Psychiatry

A 41-year-old male accountant is brought to the clinic by his partner due to a 5-week history of feeling 'completely drained.' The patient reports waking up at 3:00 AM daily, having a poor appetite with a 4.5-kg (10-lb) weight loss, and experiencing pervasive feelings of worthlessness. His medical history is notable for a psychiatric admission 7 years ago. During that time, he experienced an 8-day period of sleeping only 2 hours per night, talking rapidly, and spending his life savings on a high-risk investment because he believed he had a telepathic connection with a famous billionaire. He was hospitalized involuntarily for 10 days and discharged on a medication regimen that he discontinued a year later. His only current medication is sumatriptan, which he takes occasionally for migraines. Vital signs and physical examination are within normal limits. Mental status examination reveals psychomotor retardation and a blunted affect. Which of the following is the most appropriate next step in management?

An agitated 35-year-old woman presents to the psychiatric triage center accompanied by her sister. The patient is visibly distressed and states that her neighbors are broadcasting her thoughts over the internet. According to her sister, these symptoms began suddenly 14 days ago, shortly after the patient unexpectedly lost her job. The patient is also experiencing auditory hallucinations. She has no prior history of mental illness, takes no medications, and her urine drug screen is negative. Which of the following is the most likely diagnosis?

A 26-year-old woman comes to the outpatient psychiatric clinic seeking help for distressing daily routines that are interfering with her job as an accountant. Over the past six months, she has felt compelled to repeatedly check that her computer is locked, her office door is bolted, and her files are perfectly aligned before she can leave work. This routine takes her nearly three hours every evening. She recognizes that these behaviors are excessive and illogical, but she experiences overwhelming dread if she attempts to leave without completing the sequence. Her psychiatric history is significant for a severe manic episode at age 21 that required hospitalization, leading to a diagnosis of bipolar I disorder. She is currently euthymic, and her mood is well-controlled on maintenance lithium therapy. During the assessment, she expresses intense fear that she will be fired if her boss finds out about her condition, explicitly stating she wants this kept completely private. Which of the following is the most appropriate next step in management?

When managing patients with bipolar disorder, establishing an appropriate baseline before initiating pharmacotherapy is essential for long-term safety and adverse effect monitoring. Match each psychotropic medication below with its most critical baseline laboratory screening parameters.

Match each patient's clinical presentation with the most accurate personality disorder diagnosis.

A 31-year-old woman, G1P1, is brought to the outpatient psychiatric clinic by her husband 5 weeks after an uncomplicated vaginal delivery. Over the past three weeks, she has become increasingly sleep-deprived, tearful, and severely anxious. She tearfully reveals that she is experiencing repeated, intrusive images of herself intentionally drowning her baby in the bathtub or dropping the baby out of a second-story window. She is visibly horrified by these thoughts, stating, "I love my child more than anything, and I feel like a monster for having these terrible images in my head. I would never actually do it." As a result, she absolutely refuses to bathe the infant and will not carry the baby near any stairs or windows, demanding her husband perform these tasks. Furthermore, she checks the baby's breathing up to 20 times per night. She has no prior psychiatric history, does not hear voices, and exhibits intact reality testing. She has no history of substance use. Vital signs and physical examination are unremarkable. Which of the following are the most appropriate initial steps in the management of this patient? (Select 2 answers)

A 24-year-old male graduate student visits the campus health clinic reporting three recent episodes of intense, unprovoked terror. During these episodes, which reach maximum intensity within minutes, he experiences a racing heart, a choking sensation, tremors, and a fear of losing control. He has started avoiding large lecture halls due to the worry of having an episode in public. He has no known chronic medical conditions and takes no prescription medications. His vital signs are within normal limits. The physician suspects a primary anxiety disorder but needs to exclude physiological causes. Which of the following are the most appropriate initial diagnostic steps in management? (Select 3)

An occupational health physician evaluates a 24-year-old laboratory technician during a workplace assessment. The employee's supervisor requested the evaluation because the technician refuses to collaborate on team projects, stating that his coworkers possess 'disruptive energy fields.' During the interview, the technician avoids eye contact and speaks in a highly circumstantial and elaborate manner, frequently digressing to explain how atmospheric pressure changes alter human auras. Despite these eccentric beliefs, his speech remains logically connected, and he can be redirected to the main topic. He denies hearing voices, seeing things that others do not see, or believing that external forces are controlling his thoughts. A review of his history reveals that he has always been socially isolated and experiences intense anxiety around others that does not diminish with familiarity. His work performance in solitary tasks is excellent, and he has never experienced a major depressive or manic episode. Which of the following is the most likely diagnosis?

A 34-year-old man comes to the primary care clinic complaining of dizziness, nausea, vivid nightmares, and "electric shock-like" sensations in his head for the past 3 days. He has a history of major depressive disorder, which has been well-controlled on paroxetine for the past year. During the interview, he mentions that he felt completely back to normal, so he abruptly stopped taking his medication 4 days ago. His vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in management?

