Psychopharmacology and Psychological Therapies

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?

A 28-year-old man presents to the psychiatry clinic complaining of severe sadness, fatigue, and loss of interest in his usual hobbies for the past 3 weeks. He reports sleeping up to 14 hours a day and experiencing a significant decline in his appetite. Medical history is notable for an episode two years ago during which he felt "unstoppable," slept only 2 hours per night without feeling tired, and maxed out multiple credit cards on unnecessary purchases. That episode lasted for 10 days and resulted in a brief psychiatric hospitalization. Temperature is 37.0°C (98.6°F), blood pressure is 120/78 mmHg, pulse is 72/min, and respirations are 14/min. On mental status examination, the patient appears disheveled, makes poor eye contact, and exhibits psychomotor retardation. His mood is described as "miserable" and his affect is constricted. He denies suicidal ideation. Which of the following is the most appropriate initial pharmacotherapy for this patient's current symptoms?

An emergency medical team brings a 35-year-old woman to the hospital due to the acute onset of confusion, severe agitation, and muscle twitching. The patient's husband reports that she has a long-standing history of treatment-resistant depression that has been managed with phenelzine for the past year. Four days ago, she consulted a different clinician for persistent low mood and was started on an additional psychiatric medication. Her vital signs show a temperature of 39.4°C (102.9°F), pulse of 124/min, respirations of 20/min, and blood pressure of 165/95 mm Hg. Physical examination reveals profuse diaphoresis, dilated pupils, a bilateral resting tremor, and pronounced hyperreflexia with spontaneous clonus in the lower extremities. The addition of which of the following medications most likely precipitated this patient's current condition?

A 24-year-old woman is evaluated in the outpatient psychiatry clinic. She reports a 4-week history of severe sadness, loss of interest in her usual activities, hypersomnia, and low energy. She is diagnosed with major depressive disorder and prescribed escitalopram. The physician counsels her extensively on what to expect during the course of her treatment. Arrange the following clinical events in the typical chronological order of their occurrence after initiating this pharmacotherapy, from earliest to latest.

Match each psychological therapy modality with its core clinical focus and primary indicated psychiatric condition.

A 28-year-old man with a recent diagnosis of schizophrenia is started on haloperidol. His physician is reviewing the adverse effect profile with the patient and his family. Arrange the following extrapyramidal symptoms associated with high-potency typical antipsychotics in chronological order of their characteristic onset, from earliest to latest.

A 55-year-old woman is evaluated in the hospital for new-onset agitation, sweating, and tremors. She was admitted three days ago for a severe soft tissue infection and was recently transitioned to intravenous linezolid due to bacterial sensitivities. Her past medical history is significant for major depressive disorder, generalized anxiety disorder, hypertension, and hyperlipidemia. Her temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $158/96\text{ mm Hg}$, and pulse is $118/\text{min}$. Physical examination reveals a prominently diaphoretic and agitated woman. Neurologic examination demonstrates inducible clonus in the bilateral ankles and generalized hyperreflexia. An interaction involving linezolid and which of the following home medications is the most likely cause of this patient's current symptoms?

Match each patient's clinical presentation with the most appropriate pharmacological treatment based on their specific comorbidities and side effect profiles.

During morning rounds on the inpatient psychiatric unit, a medical team is evaluating a patient with schizoaffective disorder. The 34-year-old man's psychotic symptoms were previously refractory to numerous medication trials but are now well-controlled on clozapine. However, over the past week, the nursing staff reports that he has become increasingly hyperactive and irritable, pacing the halls and sleeping less than two hours per night. The team diagnoses an acute manic episode and decides to initiate an additional mood-stabilizing medication. A review of his morning laboratory results shows an absolute neutrophil count of 2,800/mm³. Which of the following medications should the team strictly avoid prescribing due to the risk of a synergistic and potentially life-threatening adverse effect?

Correlate the following clinical scenarios involving psychotropic polypharmacy with their underlying pharmacokinetic or pharmacodynamic interaction mechanisms and resulting clinical consequences.

