Psychiatry

A 24-year-old woman is brought to the emergency department by her friends due to severe agitation, confusion, and high fever. The friends report that she was at an electronic dance music festival earlier in the evening where she ingested a "party pill." Her medical history is notable for treatment-resistant depression, for which she currently takes tranylcypromine. Her temperature is 39.8°C (103.6°F), blood pressure is 165/95 mmHg, and pulse is 128/min. Physical examination shows pronounced diaphoresis, dilated pupils, generalized hyperreflexia, and bilateral ankle clonus. Bowel sounds are hyperactive. Which of the following substances did this patient most likely ingest?

Match each patient's clinical presentation of an antipsychotic-induced adverse effect with the most appropriate specific pharmacological management strategy.

Antipsychotic medications modulate dopamine activity across various neural circuits, leading to both therapeutic effects and distinct adverse reactions. Match each clinical presentation described below to the specific dopaminergic pathway whose dopamine D2 receptor blockade is most directly responsible for the observed outcome.

A collegiate gymnast presents to the student health center for evaluation of a persistently depressed mood, profound fatigue, and anhedonia over the past three months. During the interview, she expresses deep dissatisfaction with her body shape and an intense fear of gaining weight. Vital signs show a heart rate of $54 \text{ /min}$ and a blood pressure of $92/58 \text{ mm Hg}$. Physical examination reveals a body mass index of $17.4 \text{ kg/m}^2$, fine downy hair on her arms, and bilateral parotid gland enlargement. Laboratory results are notable for a serum potassium of $3.2 \text{ mEq/L}$. She asks the physician to prescribe an antidepressant she read about online, describing it as 'the one that does not cause weight gain or sexual problems.' If the physician complies and prescribes this specific medication, the patient would be at significantly increased risk for which of the following complications?

A medical student on a psychiatry clerkship is reviewing the adverse effect profiles of commonly prescribed psychiatric medications. Match each of the following psychotropic medications to the clinical vignette that best describes its characteristic adverse effect or toxicity.

A 28-year-old woman presents to the clinic complaining of feeling "down" and "exhausted" for the past month. She reports struggling to get out of bed, losing interest in her hobbies, and experiencing a 3-kg (6.6-lb) weight gain. She has difficulty concentrating at work. Four years ago, she had a period lasting about a week where she felt "on top of the world," required only 3 hours of sleep a night, and started a business that quickly failed, accumulating significant debt. She is currently not taking any medications. Her vital signs are temperature 37.0°C (98.6°F), blood pressure 110/70 mm Hg, pulse 72/min, and respirations 14/min. Physical examination shows no abnormalities. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $2.1 \text{ mU/L}$ and a free thyroxine (T4) level of $1.2 \text{ ng/dL}$. Which of the following is the most appropriate initial pharmacotherapy for this patient?

During a routine wellness check, a 42-year-old male executive reports feeling constantly "on edge" and exhausted. Upon further questioning, he reveals that for the past 8 months, he has been overwhelmingly worried about various issues including his company's performance, his children's academic success, and his mortgage. He states, "I just can't turn my brain off." He also notes frequent neck stiffness and difficulty falling asleep. He denies any depressed mood, sudden rushes of fear, or repetitive rituals. He drinks one cup of coffee daily and does not use illicit substances. Vital signs are within normal limits. Physical examination shows tense trapezius muscles but is otherwise unremarkable. Thyroid-stimulating hormone (TSH) level is normal. Which of the following is the most likely diagnosis?

A 27-year-old male graphic designer is brought to the emergency department by his roommate. The patient has not left his bedroom for the past 3 weeks, has been eating very little, and sleeps up to 14 hours a day. The roommate notes that for the last 5 days, the patient has been repeatedly whispering to himself and claiming that "the authorities have hidden listening devices in the ceiling." Past psychiatric history is notable for an involuntary psychiatric admission 4 years ago due to severe agitation, grandiose beliefs of having superhuman abilities, and pressured speech; that episode lasted 12 days. The patient's medical history is significant for a recent ankle sprain, for which he is currently taking tramadol. Mental status examination reveals a disheveled appearance, poor eye contact, profound psychomotor retardation, and a restricted affect. He confirms hearing a male voice calling him a "traitor." Vital signs are within normal limits. Which of the following is the most appropriate management plan for this patient?