A 64-year-old man is evaluated in the outpatient clinic for a severe major depressive episode 3 months after suffering an acute anterior myocardial infarction. He is currently hemodynamically stable and compliant with his post-myocardial infarction medical regimen, which includes dual antiplatelet therapy. He reports pervasive anhedonia, early morning awakening, profound fatigue, and feelings of worthlessness. Over the subsequent 18 months, despite extensive medical management, his depressive disorder proves highly resistant to standard therapies, eventually precipitating a severe clinical deterioration characterized by extreme food refusal, profound dehydration, and catatonic posturing requiring emergent hospitalization.

Arrange the following psychiatric management steps in the most appropriate, evidence-based chronological sequence for this patient, from initial evaluation in the outpatient clinic to the management of his final acute decompensation.

A 24-year-old man is brought to the clinic by his sister due to significant behavioral changes. For the past week, he has been sleeping only 2 hours per night but reports feeling highly energetic. He speaks rapidly, frequently jumping from one topic to another, and recently maxed out his credit cards investing in a speculative cryptocurrency. Three weeks ago, the patient was diagnosed with generalized anxiety disorder and panic disorder, for which a daily oral medication was initiated. He has a past medical history of a severe depressive episode at age 19 that lasted for four months. His vital signs are within normal limits. Mental status examination reveals psychomotor agitation, pressured speech, and grandiose delusions. Which of the following is the most appropriate next step in management?

A 28-year-old man is diagnosed with schizophrenia, and the psychiatric team is planning his long-term pharmacological management. Arrange the following interventions in the correct chronological sequence according to standard evidence-based guidelines, progressing from initial therapy to the management of highly refractory illness.

Match the following brief clinical presentations with their most appropriate DSM-5 psychiatric diagnosis.

A 32-year-old male landscape architect is evaluated in the emergency department after his husband called emergency services. The patient has refused to eat for three days and states he feels "hollow and hopeless." He reports a 4-week history of severe anhedonia, hypersomnia, and a $5 \text{ kg}$ weight gain. Four years ago, he experienced a 3-week period where he slept only 3 hours per night, spoke rapidly, and recklessly spent his life savings on a failing business venture. He is currently on day 8 of a 10-day course of oral linezolid for a methicillin-resistant Staphylococcus aureus (MRSA) cellulitis. Vital signs are within normal limits. Mental status examination reveals psychomotor retardation and a blunted affect, but he is alert, oriented, and answers questions coherently. He denies hallucinations or delusions. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $3.9 \text{ \mu U/mL}$ (reference: $0.4-4.2 \text{ \mu U/mL}$) and a free T4 of $1.2 \text{ ng/dL}$ (reference: $0.8-2.7 \text{ ng/dL}$). Which of the following is the most appropriate next step in management?

A young adult with previously undiagnosed psychiatric illness presents to emergency services exhibiting profound psychomotor agitation, persecutory delusions, and command hallucinations. Over the next two years, his condition proves exceptionally difficult to manage, eventually resulting in a life-threatening pharmacological complication. Based on established psychiatric guidelines, arrange the following clinical interventions in the chronological order they would be correctly implemented for this patient's evolving clinical course.

For each of the following patient vignettes, select the most accurate personality disorder diagnosis.

Match each atypical patient clinical presentation with the most likely substance intoxication syndrome.

Match each patient's core clinical presentation and disease progression pattern to the most likely neurocognitive disorder diagnosis.

A 35-year-old male business executive presents to a new primary care physician to establish care. Upon entering the examination room, he immediately complains that the clinic's waiting area is "substandard for someone of my caliber" and insists he should not have been required to wait. During the interview, he boasts extensively about his "unmatched genius" in corporate strategy and demands referrals only to "top-tier, world-renowned specialists" for his mild lower back pain. He expresses intense envy toward a rival executive who recently received a prestigious industry award. The patient notes that yesterday, upon hearing about his rival's award, he felt a deep sense of emptiness and experienced a 2-hour episode of intense paranoia, believing his colleagues were conspiring to ruin his career. This paranoia completely resolved after he successfully led a board meeting later that afternoon. His medical history is notable for occasional low mood, for which he takes fluoxetine. Vital signs are within normal limits. Laboratory results show a thyroid-stimulating hormone (TSH) level of 1.8 µU/mL and a normal free T4. Which of the following is the most likely diagnosis?

Police officers escort a 27-year-old man to the acute care triage desk after he was found highly agitated outside a nightclub. Witnesses reported seeing him ingest an unknown substance earlier in the evening. He is uncooperative, heavily diaphoretic, and clenching his jaw. Vital signs show a temperature of 37.7°C (99.9°F), pulse of 142/min, respirations of 24/min, and blood pressure of 188/110 mmHg. His pupils are dilated but reactive to light. Cardiopulmonary examination reveals rapid, regular heart sounds and clear lungs. He exhibits no focal motor deficits. A 12-lead electrocardiogram demonstrates sinus tachycardia. Which of the following is the best initial step in managing this patient's condition?