following is the most appropriate pharmacotherapy to help maintain alcohol abstinence in this patient?

Match each patient's clinical presentation with the most appropriate, highly specific first-line behavioral or psychotherapeutic intervention.

During morning rounds on the medical-surgical unit, a physician is urgently called to evaluate a 54-year-old male. The patient was admitted 48 hours ago for acute gallstone pancreatitis and has been managed with intravenous fluids and fasting. He has a 20-year history of consuming a pint of vodka daily, with his last drink occurring on the morning of admission. His home medications include phenelzine for treatment-resistant depression.

The nurse reports the patient suddenly became combative and is trying to pull out his intravenous lines. On evaluation, the patient is profoundly diaphoretic, tremulous, and disoriented to place and time. He is staring intently at the corner of the room, shouting, "The spiders are crawling out of the walls to get me!" His temperature is 38.9°C (102.0°F), blood pressure is 170/105 mm Hg, and pulse is 132/min.

When the physician approaches, the patient yells, "You are all trying to poison me! I am leaving right now!" and attempts to stumble out of the room. A review of his medical record indicates he has an advance directive naming his sister as his healthcare proxy, though he is currently married to an estranged wife.

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

A 29-year-old woman, G1P0, at 28 weeks gestation is evaluated in the outpatient clinic due to worsening sadness and exhaustion. For the past six weeks, she has felt 'overwhelmed and hopeless,' crying daily. She reports profound despondency that is characteristically worse in the morning, complete loss of appetite, and terminal insomnia, waking up at 3:00 AM and unable to return to sleep. She recently developed an upper respiratory infection and frequently takes over-the-counter dextromethorphan for a persistent cough. Her physical examination is unremarkable. Laboratory studies show a hemoglobin level of $10.8$ g/dL and a mean corpuscular volume of $89$ $\mu$ m $^3$. She asks the physician to prescribe an antidepressant medication to help her cope. Which of the following is the most appropriate next step in management?

Paramedics transport a 41-year-old male accountant to the emergency department after his wife found him acutely confused and sweating profusely at home. The patient has a long-standing history of major depressive disorder that has been difficult to manage. Five days ago, his outpatient psychiatrist discontinued his fluoxetine and immediately initiated a prescription for phenelzine to target different neurotransmitter receptors. On examination, the patient is visibly shivering, highly agitated, and disoriented to time and place. Vital signs reveal a temperature of $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), blood pressure of $168/102\text{ mm Hg}$, and a heart rate of $124\text{/min}$. Neurological evaluation demonstrates dilated pupils, marked bilateral hyperreflexia in the lower extremities, and sustained ankle clonus. The medical team promptly discontinues all psychiatric medications and administers intravenous normal saline along with a dose of intravenous lorazepam. Thirty minutes later, the patient remains profoundly agitated, and his hyperthermia and clonus are completely unchanged. Which of the following is the most appropriate next step in management?

A 27-year-old woman is evaluated in the outpatient psychiatry clinic for a 4-week history of profound sadness, excessive sleepiness, increased appetite, and severe difficulty concentrating at work. She states she has missed several days of work because she "cannot muster the energy to get out of bed." Two years ago, she experienced a 10-day period during which she slept only 2 hours per night, spoke very rapidly, spent her entire savings on a risky business venture, and was highly irritable. This past episode resulted in a brief psychiatric hospitalization. She is not currently taking any medications.

Physical examination shows normal vital signs. Mental status examination reveals psychomotor retardation, a blunted affect, and a depressed mood. Her thought process is linear, and she denies any suicidal ideation, delusions, or hallucinations.

Laboratory studies show:
- TSH: 1.8 µU/mL (normal: 0.5-5.0 µU/mL)
- Free T4: 1.2 ng/dL (normal: 0.8-1.8 ng/dL)
- Urine toxicology screen: negative

The physician decides to initiate pharmacotherapy for this patient's current episode. Which of the following medications are appropriate first-line monotherapy options for this patient? (Select all that apply)

A 27-year-old female medical resident presents to the clinic due to overwhelming anxiety. She reports experiencing intense palpitations, sweating, and hand tremors whenever she has to orally present patient cases during morning rounds. She states, 'I am terrified that my attendings will think I am incompetent because I look so nervous.' This anxiety is strictly isolated to public speaking; she has no difficulty interacting with patients, attending social events, or talking to colleagues in casual settings. Her past medical history is notable for asthma, which is currently managed with an albuterol inhaler as needed. Her vital signs are within normal limits. Which of the following is the most appropriate next step in management for this patient's psychiatric symptoms?

A 32-year-old woman with a severe opioid use disorder (primarily intravenous heroin) presents to an outpatient addiction clinic. She is highly motivated to achieve long-term abstinence and requests to start extended-release intramuscular naltrexone therapy, as her occupation makes daily medication adherence difficult. She used heroin this morning. Arrange the following clinical steps in the most appropriate chronological order for safely initiating extended-release naltrexone therapy in this patient.

A 42-year-old high school teacher presents for evaluation of a 7-month history of difficulty initiating sleep and frequent, prolonged nocturnal awakenings. The patient reports spending over 9 hours in bed each night in a desperate attempt to feel rested, but estimates achieving only 4 to 5 hours of total sleep. The resulting severe daytime fatigue has begun to impair her teaching performance and daily functioning. She denies snoring, witnessed apneic events, or an urge to move her legs at rest. Physical examination, neurologic assessment, and routine laboratory studies are unremarkable.

Arrange the following clinical interventions in the most appropriate chronological sequence for the evidence-based, stepped-care management of this patient's condition, proceeding from initial assessment to subsequent escalations for refractory symptoms.

