Rosh + UWorld Psych Quizlet

For patients with severe antisocial personality disorder that leads to severe aggression, what medications are indicated?

Risperidone or Quetiapine **For mild cases of antisocial personality disorder, CBT is the recommended therapy.

What is the preferred treatment for performance-related anxiety?

Beta Blockers such as Propranolol or Benzodiazepines **Performance-related anxiety is classified as performance-only social anxiety disorder. Pharmacologic treatments include as-needed beta blockers or benzodiazepines. Benzodiazepines should be avoided when cognitive and sedative side effects could impair performance.

A 19-year-old woman presents to the clinic with her family, who express concern over her recent behavior. She has been skipping her college classes and has not been to work for 2 weeks. When questioned about these behaviors, the patient states she cannot go to school or work because she has to focus on her fashion design career. She expresses profound pleasure in her new work and states she has been working closely with Giorgio Armani. The patient appears irritable and jumps from one unrelated topic to another without pause during the conversation. She has no significant medical history. Which of the following is the most likely diagnosis? A) Bipolar I disorder B) Bipolar II disorder C) Delusional disorder D) Schizophreniform disorder

Bipolar I disorder **Bipolar disorder is a mood disorder subclassified in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders as either bipolar I disorder or bipolar II disorder based on the presence of manic, hypomanic, or depressive symptoms. Manic episodes present with an abnormally elevated, expansive, or irritable mood that persists most of nearly every day during a 1-week period or longer. A single episode of mania is required for the diagnosis of bipolar I disorder, while bipolar II disorder requires hypomania with episodic depression. Mania is defined as an abnormally and persistently elevated, expansive, or irritable mood.

A 24-year-old woman with a past medical history of untreated hepatitis C virus presents to the emergency department with suicidal ideation. She reports that, for the past 7 days, she has been on a spending spree and bought three cars, which she cannot afford. She also notes during this time she has felt well-rested with minimal sleep. During your assessment, she is easily distracted and talks rapidly. She has a negative urine drug screen. Which of the following is a concerning possible adverse effect of the recommended mood-stabilizing medication for this patient?

Decline in kidney function **Lithium is classically known to cause a decline in kidney function over time. The risk factors for this decline include prolonged use, higher serum concentrations, older age, medical comorbidities, and a lower baseline glomerular filtration rate. Lithium is preferred over valproate in this patient because she is of childbearing age and has a history of hepatitis C virus. Valproate can cause hepatotoxicity and is avoided in women of childbearing age due to teratogenicity.

A 6-year-old boy presents to the clinic for assessment after his teacher noticed that he has difficulty remaining seated during class, difficulty playing quietly, and frequently interrupts others. His mother has noticed a similar pattern at home. You discuss the suspected diagnosis with his mother and decide to start him on the first-line pharmacologic treatment. Which of the following is a common adverse effect of this medication?

Decreased appetite

A 54-year-old woman presents to the office for follow-up for her major depressive disorder. She was started on low-dose imipramine a couple of months ago, and the dose was slowly titrated at her last visit after a partial response in mood symptoms was noted. Today, she reports her mood and anhedonia are improved, but she is concerned about the development of possible side effects related to the increased dosage of her medication. What side effect would she most likely report? A) Diarrhea B) Dry mouth C) Urinary urgency D) Weight loss

Dry mouth **Dry mouth is an anticholinergic side effect commonly associated with tricyclic antidepressants (TCAs), which are used to treat major depressive disorder, panic disorder, generalized anxiety disorder, bulimia nervosa, and post-traumatic stress disorder. TCAs are categorized into tertiary amines and secondary amines. Tertiary amines include amitriptyline, doxepin, and imipramine.

A 25-year-old woman is brought to the office by her husband due to intense mood swings and unusual behavior. She has rapid mood shifts that last a few hours. Although the patient is usually quiet and reserved, her husband says that she can suddenly become enraged without provocation. She does not remember these episodes. Her husband once found her at a local bar dressed in a seductive outfit; when he called her name, she did not respond and walked away. At home, the patient denied having been at the bar and hid behind a chair crying. When she was finally convinced to come out, she spoke in a childlike voice, and said "leave me alone." The patient was sexually abused from age 5-16. She has difficulty giving a detailed history and has many gaps in her memory. The patient's mood is anxious, and she hears voices that she describes as coming from inside her head. Which of the following is the most likely diagnosis? A) Bipolar disorder B) Depersonalization/derealization disorder C) Dissociative amnesia D) Dissociative identity disorder E) Schizoaffective disorder

Dissociative identity disorder **This patient's gaps in autobiographical memory and recall of everyday events and behavior suggestive of different personality states (ie, uncharacteristically aggressive and sexual behavior; regressive behavior and speaking in a childlike voice) are consistent with dissociative identity disorder (DID). DID is a severe, chronic condition in which ≥2 distinct identities, or personality states, alternately take control of an individual. Patients also experience memory loss that is too extensive to be explained by ordinary forgetfulness. Transition from one personality to another can be sudden and is usually precipitated by stress. DID is strongly associated with a history of severe and prolonged childhood trauma (eg, physical, sexual, or emotional abuse; neglect). Personality states are often connected to traumatic experiences such as a terrified, child crying or an angry, persecutory figure. Patients commonly have chronic auditory hallucinations that have been present since childhood and are perceived as inside the patient's head (as opposed to psychotic disorders in which voices seem to come from outside the head). Treatment consists of long-term, trauma-focused psychotherapy.

A 25-year-old man presents to the clinic with irritability 5 days after discontinuing a psychoactive substance containing delta-9-tetrahydrocannabinol. Which of the following is the most common manifestation of the withdrawal syndrome associated with this substance?

Disturbed sleep **There is variation in the severity of cannabis withdrawal symptoms. The symptoms typically begin 1 to 3 days after the last cannabis use, reach peak intensity within the first week, and then resolve within 1 to 2 weeks. Disturbed sleep is the most common symptom.

A 35-year-old patient reports an alcohol intake of two cases of beer per week. This alcohol consumption causes him to miss work frequently, and he reports risky sexual encounters while acutely intoxicated. He would like to discuss options to help him reduce his reliance on alcohol. In addition to behavioral and social interventions, which of the following medications is appropriate? A) Acarbose B) Chlordiazepoxide C) Disulfiram D) Naloxone

Disulfiram **Medical approaches include disulfiram and naltrexone to discourage alcohol use. Naltrexone can be initiated while the patient is still drinking while disulfiram causes unpleasant side effects such as flushing and palpitations if used concomitantly with alcohol. Acamprosate may also be used once abstinence is achieved in order to reduce the symptoms of withdrawal.

A 45-year-old woman presents to the clinic due to insomnia. She has no trouble falling asleep but awakens in the middle of the night and cannot stay asleep. She has been practicing good sleep hygiene according to a prescribed cognitive behavioral approach for the past 6 months but continues to struggle maintaining sleep. Which of the following medications is most appropriate for this patient?

Doxepin **The patient in the vignette has no difficulty falling asleep but has problems maintaining sleep. Medications that help maintain sleep include long-acting nonbenzodiazepine benzodiazepine receptor agonists, dual orexin receptor antagonists, and histamine receptor antagonists (low-dose doxepin). These medications can also be used for sleep initiation and mixed insomnia.

According to the National Institute on Alcohol Abuse and Alcoholism, which of the following would classify a male patient under the age of 65 years to have an increased health risk due to his alcohol consumption?

Drinking more than 14 standard drinks per week **They note that men under the age of 65 years old are at increased health risks if they consume more than 14 standard drinks in a given week or more than 4 standard drinks in a single day. Women under the age of 65 years old are noted to be at increased risk if they consume more than 7 standard drinks per week or more than 3 standard drinks in a single day.

A 25-year-old woman presents to the clinic with her husband due to concerns of difficulty sleeping and irritability. Her husband reports his main concern is that she has been calling out of work and has not been wanting to spend time with family because she is always tired. She reports that she recently stopped marijuana use due to being admitted into a master's program and reports occasional alcohol use. Which of the following is the appropriate treatment for this patient?

Dronabinol **She is going through cannabis withdrawal. If she had mild symptoms that wasn't affecting her daily life then treatment wouldn't be necessary. However, since it is causing her to call out of work, causing difficulty sleeping and making her irritable, it is more preferred to treat with Dronabinol or Gabapentin. Zolpidem may also be used for her insomnia symptoms.

A 43-year-old man presents with anhedonia, insomnia, weight loss, intense fatigue, and feelings of worthlessness for the past 3 weeks. In addition to psychotherapy, you decide to prescribe the most suitable atypical antidepressant based on his symptoms. Which of the following side effects for this medication should you educate the patient about? A. Diarrhea B. Drowsiness C. Orthostatic hypotension D. Psychomotor agitation

Drowsiness **The Atypical antidepressants are Mirtazapine, Bupropion, Agomelatine. Bupropion may cause insomnia or psychomotor agitation, while mirtazapine is most likely to result in drowsiness and weight gain.

A 68-year-old man is evaluated for balance issues that have lasted 2 weeks. He has had muscle stiffness and 3 near-falls recently. The patient has no musculoskeletal pain or visual concerns. He has a history of bipolar disorder and anxiety and was prescribed valproate and risperidone for a manic episode 5 months ago. The patient's other medical condition is hypertension controlled with hydrochlorothiazide. Temperature is 37.2 C (99 F) and blood pressure is 122/78 mm Hg supine and 130/80 mm Hg standing. The patient appears slightly anxious but no longer manic. There is an asymmetric resting tremor in both hands. Finger-tapping is slow and irregular bilaterally. Which of the following is the most likely cause of this patient's current condition? A) Acute dystonia B) Akathisia C) Drug-induced Parkinsonism D) Neuroleptic malignant syndrome E) Tardive dyskinesia

Drug-induced Parkinsonism **This patient recently started antipsychotic therapy (ie, risperidone) for mania and has symptoms consistent with drug-induced parkinsonism, an extrapyramidal adverse effect of antipsychotics. Symptoms include rigidity (possibly experienced as subjective stiffness), resting/postural tremor, masked facies, and bradykinesia (eg, slow finger-tapping) and typically occur within the first 3 months of drug initiation. The most common offending agents are first-generation antipsychotics (eg, haloperidol); however, second-generation antipsychotics and some antiemetics (eg, metoclopramide) are implicated to varying degrees. Extrapyramidal symptoms (EPSs) are theorized to result from D2 antagonism in the nigrostriatal pathway. In the striatum, the inhibitory effects of dopaminergic neurons (D2) are normally balanced by the excitatory actions of muscarinic cholinergic neurons (M1). Strong dopaminergic blockade causes increased cholinergic activity, resulting in extrapyramidal adverse effects (eg, acute dystonic reactions, akathisia, parkinsonism). If the offending agent cannot be removed, medications with M1 anticholinergic properties (eg, benztropine, diphenhydramine) help reestablish the dopaminergic-cholinergic balance and effectively treat symptoms.

A 45-year-old woman presents to the clinic for her annual physical exam. You have seen the patient over the years and have met her husband multiple times. During the appointment, she discusses the sexual relationship she is having with Brad Pitt and tells you he recently proposed and they are engaged. On the patient's intake form, she wrote down her relationship status as married. When asked about her husband, she states "he is doing well and has no idea about Brad and me." Her physical exam and laboratory results are unremarkable, and the following week her husband comments he is concerned about his wife's claims to be engaged to Brad Pitt. What is the minimum length of time symptoms have to be present for the suspected diagnosis?

1 month **This is delusional disorder erotomanic type

A 52-year-old man presents to the clinic for a wellness exam. Which of the following is the most appropriate frequency for screening this patient for unhealthy alcohol use?

12 months **The United States Preventive Services Task Force recommends all adults in primary care who have services available for follow-up should be screened annually to identify unhealthy alcohol use.

A 20-month-old boy presents to the pediatrician with his mother, who is concerned that he does not seem interested in interacting with her. She has also noticed that he does not like to make eye contact and has intense interests in visual stimuli, such as flashing lights. He seems easily irritated by small changes in the daily routine. At which of the following months does the American Academy of Pediatricians recommend screening for the suspected diagnosis?

18 and 24 months **The American Academy of Pediatrics recommends screening for autism spectrum disorder at 18 and 24 months of age in all children using the Modified Checklist for Autism in Toddlers, Revised with Follow-up. The purpose of this test is to identify children who are at-risk for autism spectrum disorder, but it does not confirm the diagnosis.

Which of the following patients would be most likely to present with generalized anxiety disorder? A. 16 year-old boy B. 21 year-old woman C. 35 year-old man D. 45 year-old woman

21 year-old woman **Generalized anxiety disorder is more common in women than men but is most likely to present in younger women.

A 22-year-old man presents to the emergency department in a catatonic state. He was found at home with a few white tablets in his hand. Vital signs show tachypnea, tachycardia, hyperpyrexia, and hypertension. Physical exam shows vertical nystagmus and hyperreflexia. Laboratory results show elevated creatine kinase. Which of the following substances did this patient most likely ingest?

3-Methoxyphencyclidine **Phencyclidine is a dissociative anesthetic that has been used as a recreational drug since the 1970s. In recent years, synthetic derivatives of phencyclidine have been produced, such as 3-Methoxyphencyclidine (3-MeO-phencyclidine) and 4-Methoxyphencyclidine (4-MeO-phencyclidine), that offer more potent dissociative effects. Signs and symptoms of intoxication with phencyclidine and its synthetic derivatives can include hallucinations, psychosis, catatonia, coma, agitation, hyperreflexia, hyperpyrexia, tachycardia, elevated blood pressure, disorientation, seizures, and nystagmus (horizontal, vertical, or rotatory). Common laboratory abnormalities associated with phencyclidine intoxication include elevated creatine kinase (indicative of rhabdomyolysis), hypoglycemia, elevated liver transaminases, and hyperuricemia.

A 24-year-old man presents to the emergency department with intractable vomiting. He reports he has had similar episodes previously, and his symptoms seem to be relieved by hot showers. How long is the substance suspected to be causing this patient's symptoms typically detected in the urine?

30 days **Cannabis hyperemesis syndrome is a rare complication of cannabis use in which individuals experience abdominal pain, nausea, and vomiting that is typically relieved by hot showers. It is most common in chronic cannabis users. Due to its pharmacokinetics, cannabis can be detected in urine testing for as long as 30 days, particularly in chronic users (who it can be found in for many months)

A 32-year-old woman presents to the clinic complaining of irritability, difficulty concentrating, and fatigue for the past 8 months. She reports that she feels stressed at home and work and easily becomes anxious in response to trivial stressors. She reports no anhedonia or a depressed mood. You decide to start her on venlafaxine to treat the suspected diagnosis. How long should treatment be continued before increasing the dose or switching to another medication if she is not experiencing improvement on a therapeutic dose?

6 weeks **It takes on average 4 weeks for patients to experience clinically meaningful action from a serotonin reuptake inhibitor. Therefore, it is recommended that the initial therapeutic dose be given for 4-6 weeks before an adjustment is made in the dose or medication. Patients who are not experiencing a robust response at this point should have the dose increased or be switched to a new medication. Buspirone is frequently used as an augment to selective serotonin reuptake inhibitors or serotonin and norepinephrine reuptake inhibitors. Benzodiazepines, such as lorazepam, can be used long-term in patients who are refractory to antidepressants and do not have a history of substance misuse.

A 12-year-old patient presents to the clinic for help with aggression toward parents and family pets, frequent violations of the law that include arson and theft, and bullying others at school. Which of the following is also most likely to be true of this patient?

ADHD **Conduct disorder is often comorbid with oppositional defiant disorder, attention-deficit/hyperactivity disorder, and substance use disorders. Treatment of conduct disorder begins with treatment of any comorbid disorders, specifically attention-deficit/hyperactivity disorder. Psychosocial therapy is the most effective treatment modality for conduct disorder, including counseling for both the parents and the child.

A 24-year-old woman presents to her therapist to discuss her dietary habits. She reports that she intermittently consumes large amounts of food, such as two large pizzas or two dozen cookies, and subsequently feels guilty. Which of the following additional features is most suggestive of binge eating disorder?

Absence of compensatory behaviors **Excessive exercise is an example of a compensatory behavior. This lack of compensatory behavior is what differentiates Binge eating disorder from Bulimia nervosa.

5 Distinct Stages of Change: - An active change or behavioral modification

Action (4)

A 28-year-old woman comes to the office for follow-up due to depression. She was prescribed fluoxetine after 4 weeks of depressed mood, loss of interest in activities, fatigue, hypersomnia, and carbohydrate cravings. After 8 weeks of treatment, the patient feels partially better but continues to struggle with low energy and weight gain. Although she functions adequately at work, she spends the rest of the time at home, feeling too tired and unmotivated to go out with friends or exercise. The patient has a history of antidepressant treatment for recurrent depressive episodes that start in the late fall and improve by the spring, when she feels significantly better. She usually stops taking the medication for several months until the depression returns. Which of the following is the best next step in management of this patient? A) Add aripiprazole B) Add bright light therapy C) Add valproate D) Switch to lithium E) Switch to phenelzine

Add bright light therapy **This patient's recurrent major depressive episodes with onset in the fall and remission in the spring are characteristic of major depressive disorder with seasonal pattern (ie, seasonal affective disorder [SAD]). SAD with fall-winter onset and spring-summer remission, the most common type of seasonal depression, is generally characterized by atypical features of depression such as increased sleep, increased appetite, carbohydrate craving, and weight gain. First-line treatment consists of antidepressants and bright light therapy. This patient has had a partial response to antidepressant therapy and would benefit from the addition of light therapy. Bright light therapy is typically initiated shortly after awakening. Most patients experience clinical improvement in 1-4 weeks and continue treatment through the fall or winter until spontaneous remission in the spring or summer. Light therapy alone is a reasonable alternative for patients with mild-to-moderate SAD.

A 65-year-old man is brought to the office by his daughter due to decreased activity and impaired sleep over the past month. The patient was diagnosed with Parkinson disease 2 years ago. According to his daughter, he displays very few emotions and wants to do nothing. The patient does not want to leave his house and sits in his chair and watches TV with a blank expression. He has been waking up early in the morning, which is very unusual. The patient is adherent with his levodopa-carbidopa treatment. Physical examination shows masklike facies and slowed movements. Mild hand tremor and postural instability have improved since his last visit. Which of the following is the most appropriate next step in pharmacologic management of this patient? A) Add amantadine B) Add quetiapine C) Add sertraline D) Discontinue levodopa-carbidopa E) Add selegiline

Add sertraline **Depression affects up to 50% of patients with Parkinson disease (PD) and can negatively impact their quality of life. It can be easily overlooked because some depressive symptoms may be mistakenly attributed to the progression of PD. For example, the depressed, blunted affect looks like masked facies; psychomotor slowing is similar to bradykinesia. This patient's month-long history of decreased interest, low energy, and early-morning awakening is concerning for depression. Because his other Parkinson symptoms, such as tremor and postural instability, seem improved since his last visit, an antidepressant trial would be the most appropriate next step in pharmacologic management. Selective serotonin reuptake inhibitors (eg, sertraline) are typically used first because of their favorable adverse effect profile. Nonpharmacologic approaches, such as cognitive-behavioral therapy, can also be considered.

A 5-year-old girl is brought to the office due to behavioral changes. The mother says, "We took her to a magic show a few months ago and bought a toy wand from the gift shop. Now she thinks she has special powers." The patient brings the wand to school each morning so that "bad things don't happen." A week ago, she forgot to bring her wand home, and that night, her father was in a motor vehicle collision that resulted in a fractured wrist. The patient says, "my dad got hurt because of me. It was my fault." She has become more protective of the wand and no longer shares it with her classmates because "it will lose its power." Each night before falling asleep, the patient closes her eyes and taps her wand in the air 3 times to make sure she and her family stay safe. Vital signs and physical examination are normal. Which of the following is the most likely diagnosis? A) Adjustment disorder B) Age-appropriate development C) Obsessive-compulsive disorder D) Schizotypal personality disorder E) Separation anxiety disorder

Age-appropriate development **This girl's belief that her magic wand can directly influence events around her is characteristic of magical thinking, a normal phase of cognitive development in children age 2-7. During this phase, children often combine fantasy elements taken from toys and entertainment with real life events. They can have strong beliefs in the magical powers of objects and the existence of imaginary characters (eg, tooth fairy, fantasy characters, imaginary friends). This girl's belief that she directly caused her father's injury by forgetting her wand is also an example of the egocentric thinking that characterizes normal cognitive development during these years; young children often see an event as it relates to themselves only and may feel responsible when something bad happens. (Choice D) Although magical thinking can be seen in patients who go on to develop schizotypal personality disorder, it would typically be accompanied by a persistent pattern of unusual perceptual experiences, eccentric behavior, and excessive social anxiety. This child's magical thinking is developmentally appropriate and likely to be outgrown.

A 52-year-old woman with a known diagnosis of chronic glaucoma and schizophrenia presents with a resting tremor, cogwheel rigidity, and bradykinesia. Which of the following therapeutics would be most effective in treating these symptoms?

Amantadine **Parkisonian syndrome is characterized by cogwheel rigidity, mask-like facies, shuffling gait, resting tremor, and bradykinesia. Amantadine is a nonanticholinergic antiparkinsonian medication that may be used to treat parkinsonian extrapyramidal side effects caused by antipsychotic medications. Anticholinergic medications, such as benztropine, are also used but present an increased risk in patients with glaucoma or cognitive impairment.

A 22-year-old woman with a history of congenital prolonged QT interval presents to the clinic with dysphoria for the past 2 months. She reports she has felt fatigued, been sleeping more than usual, and had decreased appetite. She has not been interested in doing activities she previously viewed as hobbies. Which of the following medications to treat her suspected condition would require an electrocardiogram prior to initiation? A) Amitriptyline B) Duloxetine C) Escitalopram D) Venlafaxine

Amitriptyline **Risk of abnormal heart rhythms, such as heart block and ventricular dysrhythmias, is one of the safety concerns associated with tricyclic antidepressants because these medications can prolong the QT interval on electrocardiogram. Therefore, patients should undergo a cardiac evaluation prior to the prescription of a tricyclic antidepressant.

A 11-year-old girl is brought to the office by her mother, who is upset over her daughter's poor grades. On her most recent report card, the girl received Cs and Ds in most academic subjects. Typical teacher comments have included, "Mind seems elsewhere," "Frequently misses important details," and "Work is handed in late and is messy, incomplete, and disorganized." At home, the girl is occasionally moody and easily frustrated when reminded to complete her chores. Apart from the issue of her grades, the girl enjoys school and is sleeping and eating well. On mental status examination, she makes good eye contact. She is responsive to questions but is occasionally distracted, requiring redirection. Which of the following medications would be most effective for this patient? A) Amphetamine B) Atomoxetine C) Fluoxetine D) Guanfacine E) No pharmacologic treatment necessary

Amphetamine **In addition to psychosocial interventions (eg, behavioral therapy), stimulant medications (eg, methylphenidate, amphetamines) are first-line agents in school-aged children with ADHD and are more effective than nonstimulant medications. They are efficacious, safe, have a rapid onset of action and are generally well-tolerated (Choice E). Nonstimulant options include the norepinephrine reuptake inhibitor atomoxetine and alpha-2 adrenergic agonists. Atomoxetine is appropriate for patients with a history of illicit substance use or when there is a strong family preference against stimulant medication (Choice B).

