Psychiatry

A 23-year-old male construction worker is evaluated at an occupational health clinic after sustaining a minor ankle sprain. During the evaluation, the physician notes that the patient exhibits psychomotor retardation and a markedly flat affect. The patient admits to feeling overwhelmingly sad and sleeping nearly 15 hours a day for the past six weeks, which has severely impaired his job performance. A thorough psychiatric review of systems reveals that two years ago, he experienced a distinct 6-week period where he worked his construction job all day, drove for a rideshare company all night, slept only 90 minutes per night, and felt "more powerful than ever." He is not currently taking any medications. Which of the following medications are appropriate monotherapy choices for his current clinical presentation? (Select all that apply)

A 45-year-old man presents to a dermatologist for the fifth time in a year. He is convinced that he has a severe parasitic infection of his skin, specifically claiming that microscopic worms are burrowing under his epidermis and multiplying. During the visit, he triumphantly shows the physician a small matchbox containing lint, scabs, and skin flakes, asserting they are "specimens" of the parasites. He reports that this infestation began 7 months ago. He strongly denies any depressed mood, hearing voices, or other unusual experiences. He continues to work successfully as a mechanical engineer and maintains a healthy relationship with his wife, who states he is completely normal except for his "obsession with his skin." Physical examination reveals numerous linear excoriations on his forearms and lower legs from chronic scratching. A comprehensive toxicology screen is negative. Which of the following is the most likely diagnosis?

Match each distinct clinical presentation to its most likely substance-related diagnosis.

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

A 22-year-old female college student presents to the university health clinic reporting recurrent, unexpected episodes of intense fear. During these episodes, she experiences palpitations, diaphoresis, shortness of breath, and a profound fear of losing control. The episodes peak within 10 minutes and have occurred four times in the past month. She now actively avoids the campus library, where two of the episodes occurred, fearing she will have another attack and be unable to escape. Her medical history is significant for a hospitalization one year ago for a 3-week period of severely decreased need for sleep, pressured speech, and grandiose delusions involving a belief that she was a prophet chosen to solve world hunger. She was stabilized and discharged but voluntarily discontinued all her psychiatric medications 6 months ago. Vital signs are within normal limits. Physical examination, electrocardiogram, and baseline laboratory studies, including a comprehensive metabolic panel, thyroid-stimulating hormone, and urine toxicology, are unremarkable. Which of the following is the most appropriate next step in management?

A 41-year-old man presents to the clinic with persistent low mood, anhedonia, and insomnia that have significantly impaired his ability to perform his job. He is diagnosed with major depressive disorder (MDD). He has no prior psychiatric history, no history of hypomanic or manic episodes, and no acute suicidal ideation. He expresses a preference for pharmacological treatment. Assuming the patient experiences inadequate clinical improvement at each successive stage of treatment, arrange the following management steps in the correct chronological sequence according to standard stepped-care guidelines for MDD.

For each of the following patients presenting with depressed mood, select the most appropriate initial or next-step intervention based on their specific clinical diagnosis.

Evaluate the following patient scenarios and match each clinical presentation to its most accurate DSM-5 psychiatric diagnosis within the eating disorder spectrum.

Match each psychiatric emergency presentation with its most appropriate specific targeted treatment or intervention.

Match each clinical presentation of a psychiatric or substance-related emergency to the most appropriate specific pharmacological treatment or reversal agent.

Paramedics bring a 21-year-old university student to the emergency department following a syncopal episode during a ballet class. Her dance instructor notes she has appeared increasingly emaciated over the past six months and frequently complains of being cold. Upon arrival, the patient expresses intense fear of gaining weight despite her visible cachexia. Vital signs show a temperature of 35.6°C (96.1°F), blood pressure of 82/50 mm Hg, heart rate of 38/min, and respiratory rate of 12/min. Her body mass index is calculated at 12.8 kg/m2. Physical assessment reveals lanugo over her back and acrocyanosis. A 12-lead electrocardiogram demonstrates marked sinus bradycardia with a prolonged QTc interval. Laboratory evaluation highlights a serum potassium of 2.9 mEq/L and a serum phosphorus of 2.2 mg/dL. Arrange the following clinical management steps in the most appropriate chronological order from initial acute presentation to long-term maintenance.

A 58-year-old man is brought to the physician by his wife due to profound changes in his behavior over the past 12 months. His wife states that he was previously a reserved and empathetic middle school teacher, but he recently began making sexually explicit comments to strangers at the grocery store. He has also developed a habit of eating exclusively sugary cereals and frequently takes food from the plates of other patrons at restaurants. When confronted about these actions, the patient is apathetic and demonstrates no remorse. His medical history is significant for hyperlipidemia. Vital signs are within normal limits. On mental status examination, he is alert and oriented to person, place, and time. He scores 26/30 on the Montreal Cognitive Assessment, primarily losing points on verbal fluency and abstraction. Memory recall is intact. Neurological examination reveals a positive grasp reflex but is otherwise unremarkable. Which of the following is the most likely diagnosis?

