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USMLE Step 2 CK High-Yield Psychiatry Topics
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Psychiatry
High Yield USMLE Step 2 CK Notes
Welcome to the Psychiatry High-Yield Notes for Step 2 CK.
These are the most commonly tested topics on the exam—ideal for quick review in your last 2 weeks before the exam, when you’re short on time, or when you’re just starting out and want to focus on what is high yield. Created and peer-reviewed by physicians who scored 260+ on Step 2 CK in a Q&A style to reinforce active learning.
How to use this file
- Read the question ➔ cover the answer ➔ self-quiz before revealing.
- Review the NOTES ➔ they include high-yield details you don’t want to miss.
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Table of Contents
Child & Adolescent Psychiatry
1. A 6-year-old boy is brought to the ED with a spiral humeral fracture. His caregiver says he fell off the bed, but the injury seems inconsistent with the reported low-impact fall. What is the next step in management?
➔ Report suspected child abuse to Child Protective Services (Multiple injuries at different stage + inconsistent injuries with developmental stage or provided history → suspect child abuse)
- Note: 1st step in management is → Immediate safety first: Hospitalize if needed
○ Mandatory reporting to CPS – you do not need proof, only reasonable suspicion
2. A 10-year-old boy with persistent inattention and hyperactivity across home and school settings is diagnosed with ADHD. His parents ask about the most effective treatment option. What is the best initial management?
➔ Stimulant medication (eg, methylphenidate) (First-line for ADHD with functional impairment → think Stimulants +/- Behavioral therapy)
- Note: If stimulants are contraindicated (history of substance use) or parent refusal → use Non-stimulants: Atomoxetine (NE reuptake inhibitor), Guanfacine, clonidine (α2 agonists)
- Treatment is only behavioral if <6 years (No drugs)
- Always assess impairment in ≥2 settings (parents and teachers fill out behavioral rating scales).
3. An 8-year-old boy often argues with teachers, deliberately refuses to follow instructions, and is spiteful toward authority figures. What is the diagnosis?
➔ Oppositional Defiant Disorder (angry/irritable mood + argumentative/defiant behavior toward authority → think Oppositional Defiant Disorder)
- Note: Treat with Cognitive behavioral therapy + parent management training.
- Unlike Conduct Disorder, Oppositional Defiant Disorder does not involve aggression toward people or animals, destruction of property, or serious violation of rules.
- Occasional arguing or defiance is normal in development; ODD is diagnosed when defiance is persistent, frequent, and impairs functioning.
4. A 10-year-old boy presents with frequent throat clearing, facial grimacing, and sudden shoulder jerks for the past year. He also blurts out words uncontrollably. What is the diagnosis?
➔ Tourette Syndrome (Multiple motor + ≥1 vocal tic for >1 year → think Tourette)
- Note: Treatment:
○ First-line: Behavioral therapy (habit reversal training)
○ If severe: Medications like tetrabenazine, antipsychotics (e.g., risperidone) - Don’t confuse it with transient tic disorder (<1 year) or chronic motor/vocal tic disorder (only one type of tic).
5. A 3-year-old boy is brought in for evaluation due to delayed speech and minimal interest in other children. He avoids eye contact, lines up toys repetitively, and becomes distressed with small routine changes. What is the next step in management?
➔ Intensive behavioral intervention (Delayed communication + impaired social interaction + restricted/repetitive behaviors → think Autism Spectrum Disorder)
- Note: It can be diagnosed even in 2-year-old kids.
- Preference for certain food types or shapes alone is not ASD — it must be accompanied by developmental or social delays to meet diagnostic criteria.
Differentiate from:
| Disorder | Key Features |
|---|---|
| Language disorder | Isolated language delay, normal social interaction |
| Intellectual disability | Global delays, social interactions may be preserved |
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6. A 7-year-old boy continues to wet the bed at night despite toilet training. Urinalysis is normal. What is the next best step in management?
➔ Begin motivational therapy (eg, reward system, voiding before bed) (Involuntary urination ≥ age 5 + normal urinalysis → Think Primary Nocturnal Enuresis)
- Note: Etiology is → Delayed CNS maturation (most common)
- Initial Workup:
○ Urinalysis → to rule out secondary causes (e.g., UTI, diabetes mellitus, diabetes insipidus).
○ Evaluate psychosocial stressors - If persistent/severe despite motivational therapy → Use Enuresis alarm + Desmopressin
7. A 15-year-old girl becomes distant from her parents and forms a strong attachment to her boyfriend. She sleeps late and has difficulty waking to school. What is the next step in management?
➔ Reassure and Educate about sleep hygiene (Identity formation + circadian delay →Think normal Adolescent Development)
- Note: Normal Adolescent behaviors include:
○ Questioning authority, parental conflict
○ Romantic infatuation, emotional intensity
○ Dieting and a degree of concern about body weight (but normal BMI)
○ Sleep Changes → Later sleep onset, trouble waking early - Distinguish from psychiatric disorders by preserved function and appropriate social context
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Psychotic disorders
8. A 25-year-old man hears voices commenting on his actions and believes others can read his thoughts. These symptoms have been present for over 7 months. What is the next step?