A 23-year-old woman with an unknown medical history presents to the emergency department via ambulance with altered mental status. The patient's partner reports finding her unconscious at home with an empty bottle of alprazolam nearby. Exam reveals a somnolent patient with slurred speech. Current vital signs are temperature 98.2°F, BP 98/65 mm Hg, HR 52 beats per minute, RR 10 breaths per minute, and oxygen saturation 92% on room air. You and your team suspect benzodiazepine overdose and are considering administering a medication to reverse the effects of the benzodiazepine. Which of the following most accurately describes the method of action of this medication?

Antagonist of the GABA receptor **Flumazenil is a nonspecific competitive antagonist of the benzodiazepine receptor on the GABA/benzodiazepine receptor complex that can be used to treat benzodiazepine-induced sedation following anesthesia or overdose

A 21-year-old man comes to the emergency department due to a broken nose. He got into a fight at a bar after he became angry with another man for looking at his girlfriend. The patient is not allowed back at that bar because he has started so many fights there. He says, "The other guy looks much worse than I do, but he had it coming." The patient has had multiple jobs in the past year and was recently fired for repeated absences. He states, "That job was beneath me. I can make more money doing something else." Starting in middle school, the patient had repeated suspensions for truancy and fighting; he blames his failure to be accepted into college on the teachers who reported his behavior. Which of the following is the most likely diagnosis in this patient? A) Antisocial personality disorder B) Borderline personality disorder C) Conduct disorder D) Intermittent explosive disorder E) Narcissistic personality disorder

Antisocial personality disorder **This patient's reckless disregard for the safety of himself and others, unstable employment history, and lack of remorse are suggestive of antisocial personality disorder (ASPD). ASPD is a lifelong disorder characterized by a pervasive pattern of disregard for and violation of the rights of others, beginning in childhood or early adolescence and continuing into adulthood (age ≥18 required for diagnosis). An essential feature for the diagnosis of ASPD is evidence of conduct disorder at age ˂15 (eg, this patient's history of truancy and fighting starting in middle school). Individuals with ASPD tend to be physically aggressive and impulsive and may repeatedly get into fights. Additional typical behaviors include illegal activities (eg, illicit drug use, theft), lying, and manipulation of others for personal gain. This patient's arrogant self-appraisal, lack of remorse, and failure to accept responsibility for his own behavior (eg, blaming teachers for not getting into college) are characteristic of ASPD.

A 19-year-old man is evaluated for a hand injury. He says, "I was just minding my own business at work when this dog bit me." The patient recently started maintenance work for a wealthy apartment complex and his "entrepreneurial skills" have made him "richer than a doctor." He has been fired from multiple jobs due to getting into arguments with coworkers and being repeatedly late to work. As an adolescent, he regularly missed school and spent time in a detention center for breaking into his teacher's home. Which of the following is the most likely diagnosis? A) Antisocial personality disorder B) Borderline personality disorder C) Conduct disorder D) Narcissistic personality disorder E) Oppositional defiant disorder

Antisocial personality disorder **This patient's suggested illegal activity, unstable employment history, irritability with coworkers, and repeated tardiness to work are most consistent with a diagnosis of antisocial personality disorder (or dissocial personality disorder). Antisocial personality disorder (ASPD) is characterized by a pattern of disregard for and violation of the rights of others, beginning by early adolescence and persisting into adulthood (age ≥18 required for diagnosis). An essential feature for diagnosis of ASPD is evidence of conduct disorder prior to age 15 (eg, this patient's history of missing school and breaking into his teacher's home). Although this patient exhibits grandiosity and lack of empathy seen in narcissistic personality disorder, this would not explain his lifelong pattern of involvement in violent and/or criminal activities.

A 36-year-old woman presents to the clinic for an annual physical and reports new-onset intermittent headaches that have been ongoing for the past month. Despite normal laboratory studies, CT, MRI, and EEG, the patient is insistent that part of her brain is rotting and frustrated that no one believes her. She reports no constitutional symptoms, hallucinations, or changes in cognition or memory. Her physical exam results are unremarkable compared to her previous visits. Which of the following medications would be most beneficial for this patient? A) Aripiprazole B) Duloxetine C) Diazepam D) Fluoxetine

Aripiprazole **Delusional disorders first-line medication are Antipsychotics. Those with fewer side effects (e.g., aripiprazole, ziprasidone) should be considered with a low initial dose and gradual dosage increases over several days or weeks.

A 23-year-old woman with schizophrenia presents to the clinic for follow-up after beginning risperidone 5 months ago. The patient reports decreased symptoms after starting risperidone, but she has not menstruated for 3 months and has noticed an increased frequency of headaches. Which of the following medications is most appropriate for continued treatment?

Aripiprazole **Risperidone, a frequently administered second-generation antipsychotic, may also cause hyperprolactinemia leading to hypogonadism (e.g., oligomenorrhea, amenorrhea, galactorrhea, decreased bone mineral density). Patients with these manifestations should be switched to alternative antipsychotic medications with a lower probability of prolactin elevation, such as aripiprazole.

A 53-year-old man has been prescribed chlorpromazine for many years for schizophrenia. His psychotic symptoms have been stable, but he has developed a tremor in his hands and he walks slower. His other medical conditions include obesity and hypercholesterolemia. The patient has been trying to exercise and has managed to lose 5 kg (11 lb) since his last visit. He is concerned about his hands shaking and would like to lose more weight. BMI is 37 kg/m2. The patient has psychomotor retardation, slow speech, and lack of facial expressions. A resting tremor of the hands is noted. He would like to switch to another medication. Which of the following medications would be most appropriate for this patient? A) Aripiprazole B) Clozapine C) Haloperidol D) Lamotrigine E) Olanzapine

Aripiprazole **This patient has Parkinsonism (tremor, bradykinesia, masked facies), an EPS, and could benefit from a switch to an SGA. Of the SGAs, aripiprazole has a lower potential for causing weight gain or metabolic syndrome and should be considered in this obese, hypertensive patient. Ziprasidone is also associated with comparatively less weight gain but has somewhat greater risk of QT prolongation than other SGAs. (Choices B and E) Clozapine and olanzapine are more likely to cause weight gain and metabolic syndrome compared to other antipsychotics. In addition, clozapine can cause life-threatening agranulocytosis and is reserved for treatment-resistant cases.

A 5-year-old boy presents to the clinic with his father who reports persistent behavioral issues since age 4 that have been recently worsening. The patient's father is concerned about daily temper tantrums and disobedient behavior at home, including arguing with his parents and deliberately annoying his siblings. He also reports teacher concerns about irritable mood and disregard for classroom rules on an almost daily basis. Which of the following interventions is most appropriate for this patient given the most likely diagnosis?

Assess psychosocial situation and parent training **This is Oppositional Defiant Disorder (ODD). Treatment consists of parent training combined with outpatient psychological therapy. It is important to evaluate the child's psychosocial environment and also provide proper support to parents, as they may experience adverse mental health effects due to the difficult behavior and social disruption. Parent training is the most important aspect of treatment as it teaches parents to be more positive and less harsh in their discipline style.

A 35-year-old man presents to the clinic for an annual wellness exam. You ask him about tobacco use, and he reports that he smokes cigarettes daily. According to the five As approach to helping patients with tobacco cessation, which of the following is the third step?

Assess readiness to quit **5 A's: - Ask (1) - Advise (2) - Assess (3) - Assist (4) - Arrange (5)

During a sleep study, electroencephalography indicates low voltage, sawtooth waves while electromyography indicates atonia. Electro-oculography indicates conjugate, irregular, sharply peaked eye movements. Which of the following is most accurate of this stage of sleep?

Associated with vivid dreaming **Sleep can be divided into nonrapid eye movement (NREM) sleep and rapid eye movement (REM) sleep. Sleep in the REM stage is characterized by low voltage, mixed EEG patterns with sawtooth waves; rapid eye movements, including conjugate, irregular, and sharply-peaked movements; and atonia as demonstrated on EMG.

A 24-year-old man with a previous history of alcohol use disorder presents to the clinic reporting symptoms of difficulty concentrating, forgetfulness, restlessness, carelessness, and fidgeting during class. He reports having similar symptoms when he was a child. He recently reenrolled in school and is concerned that he may not be able to pass his classes. Which of the following is the most appropriate treatment for this patient?

Atomoxetine **The patient in the above vignette has attention-deficit/hyperactivity disorder. For patients with a previous history of substance use disorder, such as the patient in the vignette, the first-line treatment for attention-deficit/hyperactivity disorder is atomoxetine because it has little to no overuse potential

A 13-year-old girl is brought to the office by her mother due to concerns about the girl's adjustment to a new school. The patient has always been shy and somewhat awkward. The new school emphasizes group projects, which the mother thought would help her daughter be more social but instead has made her extremely anxious. The patient is bright but underachieves at school and has few friends. She has an obsessive interest in horses. During the interview, the patient makes poor eye contact, interrupts questions by changing topics, and mentions facts about different horse breeds. When her vital signs are checked, she touches the blood pressure cuff repeatedly. Which of the following is the most likely explanation for this patient's behavior? A) Autism spectrum disorder B) Obsessive-compulsive disorder C) Schizoid personality disorder D) Schizotypal personality disorder E) Social anxiety disorder

Autism spectrum disorder **This patient's social awkwardness, intense interest in and restricted focus on a single topic (horses), and unusual sensory interest (repeated touching of the blood pressure cuff) are suggestive of a mild form of autism spectrum disorder (ASD). In cases of severe autism, where language and intellectual development are affected, children are typically diagnosed by age 5. However, in high functioning autism, where language and intellectual development may be normal, the diagnosis comes to attention only later when social demands reveal the child's social-emotional deficits. Other features suggestive of ASD include the lack of initiation or response to interaction with others, awkward body language, reduced range of affect or emotional sharing, difficulty understanding the needs of others, and lack of flexibility. Patients may have sensory aversions (eg, dislike of sounds/textures) or excessive interest in sensory experiences (eg, touching, smelling, fascination with movement).

A 53-year-old man comes to the office due to depressed mood, low energy, and poor sleep for the past 2 months. Although he spends most of the day lying in bed, he gets only 4-5 hours of sleep and never feels rested. He is isolating himself from his family and says, "I eat only because I have to." The patient has had several previous periods of depression but was never diagnosed or treated. He also has had periods lasting 5-6 days at a time in which he gets a burst of energy and feels great. During these times, he likes to work extra-long hours to take on additional projects at work, and he feels well rested despite sleeping only 4 hours a night. He has been uncharacteristically procrastinating on several projects and is frequently late to work. He has no motivation to spend time with his family. Mental status examination shows slow speech, a sad affect, and no suicidal ideation. Which of the following is the most likely diagnosis in this patient? A) Bipolar I disorder B) Bipolar II disorder C) Cyclothymic disorder D) Major depressive disorder E) Persistent depressive disorder (Dysthymia)

Bipolar II disorder **The differential diagnosis of mood disorders requires screening for hypomanic and manic symptoms. This patient is currently in a major depressive episode (eg, ≥2 weeks, depressed mood, decreased interest, low energy, sleep and appetite disturbance) but also describes a history consistent with hypomania (eg, elevated mood, increased energy and productivity at work, flight of ideas, decreased need for sleep lasting ≥4 days). Occupational functioning in hypomania is either improved, as in this patient, or only mildly impaired. Mania, in contrast, is characterized by more severe symptoms resulting in markedly impaired functioning (eg, unable to work, grossly disorganized behavior), psychosis, or need for psychiatric hospitalization. Patients with a history of ≥1 major depressive episode, ≥1 hypomanic episode, and no manic episodes are diagnosed with bipolar II disorder. In contrast, patients diagnosed with bipolar I disorder must have a history of ≥1 manic episode and frequently experience major depressive episodes, although these are not required for diagnosis (Choice A).

A 19-year-old man presents to the office accompanied by his brother for a 7-month history of changes in his behavior. The brother reports the patient's college roommate notified the family that the patient has been acting strangely. The brother reports the patient has an infatuation with a local news reporter, who the patient believed was talking directly to him during her newscast. The patient started writing letters to her and calling the station frequently to talk to his "girlfriend." He has missed several lectures for one of his courses so he would not miss the newscast. At one point, he went to the station on Valentine's Day with flowers and was turned away by security. His grades have dropped. In speaking with the patient, his speech is often off topic, and he exhibits neologisms and poor insight. He has a flat affect. Based on his presentation and suspected diagnosis, you decide to start him on treatment. What is the mechanism of action for the recommended treatment for this patient's condition?

Blocks dopamine D2 receptors at the postsynaptic membrane **Blockage of dopamine D2 receptors at the postsynaptic membrane is the mechanism of action for first-generation antipsychotic drugs. Schizophrenia is a chronic psychotic disorder. It is more common in men. It can result in significant impairment and disability.

A 7-year-old boy presents to the office accompanied by his mother, who reports that he has been struggling in school. She reports that she met with his teacher, who says he has difficulty maintaining attention and makes careless mistakes. His mother reports she has noticed he frequently daydreams and is easily distracted when she talks to him at home. Which of the following should be monitored if this patient is started on the first-line treatment for the suspected diagnosis? A) Blood pressure B) Oxygen saturation C) Peripheral blood counts D) Serum glucose

Blood pressure **Furthermore, stimulant medications may result in mild increases in heart rate and blood pressure. Therefore, these vital signs should be monitored in patients who are started on stimulant medications. Stimulant medications have not been shown to be associated with an increased risk of sudden unexpected cardiac death, myocardial infarction, or stroke in patients without underlying cardiovascular disease.

A 20-year-old woman presents to the clinic due to feeling cold and having irregular menses, stating that her last menstrual cycle was over 6 months ago. Her body mass index is 17 kg/m2, and her urine pregnancy test is negative. She states she exercises every day for at least 2 hours because she is overweight and is terrified of gaining weight. Which of the following physical exam findings is most consistent with the diagnosis? A. Bradycardia B. Eroded teeth enamel C. Hypertension D. Oily skin

Bradycardia **Eroded teeth enamel (B) is more likely to be present in bulimia nervosa than anorexia nervosa. Hypotension, not hypertension (C), would normally be seen in anorexia nervosa. Oily skin (D) is not seen in anorexia nervosa, rather dry skin or xerosis is seen due to dehydration.

A 64-year-old man presents to the clinic with severe depression that is refractory to treatment. Which of the following is considered a contraindication to the most efficacious treatment of severe unipolar depression?

Brain tumor with elevated ICP **Electroconvulsive therapy consists of inducing seizures in patients to treat refractory psychiatric conditions. One example of an absolute contraindication is a patient with a brain tumor with associated increased intracranial pressure. This condition is a contraindication because electroconvulsive therapy causes increased cerebral blood flow, which can result in neurologic deterioration. Patients with a brain tumor who do not have increased intracranial pressure can undergo electroconvulsive therapy.

A 27-year-old woman is brought to the emergency department by police after she became tearful and distraught when the officers refused to initiate an investigation of her former boyfriend. The patient recently broke up with the boyfriend. One week ago, she was fired from her job for frequent lateness. Since then, she has slept poorly and has become convinced that her ex-boyfriend plotted with her former supervisor to get her fired. She says she heard them whispering about her outside her apartment at night. The patient is admitted to the hospital and is discharged after several days with no medication. At a 2-week follow-up visit, she exhibits no paranoid beliefs and reports that she has started looking for a new job. Which of the following is the most likely diagnosis? A) Borderline personality disorder B) Brief psychotic disorder C) Delusional disorder D) Paranoid personality disorder E) Schizophreniform disorder

Brief psychotic disorder **This patient's sudden onset of psychosis (eg, paranoid delusions, auditory hallucinations), short duration of symptoms (≥1 days and <1 month), and full return to functioning are consistent with brief psychotic disorder. Brief psychotic disorder often occurs in response to extreme life stress (eg, being fired from a job). Brief psychotic disorder can be differentiated from other psychotic disorders by duration. In schizophreniform disorder, symptoms last >1 month and <6 months (Choice E). A diagnosis of schizophrenia requires a duration of ≥6 months.

A 26-year-old woman presents to the women's health clinic complaining of decreased sexual desire and pain during intercourse. She reports that she does not become lubricated during sexual activity and has never had an orgasm. Which of the following is part of the initial treatment for the suspected diagnosis? A) Abstinence B) Bringing novelty to the sexual repertoire C) Flibanserin D) Topical estrogen

Bringing novelty to the sexual repertoire **Female sexual interest and arousal disorder has various manifestations, including lack of sexual desire, impaired arousal, pain with sexual activity, and inability to achieve orgasm. Consistent date nights may lead to improved sexual function. In addition, bringing novelty to the sexual relationship can improve sexual satisfaction. This can be accomplished by trying new sexual positions, having sexual intercourse in new locations, or by using sex items, such as vibrators.

A 24-year-old woman presents for an annual examination. She reports a recent breakup, has a history of irregular menses, and is concerned about gaining weight. Further questioning demonstrates that, since high school, the patient has had a pattern of consuming large amounts of carbohydrate-rich food when feeling depressed, angry, or overwhelmed and then fasting and exercising 4-5 hours a day to prevent weight gain. BMI is 24 kg/m2. Which of the following is the most likely diagnosis? A) Anorexia nervosa B) Avoidant/restrictive intake disorder C) Binge-eating disorder D) Body dysmorphic disorder E) Bulimia nervosa

Bulimia nervosa **This patient's history of recurrent binge eating and inappropriate compensatory behavior (eg, fasting, excessive exercise) with a normal BMI leads to a diagnosis of bulimia nervosa. Patients with bulimia are excessively preoccupied with their weight and shape and engage in repeated episodes of binge eating with an associated feeling of loss of control. Episodes must occur at least once a week for 3 months to meet the criteria for the disorder. Although self-induced vomiting is the most common compensatory behavior for preventing weight gain, patients may also engage in misuse of laxatives, enemas, diuretics, and diet pills; fasting; or excessive exercise.

A 45-year-old man presents due to feeling depressed for the last several weeks. He reports he feels very depressed and fatigued, has lost interest in his hobbies, never feels like he gets enough sleep, and has not been able to concentrate at work over the last 3 weeks. You note in the patient's history that he has a history of erectile dysfunction and takes sildenafil as needed. Which of the following medications is the most appropriate treatment for this patient?

Bupropion **Bupropion is used when patients want to avoid sexual dysfunction or have concomitant tobacco use. Trazodone may be used for patients who also have insomnia, as it has somnolence as a side effect. Mirtazapine is avoided in patients who are concerned about weight gain. All medications should be started at a low dose and then titrated to the therapeutic range to minimize side effects and increase adherence.

A 24-year-old woman presents to the clinic complaining of palpitations and depressed mood. On physical exam, she is visibly cachectic with a body mass index of 13 kg/m2. A systolic murmur and systolic click are appreciated at the cardiac apex, and her skin is cool and dry with an abundance of fine, dark hair over her entire body. The patient reports eating only one small salad per day because she has an intense fear of becoming fat. The patient is admitted for evaluation and treatment. Which of the following medications should be avoided?

Bupropion **Patients with anorexia nervosa who suffer concomitant generalized anxiety, obsessive-compulsive disorder, or major depression should not be given the atypical antidepressant bupropion, as an increased incidence of seizure activity is found when bupropion is administered to patients with an eating disorder.

A 23-year-old woman presents to the clinic due to anxiety attacks. During these attacks, her heart races, she sweats and feels like she is going to die, and she gets tightness in her chest, nausea, and dizziness. Several visits to the emergency department in the past have determined no physical cause for these symptoms. The attacks started 1 year ago and have occurred only three or four times since then, but to avoid another attack, the patient now stays at home nearly all day, every day and is unable to work. Which of the following is the most effective nonpharmacologic clinical intervention for this patient?

CBT

A patient under your care with a history of symptoms, including hypervigilance, insomnia, nightmares, flashbacks, and an exaggerated startle response, after being involved in a car collision 3 months ago presents requesting help managing their symptoms. Which of the following is the best initial treatment approach?

CBT **Cognitive behavioral therapy with fluoxetine (B) or lone treatment with fluoxetine (D) are approaches used to treat patients who are refractory to psychotherapy alone or who express a desire for pharmacotherapeutic treatment. While these approaches can be efficacious, psychotherapy alone is the recommended first-line treatment.

A 23-year-old woman gives birth to a child with spina bifida after being on an unknown medication during the first trimester of pregnancy. The medication was prescribed to treat a psychiatric condition marked by hypomanic and major depressive episodes. Which of the following medications is most likely to cause spina bifida in the fetus when used during pregnancy?

Carbamazepine **Carbamazepine is associated with neural tube defects (spina bifida) and similar major malformations to those found with valproate use. However, the risk of neural tube defects is higher with exposure to valproate than carbamazepine.

An 18-year-old woman with a history of several episodes of major depression presents to the psychiatric clinic accompanied by her parents, who report she has only slept about 10 hours during the past week. Her parents are also concerned about her irresponsible spending spree the past 2 days and uncharacteristic promiscuous behavior on online dating sites. The patient is of Asian descent and reports skipping school to meet up with men she met online. During your assessment, the patient quickly jumps from one topic to another and has rapid speech. Her urine drug screen and urine pregnancy test are negative. Which of the following medications sometimes used to treat the suspected condition requires screening for the HLA-B*1502 allele prior to beginning treatment? A) Carbamazepine B) Lithium C) Olanzapine D) Valproate

Carbamazepine **Stevens-Johnson syndrome and toxic epidermal necrolysis are life-threatening rashes that are associated with carbamazepine. The rashes most commonly occur during the first 8 weeks of treatment. Furthermore, these reactions are far more common in patients with the HLA-B*1502 allele, which occurs nearly exclusively in patients of Asian ancestry.

A 32-year-old man with a history of heavy alcohol use presents to the emergency department with anxiety, tremulousness, diaphoresis, vomiting, and headache. He reports that he has heavily used alcohol for 6 years but abruptly stopped yesterday afternoon. Which of the following can be used to assess this patient's symptom severity and determine the most appropriate site for treatment?

Clinical Institute Withdrawal Assessment for Alcohol **The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A) is a scale that helps measure the severity of alcohol withdrawal symptoms and determine the appropriate setting for alcohol withdrawal management.