During a routine wellness visit, the parents of a 4-year-and-10-month-old male express significant distress regarding their son's pervasive hyperactivity. They report that he is perpetually in motion, often climbing atop tall bookshelves and abruptly darting into busy streets if his hand is not firmly held. Furthermore, he was recently dismissed from his second preschool program due to his inability to remain seated during structured activities and his tendency to forcefully snatch items from peers. These behavioral challenges are consistently observed across home, school, and social environments. His vocabulary is expansive for his age, and his gross and fine motor milestones are within expected parameters. Physical examination and sensory screenings are unremarkable. The parents inquire about initiating a trial of stimulant therapy. Which of the following is the most appropriate initial intervention for this patient?

A 28-year-old woman, G1P0 at 30 weeks gestation, presents to the emergency department with sudden-onset shortness of breath, palpitations, sweating, and a feeling of impending doom that began 30 minutes ago while she was reading a book at home. She states, "I feel like I am going to die." This is her third such episode in the past month. She has recently started avoiding grocery stores and movie theaters because she fears she might have another attack and be unable to quickly escape.

Vital signs are temperature 37.1°C (98.8°F), blood pressure 120/70 mm Hg, pulse 115/min, and respirations 22/min. Pulse oximetry is 99% on room air. Physical examination shows a gravid uterus consistent with dates. The lungs are clear to auscultation bilaterally, and heart sounds are normal.

Arterial blood gas on room air reveals:
pH: 7.44
PaO2: 104 mm Hg
PaCO2: 29 mm Hg
HCO3-: 21 mEq/L

Her past medical history is notable for a distinct 2-week episode of auditory hallucinations and persecutory delusions 5 years ago that resolved completely without recurrence. Two years ago, she was diagnosed with bipolar disorder following an episode of euphoric mood, hypersexuality, and decreased need for sleep. The patient's husband is in the waiting room. The patient explicitly tells the physician, "Please do not discuss my psychiatric history with my husband. I have never told him, and he would not understand."

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

A 29-year-old man comes to the outpatient clinic to establish care following successful completion of a 28-day residential substance use treatment program. He has a long history of severe opioid use disorder and alcohol use disorder. The patient reports that he has maintained complete abstinence from all opioids and alcohol for the past 24 days. He states, 'I am determined to stay clean this time, but my cravings for both heroin and alcohol are overwhelming.' His past psychiatric history is significant for major depressive disorder. During a previous attempt at outpatient treatment two years ago, he exhibited poor medication adherence and was ultimately discharged from the practice after admitting to diverting his prescribed sublingual buprenorphine-naloxone. Liver function tests obtained at the residential facility last week were within normal limits. Vital signs today are within normal limits. Physical examination shows no signs of intoxication or withdrawal. Which of the following is the most appropriate pharmacotherapy to prevent relapse in this patient?

A 28-year-old woman is brought to the emergency department by law enforcement after she was found walking barefoot in the center of a busy interstate highway. During the psychiatric evaluation, she displays a flat affect and disorganized speech. She calmly explains that she is an emissary of an extraterrestrial civilization and must immediately return to the highway to await her mothership. She is medically stable, unarmed, and not acutely aggressive, but she repeatedly attempts to walk out of the examination room, stating, 'You have no right to keep me here, and I will not take any of your poisons.' Arrange the following clinical and legal interventions in the most appropriate chronological order for managing this patient's admission and ongoing psychiatric care.

Match each patient's clinical presentation with the most likely corresponding neuroimaging or ancillary diagnostic finding.

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?

A 32-year-old woman presents to the outpatient clinic 3 weeks after surviving a traumatic emergency plane landing as a passenger. She describes having severe, recurrent nightmares about the event, hypervigilance, and feeling detached from her loved ones. She has refused to fly since the incident and has taken a leave of absence from her job as a corporate executive. She also reports feeling persistently 'down' and fatigued. Her past psychiatric history is significant for bipolar I disorder, but she discontinued her prescribed mood stabilizer 6 months ago. For the past month, she has been taking daily over-the-counter St. John's wort to manage her low mood. She is highly distressed and asks the physician not to disclose her visit to her company's human resources department, which requires medical clearance for her leave. The physician determines she meets the criteria for acute stress disorder. Which of the following are the most appropriate actions in the management of this patient? (Select 2)

A $19$-year-old male college student is brought to the emergency department by his roommate due to bizarre behavior and severe agitation over the past $24$ hours. The roommate reports that the patient has been barricading the door, claiming that hidden cameras are recording him. The patient has a history of major depressive disorder, for which he takes citalopram. He recently developed a mild upper respiratory infection and has been drinking multiple bottles of over-the-counter cough syrup daily to experience a "euphoric high." Temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), pulse is $126/\text{min}$, respirations are $22/\text{min}$, and blood pressure is $155/95\text{ mm Hg}$. Physical examination reveals a profusely diaphoretic, tremulous young man. Neurologic examination demonstrates bilateral hyperreflexia and prominent spontaneous clonus in the lower extremities. Which of the following is the most appropriate next step in the management of this patient?