A 34-year-old male with a history of treatment-resistant schizophrenia is hospitalized for the management of severe lower extremity cellulitis. His daily psychiatric regimen includes clozapine 400 mg daily, which has successfully managed his psychotic symptoms for the past two years without major adverse effects. The patient has a 15-pack-year smoking history and typically smokes two packs of cigarettes daily. Because the hospital is a strict tobacco-free facility, he is prescribed a continuous 21-mg nicotine transdermal patch upon admission to prevent withdrawal. On hospital day 4, the nursing staff notes that the patient is profoundly sedated, confused, and experiencing excessive drooling. Later that afternoon, he suffers a witnessed generalized tonic-clonic seizure. Vital signs reveal a blood pressure of 100/60 mmHg and a heart rate of 112/min. Laboratory studies show a leukocyte count of 7,500/mm³ and a normal basic metabolic panel. Which of the following pharmacological mechanisms is the most likely primary cause of this patient's acute neurological complication?

Match each patient's clinical presentation of a psychotropic medication adverse effect to the primary pharmacodynamic or pathophysiologic mechanism responsible for the finding.

An emergency department physician evaluates a 29-year-old man who presents with a rapidly spreading, painful dermatologic eruption. The patient has a known psychiatric history of bipolar I disorder, for which he has been maintained on divalproex sodium for the past four years without any manic relapses. Six weeks ago, his outpatient psychiatrist prescribed an additional medication to address a severe, functionally impairing depressive episode. Upon physical examination, the patient's temperature is 39.2°C (102.6°F). There is a widespread, tender, purpuric maculopapular rash exhibiting epidermal detachment when lateral pressure is applied. Erosions are visible on the buccal mucosa and bilateral conjunctivae. Which of the following prescribing oversights is the most likely cause of this patient's current presentation?

A 28-year-old male with a 5-year history of schizophrenia is evaluated in the inpatient psychiatric unit for severe, persistent commanding auditory hallucinations and paranoid delusions. He is currently prescribed olanzapine 20 mg daily. His psychiatric history reveals a prior 8-week trial of risperidone 6 mg daily, which was discontinued due to a lack of efficacy. The patient insists he takes his medication every day as prescribed. The treatment team is evaluating him for treatment-resistant schizophrenia. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A young adult male is brought to the inpatient psychiatric unit by his family due to a profound decline in functioning over the past two weeks. The patient has been entirely mute, persistently holds his arms in rigid, unnatural postures for hours, and refuses all oral intake. His current daily medication regimen includes risperidone and fluoxetine. Vital signs show a heart rate of $105/\text{min}$ and blood pressure of $130/85\text{ mm Hg}$; he is afebrile. The psychiatry team suspects catatonia. Arrange the following management steps in the most appropriate sequential order for evaluating and treating this patient's current condition.

A 62-year-old retired architect with a long-standing history of bipolar I disorder is evaluated in the emergency department for worsening confusion, sluggishness, and an unsteady gait over the past three days. He has been psychiatrically stable on a fixed dose of lithium carbonate for eight years without any recent dosage adjustments. His husband reports that the patient recently started taking an over-the-counter analgesic multiple times a day for a severe flare-up of knee osteoarthritis. Vital signs are within normal limits. Physical examination reveals a coarse, irregular tremor in both upper extremities and pronounced dysarthria. The patient is unable to perform tandem walking without losing his balance. Which of the following mechanisms best explains how the newly initiated analgesic precipitated this patient's current symptoms?

A 45-year-old woman is evaluated on the medical ward by the psychiatric consultation-liaison service due to acute-onset agitation and confusion. The patient has a history of major depressive disorder, which has been well controlled on sertraline 150 mg daily for the past two years, and poorly controlled type 2 diabetes mellitus. She was admitted three days ago for a severe diabetic foot infection. Deep tissue cultures grew Vancomycin-resistant Enterococcus faecium (VRE). Yesterday, her intravenous antibiotics were discontinued, and she was transitioned to a targeted oral antibiotic therapy to facilitate hospital discharge. This morning, she became rapidly disoriented and restless. Temperature is 38.6°C (101.5°F), blood pressure is 165/95 mm Hg, pulse is 128/min, and respirations are 20/min. Physical examination reveals a diaphoretic, flushed woman who is unable to answer questions coherently. Her pupils are dilated (6 mm bilaterally). Neurologic examination is notable for 4+ deep tendon reflexes in the lower extremities, spontaneous myoclonus, and sustained bilateral ankle clonus. Which of the following pharmacologic actions of the newly initiated antibiotic is most directly responsible for this patient's current clinical state?

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?

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 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?