DFT - EMREE - 06-10-2025 - Psychiatry

A 22 Y/O F with a known Hx of Major Depressive Disorder presents for management. She also confides in having recurrent episodes of binge eating followed by self-induced vomiting for the past year. Her BMI is 21 kg/m ². She is motivated to start both psychotherapy and pharmacotherapy. You decide to initiate an antidepressant that can address both of her conditions. Which of the following is the most appropriate initial pharmacotherapy for this patient?

• Bupropion

• Paroxetine

• Amitriptyline

• Fluoxetine

• Mirtazapine

Answer explanation

The patient has comorbid Major Depressive Disorder and Bulimia Nervosa. Fluoxetine is the only antidepressant specifically approved by the FDA for the treatment of both conditions. It has been shown to reduce the frequency of binge-purge cycles in addition to treating depressive symptoms.

A 42 Y/O F presents to the primary care clinic c/o persistent worry x8M. She reports feeling constantly "on edge" about her 10 Y/O son's school performance, health, and social life, despite his school reports being excellent and his pediatrician confirming he is healthy. She admits the worrying is excessive but feels unable to control it. She also describes difficulty sleeping, muscle tension, and fatigue. O/E, she is alert, oriented, and cooperative, but visibly tense. Her vital signs are stable. What is the most likely Dx?

• Adjustment Disorder with Anxiety

• Illness Anxiety Disorder

• Obsessive-Compulsive Disorder (OCD)

• Generalized Anxiety Disorder (GAD)

• Paranoid Personality Disorder

Answer explanation

The patient exhibits the core features of GAD: excessive, uncontrollable worry about multiple domains (school, health, social life) for a duration longer than 6 months (8 months specified), accompanied by classic somatic symptoms (muscle tension, fatigue, sleep disturbance). The worry is out of proportion to the actual situation.

A 22 Y/O M is brought to the ED by his family due to increasingly bizarre behavior over 6 months. They report he has socially withdrawn and stopped attending university. The patient states, "The government is monitoring me through a chip in my brain, and they broadcast my thoughts on the radio for everyone to hear." O/E, his speech is tangential with loose associations, and his affect is flat. He occasionally pauses, appearing to listen to something not present in the room. Which of the following best describes the primary disorder affecting this patient?

• Mood disorder

• Perceptual disorder

• Personality disorder

• Thought disorder

• Anxiety disorder

Answer explanation

The vignette describes classic features of schizophrenia. The core disturbance in schizophrenia is a disorder of thought. This is demonstrated by the patient's delusions (thought content: persecutory and thought broadcasting) and disorganized speech (thought process: tangentiality and loose associations). While perceptual disturbances (hallucinations) are present, the fundamental pathology lies in the disorganization of thought.

An 8 Y/O M is brought to the ED by his mother due to increasing social withdrawal. She reports he has no close friends, isolates himself in his room, and is preoccupied with what she calls "bizarre fantasies." The child believes he has telepathic abilities and can influence events with "magic thoughts." He is shy and anxious around unfamiliar people but does not exhibit frank hallucinations or delusions. O/E, he is cooperative but avoids eye contact, and his speech is vague and circumstantial. What is the most likely diagnosis?

• Schizophrenia, childhood-onset

• Schizoid personality disorder

• Schizotypal personality disorder

• Avoidant personality disorder

• Autism spectrum disorder

Answer explanation

The constellation of symptoms social isolation, anxiety, odd beliefs (magical thinking, telepathy), and unusual thought processes (vague, circumstantial speech) without overt, persistent psychosis is classic for Schizotypal Personality Disorder (SPD). These features often become apparent in childhood or adolescence.

A 45 Y/O F with a Hx of major depressive disorder and multiple prior suicide attempts via overdose is being discharged from an inpatient psychiatric unit. Her mood has stabilized, but she requires long-term maintenance antidepressant therapy. The treatment plan aims to minimize the risk of a lethal overdose in the event of a future attempt. Which medication is the most appropriate initial long-term Rx for this patient, considering her high-risk profile?

• Amitriptyline

• Venlafaxine

• Sertraline

• Phenelzine

• Lithium

Answer explanation

Sertraline, a Selective Serotonin Reuptake Inhibitor (SSRI), is considered a first-line treatment for major depression. Critically, SSRIs have a much wider therapeutic index and are significantly safer in overdose compared to other classes of antidepressants like TCAs or MAOIs. Given this patient's history of overdose attempts, safety is a primary concern, making an SSRI the most appropriate choice.

