Psychiatry

A 28-year-old woman is brought to the outpatient clinic by her husband for evaluation of abnormal behavior and low mood. For the past 10 weeks, she has exhibited profound sadness, extreme fatigue, and hypersomnia, often sleeping 14 hours a day. Her husband reports that for the last 6 weeks, she has been responding to unseen stimuli and admits to hearing a persistent voice calling her a "worthless failure."

Two years ago, the patient experienced a 2-week episode of euphoric mood, boundless energy, and rapid speech. During that time, she slept only 2 hours a night and spent the couple's entire savings on unneeded luxury goods, which required a brief psychiatric hospitalization.

She currently takes no medications but asks if she can be started on a combination of a selective serotonin reuptake inhibitor (SSRI) and a monoamine oxidase inhibitor (MAOI), as she read online that this combination is highly effective for severe depression.

Laboratory evaluation shows:
Thyroid-stimulating hormone (TSH): 1.8 µU/mL (Normal: 0.5-5.0 µU/mL)
Free thyroxine (T4): 0.5 ng/dL (Normal: 0.9-1.7 ng/dL)

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

A 17-year-old girl is admitted to the hospital for medical stabilization of severe anorexia nervosa, restricting subtype. Her body mass index on admission is $12.5 \text{ kg/m}^2$. Her home medication of fluoxetine is continued. Routine admission laboratories reveal a normal thyroid-stimulating hormone (TSH) level with a low total T3 and low-normal free T4. Due to her profound malnutrition, continuous nasogastric tube feeding is initiated at a high caloric rate to promote rapid weight gain. On the third day of hospitalization, the patient suddenly develops significant shortness of breath, a cough productive of pink frothy sputum, and orthopnea. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), pulse is $118\text{/min}$, respirations are $28\text{/min}$, and blood pressure is $92/60\text{ mmHg}$. Physical examination reveals distinct jugular venous distention and bilateral basilar lung crackles. Which of the following is the most likely primary mechanism for this patient's acute clinical deterioration?

Correlate the following clinical scenarios involving psychotropic polypharmacy with their underlying pharmacokinetic or pharmacodynamic interaction mechanisms and resulting clinical consequences.

Match each patient presentation with the mechanism of action of the most appropriate pharmacotherapy for their clinical scenario.

A 48-month-old boy presents for pediatric evaluation at the urging of his early childhood educator. The educator expressed strong concerns regarding potential Attention-Deficit/Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder (ASD). According to the school's behavioral report, the child is unable to sit quietly during a 45-minute continuous group reading session, frequently fidgets, and often engages in parallel play alongside his peers rather than joining their cooperative group games. The parents report that at home, he speaks in 4-word sentences, consistently uses pronouns correctly, and enjoys pedaling his tricycle. During the clinic visit, the child successfully copies a cross on a piece of paper but is unable to copy a triangle. He demonstrates robust, reciprocal eye contact and uses index finger pointing to indicate interest in toys across the room. Based on this clinical presentation, which of the following statements are correct? (Select all that apply)

A 35-year-old woman is brought to the clinic by her husband for a follow-up appointment. Two weeks ago, she was prescribed sertraline 50 mg daily for a 2-month history of pervasive sadness, sleeping 12 hours a day, a heavy sensation in her extremities, and a 10-lb weight gain following the sudden death of her father. Today, she reports no improvement in her mood and asks to stop the antidepressant because "two weeks is long enough to know it is not working."

She has a history of a pituitary microadenoma treated with transsphenoidal resection 3 years ago, for which she takes levothyroxine. She also takes a daily over-the-counter St. John's wort supplement. Upon further questioning, her husband notes that during college, the patient had a distinct 6-day period where she slept only 2 hours a night, spoke extremely rapidly, and maxed out her credit cards. She also mentions hearing her deceased father's voice calling her name once a few days ago.

Vital signs are within normal limits. Laboratory studies show:

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

A 34-year-old female software developer comes to the physician's office with her husband. She reports feeling profoundly sad and exhausted for the past month. The patient states she has no energy, sleeps up to 12 hours daily, and struggles to concentrate on her programming tasks. Two weeks ago, her primary care provider diagnosed her with major depressive disorder and prescribed fluoxetine. However, she states her mood has not improved and she now feels increasingly restless. During the interview, her husband notes that three years ago, the patient had a discrete 6-day period where she was unusually energetic, required only three hours of sleep per night, spoke very rapidly, and compulsively reorganized their entire home. She did not require hospitalization at that time and returned to her normal baseline afterward. Her past medical history is unremarkable. Vital signs are within normal limits. Laboratory studies reveal a serum thyroid-stimulating hormone (TSH) level of 1.8 µU/mL and a free T4 of 1.2 ng/dL. On mental status examination, she exhibits psychomotor retardation and a flat affect. Which of the following is the most appropriate next step in pharmacotherapy for this patient?

