Psychiatry

A 24-year-old woman is admitted to the inpatient medical unit following an intentional ingestion of acetaminophen. Her medical records indicate a history of multiple superficial wrist lacerations, chronic feelings of emptiness, and frequent abrupt changes in her career and friend groups. On the second day of admission, she privately tells the attending physician, "You are the only doctor who actually cares about my well-being. The nursing staff on this floor is incredibly cruel and they are actively ignoring my pain." She demands that only the attending physician be allowed to evaluate her and administer her treatments. She also reports feeling intensely sad and requests medication to fix her mood. Which of the following is the most appropriate next step in the management of this patient?

Match each classic clinical presentation with the corresponding substance-related syndrome.

A 24-month-old girl is brought to the clinic by her parents due to concerns about her social development. The parents report that when they take her to the local playground, she sits near other children in the sandbox but does not interact or share her toys with them. The parents are worried she might have a neurodevelopmental disorder. The child has a vocabulary of approximately 50 words, puts two words together to form simple phrases, and can follow two-step commands. She consistently makes eye contact, points to birds in the sky to show her parents, and smiles when engaged in play. She has recently begun having temper tantrums when it is time to leave the playground. Her vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in management?

Match each clinical vignette with the most accurate DSM-5 diagnostic category.

A hospital psychopharmacology safety committee is updating institutional guidelines for the management of bipolar disorder. The committee is finalizing a safety dashboard that flags critical pre-treatment screenings, monitoring parameters, and absolute contraindications for various agents. Match each of the following psychotropic medications to its corresponding essential safety alert.

A psychiatric evaluation requires careful assessment of symptom duration to differentiate between primary psychotic disorders. Arrange the following diagnoses in correct chronological order based on the minimum continuous duration of symptoms required to meet diagnostic criteria, starting with the shortest duration and ending with the longest.

A 72-year-old woman is brought to the emergency department by her son due to worsening confusion and refusal to eat or drink. For the past two months, she has experienced profound sadness, early morning awakenings, and a 9-kg (20-lb) weight loss. One week ago, her primary care physician diagnosed her with depression and started her on sertraline 50 mg daily. The son is unsure if the physician took a detailed psychiatric history. Over the last 3 days, the patient has stopped eating and drinking entirely, stating repeatedly, "My intestines are rotting away because of my sins." Her temperature is 37.1°C (98.8°F), blood pressure is 90/60 mm Hg, heart rate is 112/min, and respiratory rate is 16/min. Physical examination shows remarkably dry mucous membranes and decreased skin turgor.

After initiating intravenous fluid resuscitation, which of the following is the most appropriate next step in the management of this patient?

A 27-year-old woman is brought to the outpatient clinic by her sister. For the past 4 weeks, the patient has experienced profound sadness, sleeping up to 14 hours a day, low energy, and poor concentration. She states she lacks the motivation to get out of bed and has missed several days of work as a graphic designer. A review of her psychiatric history reveals that three years ago, she experienced an isolated 3-week episode of hearing voices and believing her neighbors were spying on her, which completely resolved without long-term intervention. One year ago, she had a distinct 10-day period during which she slept only 2 hours a night, exhibited pressured speech, and impulsively bought unnecessary high-end computer equipment that depleted her savings. She currently takes no medications. Her physical examination is unremarkable. During the visit, her sister asks the physician to call the patient's employer to explain her psychiatric condition and request a medical leave of absence on her behalf. Which of the following is the most appropriate action by the physician?

A 45-year-old man is evaluated in the hospital on postoperative day 2 following an open reduction and internal fixation of a fractured tibia. The nursing staff reports that he has become increasingly agitated, confused, and restless over the past 4 hours. He is sweating profusely and frantically points to the corner of the room, claiming that spiders are crawling on the walls. His temperature is 38.3°C (100.9°F), blood pressure is 165/100 mmHg, pulse is 118/min, and respiratory rate is 20/min. Physical examination reveals a coarse, bilateral resting tremor in his hands. When contacted, the patient's husband reports that the patient typically drinks half a bottle of whiskey every evening but has not consumed any alcohol since his hospital admission. Which of the following is the most appropriate next step in management?

A 7-year-old boy is brought to the outpatient clinic by his parents due to behavioral concerns initially raised by his second-grade teacher. The teacher reports that the boy frequently leaves his seat during lessons, blurts out answers before questions are completed, and has significant difficulty waiting his turn during group activities. The parents report that he is similarly highly active at home, rarely sits still to finish a meal, and acts as if 'driven by a motor.' These behaviors have been present consistently since he was 4 years old and cause significant frustration for the family and school staff. Hearing and vision screens are normal. He has no other medical conditions. Based on the most likely diagnosis, which of the following statements regarding the evaluation and management of this patient are correct? (Select all that apply)

A 32-year-old man presents to the emergency department with severe diffuse muscle cramps, nausea, vomiting, and profound restlessness. He has a 5-year history of intravenous heroin use. He reports that he last injected heroin 12 hours ago. Determined to quit, he took a sublingual film given to him by a friend who is currently in a medication-assisted treatment program. Within 30 minutes of taking the film, his symptoms rapidly worsened. Vital signs show a temperature of 37.2°C (99.0°F), blood pressure of 152/94 mm Hg, heart rate of 118/min, and respiratory rate of 18/min. Physical examination reveals mydriasis, rhinorrhea, excessive lacrimation, and piloerection. Bowel sounds are hyperactive. Which of the following pharmacodynamic properties of the principal active medication in this sublingual film best explains the rapid exacerbation of this patient's symptoms?

Match each clinical presentation to the most appropriate depressive disorder subtype or related diagnosis.

