Psychiatry

A 24-year-old woman presents to the emergency department after sustaining superficial lacerations to her left forearm. Her roommate brought her in, stating the patient became deeply distraught after a man she had been dating for two weeks did not immediately reply to a text message. The patient tearfully explains she felt "completely hollow and abandoned." During the initial triage, the patient tells the nurse, "You are the only person who actually listens to me; everyone else here is heartless." Thirty minutes later, when the attending physician suggests a psychiatry consultation before discharge, the patient throws a cup of water at the wall and screams, "You are an incompetent, cruel doctor trying to lock me up!" The roommate notes that the patient has a history of impulsive spending sprees, frequent binge eating, and a chronically unstable mood. The patient is currently taking paroxetine for depressive symptoms. She asks the physician to prescribe tranylcypromine, stating that a friend takes it and it "works wonders for mood swings." The patient also mentions that during severe stress, she sometimes feels disconnected from her body and has transient thoughts that people are plotting against her, which typically resolve within a day.

Which of the following statements regarding the diagnosis and management of this patient are correct? (Select all that apply)

A 34-year-old woman comes to the clinic reporting severe anxiety, recurrent nightmares, and profound fatigue. Six months ago, she was trapped in an elevator for several hours during a building fire. Since the event, she has experienced vivid, distressing nightmares about the fire, completely avoids elevators, and has an exaggerated startle response. She also reports feeling emotionally detached. Over the past three months, she has developed worsening fatigue, cold intolerance, and a $5\ \text{kg}$ ($11\ \text{lb}$) weight gain. Her past psychiatric history is significant for treatment-resistant depression, for which she takes phenelzine.

Physical examination reveals delayed relaxation of deep tendon reflexes.

Laboratory studies show:
Thyroid-stimulating hormone (TSH): $1.2\ \mu\text{U/mL}$ (Normal: $0.4-4.0\ \mu\text{U/mL}$)
Free thyroxine (T4): $0.5\ \text{ng/dL}$ (Normal: $0.9-1.7\ \text{ng/dL}$)

Which of the following are the most appropriate next steps in the management of this patient? (Select all that apply)

A 72-year-old man is brought to the clinic by his wife due to a 1-year history of progressive memory decline. She reports that his cognitive abilities fluctuate significantly; on some days he is highly alert, while on other days he is deeply confused. Over the past 6 months, he has frequently reported seeing small animals in their living room, even though none are present. Additionally, his sleep is highly disturbed; he often yells and physically thrashes in bed, appearing to act out his dreams. On physical examination, the patient has a shuffling gait, a resting tremor in his right hand, and mild cogwheel rigidity. Laboratory studies reveal a thyroid-stimulating hormone (TSH) level of 2.1 µU/mL (normal: 0.4-4.0 µU/mL) and a normal vitamin B12 level. Which of the following is the most likely diagnosis?

A 24-year-old man is brought to the clinic by his mother for a general checkup. He tells the physician that he feels nervous around other people because he can sense their "negative auras." He spends most of his time alone in his room studying astrology and believes that he can predict the weather by reading tea leaves. The mother reports that he has always been a "loner" with odd beliefs since early adolescence. He has never experienced auditory or visual hallucinations, and his thought processes are organized. He does not have any history of major depressive or manic episodes. Which of the following is the most likely diagnosis?

Match each pharmacological agent used in psychiatric practice with its characteristic adverse effect profile or specific clinical warning regarding its use in bipolar disorder.

A 31-year-old male accountant presents to the clinic for an urgent follow-up appointment. He initially presented two weeks ago with a one-month history of severe sadness, hypersomnia, and profound anhedonia. At that time, he was diagnosed with a major depressive episode and prescribed fluoxetine. Today, he reports that his mood has not improved, but he now feels "extremely irritable, wired, and completely unable to sit still." His physical examination is notable for rapid, pressured speech and psychomotor agitation. Upon detailed psychiatric review, the patient admits that he experienced a similar "wired" state twice in his twenties. During those episodes, which each lasted approximately ten days, he required only two hours of sleep per night and impulsively spent thousands of dollars on unneeded electronics. He has no significant past medical history and denies any illicit substance use. Which of the following is the most appropriate next step in management?

