Psychiatry

A 22-year-old man is diagnosed with schizophrenia after presenting with a seven-month history of auditory hallucinations, disorganized speech, and severe social withdrawal. His physician outlines a long-term pharmacologic treatment strategy, anticipating standard protocols including steps for potential treatment resistance. Arrange the following therapeutic interventions in the most appropriate sequential order, progressing from the initial treatment of a first episode to the management of severe, refractory disease.

An 8-year-old boy is brought to the outpatient pediatric clinic by his father due to unusual facial movements. The father reports that for the past 4 months, the child has been frequently blinking his eyes forcefully and scrunching his nose. These movements occur multiple times a day, worsen when he is anxious about reading aloud, and are absent during sleep. The child does not make any repetitive sounds or vocalizations. Collateral history from his second-grade teacher confirms the facial movements; the teacher notes that while his academic performance is excellent, the boy has become increasingly withdrawn because classmates have started pointing out his "funny faces." The patient's early developmental milestones were met at appropriate ages, and a recent physical examination shows no other neurological abnormalities. The father is highly anxious and asks if his son has Tourette syndrome. Which of the following is the most likely diagnosis?

Match each clinical presentation of a depressive disorder to the most appropriate next step in management or targeted therapy.

An individual with a well-documented history of bipolar I disorder is evaluated in the emergency department for altered mental status. According to family members, the patient has become progressively lethargic, confused, and unsteady on their feet over the past 48 hours. The patient has been taking divalproex sodium for several years with excellent mood control. Two weeks ago, a neurologist initiated topiramate for migraine prophylaxis. On examination, the patient is disoriented to time and place. When asked to hold their arms outstretched with wrists extended, a bilateral, non-rhythmic, flapping tremor is observed. Laboratory studies, including a complete blood count, aspartate aminotransferase, alanine aminotransferase, and total bilirubin, are all strictly within normal limits. Which of the following is the most likely cause of this patient's current presentation?

A 28-year-old man comes to the clinic seeking help for severe anxiety. Two months ago, he was the driver in a severe motor vehicle collision where his passenger sustained critical injuries. Since then, he has experienced recurrent, distressing nightmares about the event, actively avoids driving or riding in cars, and feels emotionally detached from his family. He is constantly hypervigilant and has difficulty concentrating. He has a past psychiatric history of bipolar I disorder, but he discontinued his prescribed valproate one year ago because he felt stable. He is currently employed as an accountant and asks the physician to provide a medical note for a leave of absence. However, he explicitly requests that the specific diagnosis and details of the trauma not be disclosed to his employer. During the interview, he mentions that he sometimes hears the screeching of tires when trying to fall asleep, but he recognizes this is just a memory and not a real sound. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical presentation to the most appropriate neurodevelopmental or behavioral psychiatric diagnosis.

A 20-year-old male college student is brought to the student health center by his parents due to concerning behavior. His parents report that he has become increasingly socially isolated over the past eight months. During this time, he quit the university soccer team, stopped communicating with his friends, and his academic performance dropped significantly. He spends most of his days in his room with the blinds drawn and displays a distinct lack of emotional expression. For the last six weeks, the patient has firmly believed that the university administration is using the campus wireless network to monitor his thoughts. His parents have also observed him talking animatedly to himself when alone in his room. Vital signs and physical examination are unremarkable. A urine toxicology screen is negative. Which of the following is the most likely diagnosis?

A $55$-year-old man comes to the primary care clinic seeking help to stop drinking alcohol. He reports consuming approximately a pint of vodka daily for the past six years. He says, "I was hospitalized two weeks ago with liver problems, and it really scared me into wanting to quit for good." He has not consumed alcohol for the past three days and currently reports no symptoms of withdrawal. Medical history is significant for major depressive disorder and chronic hepatitis C virus infection. Review of laboratory studies from his recent hospitalization shows an aspartate aminotransferase (AST) of $345 \text{ U/L}$, alanine aminotransferase (ALT) of $160 \text{ U/L}$, and total bilirubin of $4.5 \text{ mg/dL}$. His current medications include sertraline and a daily multivitamin. He requests a medication to help reduce his urge to drink. What is the most appropriate pharmacotherapy for this patient?

Match each clinical presentation of an anxiety, obsessive-compulsive, or trauma-related disorder to the most specific, evidence-based psychotherapeutic intervention indicated for its management.

A 24-year-old man with a history of schizophrenia is brought to the emergency department from a residential psychiatric facility due to profound muscle stiffness, confusion, and diaphoresis. His vital signs show a temperature of 39.8°C (103.6°F), blood pressure of 165/100 mmHg, and heart rate of 122/min. Physical examination reveals generalized "lead-pipe" rigidity and coarse tremors. He was recently transitioned to intramuscular fluphenazine decanoate. Laboratory studies reveal a serum creatine kinase level of 5,200 U/L. Arrange the following steps in the most appropriate chronological sequence for the management of this patient's current condition and his subsequent long-term psychiatric care.

A 5-year-old boy is brought to the pediatric clinic by his parents due to distressing nighttime episodes that have occurred once or twice a week for the past 3 months. Typically, about 90 to 120 minutes after falling asleep, the child abruptly sits up in bed, screams loudly, and breathes heavily. His parents state that he appears terrified, is dripping with sweat, and thrashes his arms defensively. When they attempt to comfort him, he stares blankly, does not recognize them, and violently resists their attempts to console him. The episodes last 5 to 10 minutes, after which he lies down and peacefully sleeps through the rest of the night. In the morning, he has no memory of the events and acts completely normal. His past medical history is unremarkable, and he is meeting all developmental milestones. The parents are exhausted and extremely worried about a potential underlying psychological or neurological problem. Which of the following is the most appropriate next step in management?

