Psychopharmacology and Psychological Therapies

An individual with a well-documented history of bipolar I disorder is evaluated in the emergency department for altered mental status. According to family members, the patient has become progressively lethargic, confused, and unsteady on their feet over the past 48 hours. The patient has been taking divalproex sodium for several years with excellent mood control. Two weeks ago, a neurologist initiated topiramate for migraine prophylaxis. On examination, the patient is disoriented to time and place. When asked to hold their arms outstretched with wrists extended, a bilateral, non-rhythmic, flapping tremor is observed. Laboratory studies, including a complete blood count, aspartate aminotransferase, alanine aminotransferase, and total bilirubin, are all strictly within normal limits. Which of the following is the most likely cause of this patient's current presentation?

A 24-year-old man with a history of schizophrenia is brought to the emergency department from a residential psychiatric facility due to profound muscle stiffness, confusion, and diaphoresis. His vital signs show a temperature of 39.8°C (103.6°F), blood pressure of 165/100 mmHg, and heart rate of 122/min. Physical examination reveals generalized "lead-pipe" rigidity and coarse tremors. He was recently transitioned to intramuscular fluphenazine decanoate. Laboratory studies reveal a serum creatine kinase level of 5,200 U/L. Arrange the following steps in the most appropriate chronological sequence for the management of this patient's current condition and his subsequent long-term psychiatric care.

A number of patients present with unique adverse effects after initiating pharmacological treatment for major depressive disorder. For each clinical presentation, select the most likely responsible antidepressant.

A 28-year-old woman comes to the clinic for a routine follow-up. She has a 5-year history of bipolar I disorder. Six months ago, she experienced a severe manic episode, and her psychiatric medication regimen was changed due to inadequate symptom control on lithium therapy. At that time, she was transitioned to a different mood stabilizer, and her mood symptoms have remained well-controlled since. She has no other medical conditions. Her only other medication is a combined oral contraceptive pill (ethinyl estradiol and levonorgestrel), which she has taken consistently at the same time every day for the past 3 years without any missed doses. Today, the patient reports a 6-week history of amenorrhea, breast tenderness, and morning nausea. A urine pregnancy test in the clinic is positive. Which of the following psychiatric medications was most likely initiated six months ago?

Emergency medical services bring a 26-year-old woman to the hospital due to severe agitation and confusion that began abruptly this morning. According to her roommate, the patient has been recovering from an upper respiratory tract infection over the past few days and recently started taking a new over-the-counter syrup for a persistent, dry cough. Her only daily prescription medication is citalopram for major depressive disorder. Upon arrival, the patient appears profoundly restless and disoriented. Vital signs show a temperature of 38.9°C (102.0°F), blood pressure of 162/94 mm Hg, heart rate of 128/min, and respiratory rate of 22/min. Physical examination reveals warm, diaphoretic skin and visibly dilated pupils. She has continuous rhythmic muscle twitching in her lower extremities, brisk patellar reflexes (4+ bilaterally), and sustained ankle clonus. Which of the following active ingredients is most likely present in the cough medication this patient consumed?

Match each acute medication-induced psychiatric emergency or toxidrome with its most appropriate specific therapeutic intervention.

A 34-year-old man is newly diagnosed with severe major depressive disorder without psychotic features. Over the course of 18 months, his symptoms prove to be highly refractory to standard treatments despite confirmed medication adherence. Arrange the following clinical management steps in the most appropriate chronological sequence, reflecting the standard escalating algorithm for treatment-resistant depression.

A 34-year-old man presents to a new primary care physician complaining of severe fatigue, sleeping 12 to 14 hours a day, significant weight gain, and an inability to experience pleasure in his usual hobbies for the past two months. He states that his depressive symptoms are significantly impairing his daily functioning and requests a specific prescription for an antidepressant. Upon detailed psychiatric review, he mentions that four years ago, he experienced a one-month period where he abruptly quit his job, maxed out several credit cards to start a speculative business venture, and felt "like a superhuman" despite resting for only an hour each night. He was involuntarily hospitalized during that period due to aggressive behavior but subsequently declined long-term medication. He has no other medical conditions and his physical examination is unremarkable. Which of the following is the most appropriate pharmacological therapy for this patient's current symptoms?

A 47-year-old man is evaluated in the emergency department for altered mental status, fever, and severe agitation that started a few hours ago. His wife reports that he had been recovering from a minor ankle sprain sustained over the weekend. His medical history is significant for treatment-resistant major depressive disorder, for which he has been taking tranylcypromine for the past two years. His temperature is 39.4°C (102.9°F), blood pressure is 168/105 mm Hg, and pulse is 128/min. On physical examination, the patient is visibly diaphoretic. Neurological examination reveals spontaneous clonus in the lower extremities and horizontal ocular clonus. He recently started taking a new medication prescribed for his ankle sprain. Which of the following medications was most likely prescribed?

A 28-year-old man is brought to the emergency department with altered mental status, severe agitation, and tremors. He recently started taking linezolid for a methicillin-resistant Staphylococcus aureus skin infection while maintaining his usual daily dose of sertraline. Vital signs are temperature 39.8°C (103.6°F), pulse 132/min, respirations 22/min, and blood pressure 165/95 mm Hg. Physical examination reveals marked diaphoresis, mydriasis, hyperreflexia, and spontaneous ankle clonus. Arrange the following management steps in the correct sequential order for this patient, from the immediate initial action to interventions reserved for progressive or severe refractory symptoms.

Match each psychotropic medication used during pregnancy with its most characteristic associated fetal or neonatal adverse effect.