A $52$-year-old man is brought to the emergency department by emergency medical services after being found somnolent in a park. He has a documented history of severe alcohol use disorder and has been unhoused for the past year. On initial evaluation, he is lethargic but easily rousable. Vital signs reveal a temperature of $35.8^\circ\text{C}$ ($96.4^\circ\text{F}$), blood pressure of $105/60\text{ mmHg}$, pulse of $112/\text{min}$, and respiratory rate of $14/\text{min}$. A point-of-care blood glucose level is $52\text{ mg/dL}$. Over the next hour, he becomes increasingly awake but is agitated, profoundly diaphoretic, and exhibits bilateral action tremors of his hands. Arrange the following clinical interventions in the most appropriate sequential order for the comprehensive management of this patient, from initial emergency presentation through hospital discharge.

A 28-year-old man is brought to the emergency department by his husband due to worsening fatigue, dizziness, and a recent syncopal episode. He is a competitive marathon runner who has been rigorously restricting his caloric intake for the past eight months to 'improve race times.' He reports an intense fear of gaining weight and strictly avoids any foods containing fat. Temperature is 35.4°C (95.7°F), blood pressure is 82/50 mm Hg, pulse is 38/min, and respirations are 12/min. BMI is 13.2 kg/m². Physical examination reveals temporal wasting, fine downy hair over his back, and cold, cyanotic extremities. Laboratory studies show:

An ECG reveals marked sinus bradycardia with a QTc interval of 490 ms. The patient is admitted to the hospital. Arrange the following multidisciplinary management steps in the most appropriate chronological order, from immediate acute intervention to long-term maintenance.

A 22-year-old man is brought to the emergency department by his college roommates after he began acting erratically and destroying furniture in their apartment. His roommates suspect he ingested a synthetic hallucinogen at a party earlier in the evening. In the evaluation room, the patient exhibits severe psychomotor agitation, rapid pacing, and hostility, loudly threatening to 'break out' of the hospital. He aggressively waves off the nurse who attempts to obtain vital signs.

Arrange the following interventions in the most appropriate sequential order for managing this patient's acute agitation, progressing from the least restrictive to the most restrictive measure.

Evaluate the following clinical scenarios of patients presenting with depressive symptoms. Match each patient's clinical presentation with the most suitable treatment modality based on their specific features and comorbidities.

A 27-year-old female is evaluated in the emergency department for severe fatigue, generalized muscle weakness, and palpitations. She has a history of major depressive disorder and a long-standing intense fear of gaining weight. She exercises vigorously for 2 hours daily and adheres to a strict diet. Her body mass index is $22.0 \text{ kg/m}^2$. She denies self-induced vomiting but admits to secretly taking "herbal bowel cleansers" containing senna extract multiple times a day for the past year to prevent weight gain. Vital signs are temperature 37.0°C (98.6°F), blood pressure 95/60 mm Hg, pulse 112/min, and respiratory rate 12/min. Physical examination reveals dry oral mucosa and diffusely decreased muscle strength in all extremities. Electrocardiogram shows flattened T waves and prominent U waves.

Laboratory studies:
Sodium: $135 \text{ mEq/L}$
Potassium: $2.4 \text{ mEq/L}$
Chloride: $115 \text{ mEq/L}$
Bicarbonate: $12 \text{ mEq/L}$
Blood urea nitrogen: $28 \text{ mg/dL}$
Creatinine: $1.1 \text{ mg/dL}$

Arterial blood gas analysis on room air:
pH: 7.27
$pCO_2$: 38 mm Hg
$pO_2$: 94 mm Hg

Based on the clinical and laboratory findings, which of the following best describes this patient's acid-base status?

A 34-year-old male with a history of treatment-resistant schizophrenia is hospitalized for the management of severe lower extremity cellulitis. His daily psychiatric regimen includes clozapine 400 mg daily, which has successfully managed his psychotic symptoms for the past two years without major adverse effects. The patient has a 15-pack-year smoking history and typically smokes two packs of cigarettes daily. Because the hospital is a strict tobacco-free facility, he is prescribed a continuous 21-mg nicotine transdermal patch upon admission to prevent withdrawal. On hospital day 4, the nursing staff notes that the patient is profoundly sedated, confused, and experiencing excessive drooling. Later that afternoon, he suffers a witnessed generalized tonic-clonic seizure. Vital signs reveal a blood pressure of 100/60 mmHg and a heart rate of 112/min. Laboratory studies show a leukocyte count of 7,500/mm³ and a normal basic metabolic panel. Which of the following pharmacological mechanisms is the most likely primary cause of this patient's acute neurological complication?

