Psychiatry

An occupational health physician is evaluating a 49-year-old male warehouse manager due to unintended sleep episodes at work over the past 7 months. The patient states, 'No matter how early I go to bed, I wake up with a morning headache and feel exhausted.' His bed partner recently moved to a separate bedroom due to his disruptive, loud snoring and intermittent gasping sounds during the night. Medical history is notable for essential hypertension and bipolar II disorder, which has been stable on lamotrigine for five years. Current medications include lisinopril and lamotrigine. His body mass index is $36 \text{ kg/m}^2$. Vital signs are within normal limits. Physical examination reveals a crowded oropharynx and 1+ bilateral pitting edema in the lower extremities. Laboratory studies reveal a normal thyroid-stimulating hormone level of $1.9 \text{ \mu U/mL}$ and a normal free T4 level. The patient expresses concern because a previous physician mentioned a 'borderline low thyroid hormone' level years ago. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old woman is brought to the emergency department by her sister due to severe agitation and paranoia. The sister reports that the patient has been awake for three days, pacing her apartment, and claiming that government agents are watching her through the smoke detectors. The patient has a past psychiatric history of bipolar I disorder. The sister suspects the patient recently began using "meth" (methamphetamine). The patient's medical record indicates that her father is her legally appointed healthcare proxy. Vital signs are temperature 38.2°C (100.8°F), blood pressure 165/100 mm Hg, pulse 122/min, and respirations 22/min. Physical examination shows diaphoresis, mydriasis, and extensive excoriations on her face and arms. She is highly combative, actively attempting to strike the nursing staff, and screaming, "I won't let you poison me!" Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old man with a 10-year history of treatment-resistant schizophrenia is evaluated on the inpatient psychiatric unit. Over the past several years, he has continued to experience severe, commanding auditory hallucinations despite adequate therapeutic trials of risperidone, olanzapine, and haloperidol. Four weeks ago, he was transitioned to clozapine, which was gradually titrated to 600 mg daily. The nursing staff notes that his psychotic symptoms have dramatically improved, and he is interacting appropriately with peers for the first time in years. However, earlier today, the patient experienced a new-onset generalized tonic-clonic seizure that lasted 90 seconds and spontaneously resolved. He has no prior history of seizures, and a non-contrast head CT is unremarkable. His current absolute neutrophil count is 4,500/mm³. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 26-year-old man with a recent diagnosis of schizophrenia is initiated on oral haloperidol therapy to manage severe psychotic symptoms. Arrange the following potential medication-induced movement disorders in the standard chronological order of their expected onset, from the earliest to appear to the latest.

A 32-year-old woman with a history of severe, treatment-resistant major depressive disorder is evaluated in the psychiatry clinic. She has experienced minimal clinical improvement on an optimized dose of fluoxetine over the past 12 weeks. The psychiatrist decides to discontinue fluoxetine and initiate phenelzine. To prevent life-threatening complications such as serotonin syndrome and hypertensive crisis, strict guidelines must be followed during this transition and in the event of future medication changes. Arrange the following clinical management steps in the correct chronological sequence required to safely execute this treatment plan.

A 26-year-old woman is evaluated in the sleep clinic for a 1-year history of irresistible daytime sleep attacks. She reports frequently falling asleep during meetings and while driving. Additionally, she experiences vivid, frightening hallucinations just as she is falling asleep, and transient periods of bilateral leg weakness triggered by sudden laughter. She takes no medications and her physical examination is unremarkable. Arrange the following steps in the most appropriate chronological sequence for the diagnostic evaluation and step-wise pharmacological management of this patient.

A mother schedules a pediatric consultation for her four-and-a-half-year-old son because she feels overwhelmed by his constant need to move. The mother describes the child as being 'driven by a motor,' noting that he routinely climbs on top of the refrigerator, sprints down the hallways, and constantly interrupts her conversations. She is convinced he has a medical condition and wants a prescription to calm him. Developmentally, the child can hop on one foot, copy a cross on paper, and speak in completely intelligible sentences. A behavior rating scale completed by his preschool teacher reveals that the child participates cooperatively in group games, sits attentively during fifteen-minute story sessions, and shares toys with peers appropriately. His physical examination, including vision and hearing screens, reveals no abnormalities. Which of the following is the most appropriate management for this patient?