A 54-year-old man presents to the emergency department after being found unconscious in the street. He has a history of intravenous heroin use and was given naloxone en route to the emergency department. The patient is alert, irritable, and restless on presentation. Vital signs include a temperature of 98.6°F, heart rate of 115 bpm, and blood pressure of 165/94 mm Hg. You notice pupil dilation, yawning, and piloerection during physical examination. Which of the following is the recommended treatment?

Clonidine **The patient in the vignette is presenting with symptoms and signs of opioid withdrawal after being treated with naloxone (opioid antagonist) for presumed opioid intoxication. It is difficult to treat patients who withdraw after the administration of naloxone with opioid agonists because the receptors are blocked by naloxone. Furthermore, there is risk of rebound intoxication. Therefore, the best treatment for this patient is symptomatic treatment, such as with clonidine. Alpha-2 adrenergic agonists, such as clonidine, are a common class of medications used in the symptomatic treatment of opioid withdrawal. It is important to consider the patient's blood pressure prior to using clonidine because it is contraindicated in hypotensive patients as it will further lower blood pressure.

A 28-year-old man presents to the emergency department with fatigue and chest pain. Electrocardiogram reveals nonspecific ST changes. Serum erythrocyte sedimentation rate and cardiac troponin are elevated. Physical exam reveals pitting lower extremity edema. The patient states he was recently started on a medication to control hallucinations, self-injurious behavior, and delusions of persecution. Which of the following medications is most likely causing his current symptoms? A) Amitriptyline B) Clozapine C) Olanzapine D) Risperidone

Clozapine **Clozapine is a potent antipsychotic medication that is indicated in the treatment of schizophrenia in individuals who are refractory to other first-line agents and in the treatment of schizophrenia in individuals with persistent self-injurious or suicidal behavior. Serious side effects that are specific to clozapine include myocarditis, cardiomyopathy, pulmonary embolism, and agranulocytosis.

A 22-year-old man presents to the emergency department due to headache, myalgia, and chest pain. He is agitated, appears angry, and is difficult to restrain. Vital signs indicate blood pressure 180/100 mm Hg, pulse 130 beats per minute, and temperature 100.1°F. Physical exam reveals mydriasis, diaphoresis, and diffuse muscular tenderness to palpation. Which of the following is most likely found on this patient's urine toxicology screening? A. Cocaine B. Lysergic acid diethylamide C. Marijuana D. Opiates

Cocaine **Signs and symptoms of acute cocaine intoxication include hypertension, tachycardia, agitation, headache, hyperthermia, rhabdomyolysis, intracerebral hemorrhage, gastric ulcers, splenic or renal infarct, mydriasis, and diaphoresis. Treatment of acute cocaine intoxication begins with stabilization of the airway and circulation. Lowering blood pressure can be accomplished with nitroprusside, nitroglycerin, or phentolamine. Beta-blocking agents should be avoided in acute cocaine intoxication to prevent unmitigated alpha-adrenergic stimulation. Diazepam is given in acute cocaine intoxication for treatment of psychomotor agitation. Immersion in ice may be necessary for severe hyperthermia.

A 33-year-old man is brought to the hospital by the police after he assaulted a stranger who he thought was following him. When the patient was arrested, he shouted, "You don't understand, I'm the one who needs protection—the Russians are after my secrets!" The patient is diaphoretic and tremulous. He is very easily distracted and cannot give a clear history. Temperature is 37 C (98.6 F), blood pressure is 164/102 mm Hg, and pulse is 112/min. Extraocular movements are intact, and the pupils are dilated. His speech is loud, rapid, and difficult to interrupt. Which of the following is the most likely diagnosis? A) Bipolar disorder, manic episode B) Cocaine intoxication C) Delusional disorder D) Opiate withdrawal E) Phencyclidine (PCP) intoxication

Cocaine intoxication **This patient's psychotic symptoms (eg, delusions, paranoia), pressured speech, and signs of sympathetic stimulation (eg, diaphoresis, tremulousness, tachycardia, hypertension, mydriasis) are most consistent with cocaine intoxication. In high doses, cocaine and other stimulants (eg, methamphetamine) may cause paranoid delusions that are often indistinguishable from those found in primary psychotic disorders (eg, schizophrenia). Auditory, visual, or tactile hallucinations (eg, insects crawling under the skin) may also occur. Patients under the influence of stimulants frequently exhibit euphoria, hyperactivity, agitation, and grandiosity that may resemble an acute manic episode. (Choice E) Phencyclidine (ie, PCP) intoxication may cause psychotic symptoms and violent behavior. It typically presents with prominent nystagmus, a finding notably absent in this patient.

A 32-year-old man is brought to the office for an evaluation after he was placed on probation at work for frequent absences and arguing with his boss. For the past 9 months, he has had unpredictable mood swings with irritability, aggressive behavior, and paranoia about his coworkers stealing his job. At other times, he is quiet and withdrawn. The patient is cooperative but tense, irritable, and talkative. He is physically restless, mildly tremulous, diaphoretic, and hypervigilant. Speech is pressured and difficult to interrupt. He says, "This is all an unfair plot to get rid of me. I have contributed more to that company than anyone, and my business plan is pure genius." Blood pressure is 160/100 mm Hg, pulse is 108/min, and respirations are 16/min. Pupils are dilated and reactive to light. Which of the following is the most likely explanation for this patient's behavior? A) Bipolar disorder B) Cocaine use disorder C) Delusional disorder, grandiose type D) Paranoid personality disorder E) Schizophrenia

Cocaine use disorder **This patient's history of mood swings and erratic behavior and his physical findings consistent with sympathetic nervous system stimulation (eg, tachycardia, pupil dilation, diaphoresis, tremors) are most likely due to cocaine use disorder. Psychiatric effects of cocaine include anxiety, irritability, mood swings, panic attacks, grandiosity, impaired judgment, and psychotic symptoms (eg, paranoia, hallucinations). With acute intoxication, patients using cocaine are frequently energetic, restless, and hypervigilant and may exhibit euphoria and grandiosity that resemble an acute manic episode. Paranoid and grandiose delusions and auditory, visual, or tactile hallucinations may occur. Cocaine withdrawal frequently presents with depression and lethargy. Toxicology screening (eg, blood, urine, saliva) may be useful in clarifying the diagnosis.

A 23-year-old man presents to the clinic with concerns that he is unable to form relationships with others. He notes that he wants to make friends with his co-workers, but he is always scared to attend social gatherings and happy hours after work. When you ask why the patient is hesitant to attend these events, he reports feeling like he may not be liked by others. Which of the following is the most appropriate intervention for this patient?

Cognitive behavioral therapy (CBT) **The patient in the above vignette has avoidant personality disorder. These individuals want to develop a relationship with others but avoid them due to feeling inadequate, inferior, or having fear of rejection or humiliation.

A 21-year-old man presents to the clinic with his father for a routine follow-up. His father notes he has improved significantly over the past few months. He states the patient is no longer worried that the FBI has hacked his computer and cell phone. The patient reports he is no longer hearing voices, and he has been making efforts to attend social gatherings on the weekend. The patient has been stable and treated with clozapine. Which of the following lab panels should be monitored for this patient?

Complete blood count (CBC) **Treatment with clozapine has an increased risk for agranulocytosis, in which case a complete blood count must be checked on a weekly basis.

A 35-year-old man presents to the emergency department after getting in a bar fight with another patron. He has been in the emergency department multiple times due to injuries relating to the destruction of private property. He reports alcohol use and occasional marijuana use and has a difficult time retaining employment. On multiple occasions on this visit, he has tried to hit the nursing staff as they attempted to place an IV. Which of the following diagnoses did this patient most likely have during childhood and adolescence?

Conduct disorder **Antisocial personality disorder is a cluster B personality disorder and is characterized by behaviors that completely disregard and violate the rights of others. Often, antisocial personality disorder begins in childhood or adolescence and is diagnosed as conduct disorder.

A 25-year-old man presents, stating his boss told him to be evaluated because he is obsessed with perfectionism. Which of the following historical elements would be present in a patient with obsessive-compulsive personality disorder versus obsessive-compulsive disorder?

Conflicts with his family about excessive perfectionism **Patients who have obsessive-compulsive personality disorder fulfill the diagnostic criteria as stated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and are obsessed with perfectionism, control, and ritualistic behaviors that interfere with the ability to perform everyday tasks or form friendships. Unlike patients with obsessive-compulsive disorder, patients with the personality disorder are not distressed over their behaviors

5 Distinct Stages of Change: - Being aware of a problem with no commitment to a plan of action

Contemplation (2)

A 37-year-old woman comes to the office due to low energy and fatigue. She recently received a promotion at work and was very excited and motivated at first, but she now finds herself procrastinating and having difficulty concentrating. For many years, the patient has had unpredictable "mood swings" consisting of periods of low energy and "up periods" in which she feels more energetic and optimistic. These vary in length from days to weeks and have no clear relationship to situations in her life. She has no history of major depressive episodes or psychosis. She drinks 1 or 2 glasses of wine several times a week. Mental status examination shows a sad affect and some lapses in concentration, although the patient brightens easily. Which of the following is the most likely diagnosis in this patient? A) Bipolar I disorder B) Bipolar II disorder C) Borderline personality disorder D) Cyclothymic disorder E) Substance-induced disorder

Cyclothymic disorder **This patient's history of chronic, fluctuating mood disturbance for many years is suggestive of cyclothymic disorder. Her symptoms are mild, and she does not have sufficient history for diagnosis of either a current or a past major depressive or hypomanic/manic episode. Cyclothymic disorder falls within the bipolar spectrum and represents a less severe form of the illness. Diagnosis requires ≥2 years' duration and insufficient number of symptoms and severity to meet full criteria for hypomanic, manic, or depressive episodes. Patients should be evaluated for a bipolar II diagnosis if they meet these criteria and have a history of hypomanic episodes (ie, ≥4 days of elevated/irritable mood, increased energy, and ≥3 of the following: grandiosity, decreased need for sleep, talkativeness, racing thoughts, distractibility, hyperactivity, and risky behavior) (Choice B).

A 32-year-old woman comes to the office because she has felt sad and worthless for the past 3 months . The patient has difficulty sleeping, decreased appetite, and no longer enjoys spending time with friends. The patient is started on first-line pharmacologic treatment. Two days later, the patient is brought to the emergency department after being found lying down next to an empty bottle of the prescribed medication. Temperature is 38.9 C (102 F), blood pressure is 146/92 mm Hg, and heart rate is 118/min. The patient is disoriented, tremulous, and diaphoretic. She has abdominal cramps and diarrhea. Bilateral lower extremities have hyperrefllexia and inducible ankle clonus. The patient is admitted to the hospital for supportive therapy, but she remains disoriented with only limited improvement. Which of the following is the antidote for this patient's condition? A) Cyproheptadine B) Flumazenil C) Haloperidol D) Naloxone E) Propranolol

Cyproheptadine **This patient's feelings of sadness and worthlessness—combined with her impaired sleep, decreased appetite, and decreased enjoyment of previously pleasurable activities (eg, socializing with friends)—lasting ≥2 weeks are consistent with major depressive disorder (MDD). First-line pharmacotherapy for MDD is a selective serotonin reuptake inhibitor (SSRI). Her apparent overdose on the prescribed SSRI and her resultant altered mental status (eg, disorientation), autonomic hyperactivity (eg, hyperthermia, tachycardia, diaphoresis), and neuromuscular excitation (eg, hyperreflexia, clonus, tremor) are characteristic of serotonin syndrome. Serotonin syndrome is caused by excessive serotonin activity, most commonly brought on by combining SSRIs with another serotonergic agent such as a monoamine oxidase inhibitor. It may also occur with a single agent if taken in overdose. Treatment includes supportive care, including airway and temperature maintenance as well as hydration. When supportive measures fail, cyproheptadine can be given as an antidote as it functions as a serotonin antagonist. Cyproheptadine is a first-generation antihistamine with nonspecific 5-HT1 and 5-HT2 receptor antagonistic properties.

A 21-year-old college student is evaluated due to swelling in her feet and ankles. The patient noticed the swelling a few days ago when her shoes would not fit. She says, "I have become so fat and have such low energy since coming to college even though I run every day and eat only healthy foods. I am also worried about my grades because my concentration is so poor." Physical examination shows a thin habitus, dry skin, excoriations on her forearms, 2+ pitting edema of her ankles, and a distended abdomen with hypoactive bowel sounds. Temperature is 37.2 C (99 F), blood pressure is 85/60 mm Hg, pulse is 50/min, and respirations are 14/min. BMI is 17 kg/m2. Which of the following abnormalities is most likely present in this patient? A) Decreased bone mineral density B) Hyperkalemia C) Hypernatremia D) Increased LH E) Increased TSH

Decreased bone mineral density **This patient's low BMI and distorted body image are suggestive of anorexia nervosa (AN). Weight loss and chronic malnutrition lead to dysfunction in multiple organ systems. This patient's clinical presentation of dry skin causing scratching and excoriations, edema, abdominal distension, hypoactive bowel sounds, and vital sign abnormalities (eg, hypotension, bradycardia) is consistent with medical complications due to AN. Gastroparesis and abdominal bloating are common. Edema is caused by electrolyte and fluid disturbances and is commonly seen in the ankles and around the eyes. Decreased bone mineral density is due to a combination of factors—including various endocrine abnormalities, hypercortisolism, and growth hormone resistance—that result in an increased risk of bone fractures. Other complications include hypercarotenemia, accelerated metabolism of cholesterol leading to hypercholesterolemia, cardiac atrophy, arrhythmias, amenorrhea, lanugo, and seizures.

A 28-year-old woman is brought to the office by her husband, who is concerned about her recent behavior. For the past 6 months, the patient has refused to eat any food that is not prepackaged out of fear of becoming ill. Before eating, she carefully examines the food on her plate, checking for any possible contaminants. The patient believes that someone has been poisoning her food, which has caused her to feel more fatigued than usual. She has continued to work but seldom interacts with coworkers. The patient has no psychiatric history. Examination shows a 2.27-kg (5-lb) weight loss since a prior visit 9 months ago. The patient's mood is anxious, and her affect is tense. Which of the following is the most likely diagnosis in this patient? A) Delusional disorder B) Illness anxiety disorder C) Obsessive-compulsive disorder D) Paranoid personality disorder E) Schizophrenia

Delusional disorder **This patient's persistent delusions about being poisoned with no other prominent psychotic symptoms are consistent with delusional disorder. Her behavior unrelated to her delusion does not appear to be bizarre or odd, and she is still able to function at work. (Choice D) Personality disorders are characterized by lifelong patterns of behavior beginning in early adulthood; they do not involve delusional beliefs. Paranoid personality disorder does involve a pervasive distrust and suspiciousness of others; however, this patient has developed delusions over the past 6 months, which represents a change from her baseline.

A 67-year-old woman is brought to the office by her son. He reports that his mother has had periodic confusion, memory loss, and poor sleep. These symptoms have gradually worsened over the past 1-2 years. The patient occasionally sees "strangers in the backyard" who are not there when her son looks. More recently, she has begun walking more slowly and has fallen twice in the past month. On physical examination, she walks slowly and has mild bilateral hand tremors and mild bilateral lower limb rigidity. On cognitive examination, the patient is oriented to person and place and can recall 1 of 3 items in 5 minutes. She can state the days of the week forward but not backward. MRI of the brain shows mild generalized cortical atrophy. Which of the following is the most likely diagnosis in this patient? A) Alzheimer's disease B) Dementia with Lewy Bodies C) Major depressive disorder D) Normal pressure hydrocephalus E) Parkinson's disease

Dementia with Lewy Bodies **This patient's 1- to 2-year history of periodic confusion, accompanied by visual hallucinations and followed by the development of parkinsonian motor symptoms (eg, tremors, rigidity), suggests dementia with Lewy bodies (DLB). DLB is characterized by alterations in consciousness, fluctuations in cognition, visual hallucinations, parkinsonism, and relatively early compromise of executive functions. Repeated falls and sleep disturbance are characteristic.

A 25-year-old woman presents to a therapist due to persistent conflict in close relationships. She reports that one day it feels like her boyfriend is the love of her life, and the next day she wants to end their relationship. She also reports that she has had trouble maintaining a job because she will abruptly become upset with her boss and leave. She has attempted suicide twice in the past 6 months. Which of the following is the first-line treatment for the suspected personality disorder?

Dialectical behavior therapy **Evidence-based psychotherapies are the primary treatment of borderline personality disorder. Dialectical behavior therapy and mentalization-based therapy are two therapies with evidence to support their use. Dialectical behavior therapy focuses on changing ineffective behaviors and improving coping skills, emotional regulation, and self-management.

A 42-year-old woman with a history of schizophrenia presents to the emergency department, brought by EMS, after being found downtown. She is very agitated. The patient is unable to be verbally calmed and is becoming a safety concern to herself and staff. You order haloperidol 5 mg IM to be administered to calm the patient. After administration, the patient begins having involuntary contractions of her neck, causing torticollis. What medication can be used to treat the patient's suspected diagnosis?

Diphenhydramine **First-generation (typical) antipsychotics, haloperidol specifically, are used to treat acute agitation, but they can cause extrapyramidal symptoms and dystonic reactions, which present as involuntary, repetitive contractions of the face, back, neck, or limb muscles. The acute phase of a dystonic reaction may be treated with diphenhydramine, an anticholinergic medication that can help to balance cholinergic and dopaminergic activity to correct the reaction. Diphenhydramine 50 mg IV or IM should be administered, and correction of the reaction should be seen within 30 minutes to 1 hour.

A 66-year-old man with a history of hyperlipidemia, type 2 diabetes, and diabetic neuropathy presents for mood disturbance for the last 3 weeks. He reports feeling his life is worthless and has lost interest in activities that used to bring him joy. He has no interest in seeing friends or family and has recurrent thoughts of death, although he has no specific suicidal plan. He reports a 5 lb unintentional weight loss but states he has lost his appetite. He mentions he has not been controlling his glucose over the last 6 months and thinks his neuropathy has worsened. Which of the following medications would be best for this patient? A) Duloxetine B) Gabapentin C) Pregabalin D) Sertraline

Duloxetine **Duloxetine is a first-line treatment for neuropathic pain. Sertraline (D) is used as a first-line treatment for major depressive disorder but is not used in treating diabetic neuropathy. This is why Sertraline is not the right answer, as SSRIs and SNRIs are first-line for MDD. However, considering the profile of the patient, Duloxetine would most benefit the patient in treating both the MDD and Diabetic neuropathy.

A 26-year-old man presents to the clinic with excessive worrying for the past 6 months. He reports that he worries about career advancement, finding a spouse, and gaining weight. These concerns lead to him having poor sleep, fatigue, and muscle tension in his neck. You decide to start him on a first-line antidepressant for the suspected condition, but you also want to start him on an agent that prevents agitation during initial treatment with an antidepressant. The patient has no history of substance misuse. Which of the following medication combinations is most appropriate? A. Amitriptyline and clonazepam B. Duloxetine and lorazepam C. Duloxetine and pregabalin D. Sertraline and hydroxyzine

Duloxetine and lorazepam **The recommended pharmacotherapy is either a selective serotonin reuptake inhibitor, such as sertraline and fluoxetine, or a serotonin and norepinephrine reuptake inhibitor, such as duloxetine or venlafaxine. The most common role for a benzodiazepine, such as lorazepam, in the treatment of generalized anxiety disorder is as a short-term agent either before antidepressants have begun to have efficacy or to treat agitation that may occur during the initial weeks of treatment with a selective serotonin reuptake inhibitor.

A 32-year-old woman presents to her obstetrician at her 6-week postpartum visit. She reports having a depressed mood for the past 2 weeks with anhedonia and increased guilt. Which of the following is the most widely used screening test for the suspected diagnosis?

Edinburgh Postnatal Depression Scale

A 26-year-old woman, gravida 1 para 0, at 8 weeks gestation is brought to the emergency department after saying that she wants to die and threatening to hang herself. In the past few weeks, the patient has become increasingly depressed and uninterested in doing anything. She sleeps 14 hours a day and has lost 4.5 kg (10 lb) due to refusal to eat or drink. The patient says that food is "allowing my demon child to grow." She has a long history of recurrent depression and has made 2 suicide attempts in the past. She takes no medications currently. The patient appears thin, with dry and chapped mucous membranes. During the examination, she makes monosyllabic responses and has slowed movements. The patient is admitted to the psychiatric unit. Which of the following is the best next step in management? A) Electroconvulsive therapy B) Fluoxetine C) Lithium D) Valproate E) Venlafaxine

Electroconvulsive therapy **This patient's severe depression with psychotic features (delusions about food and the baby), refusal to eat or drink, and active suicidality require emergency treatment. Electroconvulsive therapy (ECT) is a highly effective treatment for unipolar or bipolar depression in patients with psychotic features or persistent suicidality, or who require a rapid treatment response (eg, severe neurovegetative symptoms, nutritional depletion). ECT is considered relatively safe during pregnancy and would be most likely to achieve a rapid response in this patient, whose untreated mental illness poses great risk to herself and the fetus. (Choices B and E) It is reasonable to start antidepressant monotherapy in pregnant patients with moderate to severe unipolar depression because they are generally well tolerated and the benefits outweigh potential harms to the fetus. However, slower treatment response times are seen with pharmacotherapy and ECT is preferred in patients requiring emergent treatment.

A 72-year-old woman is admitted to the hospital because of worsening suicidal ideation for the past month. The patient has been refusing meals in order to "sacrifice" herself for "the greater good." She has stopped communicating with her family and spends most of her days sleeping or staring at the television. The patient has been treated with multiple antidepressants in the past for recurrent major depressive disorder. Two weeks ago, she discontinued taking venlafaxine because she felt it "interfered" with her plan to kill herself. BMI is 16.5 kg/m2. Physical examination shows decreased skin turgor and dry mucous membranes. Which of the following is the best next step in management? A) Clozapine B) Cognitive-behavioral therapy C) Electroconvulsive therapy D) Imipramine E) Olanzapine

Electroconvulsive therapy (ECT) **This patient's severe depression with delusions is consistent with major depressive disorder (MDD) with psychotic features. Her condition is a psychiatric emergency because she is suicidal, refusing to eat, and has become dehydrated (eg, decreased skin turgor, dry mucous membranes). First-line treatment of psychotic depression consists of either the combination of an antidepressant and antipsychotic or electroconvulsive therapy (ECT). ECT works faster than pharmacotherapy and is often preferred to achieve a rapid response in depressed elderly patients who are unable to eat and drink, psychotic, or actively suicidal. ECT is a safe and effective treatment for severe major depressive disorder and has no absolute contraindications.

A 45-year-old man with a history of chronic alcohol use presents to the emergency department with confusion. You are concerned for a condition caused by thiamine deficiency. Which of the following is the classic triad associated with this condition?

