Psychiatry

A 23-year-old man is evaluated in the psychiatric outpatient clinic for ongoing management of schizophrenia. His symptoms began seven months ago with persistent auditory hallucinations, persecutory delusions, and severe social withdrawal. He has no significant past medical history, and his initial physical examination, comprehensive metabolic panel, and urine toxicology were unremarkable. The psychiatric care team is establishing a comprehensive, long-term psychopharmacological management plan. Arrange the following clinical steps in the most appropriate standard sequence for the pharmacological management of this patient, assuming he consistently demonstrates an inadequate clinical response to each successive intervention despite appropriate time for titration.

Match each clinical presentation or constellation of chronic medical complications to the most likely primary substance use disorder.

A 24-year-old woman is newly diagnosed with schizophrenia after presenting with persistent auditory hallucinations and persecutory delusions. The treatment team outlines a comprehensive, stepwise pharmacological management plan for her condition, anticipating the possibility of treatment resistance at each stage. Arrange the following therapeutic steps in the standard sequential order they should be implemented, assuming the patient continues to have severe, unrelenting symptoms despite documented adherence to each prior intervention.

A 45-year-old woman with a history of severe alcohol use disorder is admitted to the inpatient psychiatric unit for medical detoxification. She reports that her last drink was 12 hours ago. On examination, she exhibits bilateral hand tremors, mild tachycardia, diaphoresis, and anxiety. Arrange the following clinical management steps in the most appropriate chronological sequence for this patient's comprehensive care, proceeding from initial acute stabilization to long-term relapse prevention.

A 28-year-old woman is brought to the emergency department by emergency medical services after she was found severely agitated and combative outside a nightclub. Her friends report that she consumed an unknown "party pill" a few hours ago. The patient has a history of major depressive disorder with past hypomanic episodes, for which she was recently prescribed sertraline by a new primary care physician. She also has a history of opioid use disorder and has been stable on methadone maintenance therapy for two years.

On presentation, she is hallucinating, claiming that "angels are commanding her to fly." Vital signs are temperature 39.4°C (102.9°F), blood pressure 178/108 mm Hg, pulse 142/min, and respirations 24/min. Physical examination reveals marked diaphoresis, mydriasis, and bilateral continuous ankle clonus with generalized hyperreflexia.

Laboratory studies show:
Thyroid-stimulating hormone (TSH): 0.1 µU/mL (normal: 0.4–4.0 µU/mL)
Free thyroxine (T4): 1.3 ng/dL (normal: 0.9–1.7 ng/dL)
Urine toxicology screen is positive for methadone but negative for amphetamines, cocaine, and phencyclidine (PCP).

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

During a routine visit to an outpatient clinic, a 29-year-old woman reports a 2-month history of persistent sadness, tearfulness, and profound fatigue. She states she has lost interest in reading and hiking, activities she previously enjoyed every weekend. The patient notes she has been waking up at 3 AM daily and is unable to fall back asleep. She has lost 4 kg (8.8 lb) over this period without actively dieting. She denies any substance use or suicidal ideation. She has no significant past medical history and currently takes no medications. Her physical examination is unremarkable. The patient requests to be started on a medication to help her mood, noting that a family member had significant improvement with fluoxetine. Which of the following is the most appropriate next step in the clinical evaluation of this patient?

A 58-year-old woman is evaluated in the psychiatric clinic for a severe depressive episode characterized by profound sadness, anhedonia, early morning awakening, and significant weight loss. Over the course of the following year, her major depressive disorder proves difficult to manage, requiring a progressive escalation of her treatment plan due to varying degrees of treatment resistance. Her course ultimately culminates in a severe decompensation requiring urgent intervention. Arrange the following therapeutic steps in the most appropriate chronological sequence according to standard evidence-based treatment algorithms for major depressive disorder, from her initial presentation to the management of her final life-threatening deterioration.

A 21-year-old man is brought to the outpatient psychiatric clinic by his mother. For the past 3 weeks, he has been spending up to 6 hours a day repeatedly checking locks, counting backwards from 100, and washing his hands. He states he must perform these actions because he is tormented by intrusive, unwanted thoughts that his family will die in a house fire if he does not. He recognizes that these thoughts are irrational but feels immense, paralyzing anxiety if he attempts to stop the behaviors. His psychiatric history is notable for a hospitalization at age 19 for a 2-week episode characterized by a decreased need for sleep, grandiosity, and pressured speech, which was preceded by a major depressive episode. He is currently unmedicated. At the end of the clinical assessment, the patient explicitly requests that his medical information remain private. His mother, however, demands to be informed of the diagnosis and treatment plan, stating she has a right to know because he lives in her home and is covered under her health insurance. Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old woman, gravida 2, para 1, at 28 weeks gestation is evaluated in the outpatient clinic for severe insomnia. Over the past month, she has been unable to fall asleep because of an uncomfortable, aching sensation deep within her calves. She states, "I feel an overwhelming urge to move my legs to make the feeling stop." These symptoms occur exclusively when she lies down to rest at night and improve significantly when she gets out of bed and paces around the house. Her medical history includes generalized anxiety disorder, which has been stable on sertraline for the past two years. Her prenatal course has been uncomplicated, and vital signs are normal. Neurological examination reveals normal muscle strength, tone, and deep tendon reflexes in the lower extremities. Which of the following is the most appropriate initial step in the evaluation or management of this patient's sleep complaint?