62 Y/O M with a known Hx of alcoholic cirrhosis (Child-Pugh Class C) is admitted after being found confused and agitated at home. His last drink was 36 hours ago. O/E, he is tremulous, diaphoretic, and disoriented to time and place. BP 165/95 mmHg, HR 118/min, RR 22/min, Temp 38.1°C. He has no focal neurological deficits. AST and ALT are ↑ >3x ULN, and bilirubin is 4.5 mg/dL. Which of the following is the most appropriate initial pharmacological Rx for this patient's agitation and withdrawal symptoms?

• Diazepam

• Chlordiazepoxide

• Haloperidol

• Lorazepam

• Phenobarbital

Answer explanation

Lorazepam is the best choice. It undergoes Phase II glucuronidation for metabolism, which is minimally affected by severe liver disease. Its intermediate half-life also reduces the risk of prolonged sedation in patients with impaired hepatic clearance. The "LOT" benzodiazepines (Lorazepam, Oxazepam, Temazepam) are preferred in patients with significant liver impairment or in the elderly.

A 31 Y/O M is brought to the ED by his family due to a 1-week Hx of erratic behavior. He has not slept for 4 nights, is highly irritable, and has maxed out his credit cards on luxury items. O/E, he is agitated, pacing, exhibits pressured speech, and expresses grandiose, paranoid ideas that the staff wants to steal his "genius inventions." Vitals are stable. The decision is made to initiate inpatient treatment for an acute manic episode. What is the most appropriate initial Rx to manage his acute agitation and stabilize his mood?

• Fluoxetine

• Lorazepam

• Olanzapine

• Lamotrigine

• Methylphenidate

Answer explanation

Olanzapine is a second-generation (atypical) antipsychotic that is a first-line treatment for acute mania. It is highly effective in controlling both psychotic symptoms (grandiosity, paranoia) and agitation quickly, while also serving as a mood stabilizer. Other first-line options include other atypical antipsychotics (like Risperidone) or mood stabilizers like Valproate or Lithium.

A 28 Y/O M with a known Hx of generalized tonic-clonic seizures, well-controlled on lamotrigine, is diagnosed with new-onset schizophrenia. He presents with auditory hallucinations, paranoid delusions, and social withdrawal. O/E: Vital signs are stable. Neurological exam is non-focal. Ix: Baseline ECG is normal, electrolytes and LFTs are within normal limits. The treating team decides to initiate an antipsychotic. Which of the following is the most appropriate initial antipsychotic Rx for this patient?

• Clozapine

• Olanzapine

• Aripiprazole

• Chlorpromazine

• Quetiapine

Answer explanation

Aripiprazole is a second-generation antipsychotic with one of the lowest risks of lowering the seizure threshold. Given the patient's history of epilepsy, selecting an agent with a minimal proconvulsant effect is the primary safety consideration. Aripiprazole's partial agonism at D2 receptors contributes to its favorable side-effect profile in this context.

A 45 Y/O F c/o chronic low mood, anhedonia, & low energy for the past 2 years, following a difficult divorce. Hx reveals poor appetite with weight loss, difficulty initiating sleep, & feelings of hopelessness. She has never had a manic or hypomanic episode. She reports she has "more bad days than good" but has continued to work, though her performance is ↓. Symptoms have not been absent for more than 2 months at a time. O/E: flat affect, psychomotor slowing. What is the most likely Dx?

• Major Depressive Disorder

• Persistent Depressive Disorder (Dysthymia)

• Adjustment Disorder with Depressed Mood

• Cyclothymic Disorder

• Generalized Anxiety Disorder

Answer explanation

The patient's symptoms (depressed mood plus at least two other depressive symptoms like poor appetite, insomnia, and hopelessness) have been present for ≥2 years without a symptom-free period of >2 months. This chronicity is the hallmark of Persistent Depressive Disorder (PDD).

An 18 Y/O F is brought to the clinic by her parents due to a significant change in behavior over the past 3 months. She recently moved to a new city for university. Initially, she became withdrawn, slept 12-14 hours daily, and lost interest in her studies, causing her grades to drop. For the past week, however, her parents report she is "a different person." She is excessively talkative, sleeps only 2-3 hours/night yet feels "energized," and has been making inappropriate, flirtatious comments to strangers. She has no Hx of substance use. What is the most likely Dx?

• Major Depressive Disorder

• Schizophreniform Disorder

• Bipolar I Disorder

• Borderline Personality Disorder

• Adjustment Disorder with mixed disturbance of emotions and conduct

Answer explanation

The patient presents with a classic biphasic illness. She experienced a distinct period of depressive symptoms (social withdrawal, hypersomnia, loss of interest) followed by a clear, discrete episode of manic symptoms (decreased need for sleep, pressured speech, disinhibition/inappropriate comments). This clear switch from a depressive to a manic episode is pathognomonic for Bipolar I Disorder.