Encephalopathy, oculomotor dysfunction, and gait ataxia **Wernicke Encephalopathy

A 27-year-old woman comes to the office due to recurrent episodes of anxiety, palpitations, shortness of breath, tremors, and numbness and tingling in her hands. The patient describes breaking into a sweat suddenly and feeling dizzy several times a week. The last time it happened she was embarrassed as it occurred during a meeting at work. During the meeting, she ran out of the room because she felt short of breath, had a choking sensation, and her chest was pounding. The patient now feels anxious all the time because she fears having another episode. She does not feel depressed and reports no change in her sleep pattern or appetite. Physical examination, laboratory evaluation, and ECG are normal. Which of the following is the most appropriate pharmacotherapy for this patient? A) Buspirone B) Clonazepam C) Escitalopram D) Lorazepam E) Propranolol

Escitalopram **Selective serotonin reuptake inhibitors (SSRIs), such as escitalopram, and serotonin-norepinephrine reuptake inhibitors (SNRIs) are preferred first-line pharmacotherapy due to their relatively benign side-effect profile compared to older antidepressants (ie, tricyclic antidepressants, monoamine oxidase inhibitors) and lack of the abuse potential and physiologic dependence seen with benzodiazepines.

A 26-year-old man is sexually aroused by exposing his genitals to nearby drivers while in traffic. Which of the following paraphilic disorders is the most likely diagnosis?

Exhibitionistic disorder **Exhibitionistic disorder is a paraphilic disorder characterized by an individual becoming aroused from exposing their genitals to an unsuspecting person. Individuals with exhibitionistic disorder frequently masturbate during or after the exposure.

A 20-year-old woman currently taking fluoxetine 20 mg daily for her anxiety disorder reports that she is still unable to work because she has intrusive thoughts about death and germs that lead to over-frequent handwashing and checking behaviors. The addition of which of the following clinical interventions or therapeutics would be most helpful to this patient? A) Buspirone 10mg daily B) Exposure and response prevention C) Hypnotherapy D) Risperidone 2mg daily

Exposure and response prevention **Treatment of obsessive-compulsive disorder is with selective serotonin receptor uptake inhibitors, such as fluoxetine. Concurrent psychotherapy using a cognitive behavioral approach gives the best clinical results to decrease obsessions and compulsions and increase social functioning. The cognitive behavioral approach that works well in obsessive-compulsive disorder is exposure and response prevention.

A 22-year-old man with a new diagnosis of schizophrenia presents to the office for medication management. A decision is made to start quetiapine, and you discuss side effects with the patient, along with a need for regular appointments to monitor metabolic changes. Which of the following laboratory tests should be monitored regularly?

Fasting blood glucose **The most serious side effects caused by second-generation antipsychotic agents are metabolic changes, such as insulin resistance, hyperglycemia, weight gain, and elevated lipids. Initiation of an antipsychotic requires baseline monitoring, which continues through the first year and beyond. Baseline factors to monitor include a family history of diabetes, hypertension, and cardiovascular disease and the individual's diet and physical activity level, smoking status, weight, body mass index, blood pressure, fasting blood glucose or hemoglobin A1C, and lipid profile. Fasting blood glucose should be checked at the 6-week, 3-month, and 12-month marks after starting a second-generation antipsychotic and then annually.

A 19-year-old woman is brought to the emergency department after she was found trespassing at an animal shelter. The patient had keys to a rental van, as well as numerous collars and leashes. The patient reports that the shelter was going to perform dangerous experiments on the animals and that she is the only one who can save them. She quit her job a week ago to spend more time researching escape routes for the animals. The patient repeatedly interrupts the evaluation to yell at other patients and hospital staff walking by the room. She refers to herself as a "cat burglar" and then laughs loudly for a few minutes. Urine drug screen is negative. Which of the following additional features is most likely in this patient? A) Experiencing a sensation of bugs crawling on her skin B) Experiencing intrusive, unwanted thoughts C) Feeling well rested despite minimal sleep D) Neglecting personal grooming E) Pausing for long periods prior to responding to questions

Feeling well rested despite minimal sleep **This patient's recent history of abnormal mood, impulsive, risky behavior, and grandiosity (ie, belief that only she can save the animals), as well as findings of loud speech, distractibility, and inappropriate joking and laughter on mental status examination, are characteristic of a manic episode of bipolar I disorder. Patients with mania are often expansive and disinhibited, interacting with strangers without regard to social conventions (eg, yelling at others walking by). Impaired judgment is common, as with this patient abruptly quitting her job and trespassing at the animal shelter. A key feature of mania is decreased need for sleep due to increased energy (in contrast to insomnia [difficulty sleeping despite feeling tired]). Patients in a manic episode may sleep only a few hours or go without sleep entirely for several days. Despite lack of sleep, they feel well rested and energetic. Mania typically has an acute onset with rapid progression over a few days, resulting in marked impairment in functioning. Hospitalization may be necessary to protect the patient from further destructive behaviors.

A 26-year-old woman presents to a plastic surgery clinic concerned about the appearance of her nose. She reports that her nose is long and causes her to have an ugly face. She frequently asks her close friends if her nose looks too long and spends several hours each day looking at her nose in the mirror, which temporarily makes her feel better. Physical exam reveals a relatively normal-appearing nose. You review her chart and notice she has previously had two plastic surgeries on her nose. Which of the following is an acceptable first-line treatment for the suspected diagnosis?

Fluoxetine **SSRIs such as Fluoxetine and Escitalopram are first-line in treatment for patients with Body dysmorphic disorder.

A 26-year-old woman presents to the clinic with sore gingiva. Upon inspecting the patient's mouth, she is noted to have multiple dental caries and tooth discoloration. The patient reports no illicit drug use and states she brushes her teeth regularly, but upon further questioning, she reports frequently forcing herself to vomit. These purging episodes occur after she binges a large quantity of food. She states she feels bad about herself and her weight, eats a great deal in one discrete period of time, then feels relief of anxiety and self-loathing when she purges her food. Which of the following clinical therapeutics is considered first-line for this patient?

Fluoxetine **The psychotherapy modality that has proven to be most efficacious in bulimia nervosa is cognitive behavioral therapy. First-line pharmacotherapy for bulimia nervosa is with the selective serotonin reuptake inhibitor fluoxetine, as it is well-tolerated and tends to be more weight-neutral than others in its class. The combination of cognitive behavioral therapy and fluoxetine has proven to be more effective than either modality alone.

A 20-year-old college student comes to the office due to persistent fatigue, irregular menstrual periods, and difficulty losing weight despite intensive exercise. Several times a week, the patient has episodes where she uncontrollably consumes large amounts of cookies and potato chips. She feels disgusted with herself afterward and subsequently does additional exercise. Although the patient hates her appearance and constantly compares herself to her slimmer friends, she denies feeling persistently depressed. Blood pressure is 100/60 mm Hg and pulse is 92/min. Examination shows pharyngeal erythema and minimal parotid enlargement bilaterally. Potassium level is 3.4 mEq/L and amylase is 140 U/L. Pregnancy test is negative. Which of the following medications would be most effective in treating this patient? A) Bupropion B) Fluoxetine C) Nortriptyline D) Topiramate E) No pharmacologic treatment is necessary

Fluoxetine **This patient's recurrent binge eating followed by compensatory exercise—accompanied by physical findings and laboratory values suggestive of self-induced vomiting (pharyngeal erythema, parotid enlargement, hypokalemia and elevated amylase)—is consistent with bulimia nervosa. Other findings seen in bulimia include hypotension, tachycardia, dry skin, menstrual irregularities, erosion of dental enamel, and metabolic alkalosis. Treatment options for bulimia nervosa include nutritional rehabilitation (establishing a structured and consistent meal pattern), cognitive-behavioral therapy, and pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) (Choice E). Fluoxetine is considered the drug of choice and has the best evidence of being most effective in combination with nutritional rehabilitation and psychotherapy.

A rare manifestation of delusional disorder in which the same delusion(s) is present in individuals who share a close relationship. Usually the dominant individual in the pair becomes delusional and transfers the delusion on the second, more submissive person who may or may not meet the criteria for delusional disorder

Folie à deux

A 22-year-old college student presents with tension headaches and neck pain. He has had these symptoms for many years, but they have increased in frequency over the past 7 months since he started working at a coffee shop. The patient attends college and says that although his grades are passing, he feels overwhelmed and fatigued. He sleeps poorly and frequently worries about his grades, health, and social life. He obsesses about minor comments his friends have made about how "serious" he is and gets depressed thinking that he is not attractive enough to get a girlfriend. Which of the following is the most likely diagnosis? A) Adjustment disorder B) Generalized anxiety disorder C) Major depressive disorder D) Social anxiety disorder E) Somatic symptom disorder

Generalized anxiety disorder **This patient's excessive chronic anxiety, muscle tension (tension headaches, neck pain), sleep disturbance, fatigue, and difficulty concentrating all support a diagnosis of generalized anxiety disorder (GAD). Patients with GAD experience excessive and uncontrollable worry about multiple issues. A symptom duration of ≥6 months is required for diagnosis, but many patients with GAD describe lifelong anxiety. In addition to muscle tension, other somatic symptoms are commonly seen (eg, sweating, gastrointestinal distress) and may prompt the patient to seek medical attention. First-line treatment includes cognitive-behavioral therapy and antidepressants (ie, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors).

A 25-year-old man presents to his therapist to discuss his difficulty maintaining romantic relationships. He reports that he is sexually aroused by his partners' toes, which has ended several of his past relationships. Which of the following is another common focus of sexual arousal in the suspected condition? A. Bracelets B. Ears C. Eyes D. Hair

Hair **The nonliving object or nongenital body part that leads to the sexual arousal is called the fetish. Common fetishes include women's underpants, bras, shoes, feet, toes, and hair. Fetishistic disorder can manifest with fantasies, urges, or behaviors about the fetish. It is more common in men.

An 83-year-old woman is sent to the emergency department from her nursing home for evaluation of mental status changes. At baseline, she has mild memory impairment but is otherwise cognitively intact, calm, and cooperative. Over the past 24 hours, she has become increasingly combative and agitated and stayed up all night. Temperature is 37.2 C (99 F), blood pressure is 110/80 mm Hg, pulse is 84/min, and respirations are 18/min. Neurological examination is normal, but the patient is mildly disoriented. Without provocation, she strikes out at a nurse's aide standing next to her. Urinalysis is positive for nitrites and leukocyte esterase. Head CT scan is negative. In addition to starting antibiotics, which of the following medications is most appropriate to treat this patient's behavioral symptoms? A) Clozapine B) Doxepin C) Haloperidol D) Lithium E) Lorazepam

Haloperidol **Delirium is an acute-onset "confusional state" characterized primarily by waxing and waning mental status changes and impaired attention. Disorientation, agitation, psychosis, and sleep disturbances may also occur. Delirium occurs secondary to an underlying medical condition, such as a urinary tract infection, and therefore the primary management is treating the underlying cause. The elderly and those with preexisting cognitive disorders are at a higher risk for delirium and may present with varying degrees of agitation. High-potency, first-generation antipsychotics (eg, haloperidol) and some second-generation antipsychotics (eg, quetiapine) can be used for the acute treatment of agitation and psychosis associated with delirium. Antipsychotic use is appropriate in the treatment of delirium in the elderly if the patient is at risk of acute harm to self or others and behavioral interventions have failed. Under these conditions, the benefits of antipsychotics (ie, the provision of safety) outweigh the potential risks when used at low doses and short durations.

A 31-year-old woman presents to the emergency department after ingesting a full bottle of sertraline 100 mg tablets. Her pulse is 120 beats per minute, blood pressure is 160/100 mm Hg, and temperature is 104.1°F. On exam, she has ocular clonus, hyperreflexia, agitation, dilated pupils, and diaphoresis. Which of the following represents the best first-line therapy for this patient?

Lorazepam 2 mg IV every 4 hours **Initial treatment of serotonin syndrome is with intravenous benzodiazepines, such as lorazepam 2 mg. This treatment will decrease muscle spasms, neurologic hyperstimulation, and hyperpyrexia. Patients should also be treated with supplemental oxygen and should discontinue all serotonergic agents.

A 32-year-old man comes in due to abdominal cramps that were initially mild last night but gradually worsened in intensity. Since this morning, he has had 4 loose stools. The patient has also had persistent nausea but no vomiting. Blood pressure is 144/98 mm Hg, pulse is 88/min, and respirations are 16/min. Physical examination shows a diaphoretic, thin man in considerable distress with excessive lacrimation and rhinorrhea. The pupils are dilated. This patient's clinical presentation is most consistent with withdrawal from which of the following? A) Alcohol B) Clonazepam C) Cocaine D) Heroin E) Paroxetine

Heroin **This patient is demonstrating signs often seen following abrupt withdrawal from prolonged opioid (eg, heroin) use. In opioid withdrawal, symptoms begin within 6-12 hours, can peak within 36-72 hours, and may continue for several days. Common withdrawal symptoms include myalgia, arthralgia, nausea and vomiting, diarrhea, abdominal cramps, rhinorrhea, lacrimation, and sweating. On examination, patients may be restless and irritable with elevated heart rate and blood pressure (although typically not as elevated as in alcohol withdrawal). Pupillary dilation (mydriasis), piloerection, and yawning may be evident. Symptoms can be distressing but are not life-threatening. Patients with severe opioid withdrawal due to interruption in opioid use may benefit from opioid replacement therapy (eg, methadone, buprenorphine), which reduces withdrawal symptoms without opioid intoxication.

A 21-year-old woman with anorexia nervosa is admitted to an inpatient treatment facility for nutritional rehabilitation. She develops lower extremity edema and orthopnea after a week of treatment. Her creatine kinase is 5,000 U/L. Which of the following electrolyte abnormalities is the primary cause of tissue hypoxia?

Hypophosphatemia **The clinical and laboratory findings of refeeding syndrome can include peripheral edema, seizures, hypophosphatemia, hypokalemia, hypomagnesemia, hemolysis, and rhabdomyolysis (tissue hypoxia and myocardial dysfunction). The primary cause of these clinical findings is hypophosphatemia. Refeeding syndrome is most likely to occur during the first 1 to 2 weeks of nutrition replenishment. As carbohydrates are reintroduced, insulin causes glucose, phosphate, potassium, and magnesium to move into cells, which further lowers the electrolyte concentrations in the serum. Insulin also causes cells to create molecules that require phosphate to be formed, such as adenosine triphosphate. This action further lowers phosphate levels in the serum.

A 28-year-old woman presents with a pervasive behavior pattern that includes cognitive-perceptual problems and interpersonal dysfunction. Among her symptoms is the belief she can see auras around others and she can read minds. Which of the following additional symptoms is most likely associated with the diagnosis? A. Auditory hallucinations B. Ideas of reference C. Impulsivity D. Tangential speech

Ideas of reference **Schizotypal disorder is characterized by a long-standing and pervasive behavior pattern that includes cognitive-perceptual problems and interpersonal dysfunction associated with significant disability. It is a rare psychiatric disturbance that often co-occurs with borderline personality disorder, bipolar disorder, or panic disorder with agoraphobia. Clinical manifestations include three subgroups: cognitive-perceptual, oddness or disorganized, and interpersonal. The cognitive-perceptual symptoms are chronic distortions that include odd beliefs, unusual perceptual experiences, ideas of reference, and paranoia. Odd beliefs or magical thinking may include mind reading or thought transfer

A 32-year-old woman comes to the office due to increased urinary frequency and burning. Medical history is unremarkable except for 2 previous urinary tract infections and several old injuries, including a broken arm and dislocated shoulder. She lives with her boyfriend of 3 years. During the examination, the health care provider notices bruises on the patient's arms, abdomen, and breasts. At first, she explains that she slipped and fell in the shower. When asked how things are at home, the patient mentions that her boyfriend has a bad temper and that they argue frequently. She reluctantly discloses that he has hit her several times when intoxicated; the last time was a week ago. In addition to acknowledging the abuse and providing support, which of the following is the most appropriate next step in management of this patient? A) Ask the patient why she remains in the relationship B) Encourage the patient to leave her boyfriend C) Encourage the patient to press charges D) Identify a place the patient can go in an emergency E) Refer the patient for counseling

Identify a place the patient can go in an emergency **The initial approach to the patient who has just disclosed intimate partner violence (IPV) includes expressing empathy and support, followed by an assessment of immediate and future safety. Patients who are not in imminent danger should be encouraged to make a safety plan in the event they decide to leave the abuser or need to escape immediately. Components of a safety plan include a place to go (eg, friends, family, shelter) and an emergency kit with essential items and documents. Information regarding shelters and community-based domestic violence programs should be provided. As in this case, patients are often not ready to make a decision to leave, and nonjudgmental support and education about IPV may facilitate disclosure and seeking help in the future.

A 21-year-old man presents to the clinic due to recurrent nausea, vomiting, and abdominal pain. He says that, in the last 6 months, he has unintentionally lost 20 pounds. Physical exam findings are unremarkable other than mild abdominal tenderness with palpation. Urine drug screen is positive for tetrahydrocannabinol. Which of the following is most likely to confirm the diagnosis?

Improvement in symptoms with hot showers **Cannabinoid hyperemesis syndrome is a type of cyclical vomiting syndrome. It occurs most commonly in young men and patients who have a history of chronic or daily marijuana use. Symptoms start in the morning and may be accompanied by bloating, diaphoresis, or weight loss. Compulsive hot showers help relieve the symptoms, and a positive history of this helps to confirm the diagnosis.

A 24-year-old man presents to the clinic with depressed mood, feelings of worthlessness, extreme guilt, difficulty concentrating, decreased sleep, decreased appetite, and lack of interest in any activity. These symptoms have been present for more than 1 month and are worsening in severity. The patient states that recently he has felt that life is not worth living. Which of the following is an indication for hospitalization?

Inability to discuss safety planning

5 Distinct Stages of Change: - A patient working to maintain behavioral change over the long term

Maintenance (5)

A 22-year-old man presents to the emergency department with acute confusion and paranoia. Vital signs are notable for a temperature of 99.5°F, HR of 132 bpm, and blood pressure of 198/110 mm Hg. You notice that the patient is diaphoretic with dilated pupils on exam. Urine drug screen detects the metabolite benzoylecgonine. Which of the following describes the mechanism of action of the most likely intoxicant?

Increases the uptake of biogenic amines **Cocaine is a stimulant that is often used recreationally. Cocaine is commonly used by intravenous injection, inhalation, or via intranasal snorting. It achieves its effects through three mechanisms: blocking the reuptake of biogenic amines, sodium channel blockade, and excitatory amino acid stimulation. Urine drug testing for cocaine tests for the metabolite benzoylecgonine, which is usually detectable for 2-4 days but may be detectable for up to 2 weeks with chronic use.

A 22-year-old man is admitted to the psychiatric hospital for a condition marked by recurrent psychosis. You examine him and note that he has a flat affect and is apathetic. In addition, he will maintain unnatural postures that he is put into. He was initially admitted after he attempted to break into the White House because he thought he was the president. Which of the following accurately describes the epidemiology of this condition?

Individuals born in March are at an increased risk **Schizophrenia risk factors include birth during the late winter or spring, living further from the equator, living in an urban area, immigration, advanced paternal age at conception, perinatal obstetric complications, childhood trauma or central nervous system infections, and cannabis use during adolescence. Birth during the late winter or spring is thought to be a risk factor because of an increased risk of maternal exposure to viruses during pregnancy.

A 22-year-old woman presents to the clinic due to episodes of irritable mood, increased energy, and increased talkativeness that last for 2 days and are then followed by 2 days of low energy with hypersomnolence and lack of interest in activities. The episodes cause the patient distress and have been occurring for more than 2 years on most days of the year. Which of the following, if present, would indicate a diagnosis of cyclothymic disorder? A) Auditory hallucinations B) Inflated self-esteem C) No impairment in social functioning D) Suicidal ideation

Inflated self-esteem **Cyclothymic disorder is a mood disorder characterized by mood alterations that swing between increased energy and mood and decreased energy and mood. The episodes of increased energy and irritable or expansive mood do not qualify as hypomanic or manic episodes, do not last longer than 4 days, and do not require hospitalization, but they do cause the patient distress. Symptoms of irritable or expansive mood in cyclothymia can include increased goal-directed behavior, decreased need for sleep, inflated self-esteem, talkativeness, and distractibility. Treatment of cyclothymic disorder includes cognitive behavioral therapy and the use of low-dose mood stabilizers with the goal of achieving periods of 6 months of relative mood stability at a time.

A 22-year-old man presents to the clinic complaining of sweating, tremors, and nausea. He states he feels this way if he goes 1 day without drinking alcohol. He has been drinking about six beers per day and more on the weekends for the past 2 years. Which of the following signs and symptoms is consistent with a diagnosis of mild alcohol withdrawal? A. Delirium tremens B. Hallucinations C. Insomnia D. Sinus bradycardia

Insomnia **Mild symptoms include tachycardia, diaphoresis, tremors, nausea, vomiting, anxiety, mild agitation, insomnia, alcohol craving, and headache. Moderate to severe symptoms include hallucinations, delirium tremens, and seizures, which may be fatal. Delirium tremens manifests as severe agitation, hypertension, tachycardia, fever, drenching sweats, and hallucinations. Delirium tremens occurs 72 to 96 hours after a patient's last drink and is more common with increasing age, comorbid disease, and misuse of other central nervous system depressants.

A 41-year-old woman and her 19-year-old daughter come to the emergency department out of concern that they have been poisoned. The mother reports that their landlord is harassing them because they have been late on their last few rent payments. She says, "He turns down the heat to make us freeze and asks the other tenants to spy on us. Last month, he installed video cameras in our living room while we were out." Today, the mother tasted something odd in her food and is convinced that the landlord poisoned them. She came immediately to the hospital for treatment and to obtain evidence of the poisoning. The daughter agrees with her mother's account, adding that she thinks she saw the landlord lurking outside their apartment the night before. Laboratory testing for both is unremarkable. Which of the following is the most appropriate course of action? A) Admit the mother and daughter to different psychiatric units B) Interview the daughter alone C) Obtain collateral information from the landlord D) Provide reassurance and schedule outpatient follow-up for both E) Recommend a trial of antipsychotics for the mother and daughter

Interview the daughter alone **The mother and daughter have a shared psychotic disorder (also known as folie à deux), a rare manifestation of delusional disorder in which the same delusion(s) is present in individuals who share a close relationship. Usually, the dominant individual in the pair becomes delusional and transfers the delusion onto the second, more submissive, person, who may or may not meet full criteria for delusional disorder. The most important first intervention is to separate the pair to disrupt the mutually reinforcing nature of the shared delusion and to enable a more careful assessment of each individual's pathology. The dominant individual who first had the delusion, in this case the mother, typically requires psychiatric treatment (sometimes in an inpatient setting), whereas the more submissive individual less frequently requires formal treatment. There is insufficient information regarding the daughter's psychiatric status to determine if she requires further intervention at this time. To complete the daughter's assessment, the clinician must assess the daughter while her mother is not present.

