Psychiatry

A 20-year-old man presents to the university health clinic complaining of excessive daytime sleepiness that has progressively worsened over the past 8 months. He reports struggling to stay awake during lectures and has fallen asleep several times while eating meals. The patient also describes episodes where he suddenly loses muscle tone in his knees when he hears a funny joke, causing him to occasionally fall to the floor. He remains fully awake and aware of his surroundings during these brief events. Additionally, he mentions seeing vivid, frightening shadows in his room just before he falls asleep at night. He has no past medical history, does not use illicit drugs, and takes no medications. Vital signs and physical examination are unremarkable. Which of the following is the most likely diagnosis?

A 21-year-old female university student is brought to the emergency department by her roommate due to generalized weakness, muscle cramps, and a syncopal episode earlier that morning. The roommate mentions that the patient is under immense stress due to impending final exams. For the past year, the patient has drastically restricted her food intake during the day, but at night, she frequently consumes unusually large quantities of high-calorie foods, followed by prolonged periods in the bathroom with the water running. The patient recently visited the campus clinic for low mood and to get help quitting smoking; she was prescribed a new medication that she began taking two days ago.

Physical examination reveals a frail-appearing woman. Her BMI is 17.1 kg/m². Vital signs show a temperature of 36.3°C (97.3°F), blood pressure of 90/56 mm Hg, heart rate of 112/min while supine that increases to 138/min upon standing, and respiratory rate of 10/min. She has bilateral parotid gland enlargement, poor dentition with enamel erosion, and fine, downy hair over her back.

Based on the clinical and laboratory findings, which of the following is the most accurate statement regarding this patient's condition and management?

A psychiatry resident is evaluating five different patients presenting with depressive symptoms in various clinical settings. Match each patient's clinical vignette with the most appropriate best next step in management or definitive diagnosis.

A $28$-year-old woman with a history of severe bipolar I disorder presents to the clinic for an initial prenatal visit at $6$ weeks gestation. She is currently stable on lithium carbonate and has not experienced a manic episode in $3$ years. However, she has a history of life-threatening manic episodes with psychotic features whenever she has attempted to discontinue her medication in the past. She wishes to continue her pregnancy. Arrange the following steps in the optimal pharmacological and obstetric management of this patient in chronological order, from the first trimester through the immediate postpartum period.

A 54-year-old man with a severe alcohol use disorder is brought to the emergency department for severe confusion, tremulousness, and an unsteady gait. Initial vital signs reveal a heart rate of 115/min and a blood pressure of 160/95 mm Hg. Point-of-care blood glucose is 55 mg/dL. Neurologic examination shows prominent bilateral horizontal nystagmus and resting hand tremors.

Arrange the following clinical interventions in the most appropriate chronological sequence for managing this patient, from first to last.

Match the following brief clinical scenarios and symptom duration timelines with the most appropriate DSM-5 psychiatric diagnosis.

A 52-year-old man is brought to the emergency department by his wife due to worsening confusion, unsteadiness, and a prominent tremor over the past three days. He has a history of bipolar I disorder that has been well controlled on lithium carbonate for the past five years. Two weeks ago, he was diagnosed with essential hypertension, and a new daily medication was added to his regimen. His temperature is 37.1 C (98.8 F), blood pressure is 135/85 mm Hg, and pulse is 88/min. On examination, the patient is lethargic but arousable. Neurological examination reveals dysarthria, an unsteady, broad-based gait, and a coarse resting tremor in both hands. Laboratory studies show a serum creatinine of 1.2 mg/dL (baseline 0.9 mg/dL) and a serum lithium level of 2.1 mEq/L (therapeutic range: 0.6-1.2 mEq/L). Which of the following best describes the mechanism by which the new antihypertensive medication precipitated this patient's condition?

