Psychiatry

A 24-year-old male medical student presents to the student health clinic reporting severe anxiety about his upcoming surgery clerkship. He states that whenever he sees blood or surgical instruments, he experiences severe nausea, lightheadedness, and profound diaphoresis. During a minor suture workshop 6 months ago, he had a similar reaction and fainted. He states, "I know my fear is completely irrational, but in those moments, I feel so disconnected from reality that the room seems to be shrinking." He is terrified of failing his rotation. His past medical history is significant for mild intermittent asthma, for which he uses an albuterol inhaler as needed, and bipolar I disorder, for which he stopped taking his mood stabilizer 8 months ago because he "felt cured." Which of the following is the most appropriate next step in management?

During a follow-up visit at the university health center, a 24-year-old graduate student reports persistent feelings of profound sadness and lack of motivation that have severely impacted her studies over the past eight weeks. She mentions sleeping 11 to 13 hours daily, a recent 5-kg (11-lb) weight gain, and a sensation that her limbs are "made of lead." Two weeks prior to this visit, a physician prescribed citalopram. The patient reveals she abruptly stopped taking it three days ago due to mild nausea and a belief that "the pills were completely useless." While exploring her psychiatric history, she mentions a distinct 2-day period during her freshman year when she felt "euphoric and full of energy," requiring only a few hours of sleep while celebrating the end of final exams with friends. Her mood returned to baseline shortly after the weekend. She currently takes no medications and uses no illicit substances. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old man is evaluated in the outpatient psychiatry clinic at the insistence of his husband. For the past 8 months, the patient has been absolutely convinced that a rival accounting firm has hacked his home network and is monitoring his digital footprint. Consequently, he has disconnected the home Wi-Fi and sweeps the house weekly for hidden listening devices. Despite these behaviors at home, the patient continues to excel as a senior accountant at his firm, socializes appropriately with peers, and exhibits a normal, reactive affect with no evidence of disorganized speech or hallucinations.

Two months ago, the patient developed a pervasively depressed mood, early morning awakenings, anhedonia, and a 4-kg (9-lb) weight loss. He stated he felt "hopeless about ever regaining my privacy." These mood symptoms lasted for exactly 3 weeks before completely resolving after he purchased a sophisticated electronic signal jammer. He currently reports feeling emotionally well but remains convinced of the ongoing surveillance. Physical examination and urine toxicology screens are unremarkable. Which of the following is the most likely diagnosis?

An 82-year-old man arrives at the emergency department accompanied by his daughter due to severe agitation, disorientation, and visual hallucinations that began acutely $48$ hours ago. He repeatedly points to the corner of the room, claiming that intruders are hiding there. His daughter notes that over the past $3$ years, he has developed mild forgetfulness, such as occasionally misplacing his keys, but he has always remained independent in his daily activities. His medical history includes hypertension, osteoarthritis, and major depressive disorder. His daily medications include lisinopril and fluoxetine. Two weeks ago, he was prescribed tramadol for worsening knee pain. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $130/80\text{ mmHg}$, and a heart rate of $82\text{/min}$. Physical examination reveals no focal neurologic deficits, normal muscle tone, and absent clonus. He is unable to recite the months of the year backward. Laboratory testing reveals a thyroid-stimulating hormone (TSH) level of $2.1\text{ }\mu\text{U/mL}$ (normal: $0.5-5.0\text{ }\mu\text{U/mL}$) and free thyroxine (T4) of $1.2\text{ ng/dL}$ (normal: $0.9-2.4\text{ ng/dL}$). Urinalysis is positive for leukocyte esterase, nitrites, and numerous leukocytes. What is the most accurate diagnosis for this patient's current presentation?

Match each clinical vignette describing a psychiatric presentation to the most appropriate DSM-5 diagnostic category based on core clinical features, symptomatology, and timeframe.

A 45-year-old man presents to the primary care clinic for a routine check-up. He has a history of hypertension. Vital signs show a blood pressure of 148/92 mmHg, a heart rate of 88/min, and a respiratory rate of 14/min. Physical examination reveals mild hepatomegaly. Upon questioning, he reports drinking 6 to 8 beers daily and screens positive for severe alcohol use disorder. The physician plans to use the Transtheoretical Model (Stages of Change) to guide behavioral counseling. In what chronological order do the stages of change typically occur, progressing from an initial lack of awareness to long-term sustained behavior change?

A 68-year-old woman is brought to the emergency department by her son due to progressive behavioral changes over the past 5 weeks. She has developed profound sadness, anhedonia, and terminal insomnia, typically waking at 3:00 AM and unable to return to sleep. For the past week, she has refused all food and water, repeatedly stating, "My stomach has turned to dust, it cannot process anything." She has lost 6 kg (13.2 lbs) during this period. Her medical history is significant for Parkinson disease, for which she has been taking carbidopa-levodopa and selegiline for three years.

Vital signs show a blood pressure of 96/60 mmHg and a heart rate of 112/min. Physical examination reveals severely dry mucous membranes and decreased skin turgor.

Which of the following is the most appropriate next step in management?

A 32-year-old man comes to the primary care clinic seeking advice on weight management. He reports a long history of fluctuating weight and significant distress regarding his body size. His body mass index is 35 kg/m². During the interview, he describes frequent episodes where he consumes unusually large amounts of food, such as eating an entire family-sized pizza and a large carton of ice cream in less than an hour. During these times, he feels a complete loss of control over his eating. These episodes occur at least twice a week and are followed by intense feelings of guilt and self-disgust. He explicitly denies inducing vomiting, using laxatives, fasting, or engaging in excessive exercise after these eating episodes. Which of the following is the most likely diagnosis?