A 32-year-old man presents to the clinic with recurrent, episodic intense fear with symptoms of choking and dyspnea. He cannot identify a trigger to these episodes but states they resolve spontaneously after 10 to 15 minutes. Which of the following comorbidities is the most likely to be found in this patient?

Major depressive disorder **Approximately 37% of patients with panic disorder also have a lifetime prevalence of major depressive disorder.

A 35-year-old woman presents with hearing loss and tinnitus that she says are secondary to working in a loud environment without the proper hearing protection. She is currently involved in a lawsuit against her former employer. An audiogram is performed and shows inconsistent results. An otoacoustic emissions test and an electronystagmography are performed and are within reference range. What is the most likely diagnosis?

Malingering

A 23-year-old woman with no significant prior medical history presents to the clinic reporting a chronic history of sleep issues. She states that in the evenings and during attempted sleep, she often feels a persistent "crawling and tingling" feeling in the legs that is relieved by movement, making falling asleep difficult. Physical exam is benign. Which of the following is the most likely next step in diagnosis? A) Iron studies B) MRI of the brain C) Polysomnography D) Urine drug screen

Iron studies **Restless legs syndrome is a common sleep-related movement disorder characterized by an uncomfortable or unpleasant sensation in the limbs relieved by movement. Symptoms typically occur in the evenings or at night, during periods of inactivity. Most patients with restless legs syndrome demonstrate periodic limb movements during sleep, which may or may not cause arousal from sleep. Restless legs syndrome is common, occurring in up to 15% of the population. There is a strong genetic component. Restless legs syndrome may occur as a primary, idiopathic disorder or secondary to Parkinson disease, pregnancy, iron deficiency anemia, or diabetic or uremic peripheral neuropathy. While the pathophysiology of restless legs syndrome is not completely understood, there is a strong association with reduced iron stores. Diagnosis of restless legs syndrome is often made clinically, and the only testing that is always indicated is iron studies due to the strong association with decreased ferritin stores.

What differentiates Nightmare disorder from Sleep terror disorder in terms of the dreams themselves?

Kids with nightmare disorder will be able to recall details about the dreams (like monsters were chasing them around) vs. with Sleep terror disorder they won't recall details about the dreams

A 28-year-old woman presents to the clinic with 6 or 7 nights of feeling a decreased need to sleep, racing thoughts, irritability, and an elevated mood lasting all day for the past week. She states her roommates are aware of the change in her behavior, but she is able to go to work each day and perform her duties normally. She reports no auditory or visual hallucinations, thoughts of persecution, or paranoia. Her medical history includes one episode of major depression 12 months ago that lasted 3 months and went unmedicated. Which of the following treatment options should be avoided in a patient who is hospitalized for mania but would be an appropriate choice for this patient? A) Carbamazepine B) Lamotrigine C) Lithium D) Olanzapine

Lamotrigine **Lamotrigine is an antiepileptic drug that works by inactivating voltage-gated sodium channels in the brain, thus decreasing neuronal synaptic firing. Lamotrigine works well to stabilize mood fluctuations in patients with bipolar II disorder but is not, however, an antimanic drug and is not useful when treating acute mania.

If a patient is on Valproate for Bipolar I disorder and she wants to stop oral contraceptives and get pregnant soon, what other mood medication should she be switched to due to Valproate's risk of neural tube defects?

Lamotrigine **Relatively safe in pregnancy

A 27-year-old woman with bipolar I disorder is evaluated in the office upon urgent request. She was recently started on a new medication after having difficulty tolerating lithium. The patient reports a concerning skin rash that developed over the past 36 hours. She is concerned it may be an allergic reaction related to her new medication and indicates she did not slowly titrate the dose as indicated. On her physical exam, poorly defined erythematous macules and plaques with purpuric necrotic centers are noted on the trunk and the left cheek. With what medication is this reaction most commonly associated?

Lamotrigine **Stevens-Johnson syndrome is a serious skin rash associated with the use of lamotrigine, a drug used in the maintenance therapy of bipolar disorder.

A 31-year-old woman comes to the office for follow-up of bipolar I disorder. The patient was diagnosed at age 20 and has had 2 hospitalizations for major depressive episodes. Her mood has been stable on valproate for the past 2 years. The patient hopes to become pregnant and would like to stop her oral contraceptives soon. She does not want to risk another hospitalization and would prefer to keep taking medication during pregnancy. After a discussion of the options, the patient chooses to stop the valproate and switch to a different medication. Which of the following is the best treatment option for this patient? A) Bupropion B) Carbamazepine C) Lamotrigine D) Lithium E) Sertraline

Lamotrigine **Valproate, an anticonvulsant commonly used as a mood stabilizer in the acute and maintenance treatment of bipolar disorder, is a teratogen associated with neural tube defects (eg, anencephaly, myelomeningocele). Women exposed to valproate in the first trimester, the critical period of organogenesis, are at particularly high risk (up to a 20-fold increase over the general population). Therefore, switching to lamotrigine, a mood stabilizer with a favorable pregnancy safety profile, is appropriate for euthymic patients who do not wish to continue valproate during pregnancy. (Choice B) Carbamazepine, an anticonvulsant, is associated with neural tube defects and should be avoided in pregnancy.

A 37-year-old man presents to the office with concerns of increasing stress and "difficulty controlling urges." He notes for the past few years he has found himself sexually aroused by young children. This has manifested through sexual fantasies. He reports he has not acted on these fantasies (he has not watched child pornography or sexually abused a prepubescent child), but he is finding his fantasies are becoming more intense and more difficult to control, and they are causing him significant distress. He recently contacted a young boy over the internet. The patient requests pharmacologic therapy that can reduce the frequency of his fantasies and his sex drive. What should be recommended at this time?

Leuprolide acetate **Hormonal therapy, such as leuprolide acetate, has been effective in the treatment of pedophilic disorder. Pedophilic disorder is a type of paraphilia, referring to a sexual behavior that deviates from culturally normal sexual interests and behaviors

A 6-year-old boy presents to the clinic for evaluation of a conduct disorder. His mother states he has been irritable and angry several days a week for the past year. When he is irritable, he defies her and his teachers, argues with everyone, and deliberately annoys his siblings. His grades are poor, and his friendships are few due to his anger and defiance. At least once per month, he acts vindictively toward his mother but has never harmed a person or animal. Which of the following environmental elements is more common in patients with this boy's most likely disorder? A. Maternal aggression B. Overprotective parenting C. Paternal absence D. Rigid structure in the home

Maternal aggression **These environmental factors include insecure attachment, unresponsive parents, maternal aggression, abuse, community violence, harsh punishment, parental psychopathology, inconsistent discipline, poverty, and peer rejection. Treatment of oppositional defiant disorder includes teaching the child problem-solving skills, behavioral parenting interventions for parents and caregivers, and group cognitive behavioral therapy.

A 73-year-old man with bipolar disorder is brought to the emergency department by his daughter, who has been visiting him for several days. She reports that "he's not himself." The patient has become increasingly confused, has bilateral hand tremors, has difficulty walking straight, and has vomited over the past few days. Two weeks ago, he saw his new primary care provider, who added hydrochlorothiazide to the patient's medication regimen. The patient has been psychiatrically stable for many years and has been seeing a psychiatrist, who has prescribed mood stabilizers and antipsychotics. He is disoriented, ataxic, and has a generalized seizure that lasts 2-3 minutes. Which of the following medications is the most likely cause of this patient's symptoms? A) Bupropion B) Haloperidol C) Lamotrigine D) Lithium E) Valproic acid

Lithium **This patient is exhibiting signs and symptoms of lithium toxicity. These may include new onset of severe gastrointestinal symptoms, confusion, ataxia, tremor, and other signs of neuromuscular irritability such as fasciculations and seizures. This patient was previously stable on his psychiatric medications; therefore, the recent addition of hydrochlorothiazide is likely responsible for increasing his lithium serum level. Thiazide diuretics can cause a decrease in the renal clearance of lithium and lead to lithium toxicity. The risk of lithium toxicity is higher in patients with dehydration from any cause (eg, vomiting, diarrhea, fever, diuresis) and in elderly patients due to a lower glomerular filtration rate and reduced volume of distribution.

A 23-year-old woman comes to the office for follow-up after a recent hospitalization. The patient had no known psychiatric history prior to being arrested by police 2 months ago after breaking into city hall to "find evidence of a secret organization plotting to take over the world." When police officers took her into custody, she was speaking so rapidly that they had difficulty understanding her. She was hospitalized and prescribed appropriate treatment; symptoms improved, and she was discharged 2 weeks later. Since then, the patient has been taking medications as prescribed and she has no symptoms. Vital signs are normal and physical examination is unremarkable. The patient's speech is regular and she appears calm. She is fully oriented and does not appear distracted. Laboratory studies are unremarkable except for serum calcium of 13.4 mg/dL. This patient is most likely taking which of the following medications? A) Aripiprazole B) Lamotrigine C) Lithium D) Quetiapine E) Valproate

Lithium **This patient's acute onset of rapid speech and symptoms of psychosis (ie, delusions about a secret organization), followed by a return to normal functioning with treatment, is consistent with a bipolar manic episode. Pharmacotherapy for an acute manic episode includes a mood stabilizer and/or an antipsychotic medication. This patient's serum calcium level suggests that she was prescribed lithium, which can cause hyperparathyroidism and associated hypercalcemia. Lithium is indicated for acute mania and maintenance treatment of bipolar disorder. In addition to hyperparathyroidism, potential long-term side effects include nephrogenic diabetes insipidus, chronic kidney disease, and thyroid dysfunction (most often hypothyroidism). Furthermore, first-trimester lithium exposure is associated with teratogenic effects (eg, Ebstein anomaly). Therefore, current guidelines recommend a baseline basic metabolic panel (including blood urea nitrogen and creatinine), calcium, urinalysis, pregnancy test in women of childbearing age, and thyroid function tests before lithium is prescribed. An ECG is also recommended in patients with risk factors for coronary artery disease because lithium may cause dysrhythmias in these patients.

A 40-year-old man presents with hand tremors for the past 2 months. The patient is an art teacher and has had difficulty painting due to shaky hands. When noticing others looking at his hands, he becomes increasingly anxious, which worsens the tremor. The patient has a history of bipolar disorder with a manic episode 6 months ago, for which he takes lithium. The patient has not noticed any tremor changes with alcohol use. Vital signs are normal. Physical examination shows fine, bilateral hand tremors that worsen with posture held against gravity. Muscle tone and deep tendon reflexes are normal. Gait is normal. Which of the following is the most likely cause of this patient's symptoms? A) Cerebellar degeneration B) Essential tremor C) Hyperthyroidism D) Lithium adverse effect E) Parkinson's disease

Lithium adverse effect **This patient's fine action tremor of the hands that worsens with stress is consistent with physiologic tremor. Most individuals have a fine (ie, low-amplitude, high-frequency) tremor of the hands that usually goes unnoticed. However, the tremor may become visible when enhanced by increased sympathetic activity or certain medications. This patient's history of bipolar disorder suggests that his tremor is being enhanced by lithium. Tremor is a common adverse effect of lithium; lithium-induced enhanced physiologic tremor is typically symmetric, limited to the hands and upper limbs, and occurs when the medication is started or the dose is increased (ie, after a manic episode). It is nonprogressive and often decreases over time, even with no dosage reduction. Therefore, lithium-enhanced physiologic tremor is often managed with watchful waiting and modification of aggravating factors.

A 25-year-old man presents to the emergency department, brought by emergency medical services, after getting into an altercation at a nightclub. He is agitated and yelling at the staff in the emergency department. His vital signs are notable for a HR of 135 bpm and blood pressure of 208/115 mm Hg. On exam, you notice that he is diaphoretic and has dilated pupils. You are able to obtain further information from his roommate who reports he is likely intoxicated with a substance made from pseudoephedrine in a home laboratory. Which of the following medications is considered first-line treatment for his elevated blood pressure? A) Esmolol B) Haloperidol C) Lorazepam D) Nitroprusside

Lorazepam **Amphetamine intoxication causes increased levels of central nervous system norepinephrine, dopamine, and serotonin. It has a similar mechanism and presentation to cocaine intoxication. Patients classically present with sympathomimetic findings, including tachycardia, hypertension, diaphoresis, and mydriasis. Amphetamine intoxication may also cause paranoia, anxiety, agitation, confusion, and hallucinations. Hypertension related to amphetamines is usually controlled with benzodiazepines, such as lorazepam. However, nitroprusside or phentolamine can be used as second-line agents in patients whose blood pressure is refractory to benzodiazepines. It is important to consider dehydration in patients with amphetamine intoxication and administer intravenous fluids to rehydrate.

A 43-year-old man presents with epigastric pain and vomiting. On admission, blood pressure is 100/70 mm Hg and heart rate is 90/min. Physical examination shows dry mucous membranes and prominent epigastric tenderness. Aspartate transaminase is 320 U/L and alanine transaminase is 152 U/L. Overnight, the patient experiences insomnia and restlessness. Temperature is 37.8 C (100 F), blood pressure is 162/94 mm Hg, and pulse is 120/min. On examination, the pupils are slightly enlarged, and the hands are tremulous. Which of the following is the most appropriate initial pharmacotherapy for this patient? A) Acamprosate B) Buprenorphine C) Lorazepam D) Naloxone E) Naltrexone

Lorazepam **This patient's epigastric pain, elevated liver enzymes, and development of sympathetic overactivity (ie, tachycardia, elevated blood pressure, restlessness, tremulousness) within 12 hours of admission suggest alcohol withdrawal. Other symptoms may include anxiety, insomnia, diaphoresis, nausea, and vomiting. Prompt treatment with benzodiazepines (eg, chlordiazepoxide, lorazepam) is required to prevent progression to severe alcohol withdrawal that may include seizures and life-threatening delirium tremens. (Choice E) Naltrexone, a mu-opioid receptor antagonist, is a first-line option in opioid and alcohol use disorders to reduce the pleasurable reward from intoxication and to control cravings. However, it has been associated with hepatotoxicity (not suggested with liver enzymes ≥3 times above normal), and this patient's potentially life-threatening alcohol withdrawal should be addressed first.

Extrapyramidal symptoms (EPSs) are theorized to result from D2 antagonism in the _________ pathway.

Nigrostriatal

A 48-year-old man presents to the clinic complaining of fatigue. He reports drinking 6 to 10 beers per day for the past 15 years. He currently takes lisinopril for hypertension. Physical exam reveals rhinophyma, facial erythema, hepatomegaly, an abdominal fluid wave, and external hemorrhoids. Which of the following laboratory abnormalities would be most likely in this patient?

Mean corpuscular volume 105 fl **Health problems attributable to alcohol use disorder include hypertension, anxiety, depression, gastrointestinal reflux, sleep disturbance, liver disease, bone marrow suppression, macrocytosis (mean corpuscular volume over 96 fL), cardiomyopathy, neuropathy, and trauma due to falls.

A 7-year-old girl presents to the pediatrician multiple times for hematuria until it is discovered that her mother is contaminating the urine samples with her own blood. Which of the following is the suspected diagnosis?

Medical child abuse **It's not factitious disorder because the parent is imposing the symptoms on the child. This makes it child abuse.

A 42-year-old man is brought to the emergency department by his wife after he assaulted her. The patient has not slept or eaten for days; he became agitated and started accusing her of plotting to murder him. The patient also feels as though bugs are crawling under his skin. He had a prior psychiatric hospitalization 8 months ago when he was admitted for paranoid delusions and visual hallucinations. He is uncooperative, speaks rapidly and loudly, gets up to pace during the interview, and shouts, "I don't trust any of you; you're in this together." Temperature is 37.8 C (100 F), blood pressure is 140/90 mm Hg, pulse is 104/min, and respirations are 20/min. Examination shows a thin, diaphoretic man with poor grooming and dentition. He clenches his teeth, picks at his skin, and has multiple sores on his face and body. Which of the following is the most likely diagnosis in this patient? A) Alcohol withdrawal B) Bipolar I disorder C) Delusional disorder, somatic subtype D) Methamphetamine use disorder E) Schizophrenia

Methamphetamine use disorder **This patient's paranoid delusions, tactile hallucinations (eg, bugs crawling under the skin), aggressive behavior, severe insomnia, and physical findings of poor dentition, bruxism (ie, teeth grinding), and skin sores are suggestive of chronic methamphetamine use disorder. Methamphetamine is a highly addictive and potent CNS stimulant. Heavy use frequently causes marked weight loss, psychotic symptoms, and excoriations due to chronic skin picking. Severe dental conditions ("meth mouth") can include brown discoloration, tooth decay, and cracked teeth due to severe bruxism and dry mouth. Other features of intoxication include mood disturbances, anxiety, irritability, confusion, violent behavior, and signs of sympathetic overactivity (eg, elevated pulse and blood pressure, hyperthermia, sweating, pupillary dilation).

A 10-year-old boy presents to the clinic with his mother, who is concerned about his poor school performance. She reports he makes careless mistakes, has difficulty maintaining attention, and is easily distracted during class. Which of the following medications for treating the suspected condition has a black box warning for misuse and dependence?

Methylphenidate

A 10-year-old boy presents after being referred by his teacher. He is having difficulty concentrating and sitting still while in school. He often interrupts his teacher and has problems completing in-class assignments. His parents report he has the same problems at home, with frequent outbursts and impulsive behaviors. Which of the following appropriate therapeutics works by blocking the reuptake of norepinephrine and dopamine into presynaptic neurons?

Methylphenidate **First-line treatment is generally with amphetamines or methylphenidate. The mechanism of action is through blocking the reuptake of norepinephrine and dopamine into presynaptic neurons

A 19-year-old girl presents to the clinic for an annual physical. She states she runs at least 45 miles per week to maintain her figure. The patient has no significant medical history and has been amenorrheic for 6 months. Physical examination reveals a thin patient with peripheral edema and fine, downy hair on her face and arms. Vital signs include body mass index of 16.52 kg/m2, HR of 52 bpm, RR of 17 breaths per minute, BP of 98/52 mm Hg, T of 97.2°F, and SpO2 of 97% on room air. Which of the following is the best diagnosis?

Moderate anorexia nervosa **The severity of anorexia nervosa is classified by body mass index, with a value ≥ 17 kg/m2 indicating mild disease, values between 16 and 16.99 kg/m2 representing moderate disease, and a body mass index of 15-15.99 kg/m2 defined as severe disease. Extreme anorexia nervosa is diagnosed in patients with a body mass index < 15 kg/m2 BMI: >17 = Mild 16-16.99 = Moderate 15-15.99 = Severe < 15 = Extreme

A 27-year-old man presents to the emergency department in a coma after being found on the side of a street in a parked car. Vital signs are significant for a respiratory rate of 10 breaths per minute. You examine him and notice pinpoint pupils. A standard urine drug test is performed. Which of the following drugs is most likely to return a positive result for the drug class that is suspected to have caused this patient's presentation?

Morphine **Decreased respiratory drive manifests as a decreased respiratory rate and decreased tidal volume, which can each contribute to hypoxemia and hypercarbia. Opioid overdose also causes miotic pupils and constipation.

A 37-year-old man is brought to the emergency department after his sister found him unresponsive. Several days ago, he was discharged from an inpatient facility where he was treated for multiple substance use disorders and long-standing bipolar disorder. The patient's sister states that he has been depressed and has not taken his prescribed medications since discharge. Temperature is 36.7 C (98.1 F), blood pressure is 80/40 mm Hg, pulse is 62/min, and respirations are 10/min. He is obtunded and unresponsive to verbal commands. The pupils are 1 mm and respond sluggishly to light. Fingerstick blood glucose is 72 mg/dL. The patient is ventilated, and supplemental oxygen and intravenous fluids are initiated. Which of the following is the best next step in management of this patient? A) Buprenorphine B) Flumazenil C) Intravenous glucose D) Naloxone E) Naltrexone

Naloxone **Several features of this patient's presentation suggest opioid intoxication or overdose, including decreased level of consciousness and reduced respiratory rate (a rate <12/min is the best predictor of opioid toxicity). Other classic findings include decreased tidal volume and decreased bowel sounds. Miosis is usually present as well, but normal pupil size does not rule out opioid intoxication due to possible coingestants (eg, sympathomimetics). Patients recently discharged from an inpatient facility (eg, due to substance use) are at higher risk of opioid overdose because they may have lost tolerance to opioid effects. Naloxone is a short-acting opioid antagonist that is usually administered intravenously in emergency settings to reverse respiratory depression. Naloxone is also available in intranasal form for administration by first responders in community settings. The opioid antagonist naltrexone is used as maintenance treatment for opioid use disorder (and to treat alcohol use disorder); however, it has a slower onset than naloxone and is not used to treat acute opioid intoxication (Choice E).

A 24-year-old man is found unconscious on a sidewalk and presents to the emergency department via ambulance. Vital signs include an HR of 55 bpm, BP of 100/68 mm Hg, RR of 8 breaths/minute, T of 98.6°F, and oxygen saturation of 90% on room air. Physical examination reveals a comatose man with miotic pupils and no signs of external trauma. His point-of-care glucose is 75 mg/dL. After supplemental oxygen administration, which of the following is the recommended treatment?

Naloxone (Narcan) **Opioid intoxication is marked by decreased mental status and respiratory drive following exposure to opioids. It is important to determine the drug and dose of exposure (when possible), the presence of co-exposures, and the individual's history of opioid use.

A 42-year-old man comes to the office for a follow-up. Last year, the patient was hospitalized for acute gastritis. During the hospitalization, he went into alcohol withdrawal that was treated with chlordiazepoxide. The patient was abstinent for 2 weeks following discharge but then started drinking again. Over the past several months, he has been drinking 6-10 beers daily. The patient says, "I want to cut down, but the cravings are too strong." He fears he will lose his job and family if he continues to drink. Vital signs and physical examination are normal. Which of the following is the most appropriate pharmacotherapy for this patient's alcohol use disorder? A) Buprenorphine B) Bupropion C) Chlordiazepoxide D) Naltrexone E) Varenicline

Naltrexone **Although this patient desires to reduce his alcohol intake, he is unable to control his strong cravings and is drinking increasing amounts. Pharmacotherapy should be considered in patients with moderate to severe alcohol use disorders. Medications that target the reinforcing effects of alcohol by modulating opioid and glutamate function are effective. First-line treatment options include naltrexone, a mu-opioid receptor antagonist, and acamprosate, a glutamate modulator. Naltrexone has been shown to decrease alcohol craving, reduce heavy drinking days (defined as >5 drinks for men and >4 for women), and increase days of abstinence. It can be initiated while the patient is still drinking. It is contraindicated in patients taking opioids as it can precipitate withdrawal, and in those with acute hepatitis or liver failure. Acamprosate, which is primarily used to maintain abstinence, should be avoided in patients with significant renal impairment.