A $28$-year-old software engineer presents to the clinic with a $4$-week history of profound sadness, poor concentration, and a $5$-kg ($11$-lb) weight gain. She reports sleeping up to $14$ hours a day and feeling a "heavy sensation" in her arms and legs. She has stopped attending social events and is struggling to meet her project deadlines. Her medical history is unremarkable, and she takes no medications. When asked about past psychiatric symptoms, she recalls a $6$-day period during college when she felt "unstoppable," slept only $2$ to $3$ hours a night without feeling tired, and wrote an entire novel. During that time, friends noted she was speaking much faster than usual, though her behavior did not result in hospitalization or academic failure. Vital signs are within normal limits. Laboratory results show a thyroid-stimulating hormone level of $1.8 \mu U/mL$ (normal: $0.5$ to $5.0 \mu U/mL$) and a negative urine toxicology screen. Which of the following is the most appropriate next step in pharmacotherapy for this patient?

A 24-year-old man is brought to the outpatient psychiatric clinic by his parents. For the past 10 weeks, he has been isolating himself in his bedroom, claiming that foreign intelligence agents are surveilling him through the electrical outlets. His parents frequently hear him conversing with people when he is alone. During this time, his personal hygiene has significantly deteriorated, and he was fired from his job as a data analyst. He has no prior history of psychiatric illness and does not use alcohol or illicit substances. His medical history is unremarkable, and a recent comprehensive metabolic panel and urine toxicology screen were normal. The physician initiates antipsychotic pharmacotherapy. During a family session, the parents ask for clarification about his exact diagnosis and what to expect for his future. Which of the following is the most accurate statement regarding this patient's diagnosis and long-term prognosis?

A 34-year-old graphic designer comes to the office for a follow-up visit. Four weeks ago, she presented with pervasive sadness, hypersomnia, increased appetite, and a heavy feeling in her limbs. She was diagnosed with a major depressive episode and started on sertraline 50 mg daily. Today, she reports that her mood has not improved and she is frustrated. She says, "I stopped taking the pill three days ago because it wasn't working fast enough. Can we just try something else?" Upon further questioning, the patient mentions that three years ago, she experienced a 10-day period where she felt "incredibly energized," required only 2 hours of sleep per night without feeling tired, and impulsively drained her savings account to start a speculative business venture that quickly failed. She has no history of hallucinations or delusions. Physical examination is unremarkable. Which of the following is the most appropriate next step in management?

A 27-year-old graduate student is brought to the university health clinic by his roommate. The roommate reports that for the past 14 weeks, the patient has been barricading himself in their shared apartment, claiming that rival researchers are trying to steal his thoughts using microwave beams. The patient has been hearing two voices arguing about his research outside his window, even when no one is there. He has not attended classes or bathed regularly during this time. Prior to this, he was a top-performing student with a wide circle of friends and no prior psychiatric history. Medical history is unremarkable. Vital signs and physical examination are within normal limits. A urine toxicology screen is negative. Which of the following is the most likely diagnosis?

Match each clinical presentation with the most accurate psychiatric diagnosis based on symptom duration and clinical features.

A 42-year-old woman is brought to the emergency department by her husband due to a 2-day history of worsening confusion, slurred speech, and an unsteady gait. She also reports several episodes of severe nausea and vomiting. Her medical history is significant for bipolar I disorder, which has been well-controlled on a stable dose of lithium carbonate for the past 4 years. Two weeks ago, she was evaluated by her primary care physician for newly diagnosed essential hypertension, and a daily medication was added to her regimen. Her temperature is 37.1°C (98.8°F), blood pressure is 128/82 mmHg, and pulse is 84/min. On physical examination, the patient appears lethargic. Neurological examination reveals a coarse, irregular resting tremor in both hands and truncal ataxia. Which of the following medications was most likely recently prescribed to this patient?

A 48-year-old woman with a history of bipolar I disorder is brought to the emergency department by her husband due to progressive confusion, a coarse hand tremor, and an unsteady gait over the last three days. Her psychiatric condition has been stable on a fixed dose of lithium carbonate for the past five years. Two weeks ago, she was diagnosed with essential hypertension and started on a new antihypertensive medication by her primary care provider. On physical examination, she appears lethargic, has a coarse resting tremor in both hands, and demonstrates ataxia on finger-to-nose testing. Vital signs are within normal limits except for a blood pressure of 128/82 mmHg. Which of the following antihypertensive medications was most likely prescribed to this patient?