A 26-year-old female dental hygienist comes to the outpatient psychiatry clinic reporting two months of profound sadness, lack of motivation, and sleeping 12 to 14 hours a day. She states she has lost interest in her usual hobbies and feels intense, inappropriate guilt regarding a recent decline in her work performance. She has gained 5 kg (11 lb) over this period. Her medical history is unremarkable, and she currently takes no medications. Vital signs and physical examination are within normal limits. When specifically asked about past mood fluctuations, the patient recalls a distinct five-day period during her sophomore year of college when she felt "supercharged." During that time, she required only 3 hours of sleep per night, started multiple complex art projects, and felt highly productive. That period did not result in hospitalization or significant functional impairment. Mental status examination today reveals a cooperative woman with a blunted affect, psychomotor retardation, and slow speech. She denies suicidal ideation, auditory hallucinations, and paranoia. Which of the following is the most appropriate next step in pharmacotherapy?

A 42-year-old woman is evaluated in the psychiatric clinic and diagnosed with a moderate major depressive episode without psychotic features. Over the next 18 months, she requires multiple adjustments to her treatment plan due to inadequate symptom relief. Ultimately, her condition deteriorates, and she develops severe psychotic depression with delusions of guilt and total refusal to consume food or fluids. According to standard clinical guidelines for the stepped-care management of major depressive disorder, arrange the following therapeutic interventions in the most appropriate chronological sequence of escalation.

A 38-year-old man with a history of schizophrenia is brought to the emergency department by police due to erratic behavior in public. In the triage area, he becomes increasingly agitated, pacing rapidly, clenching his fists, and shouting that the hospital staff are 'government spies trying to poison him.' He has not physically assaulted anyone but is blocking the exit and refusing to sit down. Arrange the following interventions for managing this patient's acute agitation in the most appropriate sequential order, applying the psychiatric principle of the least restrictive alternative.

A $16$-year-old boy is brought to the emergency department by his parents due to progressive muscle weakness over the past $24$ hours. He is currently unable to stand without assistance. His parents note that he has been increasingly irritable and performing poorly in school for the past $4$ months. Two weeks ago, his primary care provider prescribed fluoxetine for suspected depression, but his behavior has not improved. A routine thyroid panel obtained at that clinic visit showed a thyroid-stimulating hormone (TSH) level of $4.5$ $\mu$ U/mL (normal: $0.4-4.0$ $\mu$ U/mL) and a normal free T4. On physical examination, temperature is $37.1^\circ$ C ($98.8^\circ$ F), blood pressure is $110/70$ mmHg, pulse is $92$/min, and respirations are $22$/min. He appears lethargic. There is an erythematous, scaling rash localized around his mouth and nose. Neurologic examination reveals symmetrical proximal and distal muscle weakness in all extremities, with diminished deep tendon reflexes. Laboratory studies show:

Serum sodium: $140$ mEq/L
Serum potassium: $2.1$ mEq/L
Serum chloride: $115$ mEq/L
Serum bicarbonate: $14$ mEq/L

Arterial blood gas (room air):
pH: $7.28$
pCO $_2$: $30$ mmHg

Which of the following is the most likely diagnosis?

A 54-year-old woman is brought to the emergency department by her daughter due to progressive confusion, unsteadiness, and shaking. The patient has a history of bipolar I disorder that has been well controlled on a stable dose of lithium for the past 8 years. Two weeks ago, she visited a primary care clinic for routine evaluation and was started on a new daily medication. Today, her temperature is 37.1°C (98.8°F), blood pressure is 128/78 mm Hg, and heart rate is 82/min. Physical examination reveals an unsteady, broad-based gait and a coarse tremor in both hands. Deep tendon reflexes are 3+ bilaterally. She also reports several days of nausea, vomiting, and diarrhea. Which of the following medications was most likely added to her regimen two weeks ago?

A 24-year-old man is recently diagnosed with schizophrenia and is currently treatment-naive. Assuming he experiences sequential medication failures due to lack of efficacy at each stage of his treatment, arrange the following management steps in the correct sequential order according to standard pharmacotherapy algorithms.

A 16-year-old boy is brought to the physician by his parents due to behavioral changes and declining school performance over the past three months. The parents report that he has been isolating himself in his bedroom, and they recently discovered a stash of empty computer duster aerosol cans under his bed. When questioned, the patient is evasive, irritable, and refuses to make eye contact. Vital signs are within normal limits. On physical examination, the patient has a mildly broad-based gait and slight dysarthria. An erythematous, eczematous rash is observed surrounding his mouth and nostrils. This patient's current substance use places him at greatest risk for which of the following life-threatening complications?