A 31-year-old man is brought to the emergency department by his roommate due to increasingly erratic behavior over the past week. The patient is pacing rapidly, speaking tangentially, and claims he has discovered a mathematical formula that will solve world hunger. He states he has not slept in four days. He also reports hearing the voice of a historical figure giving him constant instructions. Review of his medical record reveals a psychiatric history beginning at age 24. Since that time, he has experienced multiple prolonged episodes of both severe depression and mania, which collectively account for more than half of the total duration of his illness. The records also clearly document a notable 4-month period last year when his mood was entirely stable and euthymic, yet he continued to experience persistent auditory hallucinations and the delusion that foreign agents were monitoring his thoughts. Urine toxicology screen is negative. Which of the following is the most accurate diagnosis?

A 42-year-old man presents to the psychiatric clinic for the management of a newly diagnosed major depressive disorder (MDD). Over the next 18 months, his clinical course is characterized by significant treatment resistance, eventually leading to a severe exacerbation with psychotic features and food refusal. Arrange the following therapeutic interventions in the correct chronological order according to standard stepped-care pharmacologic and somatic treatment guidelines for MDD, starting from his initial presentation to his most severe exacerbation.

A 35-year-old woman is being managed for cocaine use disorder over a period of three years. Her readiness to modify her substance use behavior fluctuates over time. According to the Transtheoretical Model of Change, arrange the following patient statements in the expected chronological progression from the earliest stage of behavior change to the latest.

A 29-year-old man is brought to the emergency department by his partner due to a rapidly spreading rash and fever. Over the past 48 hours, he developed flu-like symptoms followed by painful, erythematous macules on his chest and back. Physical examination reveals a temperature of 39.2°C (102.6°F). The macules have coalesced into large areas of blistering, and the epidermis sloughs off with gentle lateral pressure. Ulcerations are visible on his buccal mucosa and vermilion border. The patient has a 4-year history of bipolar I disorder and has been maintained on divalproex sodium. Three weeks ago, he sought treatment for a severe depressive episode, and his psychiatrist added a second medication to his regimen. The new medication was prescribed at a starting dose of 25 mg daily. Which of the following pharmacokinetic or pharmacodynamic mechanisms best explains the pathogenesis of this patient's current dermatologic emergency?

A 36-year-old woman presents to the primary care clinic reporting a 5-week history of profound sadness, early morning awakening, decreased appetite, and difficulty concentrating at work. She states she has never felt this way before and denies any current suicidal ideation, hallucinations, or delusions. Her medical history is unremarkable, and she takes no medications. The physician determines she is experiencing a major depressive episode and considers initiating fluoxetine therapy. Which of the following is the most appropriate next step in the clinical care of this patient?

A 20-year-old college sophomore presents to the student health clinic reporting intense fear and physical distress regarding an upcoming mandatory oral presentation scheduled in four days. He describes experiencing severe palpitations, visible hand tremors, and a "knot in his stomach" whenever he thinks about standing in front of his classmates. He states, "I know my fear is irrational, but I am terrified they will see me shaking and think I am incompetent." He has no anxiety in social gatherings, on dates, or in other academic settings. His medical history is significant for moderate persistent asthma, which is well-controlled with a daily fluticasone-salmeterol inhaler and albuterol as needed. He does not use illicit substances or alcohol. Vital signs are within normal limits. Which of the following is the most appropriate pharmacological intervention to manage his symptoms for the upcoming presentation?