A 23-year-old man comes to the office at his girlfriend's insistence. She says that the patient's frequent snoring keeps her up at night and that in the last 4 months he has twice fallen asleep while they were talking. In this same period, the patient says that he has regularly fallen asleep in the afternoon while reading or watching television but typically feels refreshed after a brief nap. The patient says that he sometimes hears a voice call his name prior to falling asleep. He also reports uncharacteristic episodes of clumsiness in which he has suddenly dropped objects or fallen to his knees. Which of the following is the most likely diagnosis in this patient? A) Delayed sleep-wake phase disorder B) Insufficient sleep C) Narcolepsy D) Obstructive sleep apnea E) REM sleep behavior disorder

Narcolepsy **Narcolepsy is a chronic sleep disorder characterized by frequent, overwhelming urges to sleep. It is commonly associated with cataplexy, a sudden loss of muscle tone that occurs in response to intense (usually positive) emotions. Narcolepsy results from the depletion of hypocretin (also known as orexin)-secreting neurons in the lateral hypothalamus that are involved in maintaining wakefulness. Patients with narcolepsy experience shortened sleep latency and typically enter rapid eye movement (REM) sleep almost immediately. They commonly experience intrusions of REM sleep phenomena during sleep-wake transitions, including hypnagogic (upon falling asleep) and hypnopompic (upon awakening) hallucinations and sleep paralysis (inability to move immediately after awakening). The clinical diagnosis of narcolepsy can be confirmed by low cerebrospinal fluid levels of hypocretin-1 or shortened REM sleep latency on polysomnography.

A 10-year-old boy presents to the clinic for evaluation after his teacher voiced concerns about his behavior in school. She reports the patient has difficulty remaining seated during class, talks excessively, interrupts others, and blurts out answers too quickly. His parents state that, since he was 4 years old, the patient gets angry when waiting for his turn and enjoys boisterous play. His family voices concerns about the first-line medication and would like to try an alternative agent. Which of the following side effects is most likely with this alternative medication?

Nausea **The alternative treatment for ADHD in kids outside of stimulants like Methylphenidate is Atomoxetine. Stimulants are first-line agents used to treat this condition in children, and common agents include methylphenidate, dexmethylphenidate, dextroamphetamine, and amphetamine-dextroamphetamine. Atomoxetine is the primary alternative nonstimulant medication if a patient or their family prefers this course of pharmaceutical intervention. Side effects for this agent include nausea, vomiting, weight loss, sleep problems, hepatotoxicity, xerostomia, insomnia, drowsiness, hyperhidrosis, erectile dysfunction, priapism, and psychosis with aggressive behavior. Additionally, cardiovascular effects include QT prolongation, hypertension, tachycardia, and cardiovascular collapse.

A 23-year-old woman presents to the emergency department for evaluation of new-onset psychosis. She is accompanied by a close friend who has been worried about her. Her friend reports that, for several months, there has been a change in the patient's behavior. The patient has been paranoid that someone has been following her and that someone can see her through her cell phone. The friend found the patient's phone in the garbage disposal. The friend was contacted by the patient's job after she had not shown up to work in several days. Today, the patient walked into oncoming traffic in the middle of a busy intersection. The patient said, "They told me to," and reports hearing commanding, unfamiliar voices. The patient reports no drug use or a family history of schizophrenia, but she does report a family history of major depression. She constantly looks over her shoulder during the exam but otherwise has a flat affect and demonstrates apathy. Which part of her history is a poor prognostic feature of the suspected condition?

Negative symptoms (flat affect, apathy) **Negative symptoms tend to be resistant to treatment, which is why they are associated with a poorer prognosis.

A 7-year-old girl is brought to the office by her mother. Over the past month, the girl has awakened almost every night, come into her parents' room, and insisted on sleeping the remainder of the night in their bed. The girl wakes up abruptly in a panicky sweat, crying and screaming, "I'm so scared; monsters are chasing me." She breathes rapidly and shakes but is able to calm down after being consoled by her parents and hugging a favorite stuffed animal. The girl started a new school 1 year ago. Although the girl is shy, she enjoys school and has several good friends. Which of the following is the most likely diagnosis in this patient? A) Adjustment disorder B) Nightmare disorder C) Nocturnal panic attack D) Separation anxiety disorder E) Sleep terror disorder

Nightmare disorder **This girl's recurrent awakenings with associated dream content and ability to be consoled are most consistent with nightmare disorder. Diagnosis requires recurrent episodes of awakening from sleep with recall of highly disturbing and frightening dream content. On awakening, the child is fully alert, remembers the dream, and is usually consolable. Although frightening, nightmares are typically transient and developmentally normal for most children. Nightmares occur during rapid eye movement (REM) sleep and are more frequent in the second half of the night. Sleep terror disorder, in contrast, is a non-REM arousal disorder characterized by incomplete awakenings, unresponsiveness to comfort, and no recall of dream content (Choice E). Sleep terrors typically occur in the first third of the night and are characterized by marked autonomic arousal and amnesia for the episode in the morning.

A 52-year-old woman comes to the office for a routine examination. During the examination, the patient confides to the health care provider that she has been "down" since her youngest child left for college 2 months ago. The patient is worried about her daughter being away from home for the first time. At work, the patient occasionally has lapses of concentration when worrying about her daughter, but it has not affected her productivity. She still enjoys going out with her husband but says all they do is talk about their kids. Which of the following is the most likely explanation for this patient's condition? A) Adjustment disorder with depressed mood B) Generalized anxiety disorder C) Major depressive disorder D) Normal sadness E) Persistent depressive disorder (Dysthymia)

Normal sadness **Periods of sadness are a normal part of human experience and should not be diagnosed as a psychiatric disorder unless criteria are met for severity, duration, and clinically significant distress or impairment. This patient's mild depression in response to life changes is consistent with normal sadness. She does not meet the full criteria for any disorder. Significantly, her social and occupational functioning is not impaired, which is a DSM-5 requirement for the diagnosis of most psychiatric disorders, including adjustment disorders.

A 19-year-old man comes to the office after being referred by his professor. The patient says his professor "got annoyed" after he requested several extensions for his first writing assignment. He reports that he wrote multiple rough drafts because he wanted to make sure he submitted "something great." The patient repeatedly mentions that he was valedictorian of his high school class because he was "the most diligent and dedicated student." He has developed his own method of test preparation and keeps a rigid daily study schedule. The patient was invited to join a study group but declined because the other students refused to adopt his approach. He lives alone and does not have hobbies because they are a "waste of time." Which of the following best explains this patient's behavior? A) Adjustment disorder with anxious mood B) Narcissistic personality disorder C) Obsessive-compulsive disorder D) Obsessive-compulsive personality disorder E) Schizoid personality disorder

Obsessive-compulsive personality disorder **This patient's rigidity and perfectionism are characteristic of obsessive-compulsive personality disorder (OCPD). Individuals with OCPD are preoccupied with orderliness, details, scheduling, and rigid rules. Their perfectionism often interferes with efficiency and task completion, such as this patient's inability to finalize his paper due to his overly rigid standards. His reluctance to work with others unless they agree to his way of doing things is also characteristic. Other features include stubbornness, excessive devotion to work, inability to delegate tasks, and a miserly spending style. Although this patient's OCPD traits might have helped him excel in high school, the increased demands and pace of college work have amplified his difficulties and now impair his functioning. Like patients with other personality disorders, he has limited insight into the problematic nature of his behavior (eg, he believes that his study approach is superior) and sees these traits as positive attributes (ie, ego-syntonic). (Choice B) Individuals with narcissistic personality disorder may also be preoccupied with perfection and believe that others cannot do things as well as they can. However, they are motivated by a need for praise and admiration, whereas those with OCPD are driven by the need for orderliness and control.

A 32-year-old man presents to the clinic at the request of his family. He reports that it is difficult for him to maintain a job or friendships because he cannot trust anyone. He is also recently separated from his wife who he continuously thought was unfaithful. What are the core characteristics of the cluster that the suspected personality disorder is in?

Odd and eccentric **Paranoid personality disorder is a cluster A personality disorder. The core features that describe cluster A personality disorders are odd and eccentric. Paranoid personality disorder is characterized by a pervasive pattern of distrust and suspiciousness of others.

A 53-year-old man with a history of schizophrenia was recently transitioned to a new antipsychotic drug after becoming refractory to several other antipsychotics. At his follow-up visit, he has gained 10 pounds. Which antipsychotic most commonly causes weight gain?

Olanzapine **While second-generation antipsychotics have fewer EPS, they may lead to weight gain, causing metabolic syndrome, cardiac side effects (including QTc prolongation), hyperprolactinemia, or drowsiness. Weight gain can be a common side effect seen with the use of olanzapine. When a patient is on olanzapine, food intake, hyperglycemia, and hyperlipidemia should be monitored by obtaining fasting blood glucose and lipids every 3-6 months and obtaining a weight at each visit.

Unresponsiveness, reduced respirations, shallow breathing, and decreased bowel sounds are signs of __________. Miosis is usually present as well but may vary due to possible coingestants. For emergency management, naloxone (Narcan) should be administered to reverse respiratory depression.

Opioid intoxication/overdose

A 23-year-old woman reports to the clinic with pain, swelling, and instability in her right knee. She states her symptoms arose while playing soccer 2 days ago when she felt a "pop" while cutting and had subsequent swelling. She reports severe anxiety when discussing first-line diagnostic testing. Which of the following is most appropriate?

Oral diazepam **This is a MRI claustrophobia (specific phobia) for possible ACL tear -- Magnetic resonance imaging (MRI) claustrophobia is one of the most common procedural related specific phobias and is associated with the fear of suffocating during an MRI scan. Primary intervention for MRI claustrophobia involves adjusting the patient's position within the scanner. If this is not feasible or does not resolve anxiety, a benzodiazepine (e.g., diazepam, lorazepam, alprazolam) is the first-line medication used for MRI claustrophobia.

An 18-year-old woman with no prior psychiatric history presents to the emergency department by ambulance after having a witnessed seizure at home. The patient's height is 5 foot 8 inches and weight is 105 pounds (BMI 16 kg/m2). Physical exam reveals lanugo on bilateral upper extremities, brittle nails, and cyanosis of the hands and feet. Laboratory workup reveals hyponatremia with hypokalemic alkalosis. In addition to seizures, which of the following complications is consistent with the suspected diagnosis?

Osteoporosis **Patients with anorexia nervosa can experience profound bone loss due to malnutrition causing increased resorption and decreased formation of bone and are therefore at increased risk of developing osteoporosis

An 18-year-old woman presents with concerns for anxiety. She reports that symptoms mostly occur in social situations and fears that her peers will notice her anxiety resulting in embarrassment. Which of the following is a clinical manifestation of the most likely diagnosis? A) Delusions B) Inattention C) Palpitations D) Poor social skills

Palpitations **Clinical manifestations may include anxiety or panic, sweating, trembling, and palpitations during the social event. Typically, selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, are used as first-line therapy for social anxiety disorder.

A 32-year-old woman is brought to the office by her husband due to his concern about her increasing social withdrawal. The patient prefers to stay at home. When she must run errands, she insists that her husband accompany her. She stopped working 2 years ago due to severe episodes of anxiety that would occur unpredictably for no apparent reason. Since that time, the patient has continued to have these episodes several times a week and has become more socially isolated due to fears of having another episode. She avoids seeing her friends except for when they come to her home. The patient feels badly that she is no longer working and contributing to the household finances. She has occasional difficulty falling asleep and problems with concentration. Although she is not looking for work, she keeps her home clean, cooks nightly, and enjoys watching television. Which of the following is the most likely cause of this patient's social withdrawal? A) Avoidant personality disorder B) Dependent personality disorder C) Panic disorder D) Persistent depressive disorder E) Social anxiety disorder

Panic disorder **The patient's recurrent, spontaneous anxiety attacks and development of avoidance behavior are most consistent with panic disorder. Patients with panic attacks frequently develop agoraphobia, which is anxiety and avoidance of ≥2 situations in which it may be difficult to escape or get help (eg, being outside the home or in enclosed spaces, using transportation) in the event of a panic attack. In severe cases, patients can become homebound or leave home only when accompanied by others, resulting in marked social and occupational impairment. Agoraphobia can also be diagnosed independently of panic disorder. Avoidance behavior and agoraphobia are best treated with cognitive behavioral approaches. (Choices A and B) Although this patient has become socially avoidant and dependent on her husband, these behaviors are better explained as complications of her 2-year history of panic disorder. Personality disorders involve long-standing patterns of behavior dating back to adolescence. Patients with avoidant personality disorder fear negative evaluation and do not have panic attacks. Dependent personality disorder involves a pattern of submissive and clinging behavior in order to be cared for by others. (Choice E) Although patients with social anxiety disorder may also avoid certain public places, their fear is of social humiliation and criticism and they do not experience spontaneous panic attacks.

When giving Varenicline for smoking cessation, what population of patients should be cautioned when using this drug?

Patients with depressed mood or suicidal ideations **Depressed mood is one of the potential side effects of varenicline. Some individuals who take varenicline have reported experiencing symptoms of depression or worsening of pre-existing depressive symptoms while using the medication

A 62-year-old woman comes to the office accompanied by her daughter, who is concerned that her mother is depressed. The patient has become more withdrawn and socially isolated after her husband's unexpected death from a heart attack 2 years ago. She still misses her husband terribly and thinks about him constantly. The patient says, "I can't believe he is gone." She feels guilty that she did not recognize his heart condition and blames herself for not insisting that he get medical care earlier. The patient does not have sleep or appetite disturbance but sleeps on the couch because she cannot bear to lie in the bed that she and her husband shared. She has stopped playing golf and attending concerts--activities that they had enjoyed together. The patient has no suicidal ideation. She continues to work at her part-time job and help her daughter with the grandchildren. Which of the following is the most likely diagnosis in this patient? A) Dependent personality disorder B) Major depressive disorder C) Normal grief D) Persistent complex bereavement disorder E) Posttraumatic stress disorder

Persistent complex bereavement disorder **This patient's prolonged grief (>12 months after the loss), difficulty accepting the death, persistent yearning for the deceased, and avoidance of reminders of the deceased are suggestive of persistent complex bereavement disorder (also known as complicated grief). Risk factors for complicated grief include an unexpected or violent loss, death of a close loved one (eg, spouse, child), and a prior psychiatric disorder (eg, depression, anxiety). Difficulty envisioning a meaningful life without the deceased, suicidal ideation (ie, to join the deceased), and guilty ruminations about the circumstances of the death are more common compared to normal grief. In addition, normal grief typically improves over the course of a year, with gradual adaptation to the loss and renewed interest in life (Choice C). If left untreated, persistent complex bereavement disorder can continue for years or decades after the loss and result in poor quality of life, increased substance use, and increased mortality due to medical conditions or suicide. Treatment consists of psychotherapy geared to helping the patient come to terms with the loss and re-engage in a meaningful life without the deceased.

A 35-year-old woman presents due to depressed mood. She states she has felt depressed for 3 years, feels the need to sleep all the time, has poor concentration at work, and feels hopeless her symptoms will ever get better. She has tried cognitive behavioral therapy and several antidepressants at times without significant relief. Which of the following is the most likely diagnosis?

Persistent depressive disorder (Dysthymia)

A 32-year-old woman comes to the office due to depressed mood, fatigue, irritability, and feelings of low self-worth on more days than not for the past 2 years. The patient reports that her symptoms are worse during the week prior to menstruation but occur at other times as well. During the week prior to menses, she experiences physical symptoms of mild bloating and breast tenderness that resolve with the onset of menses. Which of the following is the most likely diagnosis in this patient? A) Borderline personality disorder B) Dysmenorrhea C) Persistent depressive disorder (Dysthymia) D) Premenstrual dysphoric disorder E) Premenstrual syndrome

Persistent depressive disorder (Dysthymia) **Women with underlying primary mood disorders that worsen intermittently before menses may be misdiagnosed as having premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). This patient's description of a 2-year history of chronic depressive symptoms that occur throughout the menstrual cycle suggests that she has persistent depressive disorder (dysthymia) that is exacerbated during the premenstrual period.

A 27-year-old woman presents to the emergency department reporting dysphoria, muscle aches, yawning, diaphoresis, restlessness, rhinorrhea, lacrimation, nausea, vomiting, and diarrhea. Her symptoms began about 12 hours ago. On physical exam, she is tachycardic and hypotensive, with decreased skin turgor, increased bowel sounds, and several scabs and scars noted over both antecubital fossae. Which of the following signs and symptoms is consistent with the patient's most likely diagnosis? A) Altered mental status B) Hyperpyrexia C) Miosis D) Piloerection

Piloerection **Classic opioid withdrawal signs and symptoms include piloerection, diaphoresis, yawning, restlessness, dysphoria, myalgia, arthralgia, rhinorrhea, lacrimation, nausea, vomiting, diarrhea, palpitations, mydriasis, insomnia, tremor, and irritability. Tachycardia and hypotension can result if the patient becomes dehydrated due to vomiting and diarrhea.

A 6-year-old boy is brought to the office due to behavioral difficulties at school. He has been hitting other children and breaking their toys. The patient was adopted by his grandmother a year ago after his parents died in a motor vehicle collision. He attends the same school but no longer wants to play with his friends or join group activities. The patient wakes up a few times a week crying about monsters and asking to sleep in his grandmother's room. He is meeting appropriate developmental milestones. The patient is restless and rams a toy truck into a stuffed animal repeatedly while his grandmother speaks. He makes poor eye contact and answers most questions by saying "I don't know." Which of the following is the most likely diagnosis? A) Age-appropriate behavior B) ADHD C) Autism spectrum disorder D) Oppositional defiant disorder E) Posttraumatic stress disorder

Posttraumatic stress disorder **This child's recurrent nightmares, violent themes in play, emotional reactivity with aggressive play (eg, hitting, breaking), and social withdrawal after a traumatic loss suggest posttraumatic stress disorder (PTSD). Exposure to trauma can occur through direct involvement in or witnessing a traumatic event or by learning about violent trauma to a loved one. Young children with PTSD, whose memories may not be fully consolidated, often have nightmares that are not specific to the traumatic event (eg, monsters, being chased), as well as repetitive traumatic themes in play. They often struggle with emotional regulation and may appear easily upset or angered with little provocation. They may struggle with feelings of guilt, shame, or sadness.

5 Distinct Stages of Change: - Initial denial or no intention to change behavior

Precontemplation (1)

A 25-year-old man presents to the emergency department in police custody for aggressive behavior. The police report he has a history of violent acts, including killing his neighbor's dog, and does not have remorse for his actions. You suspect a personality disorder. Which of the following is the recommended daily pharmacologic treatment for individuals with aggressive behavior due to this condition?

Risperidone **Pharmacologic therapy is not recommended for all patients with antisocial personality disorder. However, individuals with severe aggression who are willing to take medication should be treated with a second-generation antipsychotic, such as risperidone or quetiapine.

A 63-year-old man comes to the office for a follow-up examination of hypertension. At his last appointment, he revealed that he had increased his intake of 12-oz cans of beer from 3 to 6 cans a day due to stress at work. The patient was advised on his last visit to seek help for his alcohol use because it could be causing his elevated blood pressure and has many other negative health risks. Today, the patient states, "I thought about what you said. I know my alcohol use has gotten out of hand and is affecting my health. My wife and daughter also say that I need to stop drinking. I have decided to look into treatment options to get some help." Which of the following best describes this patient's stage of behavioral change? A) Action B) Contemplation C) Maintenance D) Pre-contemplation E) Preparation

Preparation **It is often helpful to consider a patient's readiness for change using a transtheoretical (or stages of change) model, where most people will move through 5 distinct stages of change: 1) Precontemplation is initial denial or no intention to change behavior. 2) Contemplation is being aware of a problem with no commitment to a plan of action. 3) Preparation is when a patient decides and prepares to take action to change behavior. 4) Action is an active change or behavioral modification. 5) Maintenance is a patient working to maintain behavioral change over the long term.

5 Distinct Stages of Change: - When a patient decides and prepares to take action to change behavior

Preparation (3)

A 28-year-old man is brought to the emergency department by his roommate, who is concerned about his change in behavior over the past 2 weeks. The roommate describes the patient as "a regular guy who is usually very responsible." Last week, the patient abruptly quit his job as a computer programmer and started placing large bets on an online gambling site because he was "sure to make millions." The roommate says that the patient has been staying up most nights scribbling notes for his autobiography on small scraps of paper. The patient says, "My new mission is to spread understanding." He denies any alcohol or drug use, which his roommate affirms. This patient is most likely to exhibit which of the following additional findings? A) Flat affect B) Poor hygiene C) Pressured speech D) Social withdrawal E) Thought blocking

Pressured speech **This patient's grandiose ideas about his special mission, impulsive risk-taking behavior, and decreased need for sleep lasting ≥1 week are suggestive of a manic episode consistent with bipolar I disorder. Other features of mania include elevated/euphoric/irritable mood, increased energy, and hyperactivity. Increased production, volume, and rate of speech (ie, pressured speech) and a sense that one's thoughts are moving very quickly (ie, racing thoughts) are also common.

A 28-year-old man with a history of substance use presents to the emergency department due to headache, nausea, vomiting, and restlessness. He is agitated upon arrival, making it difficult to obtain the history. Physical exam findings include mydriasis, pallor, tremors, and diaphoresis. Vital signs reveal blood pressure of 175/98 mm Hg and pulse of 110 bpm. Urine drug screen is positive for cocaine. Which of the following medications should be avoided in the acute phase of treatment?

Propranolol **Cocaine intoxication is one of the most common causes of drug-related visits to the emergency department in the United States. Often, patients have also taken other drugs together with cocaine, which can lead to greater mortality. In the early stages of cocaine intoxication, patients present with headache, nausea, vomiting, tremors, and hallucinations. Pallor, mydriasis, and bruxism may also be seen. Blood pressure, pulse, temperature, and respiratory rate are often elevated. Beta-blockers, such as propranolol, should be avoided due to concern for hypertension and coronary artery vasoconstriction, which can occur due to unopposed alpha-adrenergic stimulation. Beta-blockers have also been shown to worsen coronary artery vasoconstriction and are associated with poor clinical outcomes in patients experiencing acute cocaine intoxication.

A 30-year-old man with no comorbidities and who takes no medications presents to the clinic with tachycardia that occurs while speaking to large crowds. This has not been a problem in the past, but he has recently been promoted and must address many coworkers on a weekly basis. When he gives his presentations, he sweats profusely, trembles, and feels as if his heart is beating out of his chest. Which of the following is the most appropriate therapy for this man's clinical disorder?

Propranolol **Social anxiety disorder is characterized by feelings of anxiety in social settings and often leads to avoidance of social gatherings. These patients may only require treatment on an as-needed basis. Such treatment can include benzodiazepines, such as clonazepam or lorazepam, or beta-blockers, such as propranolol.