A 20-year-old female college student is brought to the student health clinic by her roommate due to severe generalized weakness, muscle cramps, and dizziness upon standing. The patient admits to having an intense fear of gaining weight and reveals that she has been using over-the-counter pills to "stay thin", though she refuses to specify the exact medication. Her body mass index is $22 \text{ kg/m}^2$. Vital signs show a blood pressure of 105/65 mm Hg supine and 85/50 mm Hg standing. Pulse is 92/min supine and 118/min standing. Physical examination is unremarkable, with no dental erosions or calluses on her hands. Laboratory studies show:

Sodium: $139 \text{ mEq/L}$
Potassium: $2.6 \text{ mEq/L}$
Chloride: $115 \text{ mEq/L}$
Bicarbonate: $14 \text{ mEq/L}$

Arterial blood gas on room air:
pH: $7.28$
$pCO_2$: $30 \text{ mm Hg}$

Which of the following inappropriate compensatory behaviors is most likely responsible for this patient's laboratory findings?

A 28-year-old male fitness coach presents to the psychiatry clinic with a 5-week history of profound sadness, anhedonia, and sleeping up to 14 hours a day. He reports significant fatigue and difficulty concentrating on his clients' workout plans. Past psychiatric history reveals an episode 3 years ago characterized by 10 days of feeling "invincible," sleeping only 2 hours nightly, and maxing out several credit cards to start an ill-advised supplement company. His medical history is unremarkable. Vital signs are within normal limits. Mental status examination reveals psychomotor retardation, poor eye contact, and a constricted affect. Which of the following pharmacological interventions are appropriate for the acute management of this patient's current episode? (Select all that apply)

A 29-year-old man comes to the primary care clinic for a routine physical examination required by his employer. He works as a night-shift security guard, a job he specifically chose to minimize interaction with others. He is wearing a heavy winter coat despite the hot summer weather, and he has multiple protective amulets around his neck. He speaks in a vague, metaphorical manner, explaining that he can 'feel the auras' of people around him and often senses an invisible 'presence' when alone. However, he denies hearing voices and does not hold any fixed, false beliefs when his thoughts are gently challenged by the physician. He reports having no friends other than his parents. He experiences severe anxiety in social situations, which he attributes to others harboring 'dark energy,' and notes this anxiety does not improve even when he spends more time with people. He states he has been this way since adolescence. Which of the following statements regarding this patient's clinical presentation are correct? (Select 2)

A 58-year-old man is brought to the clinic by his husband due to a 14-month history of progressive behavioral changes. Previously known as a meticulous and empathetic high school teacher, the patient has become increasingly apathetic and frequently makes sexually explicit remarks to neighbors. He recently ate a stranger's sandwich off their plate at a local restaurant and showed no remorse when confronted by the staff. He denies feeling sad or anxious, stating, "Everything is perfectly fine." The patient has a remote history of a single depressive episode in his 20s. He takes over-the-counter diphenhydramine occasionally for sleep but takes no prescription medications. Vital signs are within normal limits. Laboratory studies, including a thyroid-stimulating hormone (TSH) level of 1.2 mU/L and a free T4 of 1.2 ng/dL (normal: 0.8-1.8 ng/dL), are normal. On mental status examination, he has a blunted affect and poor insight, but no delusions or hallucinations are elicited. Montreal Cognitive Assessment (MoCA) score is 23/30; he loses points primarily on clock drawing and verbal fluency tasks, but successfully recalls 3 out of 3 objects after a 5-minute delay. Neurological examination reveals no focal weakness, rigidity, or resting tremor. Which of the following is the most likely diagnosis?

A 72-year-old woman is evaluated in the outpatient geriatric clinic due to progressive memory impairment and behavioral changes. According to her son, who accompanies her, she has experienced significant day-to-day fluctuations in her alertness and attention over the last 10 months. Furthermore, she frequently describes seeing detailed, silent figures of people standing in her bedroom. Her sleep is often restless, and she frequently shouts and thrashes her arms as if she is acting out her dreams. On physical examination, the patient has a mask-like facial expression, a resting tremor in her left hand, and cogwheel rigidity in both upper extremities. The physician explains the likely diagnosis to the son and discusses management options. The physician strongly cautions against the use of a specific class of medications to treat her perceptual disturbances, noting that it could trigger a severe, potentially fatal reaction characterized by irreversible parkinsonism and autonomic dysfunction. Which of the following medications is most likely to cause the severe reaction described by the physician?