Match each clinical scenario describing a patient with psychotic symptoms to the most appropriate primary psychiatric diagnosis.

A 32-year-old man is court-mandated to attend a substance use disorder treatment program following an arrest for possession of cocaine. The clinic utilizes the Transtheoretical Model of Change to tailor motivational interviewing interventions. Over a two-year period, the patient progresses sequentially through the recognized behavioral stages of recovery. Arrange the following patient statements in chronological order, corresponding to the progression from the earliest stage of change to the latest.

A 23-year-old woman comes to the outpatient clinic for a follow-up visit. Two weeks ago, she was evaluated in the emergency department after ingesting a handful of acetaminophen tablets following a brief but intense argument with her new boyfriend. She reports a history of multiple intense and short-lived relationships, frequent feelings of profound emptiness, and sudden outbursts of extreme anger. During the interview, she tells the physician, "You are the only person who has ever truly cared about me; all my previous doctors were completely useless." She is medically stable, denies any active suicidal ideation or intent, and expresses a desire to improve her coping skills. She has no history of manic episodes or psychosis. Which of the following is the most appropriate next step in the long-term management of this patient?

A 25-year-old man is brought to the outpatient clinic by his sister, who is concerned about his profound social isolation. For the past 6 years, the patient has lived alone and worked as a night-shift security guard specifically to avoid interacting with others. He reports that he prefers to be alone because he feels "uncomfortable and suspicious" around people, believing they are secretly judging his aura. He has a long-standing belief in telepathy and claims he can occasionally predict the future through his dreams, although he denies ever hearing voices or seeing things that are not there. During the interview, he displays restricted affect and wears a heavy winter coat lined with aluminum foil, despite it being a warm summer day. His speech is vague and overly elaborate but remains logically connected. He has never been hospitalized and has maintained his employment. Which of the following is the most likely diagnosis?

A 34-year-old woman comes to the outpatient psychiatry clinic reporting that she "cannot get out of bed" and feels completely hopeless. Over the past 6 weeks, she has experienced a persistently depressed mood, slept 14 hours a day, gained 4.5 kg (10 lb), and suffered from profound fatigue. She admits to passive suicidal ideation but denies any active plan. Her past psychiatric history is notable for a major depressive episode at age 22, for which she was prescribed paroxetine. Three weeks after starting paroxetine, she developed a severely elevated mood, rapid and pressured speech, decreased need for sleep (2 hours per night), and grandiose delusions resulting in psychiatric hospitalization. She was stabilized on a medication that she discontinued 5 years ago because she "felt fine." Her medical history includes type 2 diabetes mellitus, hypertension, and osteoarthritis. Current medications are metformin, lisinopril, hydrochlorothiazide, and daily ibuprofen. Her vital signs show a blood pressure of 145/90 mmHg. Her BMI is 38 kg/m². Laboratory studies reveal a hemoglobin A1c of 9.2%. Mental status examination shows marked psychomotor retardation, a flattened affect, and a depressed mood. Which of the following is the most appropriate next step in pharmacotherapy for this patient's current psychiatric symptoms?

A 25-year-old man presents to the outpatient clinic with a 2-month history of sudden, unpredictable episodes of intense fear accompanied by palpitations, sweating, shortness of breath, and a feeling of impending doom. The episodes typically reach their peak severity within 10 minutes. Because of these episodes, the patient has become increasingly fearful of leaving his house. He has a past medical history of bipolar I disorder, which was diagnosed three years ago, but he stopped taking his mood stabilizer 6 months ago. His vital signs are within normal limits. Physical examination, electrocardiogram, and basic metabolic panel are unremarkable. Which of the following is the most appropriate initial long-term management for this patient's current condition?