Psychopharmacology and Psychological Therapies

A $27$-year-old man with a history of schizophrenia is brought to the emergency department by his family because he has been standing completely still in the corner of his room for the past $12$ hours. He does not respond to questions, maintains his arm in a raised position when the physician moves it there, and has not eaten or drank anything all day. His current medications include haloperidol and benztropine. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $120/80\text{ mm Hg}$, pulse $82/\text{min}$, and respirations $14/\text{min}$. Arrange the following management steps in the most appropriate chronological order for this patient's current condition.

A patient with a recent history of ischemic heart disease is evaluated at an outpatient psychiatry practice. The $58$-year-old male suffered a myocardial infarction $3$ months prior, for which he takes aspirin, ticagrelor, rosuvastatin, and metoprolol. He now describes a $6$-week history of unremitting dysphoria, anhedonia, insomnia, and feelings of worthlessness, without any thoughts of self-harm. His physical examination and vital signs are unremarkable at this visit. A diagnosis of major depressive disorder is established, and pharmacotherapy is initiated. Eight days following this appointment, the patient arrives at the urgent care clinic complaining of severe dizziness and near-fainting episodes. Triage vital signs demonstrate a pulse of $40\text{/min}$ and a blood pressure of $88/54\text{ mm Hg}$. A $12$-lead electrocardiogram confirms pronounced sinus bradycardia. Which of the following psychiatric medications is most likely responsible for precipitating this patient's acute presentation?

A 31-year-old woman with severe, treatment-resistant atypical depression has failed multiple antidepressant trials. She is currently taking fluoxetine 60 mg daily but remains profoundly symptomatic. Her psychiatrist decides to transition her to phenelzine.

Arrange the following clinical steps in the correct chronological sequence to safely and effectively execute this medication transition and its long-term management.

Match each psychotropic medication with its most characteristic adverse effect, specific monitoring requirement, or clinical contraindication.

A 45-year-old woman is brought to the emergency department by her husband due to a severe, throbbing headache, blurred vision, and chest palpitations that began 45 minutes ago. She has a 10-year history of major depressive disorder that was poorly responsive to multiple trials of selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Six weeks ago, her psychiatrist started her on tranylcypromine. Vital signs are temperature 37.2°C (99.0°F), blood pressure 228/132 mm Hg, pulse 118/min, and respirations 20/min. Physical examination reveals profuse diaphoresis, facial flushing, and pupillary dilation. Neurological examination shows normal muscle tone, 2+ deep tendon reflexes symmetrically, and absent clonus. Mental status examination reveals an anxious woman who is fully oriented to person, place, and time. Her husband mentions they were celebrating their anniversary at a restaurant earlier this evening, where they shared a large platter of aged cheeses and cured meats. Which of the following is the most appropriate initial pharmacological intervention for this patient's current condition?

Match each patient's clinical presentation of a psychotropic adverse effect with the medication most likely responsible.

A 35-year-old male construction worker is brought to the emergency department by his wife due to sudden-onset severe agitation, fever, and muscle stiffness. His medical history is significant for major depressive disorder, for which he has been taking sertraline for the past 2 years. Two days ago, the patient underwent a complex root canal procedure and was prescribed a short course of a centrally acting analgesic. On physical examination, his temperature is 39.4°C (102.9°F), blood pressure is 165/100 mmHg, and heart rate is 118/min. He is diaphoretic, flushed, and noticeably disoriented. Neurologic examination reveals bilateral ankle clonus, marked shivering, and generalized hyperreflexia that is most prominent in the lower extremities. Which of the following describes the mechanism of action of the analgesic that most likely precipitated this patient's current condition?

Match each patient's clinical scenario and specific medication requirement with the most appropriate second-generation antipsychotic.

Match each patient's clinical presentation of an adverse drug reaction to the psychotropic medication most likely responsible for their symptoms.