Match each clinical presentation to the most likely personality disorder diagnosis.

A 22-year-old law student schedules an appointment at the university health center due to severe distress regarding his upcoming moot court arguments. He explains that whenever he has to speak in front of a panel of judges, he experiences intense palpitations, a prominent hand tremor, and a trembling voice. These symptoms begin roughly 30 minutes before he is scheduled to speak and severely impair his performance. He does not experience this anxiety during written exams, while studying in groups, or in everyday social interactions. He is otherwise healthy, exercises regularly, and takes no daily medications. His pulse is 78/min and blood pressure is 118/76 mm Hg. Which of the following is the most appropriate initial pharmacotherapy to manage this patient's symptoms?

A 42-year-old male architect is brought to his primary care physician by his husband due to a 2-month history of severe depressed mood, excessive guilt, and terminal insomnia. The patient states that he has completely lost interest in his architectural projects, feels like a burden to his family, and has lost 6.8 kg (15 lb) over this period. His medical history is significant for primary hypothyroidism, which has been well-controlled on levothyroxine. Review of his past medical records reveals a prior psychiatric admission at age 26 after he spent his entire life savings on a spontaneous trip to Europe, during which he believed he was a prophet destined to unite the world. He was treated with an unknown medication and stabilized but stopped all psychiatric care a year later. His current vital signs are stable. Physical examination is unremarkable. Mental status examination reveals a disheveled appearance, marked psychomotor retardation, flat affect, and poverty of speech. He denies current suicidal ideation or auditory hallucinations. Laboratory testing demonstrates a thyroid-stimulating hormone (TSH) level of 1.8 µU/mL (normal: 0.5-5.0 µU/mL) and a free thyroxine (T4) level of 1.3 ng/dL (normal: 0.9-1.7 ng/dL). Which of the following is the most appropriate next step in pharmacotherapy?

An outpatient psychiatric evaluation is requested for a 31-year-old female software developer who reports feeling 'empty and constantly on edge.' The patient states that she has struggled with intense, unstable interpersonal relationships since late adolescence, often fluctuating between idealized infatuation and extreme devaluation of her partners. She exhibits the defense mechanism of splitting, explicitly categorizing her current treatment team as 'the only ones who actually care' and her previous providers as 'malicious and incompetent.' Her history is notable for recurrent non-suicidal self-injury via superficial skin cutting following perceived abandonments. Over the past week, following a severe conflict with her roommate, she has experienced transient, stress-induced auditory hallucinations of a voice whispering her name. Furthermore, she describes short-lived periods of profound depressive symptoms interspersed with significant irritability and impulsive spending. She is currently prescribed paroxetine for anxiety. During the interview, she mentions having found a bottle of phenelzine in her mother's medicine cabinet and asks if she should start taking it alongside her paroxetine for 'extra help.' She also expresses intense anger toward her roommate, vaguely stating she would 'love to see her get hit by a bus,' but when assessed further, she denies any actual plan or intent to harm her. Which of the following is the most appropriate management strategy for this patient?

A 28-year-old woman is evaluated in the outpatient psychiatric clinic for maintenance pharmacotherapy following a recent hospitalization for an acute manic episode. Her past psychiatric history includes two prior episodes of major depression. Physical examination is unremarkable, and on mental status examination, her mood is euthymic with normal speech and thought processes. The physician discusses several medication options, emphasizing the importance of specific baseline laboratory testing, adverse effect profiles, and appropriate prescribing practices in bipolar disorder. Match each psychotropic intervention with its characteristic adverse effect profile, required monitoring, or primary clinical risk.