A 34-year-old female with schizoaffective disorder is admitted to the hospital for intravenous antibiotic therapy for a complicated cellulitis. Her psychiatric symptoms have been well controlled for the past three years on a stable dose of clozapine. She typically smokes one and a half packs of cigarettes daily but is currently in a strict smoke-free inpatient unit; a transdermal nicotine patch was prescribed on admission to prevent withdrawal. Her other home medications include a combined oral contraceptive pill and ibuprofen as needed. On hospital day 4, the patient becomes progressively lethargic and develops significant sialorrhea. Later that evening, she experiences a generalized tonic-clonic seizure. Her vital signs are temperature 37.1°C (98.8°F), blood pressure 110/70 mm Hg, pulse 92/min, and respirations 14/min. Laboratory studies show a normal basic metabolic panel, and her white blood cell count is 8,500/mm³. Which of the following is the most likely pharmacological explanation for this patient's acute neurological presentation?

Emergency medical personnel transport an unresponsive 27-year-old male to the resuscitation bay after bystanders discovered him collapsed in a public restroom. Upon initial assessment, the patient is deeply obtunded and making no spontaneous movements. Hemodynamic monitoring reveals a blood pressure of 105/60 mm Hg and a heart rate of 55/min. His respiratory rate is markedly depressed at 5/min with shallow, irregular excursions, and pulse oximetry indicates an oxygen saturation of 78% on room air. Physical examination is notable for symmetric, 1-mm miotic pupils and cyanosis of the lips. Paramedics note that an empty syringe and a bent spoon were recovered at the scene. Arrange the following clinical interventions in the most appropriate chronological sequence for managing this patient's acute presentation and subsequent transition to recovery.

A 35-year-old woman is brought to the psychiatric clinic by her husband due to behavioral changes over the past 3 months. Her husband reports that she recently took a sudden leave of absence from her job as a middle school teacher. During the interview, the patient states she had to stop teaching because the school's intercom system was intercepting her private thoughts and broadcasting them to the students. She also reports hearing two distinct male voices discussing her daily activities. These symptoms began precisely 3 months ago, shortly after she moved to a new neighborhood, and have been present continuously since. She has no history of depressive or manic episodes, and her medical history is unremarkable. A urine toxicology screen is negative. Which of the following is the most likely diagnosis?

A 21-year-old college junior is brought to the student health clinic by his roommate. The roommate reports that for the past 6 weeks, the patient has been behaving unusually, such as wrapping his laptop in aluminum foil and claiming that foreign intelligence agents are tracking his brainwaves. During the interview, the patient appears visibly guarded, avoids eye contact, and frequently pauses mid-sentence as if listening to an unseen presence. When contacted, the patient's parents state that he was an outgoing and high-achieving student until approximately 8 months ago. At that time, he abruptly quit the university track team, withdrew from social activities, and began speaking in a monotonous tone with minimal facial expressivity. The parents note his sleep and appetite have remained normal, and he has consistently denied feeling sad or hopeless. A comprehensive metabolic panel and a urine toxicology screen show no abnormalities. Which of the following is the most likely diagnosis?

Match each polysomnography (PSG) or Multiple Sleep Latency Test (MSLT) finding to the most appropriate sleep-wake disorder diagnosis.

Seeking relief from pervasive, uncontrollable worry, a 38-year-old female executive presents to a new psychiatrist. For the last eight months, she has been continuously anxious about her career stability, her children's academic performance, and her personal health. This worry has led to chronic muscle tension, fatigue, and disrupted sleep. Her past medical records reveal a psychiatric hospitalization in her twenties for a discrete episode characterized by euphoric mood, hypersexuality, and a complete lack of sleep for eight consecutive days. Three weeks ago, a different provider prescribed her phenelzine for her anxiety. She took the medication for two weeks but abruptly stopped it three days prior to this appointment due to intolerable orthostatic hypotension. The current physician establishes a diagnosis of generalized anxiety disorder. Which of the following are appropriate components of this patient's management plan? (Select 2 answers)

Match each of the following clinical presentations of childhood psychiatric and neurodevelopmental conditions with the cellular mechanism of action of its indicated first-line pharmacotherapy.

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

Match each clinical presentation involving anxiety, stress, or fear-based symptoms to the most appropriate DSM-5 diagnosis based on symptom duration and characteristics.

Match each clinical presentation or medication adverse effect with the corresponding dopaminergic pathway involved in its pathophysiology.

An emergency department physician evaluates a 29-year-old female patient after police found her wandering in traffic. The patient is highly agitated and states, "The angels are speaking to me, they say the end is coming!" Her sister arrives at the hospital and explains that the patient had been functioning perfectly normally until two weeks ago. At that time, the patient's house was destroyed in a severe fire, and she immediately began exhibiting disorganized speech and reporting auditory hallucinations. She has no prior history of mental illness, and she does not use alcohol or recreational drugs. Vital signs are within normal limits. A thorough medical workup reveals no metabolic, infectious, or neurologic abnormalities. Which of the following is the most likely diagnosis?