A 20-year-old woman comes to the office at her parents' urging. She is a college student required to give presentations in front of the class, during which she experiences severe anxiety. The patient says, "My face turns bright red, my hands start shaking, and I break out in a sweat. I had to leave the classroom in the middle of my last presentation." The patient is worried as she has several important presentations coming up in the next few weeks. The patient enjoys socializing with friends at parties. Mental status examination shows an initially anxious patient who relaxes as the interview progresses. Physical examination is unremarkable. Which of the following is the most appropriate pharmacotherapy for this patient? A) Bupropion B) Buspirone C) Lorazepam D) Paroxetine E) Propranolol

Propranolol **This patient has performance anxiety, which is classified as social anxiety disorder, performance-only. Individuals with performance-only social anxiety disorder do not fear nonperformance social situations; this patient enjoys socializing and is able to relax during the interview. The pharmacologic treatment of performance-only social anxiety disorder includes beta blockers or benzodiazepines. Beta blockers (eg, propranolol) on an as-needed basis help control the associated autonomic response (tremors, tachycardia, diaphoresis). Benzodiazepines (eg, lorazepam) can also be used but are not preferred when performance could be impaired by sedation and cognitive side effects (eg, giving a presentation, taking an oral exam) (Choice C). Cognitive-behavioral therapy is an effective nonpharmacologic approach.

A 25-year-old man presents to the clinic due to breast tenderness and milk discharge from bilateral nipples for the past 3 weeks. Two months ago he presented to the clinic with auditory and visual hallucinations, persecutory thoughts, and paranoia and was prescribed a medication that he believes is causing his current symptoms. Which of the following medications is the most likely culprit? A) Aripiprazole B) Divalproex C) Quetiapine D) Risperidone

Risperidone **Risperidone is a very effective second-generation antipsychotic with a large side effect profile and is much more likely to cause elevated serum prolactin levels than other second-generation antipsychotics (with the exception of paliperidone). Other side effects common to risperidone include weight gain, glucose abnormalities, and orthostatic hypotension.

A 26-year-old man is brought to the office by his former girlfriend, who became alarmed after receiving a message in which he threatened suicide. The patient says he went into an overwhelming state of panic and depression when he heard that his former girlfriend was dating a new man and "wanted to get back at her." The patient has a history of "mood swings" since his teens and rage attacks when he feels that people are unsupportive. He has no suicidal intent or plan. He describes his mood as "a deep pit of emptiness." Physical examination is normal except for cigarette burns on his thighs that he explains as self-harming behavior performed to relieve tension. Which of the following is the best treatment for this patient? A) Citalopram B) Lithium C) Olanzapine D) Psychotherapy E) Venlafaxine

Psychotherapy **This patient's suicidal threat in the setting of feeling abandoned is characteristic of borderline personality disorder. Patients with this condition frequently come to health care settings during interpersonal crises and exhibit a persistent pattern of unstable relationships, mood lability, and impulsivity. They may engage in non-suicidal self-injury (eg, cutting, burning) to alleviate tension or feelings of numbness. The primary treatment for borderline personality disorder is psychotherapy. Dialectical behavioral therapy is a form of cognitive behavioral therapy developed specifically for borderline personality disorder. This treatment integrates techniques of emotion regulation, principles of mindfulness, and distress tolerance to target the affective instability, impulsivity, unstable relationships, and poor self-image that characterize borderline personality disorder.

A 45-year-old man with a history of heroin dependence presents to the clinic requesting medical treatment for his addiction. He has tried both cold turkey and 12-step programs without success. He is specifically interested in trying methadone. Which of the following is a potentially life-threatening adverse effect of methadone?

QT prolongation **Methadone use has been associated with QT prolongation, which can lead to cardiac dysrhythmias. There are a number of risk factors that increase the likelihood of developing QT prolongation while taking methadone, including age > 65 years, female sex, liver and kidney disease, hemodialysis, anorexia nervosa, and cardiovascular disease. Prior to starting a methadone program, patients should be advised of the risk of dysrhythmia; screened for a history of structural heart disease, dysrhythmia, or syncope; and assessed for other risk factors associated with QT prolongation

A 35-year-old man with a history of previously diagnosed schizophrenia presents to the office with worsening symptoms of his mental illness. He tells you last year he was sent to an inpatient drug treatment facility and has been sober since then. Which of the following antipsychotic medications should be avoided due to the potential for misuse and side effects of sedation? A. Clozapine B. Olanzapine C. Quetiapine D. Risperidone

Quetiapine **Quetiapine has been found to have higher rates of misuse than the other second-generation antipsychotics and is known to cause sedation (drowsiness). Use of quetiapine should be avoided in patients with schizophrenia who have a history of substance use.

What medication is indicated for patients exhibiting Bipolar depression? These patients will have signs of major depression but also exhibit signs of a manic episode. They may or may not have delusions or hallucinations.

Quetiapine **Quetiapine is a second-generation antipsychotic used to treat bipolar depression and is effective in patients with or without psychotic features. Other treatment options for bipolar depression include the second-generation antipsychotic lurasidone, the mood stabilizer lithium, and the anticonvulsants lamotrigine and valproate.

A 48-year-old man presents to the clinic for a rash. He states he has had poor personal hygiene for as long as he can remember. He likes to wear his shirts until they fall apart then keep a piece of them in his pocket when he picks out a new shirt. He believes his Magic 8-ball gives him good advice every morning. He has been a factory worker for the past 10 years and is often faulted for his disorganization and lack of attention to detail. He reports no auditory or visual hallucinations. He states he has always been too nervous, distrustful, and shy to get married. Which of the following pharmacologic interventions may be beneficial for this patient's personality disorder? A) Fluoxetine B) Haloperidol C) Mirtazapine D) Quetiapine

Quetiapine **The patient in the vignette demonstrates several qualities of schizotypal personality disorder. Core characteristics of schizotypal personality disorder include cognitive and perceptual disturbances, interpersonal difficulties, and oddities of behavior or appearance along with disorganized thought or speech. Common perceptual disturbances include magical thinking, paranoia, suspiciousness, and ideas of reference. Quetiapine can help patients with schizotypal personality disorder gain cognitive organization while also decreasing anxiety.

A 32-year-old man comes to the office due to severely depressed mood. For the past month, the patient has had no energy. He has missed several days at work because he cannot motivate himself to get out of bed. The patient is sleeping 12 hours a day, and his appetite is poor. He has no delusions or hallucinations. The patient has a history of depression in his 20s that responded poorly to fluoxetine. He was hospitalized briefly 2 years ago after being arrested for aggressive behavior when police attempted to restrain him when he entered a government building without authorization; he wanted to explain his "strategy for world peace" and was speaking rapidly and often illogically. Following discharge, he did not follow up with treatment. Which of the following is the most appropriate pharmacotherapy for this patent? A) Bupropion B) Nortriptyline C) Paroxetine D) Quetiapine E) Venlafaxine

Quetiapine **This patient with depressed mood, amotivation, hypersomnia, low energy, and loss of appetite meets the criteria for a major depressive episode. However, his history of hospitalization for impulsive, aggressive behavior; rapid speech; and grandiose delusions (ie, "strategy for world peace") suggests a prior manic episode, supporting a diagnosis of bipolar I disorder. Patients with bipolar I disorder must have a history of ≥1 manic episodes and may frequently experience major depressive episodes, although these are not required for diagnosis. Screening for a history of mania is important in all patients with depression symptoms because initial treatments differ in unipolar and bipolar depression. Quetiapine is a second-generation antipsychotic used to treat bipolar depression and is effective in patients with or without psychotic features. Other treatment options for bipolar depression include the second-generation antipsychotic lurasidone, the mood stabilizer lithium, and the anticonvulsants lamotrigine and valproate.

A 5-year-old girl is brought to the office for evaluation of night awakenings. The patient has awakened screaming once or twice each month over the past few months shortly after going to sleep. During these episodes, she is short of breath, crying, and sweating, and her face is flushed. The patient appears frightened, does not respond to her parents' attempts at comforting her, and continues to cry. She eventually goes back to sleep on her own and does not recall the incident the next morning. Until starting kindergarten 2 months ago, the patient stayed at home with her mother, and she no longer naps during the day. Vital signs and physical examination are unremarkable. Which of the following is the best next step in management of this patient? A) Cognitive behavioral therapy B) Daytime naps C) Intranasal desmopressin D) Polysomnography E) Reassurance

Reassurance **This child's awakenings are suggestive of sleep terrors, a type of parasomnia that occurs during nonrapid eye movement (NREM) sleep. Sleep terrors are characterized by episodes of screaming and/or crying during which the child is inconsolable and cannot be fully awakened. A flushed face, sweating, and tachycardia are common. These episodes typically last a few minutes before the child settles back down to sleep. The child usually has no memory of the incident and will have no recollection of a distressing dream. Sleep terrors are commonly seen in children age 2-12, with a peak incidence at age 5-7. In healthy children with a classic presentation, the diagnosis is clinical, and no further workup is required. Parents should be reassured that sleep terrors are not dangerous and usually resolve spontaneously within 1-2 years.

A 34-year-old woman comes to the office with her husband due to behavioral changes over the past 6 weeks. The husband says, "She's not an angry person, but ever since she was in a car accident, little things seem to set her off. She yells and honks at people for not using their turn signals and gets upset when we have to wait for a table at restaurants." The patient describes difficulty sleeping due to thoughts "swirling" in her head and feeling panicked every time she wakes up. She sustained a wrist fracture in a motor vehicle collision 2 months ago; medical history is otherwise unremarkable. Vital signs and physical examination are normal. On mental status examination, she appears restless and tired. Which of the following is the best next step in management of this patient? A) Begin buspirone B) Obtain an MRI of the head C) Recommend cognitive-behavioral therapy D) Refer for group therapy E) Start lithium

Recommend cognitive-behavioral therapy (CBT) **This patient's recent onset of behavioral changes following a traumatic event (motor vehicle collision) is suggestive of posttraumatic stress disorder (PTSD). Extreme irritability, sleep disturbance, anxiety/panic, and intense psychologic distress in response to reminders of the event are characteristic. Angry outbursts with little or no provocation may also occur, as seen in this patient. Other common symptoms of PTSD include nightmares, flashbacks, emotional detachment, and avoidance. Treatment of PTSD consists of psychotherapy and/or pharmacotherapy with a selective serotonin reuptake inhibitor (SSRI). Trauma-focused cognitive-behavioral psychotherapy (CBT) is commonly the first-line treatment, although other forms of psychotherapy (eg, interpersonal therapy) may also be used. CBT helps the patient emotionally process the trauma and recognize and correct maladaptive thought patterns while also targeting avoidance behaviors with exposure techniques.

A 72-year-old man is brought to the office due to visual disturbances that are causing significant distress. The patient describes seeing prowlers in the bushes outside of his windows at night that disappear when he moves in for a closer look. His daughter could not see these people. The patient has Parkinson disease, for which he takes carbidopa-levodopa, and generalized anxiety disorder, for which he takes sertraline. Vital signs are normal. The patient is alert and oriented. He has a mild resting tremor and minimal rigidity. Movements are slightly slowed. Which of the following is the best next step in management of this patient's visual disturbances? A) Add benztropine B) Add pramipexole C) Increase carbidopa-levodopa D) Increase sertraline E) Reduce carbidopa-levodopa

Reduce carbidopa-levodopa **This patient's new onset of visual hallucinations is most likely related to Parkinson disease (PD). Psychosis (eg, hallucinations, delusions, paranoia) in PD is common and may be due to the underlying disease process, medication, or a combination of the two. Two of the most common anti-Parkinson medication classes associated with psychosis are dopamine precursors (eg, levodopa) and dopamine agonists (eg, pramipexole) (Choice B). The first step in management of psychosis in PD includes reviewing the patient's medications and considering a cautious dose reduction (eg, reducing the dose of carbidopa-levodopa in this patient) (Choice C).

A 48-year-old man is evaluated for insomnia. The patient was attacked and robbed at gunpoint 3 weeks ago, during which he was kicked in the abdomen and chest. He has no pain but describes difficulty falling asleep, frequent nightmares, and multiple nighttime awakenings since the incident. The patient further describes being irritable and having difficulty concentrating. He is unable to remember details of the attack and has avoided walking alone at night. Although his friends have offered support, the patient has no interest in seeing them and feels emotionally distant from his family. On mental status examination, the patient is anxious and tense and startles easily. Which of the following is the best next step in management of this patient? A) Prescribe daily alprazolam B) Prescribe daily fluoxetine C) Provide reassurance that symptoms will improve D) Refer for cognitive-behavioral therapy (CBT) E) Refer for dialectical-behavioral therapy (DBT)

Refer for cognitive-behavioral therapy (CBT) **This patient's abrupt onset of insomnia, nightmares, amnesia, impaired concentration, and emotional detachment following a traumatic incident 3 weeks ago is consistent with acute stress disorder (ASD). ASD develops within 1 month following a traumatic event. Patients typically have some form of intrusive reexperience (eg, distressing memories, nightmares, flashbacks) and avoid reminders of the event. Arousal symptoms, such as sleep disturbance, irritability, impaired concentration, hypervigilance, and an exaggerated startle response, are common. Dissociation, or an altered sense of reality (eg, amnesia, depersonalization, derealization), is often present. Early recognition and intervention are important as patients with untreated ASD are at higher risk for a more chronic and disabling psychiatric illness (ie, posttraumatic stress disorder [PTSD]). PTSD is characterized by symptoms similar to those of ASD that persist for >1 month. First-line treatment of ASD consists of trauma-focused cognitive-behavioral therapy (CBT), which has been shown to reduce the likelihood of PTSD development. Pharmacotherapy has shown little benefit for treating ASD other than symptomatic management (eg, anxiety, insomnia).

A 28-year-old woman presents to the clinic reporting ongoing intermittent abdominal pain, fatigue, and back pain for the past 7 months. The patient notes she has been evaluated in the emergency department multiple times and has seen other health care clinicians, none of whom have found a cause of her pain. She is constantly worried about her symptoms. On physical exam, the patient appears anxious. Otherwise, there are no significant findings. Labs and imaging results that she had completed recently are all within normal range. Which of the following is the most appropriate initial treatment for this patient?

Regularly scheduled visits in the office **The patient in the above vignette has somatic symptom disorder, which is when an individual has one or more somatic symptoms that are not explained by a physical or medical condition. These symptoms cause significant distress or dysfunction on a day-to-day basis. It is important to suspect this disorder when a patient presents with vague symptoms and an inconsistent history.

Indicated treatment for patients undergoing Cannabis withdrawal symptoms that are mild and not affecting their daily life

Relaxation techniques **Meditation, physical exercise, and improved sleep hygiene are appropriate for patients who have mild cannabis withdrawal symptoms, meaning those whose symptoms do not affect their day-to-day function.

A man presents to the emergency department, brought by emergency medical services after he was brandishing a knife in the city park. Upon arrival, emergency personnel noted bizarre behavior with self-inflicted cuts on the man's arms. He told first responders the voices told him he is invincible, and he resisted their initial attempts at treating his wounds. In the emergency department, the patient reports ingesting angel dust. Which of the following is most likely found on physical examination?

Rotatory nystagmus **Phencyclidine (PCP) is a hallucinogenic substance first used as a dissociative anesthetic in the 1950s. The drug is used recreationally in powder, crystal, liquid, and tablet form, with street names including angel dust, embalming fluid, killer weed, peace pill, horse tranquilizer, and hog. Another common physical exam finding, nystagmus, can be horizontal, vertical, or rotatory.

Delusions or hallucinations for ≥2 weeks with no mood episodes (ie, depressive or manic) might be indicative of this diagnosis

Schizoaffective disorder

A 22-year-old man presents with "hearing voices." He has had progressively worsening symptoms over the last 7 months. He has heard voices saying negative statements that seem to come from inside of his head. He has also had a belief that his neighbors are trying to poison him and have planted cameras and listening devices inside his house. When speaking about these symptoms, he becomes distracted easily and gets off topic quickly. He is also speaking quickly and is very talkative. He notes he has not slept in 2 days but does not feel tired. He reports no substance use or use of other medications. What is the most likely diagnosis?

Schizoaffective disorder **Schizoaffective disorder is distinguished from schizophrenia by the presence of manic episodes or a significant depressive episode in addition to the symptoms normally considered for Schizophrenia. --> "He is also speaking quickly and is very talkative." and "He notes he has not slept in 2 days but does not feel tired." are the examples of manic episodes from the vignette.

A 28-year-old woman is brought to the hospital due to depressed mood, disorganized behavior, and hearing voices. Over the past 2 months, the patient has developed worsening auditory hallucinations and now fears that her family has been replaced by imposters. She is afraid to leave the house, stays in bed most of the day, sleeps longer than usual, is not eating, and is unable to care for herself. The patient has had 4 hospitalizations for depressive and psychotic symptoms over the past 8 years. Between hospitalizations, she has had rare month-long periods during which she is not depressed but continues to hear voices. On mental status examination, the patient's mood is depressed, and she has current suicidal ideation. Which of the following is the most likely diagnosis? A) Bipolar I disorder with psychotic features B) Delusional disorder C) Schizoaffective disorder D) Schizophrenia E) Schizophreniform disorder

Schizoaffective disorder **This patient most likely has schizoaffective disorder, which requires the following: Major mood (depressive or manic) episodes concurrent with symptoms of schizophrenia (ie, ≥2 of the following for ≥1 month: delusions, hallucinations, disorganized speech, grossly disorganized behavior, negative symptoms) Delusions or hallucinations for ≥2 weeks with no mood episodes (ie, depressive or manic) This patient has an 8-year history of psychotic symptoms with concurrent depressive symptoms but also has month-long periods during which psychosis persists in the absence of mood symptoms (eg, hearing voices even when not depressed). Differentiating schizoaffective disorder from bipolar disorder and schizophrenia requires determining the temporal relationship of psychotic symptoms to mood symptoms. In bipolar disorder, psychotic symptoms occur exclusively during manic or depressive episodes (ie, when the patient's mood is stable, there are no psychotic symptoms). In schizophrenia, if mood symptoms occur, they are present for a small portion of the illness.

A 15-year-old boy is brought to the office by his mother due to "odd behavior." Since moving to a new school 8 months ago, the boy has started talking to his imaginary friend Henry again. His mother reports that he had this imaginary friend for a few months in kindergarten. The boy has been spending more time alone, and he spends time laughing and talking to Henry. His teachers report that the patient has not been paying attention in class or completing homework. He no longer spends time with his siblings and says he "would rather play videogames with Henry." The patient states, "Henry is always with me and likes to comment on what I am doing." He has tried marijuana in the past but does not use other drugs. On mental status examination, the patient avoids eye contact and has a flat affect. Which of the following is the most likely explanation for the patient's behavior? A) Schizoid personality disorder B) Schizophrenia C) Schizophreniform disorder D) Schizotypal personality disorder E) Substance-induced psychotic disorder

Schizophrenia **This boy's 8-month history of auditory hallucinations and negative symptoms (social withdrawal, flat affect) resulting in significant functional decline from baseline is consistent with schizophrenia. Onset of psychotic symptoms prior to age 18 is referred to as early-onset schizophrenia and is associated with a more severe course of illness. Adolescents commonly have a prodromal phase marked by social withdrawal and academic decline, which can last for weeks to years prior to the onset of active psychotic symptoms. Hallucinations are more common than delusions in pediatric schizophrenia. Auditory hallucinations may consist of comments about what the patient is doing, as in this case, or commands. Visual and tactile hallucinations as well as multisensory hallucinations may also occur. Youth with schizophrenia frequently name their hallucinations, which need to be differentiated from imaginary friends.

A 23-year-old man is brought to the office due to increasingly odd behavior and progressive social withdrawal over the past year. The patient dropped out of college last year because of failing grades. Since returning to live with his parents, he stopped going out with his friends and sits in his room all day. For the past few months, he has been watching the same videos over and over, telling his mother that he is "listening for messages from secret channels." The patient says, "I'm fine. I don't know why everyone's upset." His appetite, sleep, and energy level are normal. On examination, the patient appears anxious, avoids eye contact, and shows little emotion. His answers are very brief, and he asks if the interview is being secretly recorded. The patient has no suicidal ideation, symptoms of mania, or hallucinations. Which of the following is the most likely diagnosis in this patient? A) Delusional disorder B) Schizoaffective disorder C) Schizoid personality disorder D) Schizophrenia E) Schizotypal personality disorder

Schizophrenia **This patient's delusions (ie, receiving secret messages from videos, being secretly recorded), negative symptoms, significant functional decline, and continuous impairment lasting ≥6 months are consistent with schizophrenia. Although common, hallucinations are not required for diagnosis. This patient's negative symptoms include apathy, avolition, affective flattening (ie, lack of facial expression), alogia (ie, very brief answers), and asociality (ie, social withdrawal and diminished interest in relationships). His course of illness is characterized by a prodromal phase (ie, deterioration in academic functioning and progressive social withdrawal prior to the onset of psychosis) and prominent negative symptoms, which are often mistaken for depression. (Choice A) Delusional disorder is characterized by ≥1 delusion with no other psychotic symptoms. Functioning is normal apart from the direct impact of the delusion. A diagnosis of delusional disorder would not explain this patient's prominent negative symptoms and significant functional decline

A 24-year-old man presents to the psychiatry clinic with his wife for follow-up. He was brought to the emergency department 3 months ago after the police found him blocking traffic on the highway and telling drivers that the apocalypse was coming. At that time, he says he could hear voices telling him to save the world. His wife reports that these behaviors began abruptly 3 months ago after his father died, and he was subsequently treated in a psychiatric hospital, where his symptoms improved. However, he has been withdrawn with a flat affect since then and has not been able to function well enough to find a job. The patient had a negative medical workup near the onset of symptoms, and it included a negative drug test result. He reports no depressed mood. Which of the following is the most likely diagnosis?

Schizophreniform disorder

A 35-year-old man presents with a persistent pattern of odd behavior since early adulthood. He often believes that people talking on the radio have special messages for him. In addition, he has few close friends, pervasive suspicion of others, and social anxiety. Which of the following personality disorders does this individual most likely have?

Schizotypal **Schizotypal personality disorder is a cluster A personality disorder marked by cognitive-perceptual abnormalities, oddness or disorganized behavior, and interpersonal difficulties. The cognitive-perceptual abnormalities include odd beliefs, unusual perceptual experiences, ideas of reference, and paranoia.