A 24-year-old woman comes to the outpatient psychiatric clinic due to a 4-week history of feeling severely depressed, lacking energy, and sleeping 12 to 14 hours a day. She reports a loss of interest in her usual hobbies and a 5-kg (11-lb) weight gain over this period. The patient has no significant past medical history. Upon further questioning, the patient's roommate states that 8 months ago, the patient had a 10-day episode where she was extremely energetic, required only 3 hours of sleep per night, and spoke so rapidly it was difficult to interrupt her. During that time, she spontaneously booked an expensive, non-refundable trip to Europe that she could not afford. She was not hospitalized and eventually returned to her baseline. Which of the following is the most appropriate pharmacotherapy for this patient's current condition?

A collegiate gymnast presents to the student health center for evaluation of a persistently depressed mood, profound fatigue, and anhedonia over the past three months. During the interview, she expresses deep dissatisfaction with her body shape and an intense fear of gaining weight. Vital signs show a heart rate of $54 \text{ /min}$ and a blood pressure of $92/58 \text{ mm Hg}$. Physical examination reveals a body mass index of $17.4 \text{ kg/m}^2$, fine downy hair on her arms, and bilateral parotid gland enlargement. Laboratory results are notable for a serum potassium of $3.2 \text{ mEq/L}$. She asks the physician to prescribe an antidepressant she read about online, describing it as 'the one that does not cause weight gain or sexual problems.' If the physician complies and prescribes this specific medication, the patient would be at significantly increased risk for which of the following complications?

A medical student on a psychiatry clerkship is reviewing the adverse effect profiles of commonly prescribed psychiatric medications. Match each of the following psychotropic medications to the clinical vignette that best describes its characteristic adverse effect or toxicity.

A 54-year-old woman is brought to the emergency department by her daughter due to progressive confusion, unsteadiness, and shaking. The patient has a history of bipolar I disorder that has been well controlled on a stable dose of lithium for the past 8 years. Two weeks ago, she visited a primary care clinic for routine evaluation and was started on a new daily medication. Today, her temperature is 37.1°C (98.8°F), blood pressure is 128/78 mm Hg, and heart rate is 82/min. Physical examination reveals an unsteady, broad-based gait and a coarse tremor in both hands. Deep tendon reflexes are 3+ bilaterally. She also reports several days of nausea, vomiting, and diarrhea. Which of the following medications was most likely added to her regimen two weeks ago?

You are evaluating five different patients who have recently initiated psychotropic medications. Each patient is now presenting with a specific adverse effect based on their history and examination findings. Which primary pharmacological mechanism best corresponds to the responsible medication for each patient's clinical presentation?

A 35-year-old man with a history of schizophrenia is brought to the emergency department from a residential psychiatric facility due to high fever, severe muscle rigidity, and progressive confusion over the past 24 hours. His current medication regimen includes high-dose fluphenazine. His temperature is 39.8°C (103.6°F), blood pressure is 168/104 mm Hg, and pulse is 122/min. Physical examination reveals generalized lead-pipe rigidity and profuse diaphoresis. Laboratory studies show a markedly elevated creatine kinase level. Arrange the following interventions in the most appropriate sequential order for the standard step-wise management of this patient's condition, from the initial immediate action to the last-resort treatment.

A 34-year-old man with a history of treatment-resistant depression is brought to the emergency department by his partner. The patient was doing well on a newly prescribed psychiatric medication until this morning, when he took an over-the-counter nasal decongestant for a severe cold. Within an hour of taking the cold medication, he developed a severe, throbbing headache, blurred vision, and neck stiffness. On triage, his temperature is 37.1°C (98.8°F), pulse is 115/min, and blood pressure is 220/125 mm Hg. Physical examination shows diaphoresis and normal deep tendon reflexes without clonus. Which of the following psychiatric medications is this patient most likely taking?

A 42-year-old woman is brought to the emergency department by her husband due to worsening confusion, severe nausea, vomiting, and a prominent hand tremor. Her husband reports that she has been unusually unsteady on her feet for the past three days. Her medical history is significant for bipolar disorder, which has been well-controlled on a stable dose of lithium for the past five years. Three weeks ago, she was diagnosed with essential hypertension by her primary care provider and was started on a new daily medication. On physical examination, the patient is lethargic and exhibits a coarse resting tremor, hyperreflexia, and ataxia. Her serum lithium level is 2.1 mEq/L (therapeutic range: 0.6-1.2 mEq/L). Which of the following antihypertensive medications was most likely prescribed to this patient?

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 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 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?