A 24-year-old woman comes to an urgent care clinic reporting a painful skin rash, sore throat, and a low-grade fever that began 48 hours ago. Her medical history is notable for bipolar I disorder. She has been stable on valproate for three years. Five weeks ago, her psychiatrist initiated a cross-taper to a new mood stabilizer due to the patient's concerns regarding ongoing weight gain and hair thinning. She has been taking both medications exactly as prescribed. Her temperature is 38.8°C (101.8°F), pulse is 108/min, and blood pressure is 110/70 mm Hg. Physical examination reveals a diffuse, tender, erythematous, macular rash that easily coalesces into large blisters. Gentle pressure on the skin causes the top layer of the epidermis to detach. There are multiple painful erosions on her buccal mucosa and lips. Which of the following pharmacokinetic interactions most likely contributed to this patient's current condition?

A psychiatric consultation is requested for a 31-year-old male inpatient admitted to the medical intensive care unit. The patient was transferred from an outpatient psychiatric facility after developing severe muscle stiffness, diaphoresis, and altered mental status. He has a history of schizoaffective disorder and was recently prescribed fluphenazine. Current vital signs include a pulse of 115/min, blood pressure of 165/95 mmHg, and a temperature of 39.1°C (102.4°F). Physical examination reveals mutism and profound 'lead-pipe' rigidity. Laboratory evaluation reveals a significantly elevated serum creatine kinase level. The diagnosis of neuroleptic malignant syndrome (NMS) is established.

Arrange the following clinical interventions in the correct chronological sequence for managing this patient's condition, from the most immediate initial step to the final long-term management step.

Match each patient's clinical presentation to the psychological therapy that represents the most appropriate, evidence-based first-line treatment for their specific condition.

A 38-year-old man is brought to the emergency department by his husband due to a sudden, severe, pounding headache, blurred vision, and chest palpitations. The symptoms began approximately 45 minutes ago. The patient has a history of severe, treatment-resistant major depressive disorder. He recently started a new psychiatric medication after trials of several selective serotonin reuptake inhibitors and a serotonin-norepinephrine reuptake inhibitor failed to improve his mood. Earlier this evening, he attended a holiday party where he consumed multiple glasses of tap beer, aged cheddar cheese, and cured sausages. His temperature is 37.2°C (99.0°F), blood pressure is 218/124 mm Hg, pulse is 122/min, and respirations are 18/min. Physical examination reveals a diaphoretic and tremulous man. Neurological examination shows no focal deficits, and an unenhanced head CT scan reveals no abnormalities. Which of the following medications is this patient most likely taking?

A 34-year-old man with treatment-resistant schizophrenia is brought to the emergency department by his partner after experiencing a generalized tonic-clonic seizure lasting approximately 2 minutes. He has no prior history of seizures. His psychotic symptoms have been well controlled on a stable regimen of clozapine 400 mg daily for the past 3 years. Four weeks ago, the patient suffered an uncomplicated myocardial infarction and was discharged on aspirin and atorvastatin. At that time, the patient successfully quit smoking cold turkey after previously smoking 2 packs of cigarettes daily for 15 years. He reports no illicit drug or alcohol use. His temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, pulse is 88/min, and respirations are 16/min. Physical examination reveals a postictal state but is otherwise unremarkable. Laboratory studies show an absolute neutrophil count of $5,200/mm^3$ and normal liver function tests. Which of the following is the most likely mechanism responsible for this patient's new-onset seizure?

A 24-year-old man is diagnosed with schizophrenia after presenting with a 7-month history of auditory hallucinations and persecutory delusions. His psychiatrist is planning a long-term pharmacotherapy strategy. Assuming the patient exhibits an inadequate clinical response to each consecutive intervention despite optimal dosing and confirmed medication adherence, arrange the following treatment steps in the correct standard algorithm for the management of schizophrenia.

A 62-year-old man is evaluated in the hospital due to rapidly worsening mental status. He was admitted three days ago for complicated cellulitis of the right lower extremity and was started on intravenous linezolid. His past medical history is significant for major depressive disorder, for which he has taken fluoxetine for several years. Today, he developed sudden-onset severe agitation, restlessness, and confusion. His temperature is 39.2°C (102.6°F), blood pressure is 165/100 mmHg, pulse is 124/min, and respirations are 22/min. Physical examination demonstrates excessive diaphoresis and shivering. Neurological examination reveals prominent hyperreflexia and inducible ankle clonus bilaterally in the lower extremities. Initial management with intravenous normal saline, cooling blankets, and intravenous lorazepam does not sufficiently control his severe symptoms. Which of the following is the most appropriate next step in pharmacologic management?

A 31-year-old man presents to the clinic to discuss starting medication for newly diagnosed major depressive disorder. He is prescribed escitalopram 10 mg daily. The physician provides psychoeducation regarding what to expect during the course of treatment. Arrange the following clinical events in the most likely chronological sequence of their typical onset or occurrence after initiating this selective serotonin reuptake inhibitor (SSRI).

A 32-year-old woman with a history of bipolar I disorder comes to the outpatient psychiatry clinic due to a 4-week history of depressed mood, profound fatigue, and sleeping up to 14 hours a day. Her last manic episode occurred two years ago, and she has been maintained on a stable dose of valproate since that time. Vital signs include a heart rate of 72/min, blood pressure of 118/76 mm Hg, and respiratory rate of 14/min. Mental status examination reveals psychomotor retardation, a blunted affect, and a sad mood. She denies any suicidal ideation. The physician decides to add lamotrigine to her current regimen to target the depressive symptoms. To minimize the risk of a life-threatening dermatologic complication, which of the following pharmacokinetic principles must be applied to the management of this patient?