A 42-year-old woman is brought to the emergency department by her husband for new-onset tremors and extreme restlessness. She feels nauseated and anxious. The patient recently injured her back and was prescribed tramadol. She has major depression with psychotic features for which she takes venlafaxine and aripiprazole. Temperature is 38.3 C (101 F), blood pressure is 160/100 mm Hg, pulse is 125/min, and respirations are 20/min. On examination, the patient is flushed and diaphoretic and her voice is tremulous. Mild rigidity and tremors are noted in her lower extremities. Deep tendon reflexes are 3+. Pupillary dilation and ocular clonus are present. Dysregulation of which of the following neurotransmitters is the most likely cause of this patient's symptoms? A) Acetylcholine B) Dopamine C) Gamma-aminobutyric acid D) Norepinephrine E) Serotonin

Serotonin **This patient has serotonin syndrome, a potentially dangerous condition associated with excess serotonergic activity in the central nervous system. It is usually caused by serotonergic medications alone or in combination, drug interactions (eg, serotonergic drugs and a monoamine oxidase inhibitor), or intentional overdose on serotonergic medications. This patient is taking 2 serotonergic medications: venlafaxine, an antidepressant that works as a serotonin-norepinephrine reuptake inhibitor, and tramadol, an analgesic medication with serotonergic activity.

___________ is characterized by the triad of mental status changes, autonomic dysregulation, and neuromuscular hyperactivity.

Serotonin syndrome

A 32-year-old woman presents to the emergency department with mental status changes, including agitation and confusion. Her vital signs reveal tachycardia and hyperthermia. On a physical exam, the patient is flushed and dilated pupils are noted. She has hyperreflexia and an inducible clonus. Her medical history includes gastroparesis and generalized anxiety disorder for which she takes metoclopramide and sertraline. Which of the following is the most likely diagnosis?

Serotonin syndrome **Symptoms include a wide spectrum of mental status changes, neuromuscular hyperactivity, and autonomic dysfunction. Mental status changes can include agitation, anxiety, and confusion. Neuromuscular hyperactivity includes hyperreflexia, tremor, muscle rigidity, myoclonus, and a bilateral positive Babinski sign. Autonomic dysfunction can manifest as diaphoresis, tachycardia, or hyperthermia. Physical examination may include increased heart rate, large fluctuations in pulse and blood pressure, dilated pupils, flushed skin, and muscle clonus.

A 21-year-old woman is brought in for evaluation by her roommate due to anxiety. The patient has generalized anxiety disorder and takes sertraline but has been increasingly restless for the past 2 days, pacing in her room and startling easily. She has been studying for a school examination for the past month, staying up late and drinking 2 cups of coffee a day. The patient has been taking her roommate's tramadol for headaches that have become more frequent. Temperature is 37.7 C (99.9 F), blood pressure is 140/80 mm Hg, pulse is 100/min, and respirations are 14/min. The patient appears jittery and is diaphoretic. Cardiopulmonary examination is normal. Muscle tone is mildly increased in the upper and lower extremities. Deep tendon reflexes are symmetric and 3+ throughout. Which of the following is the most likely diagnosis? A) Caffeine intoxication B) Hyperthyroidism C) Panic attack D) Serotonin syndrome E) Stimulant intoxication

Serotonin syndrome **This patient's acute onset of increasing anxiety and restlessness and physical examination findings of jitteriness, diaphoresis, tachycardia, hypertension, increased muscle tone, and hyperreflexia are consistent with serotonin syndrome, likely due to the combined effects of 2 serotonergic medications. Sertraline is a selective serotonin re-uptake inhibitor for generalized anxiety disorder, and tramadol is an analgesic medication with serotonergic activity.

A 59-year-old woman is brought to the hospital by her son, who found her confused, shaking, sweating profusely, and unsteady on her feet. Two weeks ago, fluoxetine was discontinued due to minimal improvement in her depression symptoms; she was started on phenelzine a few days ago. Her other medications include diphenhydramine and lorazepam. Temperature is 38.3 C (101 F), blood pressure is 160/90 mm Hg, pulse is 116/min, and respirations are 24/min. The patient is oriented to person and place but not time. She is agitated, diaphoretic, and tremulous. Mucous membranes are dry. Abdominal examination shows increased bowel sounds. Deep tendon reflexes are increased. There is some muscular rigidity in the lower extremities. Which of the following is the most likely diagnosis? A) Anticholinergic toxicity B) Benzodiazepine withdrawal C) Fluoxetine withdrawal D) Neuroleptic malignant syndrome E) Serotonin syndrome

Serotonin syndrome **This patient's anxiety, confusion, tremulousness, diaphoresis, and hyperreflexia are suggestive of serotonin syndrome that is likely due to a drug interaction between the monoamine oxidase inhibitor phenelzine and the selective serotonin reuptake inhibitor (SSRI) fluoxetine. The recommended washout period for most antidepressants prior to beginning treatment with a MAOI is 14 days (which did not occur in this patient). Serotonin syndrome symptoms include a classic triad of mental status changes (eg, anxiety, delirium, confusion, restlessness), autonomic dysregulation (eg, diaphoresis, tachycardia, hypertension, hyperthermia, diarrhea, hyperactive bowel sounds, mydriasis), and neuromuscular hyperactivity (eg, hyperreflexia, tremor, rigidity, myoclonus, ocular clonus).

A 25-year-old woman who is 5 weeks postpartum and breastfeeding presents to the clinic with decreased interest in activities that are usually pleasurable for the past 3 weeks. She also reports excessive feelings of guilt, decreased concentration, dysphoria, and fatigue. You offer to refer the patient for psychotherapy, and she declines. She has no prior history of psychiatric conditions. Which of the following is the most appropriate pharmacologic treatment for the suspected diagnosis?

Sertraline **The preferred first-line pharmacologic treatment is selective serotonin reuptake inhibitors, specifically sertraline or paroxetine. Studies show these two agents are typically undetectable in the serum of breastfed infants whose mothers are taking them. Escitalopram, fluoxetine, and fluvoxamine are less studied in lactating women, thus sertraline and paroxetine are preferred.

A 5-year-old boy presents to the pediatric clinic with his parents who are concerned about episodes that occur during his sleep. They describe the episodes as the patient waking up with a loud scream, facial flushing, and sweating. The episodes usually occur during the first 3 hours of nocturnal sleep. The patient is difficult to console during these episodes and does not remember them the next day. Which of the following is the most likely diagnosis?

Sleep terrors **Sleep terrors (night terrors) are a parasomnia seen during childhood. They occur most often between 4 and 12 years of age. During a sleep terror episode, children typically awake abruptly from sleep with a loud scream and have associated facial flushing, sweating, and tachycardia. It is often difficult for parents to console children during these episodes. Sleep terrors occur most often during the first one-third of nocturnal sleep, and children typically do not remember them in the morning.

A 25-year-old woman with a history of substance use disorder presents to the office for follow-up evaluation. She was started on sertraline and titrated to a dose of 200 mg daily after struggling with symptoms of excessive worry, fatigue, and insomnia. She has tolerated the medication at this dosage for the past 8 weeks but has only noted partial improvement in her anxiety symptoms. What would be an appropriate intervention at this time? A) Continue sertraline for 6 months and then reassess B) Start adjunctive treatment with buspirone C) Supplement sertraline with lorazepam up to 3 times daily if needed D) Taper off sertraline and change to fluoxetine

Start adjunctive treatment with buspirone **Buspirone can be used as adjunctive therapy in patients with generalized anxiety disorder who have a partial response to serotonin reuptake inhibitors. Patients who have a partial response to a first-line medication can receive adjunctive therapy with either buspirone, as was observed in this patient, or pregabalin. Taper off sertraline and change to fluoxetine (D) is incorrect. Since the patient had a partial response to sertraline, it is recommended to adjust the response with the addition of a second-line drug, such as buspirone or pregabalin. If the patient did not have any response to sertraline, then tapering off the medication and transitioning to an alternative serotonin reuptake inhibitor would be an appropriate option.

A 35-year-old man presents to the emergency department at his attorneys' request 3 days after a motor vehicle collision. He reports low back pain that radiates down his lower extremities, and he is unwilling to move his lower extremities or walk during your evaluation. However, you later see him ambulating to the restroom without difficulty. Which of the following is the most appropriate treatment for the suspected diagnosis? A) Antidepressants B) Opioid pain medications C) Psychotherapy D) Subtle confrontation

Subtle confrontation **Malingering is the intentional faking or exaggerating of symptoms for secondary gain. However, subtle confrontation that indicates you know they are malingering can sometimes make them stop intentionally producing the symptoms. It is important to avoid ordering unnecessary diagnostic or therapeutic tests.

A 32-year-old woman with bipolar disorder comes to the office for follow-up. The patient was diagnosed and treated for a manic episode at age 29 and has been stable on a combination of lithium and risperidone. Her mood has been "fine" overall, but she has been "stressed" about work. After a staff meeting a few weeks ago, her supervisor said she appeared angry because she was repeatedly frowning while others were presenting. Physical examination is significant for occasional grimacing and slow inversion and tapping movements of her right foot. Lithium level is 0.9 mEq/L (normal: 0.6-1.2). Which of the following is the best next step in management of this patient? A) Add Benztropine as needed B) Add daily propranolol C) Discontinue lithium and start valproic acid D) Maintain current regimen E) Taper and discontinue risperidone

Taper and discontinue risperidone **This patient's abnormal involuntary movements of facial grimacing and foot tapping with inversion movements are most likely signs of tardive dyskinesia (TD) caused by exposure to risperidone, a second-generation antipsychotic (SGA) used in the treatment of bipolar and psychotic disorders. Although most commonly associated with first-generation antipsychotics and antiemetic metoclopramide, TD can also occur with some SGAs. The risk of TD and extrapyramidal symptoms varies significantly within the SGA class. Risperidone is among the highest-risk SGAs, and clozapine and quetiapine are among the lowest-risk SGAs. Patients receiving maintenance antipsychotic medication should be assessed for TD at regular intervals, and the causative medication should be tapered and discontinued if possible. This patient has been stable for 3 years and may not require maintenance risperidone because lithium may adequately control her symptoms. Therefore, a gradual taper and discontinuation of risperidone is the best next step in management.

Prolonged exposure to treatment with antipsychotics could lead a patient to develop ________

Tardive dyskinesia **Tardive dyskinesia is characterized by abnormal involuntary movements of the face, lips, tongue, trunk, or extremities that develop due to prolonged exposure to antipsychotic medication. If possible, the causative medication should be tapered and discontinued.

A 46-year-old truck driver comes to the office for a follow-up visit for alcohol, amphetamine, and opioid addiction. The patient reports a reduction in substance use and cravings over the last 3 months with naltrexone therapy and participation in Alcoholics Anonymous meetings. He has been on a medical leave of absence from work to help him abstain from substance use and focus on recovery. The patient feels ready to return to work and brings a letter from his employer asking when he can return and if there are any restrictions or safety concerns. The patient has signed a release of information. Which of the following would be the most appropriate response to the employer? A) Patient confidentiality prohibits me from providing information on this case B) The patient is able to return to work, but random urine drug screening is recommended C) The patient is medically stable and may return to work D) They patient may return to work and should do well provided he continues to take his medication E) The patient's addiction is in remission, and he is able to return to work

The patient is medically stable and may return to work **This patient has signed a release of information authorizing the health care provider to share information with the patient's employer. Although the provider must respond to the employer's request, he also must adhere to a fundamental principle of the Health Insurance Portability and Accountability Act's Privacy Rule (HIPPA Privacy Rule) that requires "minimum necessary" release of information to meet the "purpose of the use, disclosure, or request" for protected health information (PHI) (Choice A). This patient is currently doing well, with no evidence of substance use. (Choice B) Commercial driver's licensing requires that employers follow alcohol and drug testing rules. Although random urine drug testing is indicated given this patient's job, it would not be appropriate for the health care provider to recommend it because the recommendation would imply that the patient might be using.

What separates Bipolar II disorder from Cyclothymic disorder?

The presence of 1 or more major depressive episodes. Both disorders have mood swings but Cyclothymic disorder will be mood swings for years without the presence of any form of a major depressive disorder

A 30-year-old woman who is obese and has chronic hepatitis C presents to the clinic with episodes of deep depression followed by weeks of expansive mood, flight of ideas, risk-seeking behavior, and insomnia. Which of the following would need to be monitored frequently if the patient is started on the most appropriate therapy?

Thyroid function tests **She is on Lithium therefore you need to continue to check TSH levels. Lithium has a narrow therapeutic index, and serum lithium levels should be monitored regularly along with thyroid function, electrolytes, kidney function, and electrocardiography.

Which of the following is the most commonly abused substance by schizophrenic patients? A) Cannabis B) Alcohol C) Cocaine D) Tobacco

Tobacco **Substance abuse can present with a variety of manifestations, depending on the substance being abused. The most commonly used substances include caffeine, alcohol, and tobacco or nicotine products. In an epidemiologic study, researchers found 90% of schizophrenic patients use nicotine.

A 6-year-old girl is brought to the office by her parents for evaluation of odd behaviors. For the past year, the patient has had brief episodes of repetitive blinking. The blinking worsens when she is excited and subsides when she is watching television. Due to the episodes, she has difficulty paying attention in class and plays alone because other children make fun of her. During evaluation, the patient intermittently squeaks and scrunches her nose; when asked about this, she says she cannot stop pretending to be a bunny. Her parents state that she has been "acting like a rabbit" every day for the past month. Physical examination, including ocular examination, is unremarkable. Which of the following is the most likely diagnosis in this patient? A) Absence seizures B) Attention deficit hyperactivity disorder C) Autism spectrum disorder D) Persistent motor tic disorder E) Tourette syndrome

Tourette syndrome **This patient's multiple motor tics (blinking, scrunching her nose) and one vocal tic (squeaking) are consistent with Tourette syndrome (TS), which commonly presents in children age 6-15. --> Motor tics include simple movements such as blinking or shrugging and complex movements such as kicking and writhing. --> Vocal tics may include simple sounds (eg, squeaking) or more complex vocalizations such as coprolalia (ie, using obscene words) and echolalia (ie, repeating other people's words). These tics do not have to occur concurrently and often wax and wane in intensity. Tics are repetitive, often preceded by a premonitory urge, and can be briefly suppressed. They may be distracting and cause difficulty for the patient in academic settings. Tics are often interpreted as volitional or bizarre, resulting in teasing (as with this patient).

A 28-year-old man is brought to the emergency department by his roommate 45 minutes after he was observed having a seizure. The patient has no known history of a seizure disorder. The roommate reports that the patient has been depressed since a serious motorcycle collision 5 years ago and recently completed a drug rehabilitation program for cocaine and prescription opioid abuse. He thinks the patient is taking an antidepressant but is not sure of which one. On examination, the patient is sedated, disoriented, and flushed. Temperature is 38.3 C (101 F), blood pressure is 90/50 mm Hg, and pulse is 130/min. Pupils are dilated and bowel sounds are decreased. ECG shows sinus tachycardia and QRS duration of 130 msec. Which of the following is the most likely cause of this patient's symptoms? A) Bupropion overdose B) Cocaine overdose C) Opioid withdrawal D) Serotonin syndrome E) Tricyclic antidepressant overdose

Tricyclic antidepressant overdose **This patient's new-onset seizure, signs of anticholinergic toxicity (ie, dilated pupils, hyperthermia, flushed skin, decreased bowel sounds), and QRS interval prolongation (>100 msec) are most likely due to tricyclic antidepressant (TCA) overdose. Although newer classes of antidepressants (eg, selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors) are commonly used as first-line therapy, TCAs continue to have a role in the treatment of major depression. Common signs of TCA overdose include mental status changes (eg, sedation, delirium), seizures, tachycardia, hypotension, cardiac conduction delay, and anticholinergic effects. Patients with a QRS prolongation >100 msec are at an increased risk for ventricular arrhythmia and seizures and should be treated with sodium bicarbonate. (Choice D) Serotonin syndrome can occur with overdose of serotonergic antidepressants. It typically presents with agitation, diaphoresis, tachycardia, hypertension, hyperthermia, increased bowel sounds, and neuromuscular hyperactivity (eg, hyperreflexia, clonus).

A 27-year-old man is brought to the emergency department by his wife. She says that he has been "acting crazy" for the last 2 weeks. He has hardly slept for the past 7 days and instead has worked on miscellaneous projects around the house. The patient spent several thousand dollars on new power tools to accomplish these tasks. When questioned, his speech is pressured. He feels "spectacular" and is creating an "architectural masterpiece." The patient has had 2 previous depressive episodes. Which of the following medications is the most appropriate agent for long-term management of this patient? A) Bupropion B) Chlorpromazine C) Haloperidol D) Paroxetine E) Valproate

Valproate **This patient's euphoric mood, decreased need for sleep, hyperactivity, grandiosity, and pressured speech lasting more than a week are characteristic of an acute manic episode of bipolar I disorder. Bipolar disorder is a highly recurrent illness requiring maintenance treatment with medications that have mood-stabilizing properties to decrease the risk of recurrent mood episodes. Preferred medications for bipolar maintenance treatment include lithium, the anticonvulsants valproate and lamotrigine, and the second-generation antipsychotic quetiapine.

A 28-year-old graduate student is brought to the emergency department by 3 police officers after causing a disturbance in the dean's office. The student has not slept in a week because he is developing a cure for cancer that will result in a Nobel Prize. The patient has "endless energy" and "a million ideas." He has difficulty focusing on answering questions at times and becomes irritable and hostile when efforts are made to redirect him. The patient was diagnosed with depression at age 19. His father has adult polycystic kidney disease. Blood pressure is 142/82 mm Hg. Physical examination is unremarkable. Serum creatinine level is 1.8 mg/dL. Which of the following medications is most appropriate for long-term management of this patient's illness? A) Bupropion B) Haloperidol C) Lorazepam D) Topiramate E) Valproate

Valproate **This patient's grandiose delusions, racing thoughts, distractibility, increased energy, and irritability are highly suggestive of a manic episode. His history of depression at age 19 and now manic symptoms, with normal functioning between episodes, is consistent with bipolar I disorder. Bipolar disorder is a highly recurrent illness. Following stabilization of acute symptoms, patients require maintenance treatment to delay or prevent recurrence of new mood episodes. Commonly used first-line mood stabilizers for bipolar maintenance include lithium and valproate. The second-generation antipsychotic quetiapine and the anticonvulsant lamotrigine have also demonstrated efficacy. This patient's elevated creatinine level suggests possible renal dysfunction, making valproate the preferred treatment over lithium. Lithium is excreted unchanged by the kidneys and may build up to toxic levels in patients with renal dysfunction. Long-term use of lithium has been associated with nephrogenic diabetes insipidus and chronic tubulointerstitial nephropathy, which in rare cases can progress to end-stage renal disease. Valproate, in contrast, is not nephrotoxic, although periodic monitoring of liver function tests and platelets is necessary due to possible hepatotoxicity and thrombocytopenia.

A 56-year-old woman comes in for a follow-up for major depressive disorder. Six months ago, the patient was treated with escitalopram, but her depressive symptoms were only slightly improved after 2 months of treatment. Her medication was switched to venlafaxine and subsequently titrated to maximal therapeutic dosage over 3 months, which has improved her symptoms. Which of the following should be monitored at this visit? A) Antidepressant plasma level B) Blood pressure C) Complete blood count D) Hemoglobin A1c E) Thyroid function tests

Venlafaxine **Serotonin-norepinephrine reuptake inhibitors (SNRIs) (eg, venlafaxine, duloxetine) are frequently prescribed as a next-step treatment after an adequate trial of a selective serotonin reuptake inhibitor (SSRI) (eg, escitalopram) fails. Many SNRIs, including venlafaxine, are associated with dose-dependent increases in diastolic and systolic blood pressure. Blood pressure should be assessed before starting an SNRI and regularly monitored throughout treatment. As a class, SNRIs inhibit the reuptake of both serotonin and norepinephrine. Venlafaxine has the unique property of possessing significantly higher affinity for the serotonin transporter relative to the norepinephrine transporter, which results in venlafaxine behaving like an SSRI at lower doses and demonstrating significant norepinephrine reuptake inhibition at higher doses. Because this noradrenergic drive is what leads to hypertension, the risk with venlafaxine is most pronounced at high doses. If sustained increases in blood pressure are noted, options include dose reduction or switching to an alternate antidepressant.

A 32-year-old man comes to the office due to extreme nervousness, irritability, restlessness, muscle tension, and insomnia for the past 6 months. The patient fears making mistakes in his job as an attorney and often worries that he has said or done something wrong. His worrying makes it difficult to concentrate or perform his duties efficiently. The patient is also engaged to be married and spends sleepless nights thinking about the responsibilities of married life. He worries that he will not be a good husband or father. Which of the following medications is most appropriate for this patient? A) Bupropion B) Diazepam C) Propranolol D) Quetiapine E) Venlafaxine

Venlafaxine **This patient's 6-month history of excessive worry and anxiety, restlessness, irritability, difficulty concentrating, muscle tension, and sleep disturbance is consistent with generalized anxiety disorder (GAD). In GAD, the anxiety is chronic, excessive, and difficult to control, and as a result it causes significant distress or impairment. Treatment of GAD includes cognitive-behavioral therapy, medication, or a combination of both. First-line medications for GAD include selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) (eg, venlafaxine). SSRIs/SNRIs are also effective in treating depression, a common comorbidity.

A 34-year-old man presents to the psychiatry clinic for a 3-month follow-up visit. You suspect, based on his flat affect and apparent reacting to internal stimuli, that he has been noncompliant with his prescribed medication regimen. When asked about his medications, he verbalizes words repeatedly and does not answer the question. Which of the following most accurately describes this speech pattern?

Verbigeration **Speech may become even more disorganized, consisting of repetitive words called verbigeration, or word salad, where words are strung together that do not make logical sense.

A 45-year-old man presents to therapy for unusual sexual behavior. He reports being sexually aroused by using binoculars to watch women who live in the complex across the street from him undress. He has been doing this for 12 months. Which of the following paraphilic disorders does this patient most likely have?

Voyeuristic disorder **Voyeuristic disorder is a paraphilic disorder characterized by sexual arousal from observing an unsuspecting nude or undressing person. Paraphilic disorders require engagement in unusual sexual activities or preoccupation with unusual sexual urges for at least 6 months

An 8-year-old boy presents to the office for a follow-up evaluation. At prior visits, his teacher expressed concern over him being disruptive in class. The patient had difficulty remaining seated and talking excessively (blurting out answers without raising his hand, interrupting his classmates, and difficulty remaining quiet during silent reading time). This behavior had started to affect his relationships with his peers and his grades in class. The patient's parents noted he had trouble sitting still for long periods of time, such as in church, and he was restless at home, often waking up his baby sister when she was napping. He was started on a medication at his last visit for his suspected diagnosis. What must be monitored throughout treatment in patients taking the first-line agent for this condition?

Weight **Weight and height are important to monitor in pediatric patients taking stimulant medications for attention-deficit/hyperactivity disorder (ADHD), such as methylphenidate and dextroamphetamine, because of the side effects of decreased appetite and poor growth.

What drug is tested for in urine drug testing for suspected cocaine intoxication?

the metabolite of Cocaine known as Benzoylecgonine