A kindergarten teacher raises concerns about a 5-year-old boy who recently transferred to her classroom. The child rarely initiates play with peers, often avoids eye contact when addressed, and frequently flaps his hands when excited. The school psychologist and pediatrician collaborate to evaluate him for Autism Spectrum Disorder (ASD). When distinguishing ASD from an isolated speech delay or global developmental delay, which of the following findings would specifically fulfill the core diagnostic criteria for ASD? (Select all that apply)

For the following individuals presenting with psychiatric symptoms, select the most accurate diagnosis by pairing the clinical history with the corresponding condition.

A 52-year-old man is brought to the emergency department by his husband due to severe confusion, agitation, and visual hallucinations. The husband reports that the patient has a history of bipolar disorder and has been hospitalized twice in the past for manic episodes. The patient recently experienced a severe depressive episode and was started on fluoxetine three weeks ago by a new provider. The patient also has a severe alcohol use disorder but abruptly stopped drinking 72 hours ago. On physical examination, the patient is profoundly diaphoretic, tremulous, and continuously picks at his skin, claiming there are "spiders everywhere." His temperature is 38.8°C (101.8°F), blood pressure is 158/96 mm Hg, pulse is 118/min, and respirations are 20/min. Physical examination reveals no nuchal rigidity, clear lungs to auscultation bilaterally, and a benign abdomen. Which of the following is the most appropriate next step in management?

A primary care physician evaluates a 29-year-old female patient complaining of unrelenting anxiety regarding her job security, personal finances, and general health that has persisted for the past 9 months. She describes experiencing frequent muscle tension, daytime fatigue, and poor concentration. During the psychiatric history, she mentions that 4 years ago she had a distinct 14-day period where she "felt invincible," required only 90 minutes of sleep per night, and maxed out her credit cards on impulsive purchases. She states her mood is currently euthymic. Her past medical history is notable for a methicillin-resistant Staphylococcus aureus (MRSA) skin infection, for which she was prescribed linezolid 3 days ago. Which of the following are appropriate considerations regarding this patient's diagnosis and management? (Select exactly 2 options)

A 67-year-old man is evaluated by the consultation-liaison psychiatry team on the medical floor. He was admitted one week ago for a non-ST-elevation myocardial infarction and subsequently developed a complicated soft-tissue infection at the catheter insertion site, for which he is currently receiving intravenous linezolid. The nursing staff reports that the patient has been increasingly withdrawn, tearful, and refusing to participate in physical therapy. During the interview, the patient is fully oriented and demonstrates intact decision-making capacity. He reports a two-month history of a profoundly depressed mood, pervasive anhedonia, early morning awakenings, a 5-kg (11-lb) weight loss, and hearing a voice repeatedly telling him he is a "total failure." He states, "I just have no energy left to fight, but I definitely do not want any sort of shock treatments." His wife, who is present, privately tells the physician, "He doesn't know what he's saying. I give you full permission to do electroconvulsive therapy if it will fix this." Review of his past medical history reveals an episode at age 26 when he was hospitalized for a week after staying awake for five consecutive days and recklessly spending his life savings on an impulsive business venture. Which of the following is the most appropriate next step in the psychiatric management of this patient?

An outpatient psychiatrist is reviewing the longitudinal chart of a 34-year-old female patient who recently relocated to the area. Her psychiatric symptoms began 5 years ago. During this time, she has experienced recurrent, distinct episodes characterized by pervasive sadness, insomnia, poor appetite, and suicidal ideation. According to her medical records, these mood episodes cumulatively account for approximately 4 years of her clinical history. She has never had an episode of elevated mood, impulsivity, or a decreased need for sleep. The charts clearly document that on two separate occasions—each lasting approximately 4 to 6 weeks—her mood symptoms completely resolved following medication adjustments. However, during both of these specific periods of euthymia, she continued to experience prominent auditory hallucinations and the steadfast delusion that the government was monitoring her thoughts. Based on the patient's longitudinal history, which of the following is the most accurate diagnosis?

Correlate each distinct clinical presentation observed in the acute care setting with the most accurate corresponding substance-related syndrome.