A 29-year-old man comes to the psychiatry clinic seeking help for distressing mental images. For the past 3 months, he has experienced recurrent, intrusive thoughts of violently harming strangers. He finds these images horrifying and states, "I would never do such a thing, but I just can't stop the thoughts." To temporarily relieve his anxiety, he taps his forehead exactly 15 times whenever an image appears. His psychiatric history is notable for treatment-resistant depression, for which he was prescribed phenelzine 2 years ago with a good response. A review of his electronic medical record reveals a 5-day episode last year characterized by grandiosity, a decreased need for sleep, rapid speech, and hypersexuality. The patient is employed as an accountant. His manager recently left a voicemail at the clinic requesting a medical update because the patient has been taking frequent breaks. Which of the following is the most appropriate next step in management?

A 23-year-old woman comes to the outpatient psychiatric clinic for a follow-up appointment. Five months ago, she experienced the sudden onset of auditory hallucinations and persecutory delusions, believing that her university professors were conspiring to harm her. These symptoms began abruptly three days after she was involved in a severe motor vehicle collision. She was hospitalized and started on oral aripiprazole. Her psychotic symptoms completely resolved 3 weeks after they initially began. She was subsequently discharged and has been taking aripiprazole daily. She has had no recurrence of symptoms for the past 4 months, and her academic and social functioning have returned entirely to their premorbid baseline. She is bothered by mild weight gain and asks how much longer she must continue taking the medication. What is the most appropriate next step in the management of this patient's pharmacotherapy?

Match each mood stabilizer or second-generation antipsychotic used in the management of bipolar disorder with its most characteristic adverse effect profile, baseline monitoring requirement, or presentation of toxicity.

A 68-year-old woman is evaluated in the outpatient clinic for an acute episode of major depressive disorder without psychotic features. Over the course of the next year, her condition proves highly resistant to standard therapies, eventually culminating in severe clinical deterioration. Arrange the following clinical management steps in the correct evidence-based chronological sequence, reflecting the standard escalation of psychiatric care from initial presentation to the eventual onset of life-threatening psychotic depression with severe food refusal.

A 38-year-old male accountant is brought to the outpatient psychiatric clinic by his husband due to a 3-week history of worsening depressed mood, severe fatigue, and anhedonia. He reports sleeping up to 14 hours a day and has gained 5 kg (11 lbs) during this time. The patient states he feels completely hopeless and occasionally wishes he would not wake up in the morning, though he denies any active plan to end his life. When asked about unusual experiences, he mentions that over the past few days, he has occasionally heard his mother's voice calling his name just as he is drifting off to sleep. His psychiatric history is notable for an episode four years ago during which he felt "invincible" for 2 weeks. During that time, he slept only 3 hours per night, spoke incessantly, and impulsively spent his entire life savings on a high-risk cryptocurrency venture, resulting in personal bankruptcy. He was not hospitalized for that episode and currently takes no medications. Vital signs are within normal limits. Laboratory results show a thyroid-stimulating hormone (TSH) level of 1.5 µU/mL (normal: 0.4-4.0 µU/mL) and a free T4 of 1.1 ng/dL (normal: 0.8-1.8 ng/dL). Which of the following is the most appropriate next step in management?

Match each clinical presentation of a patient with an eating or somatic symptom-related disorder to the most characteristic laboratory abnormality or physical finding associated with their condition.

A 15-year-old female is brought to the outpatient psychiatric clinic by her parents due to increasing school refusal, irritability, and tearful outbursts over the past six months. She recently started high school and complains that she is "exhausted all the time." When asked to explain, she states, "I have to constantly study how other girls act and rehearse my conversations so I don't seem weird. I never naturally know when it is my turn to speak or what people's facial expressions mean." The patient also reports that the noise and fluorescent lights in the school cafeteria cause her physical pain, prompting her to eat alone in a quiet stairwell. Her parents note that she has an intense, exclusive fascination with 19th-century European royalty, spending several hours daily memorizing genealogical trees. She becomes highly distressed and has "meltdowns" if her rigidly structured evening routine is altered. Her early motor and language milestones were reportedly achieved at appropriate ages, though she was considered a solitary child.

Which of the following best describes the underlying nature of this patient's condition?