A 21-year-old man is brought to the psychiatrist by his parents for a follow-up appointment. Eight weeks ago, the patient was a passenger in a severe motor vehicle collision in which he sustained minor physical injuries. One week after the accident (seven weeks ago), he abruptly began hearing unfamiliar voices conversing about his actions and developed the belief that local traffic lights were sending him coded government messages. He exhibited grossly disorganized behavior, prompting hospitalization. He was started on oral risperidone, and his parents report that his hallucinations and delusions completely resolved three weeks ago. However, since his positive symptoms ceased, he has remained socially withdrawn, speaks only in rare monosyllables, and exhibits a strikingly flat affect. He has not returned to his college classes or his part-time job, and spends most of his day staring blankly out the window. His physical examination and vital signs are unremarkable. A urine toxicology screen is negative. Which of the following is the most accurate diagnosis for this patient at this time?

Match each clinical presentation to the most appropriate psychiatric or behavioral diagnosis on the somatic symptom spectrum.

A 47-year-old male accountant presents to an outpatient psychiatric clinic with a 3-month history of pervasive sadness, anhedonia, terminal insomnia, profound fatigue, impaired concentration, and a 12-lb (5.4 kg) weight loss. He is diagnosed with a severe episode of major depressive disorder without psychotic features. Over the next 14 months, his condition proves remarkably difficult to treat, eventually culminating in a hospitalization for depressive stupor and mood-congruent delusions.

Arrange the following therapeutic interventions in the most appropriate chronological sequence according to standard stepped-care escalation algorithms for major depressive disorder.

A high school student is transported to the acute care clinic by her family following a fainting spell. She reports eating less than 500 calories daily for several months. Her current body mass index is $13.8 \text{ kg/m}^2$. Triage vitals reveal marked hypotension ($80/50 \text{ mm Hg}$), profound sinus bradycardia ($36/\text{min}$), and hypothermia ($35.4^\circ\text{C}$). Examination shows marked cachexia, temporal wasting, and lanugo. Arrange the following steps in the most appropriate chronological sequence for the comprehensive management of this patient.

A $27$-year-old man is brought to the emergency department by his sister due to increasingly bizarre behavior over the past $6$ weeks. The sister reports that he has been barring the doors to their apartment, claiming that intelligence agencies have placed listening devices in the walls. He has also been talking to himself and appears to be responding to unseen stimuli. Over the past three days, he has not slept. He has no prior psychiatric history. His temperature is $37.7^\circ\text{C}$ ($99.9^\circ\text{F}$), pulse is $118/\text{min}$, and blood pressure is $152/94\text{ mm Hg}$. Physical examination reveals a thin, disheveled man. He is diaphoretic and has prominent dental caries along with multiple healing excoriations on his bilateral forearms and face. He is hypervigilant and frequently paces the room. Which of the following is the most likely diagnosis?

Pair the following clinical presentations with the most likely corresponding neurocognitive disorder.

A 28-year-old man with a known history of schizophrenia is brought to the emergency department by police due to severe agitation. He is pacing rapidly in the evaluation room, shouting at unseen stimuli, and intermittently clenching his fists. When nursing staff approach, he yells, 'Stay away from me, you are trying to poison me!' Arrange the following management steps in the most appropriate, evidence-based escalating sequence for addressing this patient's acute agitation, from the initial preferred approach to the intervention of last resort.

A 7-year-old girl is brought to the pediatric clinic by her parents at the recommendation of her second-grade teacher. Over the past four months, the teacher has noted that the patient frequently "zones out" during reading and math groups. During these episodes, she stares blankly at the wall for several minutes and fails to complete her assignments. Her desk is highly disorganized, and she frequently loses her school supplies. When the teacher loudly calls her name during one of these staring episodes, she startles, immediately apologizes, and asks for the instructions to be repeated. At home, she takes hours to complete brief homework assignments, frequently misplaces her jacket, and struggles to follow multi-step commands such as "brush your teeth, put on your pajamas, and pick out a book." There is no history of lip smacking, eyelid fluttering, or sudden loss of postural tone. Her physical and neurologic examinations are unremarkable. Which of the following clinical features is most specific for distinguishing this patient's most likely underlying disorder from childhood absence epilepsy?

Match each patient's clinical presentation of a psychotropic medication adverse effect to the primary pharmacodynamic or pathophysiologic mechanism responsible for the finding.

A metropolitan toxicology service is evaluating several patients with suspected substance use disorders. Correlate the following distinct clinical manifestations with their correct underlying etiology.

A 52-year-old woman comes to the primary care clinic for evaluation of sleep disturbance and leg discomfort over the past 3 months. She describes a deep, "crawling" sensation in her calves and thighs that begins almost exclusively when she lies down in bed or relaxes on the couch in the evening. The sensation is accompanied by an irresistible urge to move her legs, and she must pace the hallway for several minutes to find temporary relief. She has no symptoms during the day and sits calmly throughout the examination. Her medical history is significant for bipolar I disorder, hyperlipidemia, and uterine leiomyomas causing heavy menstrual bleeding. Current medications include lithium, lurasidone, and atorvastatin. Vital signs are normal. Neurological examination shows no resting tremor, rigidity, or focal deficits. Laboratory testing reveals a hemoglobin of $11.2 \text{ g/dL}$, mean corpuscular volume of $76 \text{ fL}$, and serum ferritin of $18 \text{ ng/mL}$ (Normal: $15-200 \text{ ng/mL}$). Which of the following is the most appropriate next step in the management of this patient's sleep-related symptoms?