A 26-year-old man comes to the clinic seeking treatment for opioid use disorder. He has been injecting heroin daily for the past three years. The patient states, "I am tired of living like this and want to start the medication that stops cravings." He reports his last heroin use was two hours ago. Currently, he appears comfortable and cooperative. Vital signs are temperature 37.0°C (98.6°F), blood pressure 118/76 mm Hg, pulse 72/min, and respiratory rate 14/min. Physical examination reveals pinpoint pupils and track marks on bilateral antecubital fossae. The physician discusses initiating buprenorphine-naloxone therapy. Arrange the following steps for initiating this therapy in the correct chronological order from first to last.

Match each clinical presentation of a patient receiving antipsychotic therapy with the most appropriate next step in management.

A 10-year-old girl is brought to the outpatient pediatric clinic by her parents due to persistent academic difficulties. She is currently in the fourth grade. Her teacher reports that she frequently loses her assignments, makes careless mistakes on tests, and seems to "space out" during reading and math lessons. These behaviors have been consistently noted since she was in the first grade. At home, her parents observe that she struggles to follow multi-step instructions and often leaves her chores half-finished. However, she can spend several hours intensely focused on painting and drawing without any distraction. Her recent hearing and vision screenings were normal. She has no history of behavioral outbursts or defiance. Which of the following statements regarding this patient's likely diagnosis and management are accurate? (Select all that apply)

A 28-year-old woman is brought to the psychiatry clinic by her husband. He reports that for the past month, she has been experiencing exceptionally low mood, sleeping up to 14 hours a day, eating very little, and expressing pervasive, inappropriate guilt. The husband notes that her psychiatric struggles began three years ago. Over the past three years, she has spent approximately thirty months experiencing either severe depression or acute mania. However, he specifically recalls a distinct four-week period last summer where her mood, energy, and sleep were completely normal, yet she firmly believed the television was broadcasting secret messages directed at her and frequently heard voices conversing about her actions. She takes no medications, and her urine toxicology screen is negative. Which of the following is the most likely diagnosis?

A number of patients present with unique adverse effects after initiating pharmacological treatment for major depressive disorder. For each clinical presentation, select the most likely responsible antidepressant.

A 7-year-old girl is evaluated in the pediatric clinic due to academic difficulties. She is currently in the second grade. Her teacher reports that she has significant trouble reading aloud, frequently mispronounces words, and performs poorly on weekly spelling tests. However, she excels in mathematics and enjoys group art projects. Her parents report that she was a "late talker" but caught up by age 4. She achieved all motor milestones on time and is fully independent with dressing and feeding. She has several close friends at school and enjoys playing collaboratively. Audiology and optometry evaluations performed last week were entirely normal. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old woman comes to the clinic for a routine follow-up. She has a 5-year history of bipolar I disorder. Six months ago, she experienced a severe manic episode, and her psychiatric medication regimen was changed due to inadequate symptom control on lithium therapy. At that time, she was transitioned to a different mood stabilizer, and her mood symptoms have remained well-controlled since. She has no other medical conditions. Her only other medication is a combined oral contraceptive pill (ethinyl estradiol and levonorgestrel), which she has taken consistently at the same time every day for the past 3 years without any missed doses. Today, the patient reports a 6-week history of amenorrhea, breast tenderness, and morning nausea. A urine pregnancy test in the clinic is positive. Which of the following psychiatric medications was most likely initiated six months ago?

A son brings his 68-year-old mother to the geriatric psychiatry clinic due to a 6-week history of profound lethargy, worsening sadness, and uncharacteristic behavior. He reports that she now spends most of her day in bed and has lost 4.5 kg (10 lb) due to a near-total loss of appetite. During the interview, the patient repeatedly states that her internal organs are 'turning to dust' as a punishment for her past sins, and she mentions hearing a male voice that agrees with her. Her medical history includes severe osteoarthritis, for which she takes scheduled tramadol and acetaminophen. A review of her past psychiatric history reveals that at age 40, she experienced a 3-week episode characterized by a severely decreased need for sleep, rapid and pressured speech, and grandiose plans to start a nationwide business, which resulted in an involuntary psychiatric hospitalization. She was treated with medication at the time but discontinued it shortly after discharge and has not taken any psychiatric medications since. Vital signs are within normal limits. Physical examination is unremarkable. Which of the following is the most appropriate next step in management?

Three weeks after surviving an armed robbery at his workplace, a 35-year-old bank teller is brought to the psychiatry clinic by his husband. The patient was held at gunpoint for several minutes during the incident. Since that day, he reports experiencing intense, distressing flashbacks of the weapon being pointed at his face, which often cause him to wake up sweating in the middle of the night. He strongly refuses to return to the bank, avoids watching any media that might depict crime, and states that he feels completely detached from his family. His husband notes that the patient is constantly "on edge" and becomes easily startled by sudden, normal noises like a door closing. He has no significant past medical or psychiatric history and takes no medications. The patient requests a daily medication to suppress his memories and reduce his hyperarousal. Which of the following is the most appropriate next step in management?