A 62-year-old man comes to the cardiology clinic for a routine follow-up 6 weeks after being hospitalized for an acute anterior wall myocardial infarction, for which he received a drug-eluting stent. His cardiac function has stabilized, and he is compliant with his medication regimen, which includes aspirin, clopidogrel, metoprolol, lisinopril, and atorvastatin. Today, his wife expresses deep concern about his emotional well-being since discharge. The patient states, 'My life is basically over. I am just a burden to my family now, and there is no point in going on.' He reports a 10-lb (4.5-kg) weight loss due to poor appetite and says he wakes up every day at 3:00 AM unable to fall back asleep. He admits to recurrent thoughts that his family would be better off if he were dead, though he lacks a specific suicide plan. His physical examination is unremarkable, and an electrocardiogram shows normal sinus rhythm with a QTc interval of 420 ms. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

Select the most accurate personality disorder diagnosis for each described patient presentation.

A 41-year-old man is brought to the clinic by his wife due to severe anhedonia, feelings of worthlessness, and hypersomnia lasting for the past six weeks. He has a past medical history of obesity (BMI 36 kg/m²), poorly controlled type 2 diabetes mellitus, and essential hypertension. His current daily medications are metformin, valsartan, and indapamide. His wife reports that three years ago, he experienced a distinct three-week period where he slept only two hours per night, spoke incessantly, and exhibited grandiosity, claiming he was a covert operative for a secret intelligence agency. That episode resolved without psychiatric intervention, and he has taken no psychotropic medications since. Mental status examination reveals psychomotor slowing, poor eye contact, and a severely depressed mood, but no current delusions or hallucinations. Which of the following is the most appropriate next step in pharmacologic management?

A 34-year-old woman comes to the clinic reporting a 6-week history of pervasive sadness, frequent tearfulness, and profound fatigue. She states that her arms and legs feel "like they are made of lead" and she is sleeping up to 14 hours a day. She feels immense guilt about being an inadequate mother to her 4-month-old infant, whom she is exclusively breastfeeding. Three years ago, the patient was prescribed paroxetine for generalized anxiety. Two weeks after starting the medication, she became unusually energetic, slept only 2 hours a night without feeling tired, and began making impulsive, large investments in cryptocurrency, which depleted her savings. The paroxetine was immediately discontinued, but her hyperactive and grandiose state persisted for another 5 weeks before gradually resolving. She has not taken any psychiatric medications since that time. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate pharmacotherapy for this patient's current symptoms?

Match the following clinical presentations to the most appropriate psychiatric diagnosis based on DSM-5 criteria.

During a routine health clearance appointment, a 20-year-old nursing student confides in the physician about severe anxiety that is jeopardizing her clinical rotations. For the past 4 months, she has experienced overwhelming fear, nausea, diaphoresis, and lightheadedness exclusively when asked to perform venipuncture or assist with wound care. On two occasions, she lost consciousness while observing minor surgical procedures. She states, "I understand the procedures logically, but the moment I see blood or needles, the room starts spinning." She denies anxiety during lectures, written examinations, or general patient interactions. She has no past psychiatric history, takes no medications, and her physical examination today is unremarkable. 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 clinic by her sister due to profound behavioral changes over the past 5 weeks. Six weeks ago, the patient was sexually assaulted at a social gathering. She has not reported the incident to law enforcement and explicitly asks the physician to keep the event completely confidential. The patient describes experiencing intense, intrusive flashbacks of the assault and has actively avoided leaving her apartment. She exhibits an exaggerated startle response and reports severe insomnia. Her past psychiatric history is significant for a hospitalization at age 22 for a distinct episode of elevated mood, decreased need for sleep, and grandiosity. She currently takes lithium for maintenance therapy. She also mentions that she recently started taking over-the-counter St. John's wort to help manage her current distress. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in the management of this patient?

Match each clinical vignette describing a patient's pervasive interpersonal and behavioral patterns to the most likely personality disorder diagnosis.

Review the following patient summaries describing complex depressive presentations. Match each clinical profile with the most appropriate next step in pharmacologic or somatic management.