Review the following psychiatric clinical scenarios and correlate each presentation with the most accurate DSM-5 diagnostic classification.

A 28-year-old woman, 3 months postpartum, is brought to the clinic by her husband for a psychiatric evaluation. She has been exclusively formula-feeding her infant. For the past 4 weeks, she has experienced profound sadness, frequent crying spells, excessive sleepiness, and an inability to care for her baby. She states, "I am a terrible mother and my baby deserves better." Three weeks ago, her obstetrician prescribed sertraline, but she discontinued it after 5 days because she "felt it wasn't working fast enough." Her husband notes that 4 years ago, she had a 2-week period where she slept only 2 hours a night, spoke rapidly, and claimed she was chosen by God to lead a new religion; this episode required a brief psychiatric hospitalization. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $110/70 \text{ mm Hg}$, and pulse is $78/\text{min}$. Physical examination is unremarkable. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $1.5 \ \mu\text{U/mL}$ (normal: $0.5-5.0$). She is currently taking no medications. Which of the following is the most appropriate next step in management?

Match each patient's clinical presentation with the most appropriate next step in management or pharmacotherapy.

Match each of the following patient clinical vignettes with the most appropriate personality disorder diagnosis.

A 17-year-old male is evaluated in the emergency department after experiencing a syncopal episode during cross-country track practice. He reports strictly limiting his food intake over the past 8 months to 'optimize his race times' and has subsequently lost 18 kg (40 lb). Temperature is 35.8°C (96.4°F), blood pressure is 80/50 mmHg, pulse is 38/min, and BMI is 13.5 kg/m². Physical examination reveals temporal wasting, lanugo on his back, and cold, cyanotic extremities. An electrocardiogram reveals marked sinus bradycardia with a prolonged QTc interval. Laboratory studies demonstrate significant hypokalemia, hypomagnesemia, and hypophosphatemia. Arrange the following interventions in the most appropriate chronological order for the comprehensive management of this patient, from the most immediate acute intervention to long-term follow-up.

A 41-year-old man is brought to the emergency department by emergency medical services due to severe agitation and abdominal cramps. The patient states he was discharged earlier this morning from a residential rehabilitation facility after completing a 5-day medically supervised withdrawal for alcohol use disorder. His past medical history is significant for a 10-year history of severe opioid use disorder, for which he has been enrolled in a methadone maintenance program for the last 3 years with no recent illicit opioid use. At the time of his discharge from the alcohol rehabilitation facility today, he was prescribed a daily oral medication to reduce alcohol cravings. He took the first dose of this new medication 45 minutes ago and rapidly developed his current symptoms. He denies consuming any alcohol since entering the rehabilitation program. His temperature is 37.8°C (100.0°F), blood pressure is 156/94 mm Hg, pulse is 112/min, and respirations are 22/min. Physical examination reveals a restless, profusely diaphoretic man. He is yawning frequently and has prominent rhinorrhea. Pupils are dilated at 7 mm bilaterally and reactive to light. Neuromuscular examination reveals diffuse myalgias but no rigidity or clonus. Bowel sounds are hyperactive. The medication prescribed at discharge most likely exerts its primary effect at which of the following targets?

A 41-year-old male electrician is brought to the outpatient psychiatric clinic by his brother. The patient reports a 6-week history of overwhelming fatigue, anhedonia, and sleeping 12 to 14 hours daily. He has been unable to work and struggles to perform basic personal hygiene. Review of his psychiatric history reveals an episode three years ago during which he experienced a persistently elevated mood, believed he had discovered a groundbreaking theory of electricity, and stayed awake for 8 days straight working on erratic diagrams. That episode culminated in involuntary psychiatric hospitalization. He currently takes no medications, and his basic laboratory workup, including a thyroid panel, is unremarkable. Which of the following is the most appropriate pharmacotherapy for this patient's current presentation?

An $80$-year-old man with a history of moderate Alzheimer disease and benign prostatic hyperplasia is brought to the emergency department by his daughter, who is his legally appointed healthcare proxy. Over the past $48$ hours, he has become acutely agitated, disoriented, and has been grasping at invisible objects. Two days ago, he started taking an over-the-counter diphenhydramine preparation for insomnia. The patient's visiting son arrived today and insists the patient be transferred immediately to a psychiatric facility. A recent outpatient urine culture grew $>10^5 \text{ CFU/mL}$ of Escherichia coli sensitive to nitrofurantoin and cephalexin. Recent thyroid tests showed a serum thyroid-stimulating hormone of $1.5 \ \mu\text{U/mL}$ (normal: $0.4-4.0 \ \mu\text{U/mL}$) and a free thyroxine of $0.5 \text{ ng/dL}$ (normal: $0.9-2.4 \text{ ng/dL}$). Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $135/85 \text{ mm Hg}$, pulse $108\text{/min}$, and respirations $16\text{/min}$. Physical examination reveals dry oral mucosa, flushed skin, and a palpably distended bladder. Which of the following is the most appropriate initial management for this patient?

Match each clinical presentation of acute substance intoxication to the primary molecular mechanism of the offending agent.

Match each patient's clinical presentation with the most appropriate tailored pharmacotherapy or neuromodulation therapy.

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

Match each clinical vignette with the most likely underlying neurocognitive diagnosis.