A 42-year-old man comes to a new primary care clinic to establish care. During the interview, he is highly suspicious of the electronic medical record system and demands to know exactly who will have access to his data. He mentions he is involved in multiple ongoing lawsuits against former employers, whom he claims were "sabotaging his career" and "spying on his daily activities." He refuses to provide a complete medical history, stating, "Any information I give you will eventually be used against me." He also complains that the clinic's triage nurse intentionally delayed his vital signs assessment to mock him. His thought processes are organized, and there is no evidence of auditory or visual hallucinations. He states these interpersonal issues have been present since he was a young adult. Which of the following is the most appropriate next step in the management of this patient?

A 28-year-old woman presents to a new primary care physician to establish care. She reports feeling chronically "empty" and describes a history of intense, unstable relationships. She recently ended her engagement after a minor disagreement and subsequently engaged in reckless driving and binge eating. She states her previous psychiatrist was "completely incompetent," whereas she feels the current physician is "the only one who truly listens." Her current medication is tranylcypromine, an monoamine oxidase inhibitor (MAOI), which she takes for atypical depression. During the evaluation, she denies active suicidal ideation or intent but mentions she occasionally feels like she would be "better off dead." Which of the following are appropriate management steps for this patient? (Select all that apply)

A 54-year-old man is brought to the outpatient psychiatry clinic by his wife due to a 4-month history of significant behavioral changes. Previously known as a quiet and highly professional bank manager, he has recently become excessively blunt, apathetic, and socially disinhibited. Last week, he made explicit sexual remarks to a neighbor and was reprimanded at work for taking food directly off a colleague's desk. He has no prior psychiatric history. His medical history includes hypertension and hyperlipidemia. He currently takes lisinopril and atorvastatin; he also recently started occasionally taking his wife's fluoxetine. Vital signs are within normal limits. Laboratory results, including a complete blood count, comprehensive metabolic panel, and a normal thyroid-stimulating hormone (TSH) level, are unremarkable. On mental status examination, he is alert and fully oriented. His short-term memory recall is intact, but he demonstrates significant impairments on the trail-making test and verbal fluency tasks. Which of the following is the most likely diagnosis?

Review the following brief patient profiles and match each clinical presentation to its most likely DSM-5 psychiatric diagnosis.

A 42-year-old woman presents to the oncology clinic for a routine follow-up. She was diagnosed with estrogen receptor-positive breast cancer 8 months ago, underwent a lumpectomy and radiation therapy, and is currently taking tamoxifen. When asked about her general well-being, she reports an 8-week history of profound fatigue, sleeping up to 14 hours a day, increased appetite with a 4-kg (8.8-lb) weight gain, and a heavy, "leaden" feeling in her arms and legs that makes it difficult to get out of bed. Her functional impairment is significant, and she recently took a leave of absence from her job. A review of her psychiatric history reveals a similar depressive episode at age 22. Further questioning reveals that at age 24, she experienced a 5-day period where she felt "euphoric and invincible," required only 3 hours of sleep per night, and rapidly outlined a 300-page screenplay. This period resolved spontaneously without hospitalization. Last week, her primary care physician diagnosed her with depression and prescribed paroxetine, but the patient discontinued it after 2 days due to mild nausea. She currently takes no medications other than tamoxifen. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in the pharmacological management of this patient's psychiatric symptoms?

A 65-year-old man comes to the clinic accompanied by his husband. He has a history of early-stage colon cancer that was surgically resected $6 \text{ months}$ ago. For the past two months, the patient has experienced pervasive sadness, a $6 \text{ kg}$ ($13.2 \text{ lb}$) weight loss, severe insomnia, and a complete lack of energy. He has also developed the conviction that his cancer is a direct punishment for his past mistakes. He states, "I just need an antidepressant to get my life back." His only current medication is lisinopril for hypertension. Laboratory studies reveal a low free thyroxine (T4) level and a normal thyroid-stimulating hormone (TSH) level of $1.2 \text{ mIU/L}$. Which of the following is the most appropriate next step in the evaluation and management of this patient?

A 69-year-old man is evaluated in the hospital after being admitted for urosepsis. Over the past 24 hours, he has become profoundly confused and agitated, attempting to strike the nursing staff and pull out his intravenous lines. His medical history is significant for an 11-month history of progressive cognitive decline. His wife reports that over the past year, he has had episodes of staring blankly for prolonged periods, recurrently claims to see small animals running across the living room floor, and frequently kicks and thrashes while asleep. Physical examination earlier in the admission revealed increased resistance to passive movement in all four extremities and a slow, shuffling gait. The primary team decides that pharmacological intervention is urgently necessary to prevent the patient from harming himself and staff. Administration of which of the following medications is most likely to provoke a severe, potentially fatal deterioration characterized by extreme rigidity and autonomic dysfunction in this patient?

A 35-year-old male teacher presents to the primary care clinic accompanied by his sister. He reports a 6-week history of profound sadness, excessive sleepiness, and a 6-kg (13.2-lb) weight gain. He states, "I am a terrible person. I am directly responsible for the recent earthquake in South America." His sister expresses deep concern about his withdrawal from family. When asked about his past psychiatric history, his sister notes that three years ago, he had a distinct 7-day period where he was extraordinarily energetic, spoke rapidly, slept only two hours a night, and wrote an entire 300-page manuscript in a few days. He was not hospitalized at that time. He has no other medical conditions and takes no medications. Vital signs are within normal limits. Mental status examination reveals a disheveled man with psychomotor retardation, downcast gaze, and restricted affect. His speech is slow but coherent. Which of the following is the most appropriate next step in management?