➔ Atypical antipsychotics (e.g., risperidone) (Symptoms suggestive of Schizophrenia)
- Note: Schizophrenia: ≥6 months, requires ≥2 Symptoms (at least 1 must be from the first three points)
1. Delusions
2. Hallucinations (mostly auditory)
3. Disorganized speech
4. Disorganized/catatonic behavior
5. Negative symptoms (flat affect, anhedonia) - If you are choosing schizophrenia, make sure the symptoms are present for ≥6 months:
→ If symptoms are present for 1-6 months → think Schizophreniform Disorder.
→ If symptoms are present for less than 1 month → think Brief Psychotic Disorder.
9. A 50-year-old man with chronic paranoid schizophrenia and multiple past hospitalizations agrees to take antipsychotic meds in the hospital but plans to stop them after discharge. What is the next step in management?
➔ Initiate a long-acting injectable (LAI) antipsychotic (History of nonadherence + schizophrenia → LAI antipsychotics reduce relapse/hospitalization)
- Note: Long-acting injectable antipsychotics (e.g., haloperidol) are essential for nonadherent patients.
10. A 30-year-old man with treatment-resistant schizophrenia is started on clozapine. Two weeks later, he developed a fever and a sore throat. What is the next step?
➔ Check complete blood count (CBC) (Clozapine can cause agranulocytosis — monitor with regular CBCs)
- Note: Clozapine is reserved for treatment-resistant schizophrenia or recurrent suicidality.
- Major adverse effects:
○ Agranulocytosis → requires weekly to monthly CBC monitoring
○ Seizures (dose-dependent)
○ Metabolic syndrome - Clozapine is the most effective antipsychotic but also the most dangerous — always monitor WBC/ANC regularly.
11. A 45-year-old woman repeatedly visits multiple doctors, convinced that she is infested with parasites, despite all medical evaluations showing no evidence of infestation. She has no hallucinations or disorganized behavior. What is the diagnosis?
➔ Delusional Disorder (Delusional parasitosis subtype) (Presence of ≥1 delusion(s) lasting ≥1 month + no other psychotic symptoms and no functional impairment → Think Delusional Disorder)
- Note: Treat with Antipsychotics + Psychotherapy.
Differentiate From:
| Disorder | Key Features |
|---|---|
| Schizophrenia | Delusions + hallucinations + disorganized speech/behavior |
| Somatic Symptom Disorder | Preoccupation with somatic symptoms but no fixed false beliefs |
12. A 19-year-old college student is brought up by his parents due to new-onset paranoid delusions and auditory hallucinations. His symptoms began a few weeks ago. What is the next best step in management?
➔ Toxicology screen + medical evaluation (New-onset psychosis → first rule out substance use or medical causes before psychiatric diagnosis)
- Note: Rule out reversible causes — includes substance use (e.g., cannabis, amphetamines) and medications (e.g., corticosteroids).
Mood and Anxiety Disorders
13. A 16-year-old girl presents with a 3-month history of low mood, fatigue, poor academic performance, loss of interest in activities, and passive suicidal ideation. What is the most appropriate next step in management?
➔ Start SSRI and initiate cognitive-behavioral therapy (CBT) (Symptoms suggestive of Major depressive disorder)
- Note: Key clinical clue: Always evaluate functionality (school decline, isolation) when assessing teens
- In patients with suspected or confirmed MDD, physicians should promptly screen for → suicidal ideation.
- Depression in children and elderly may present as → irritability or anger rather than sadness
- Differentiate from:
→ Normal teenage stress: Usually transient, no significant functional impairment → manage with Reassurance
→ Adjustment disorder: Symptoms occur within 3 months of identifiable stressor, but don’t meet full criteria for MDD → manage with Psychotherapy
→ Persistent depressive disorder (Dysthymia): refers to at least three depression symptoms that have endured for at least 2 years → Similar treatment (CBT + SSRI)
14. A 17-year-old boy with a known diagnosis of major depressive disorder is brought to the ED by his parents after he wrote a suicide note and tried to give away personal belongings. He reports thinking about ending his life. What is the next step?
➔ Admit to inpatient psychiatric unit (Active suicidal ideation with warning signs → requires hospitalization)
- Note: Hospitalization criteria in MDD:
○ Active suicidal ideation, especially with plan or intent
○ Psychotic features (e.g., hallucinations, delusions)
○ Severe functional decline (e.g., unable to eat, attend school)
○ Lack of safety at home or no support system - Passive suicidal ideation (e.g., “I wish I were dead” without a plan) → may be treated outpatient (SSRIs, CBT) → if the patient is stable, cooperative, and the home is safe.
15. A 29-year-old woman with severe depression and auditory hallucinations has failed multiple antidepressant trials. She is refusing food, has lost weight, and exhibits poor communication. What is the step in management?
➔ Initiate electroconvulsive therapy (ECT) (Treatment-resistant depression with psychosis and poor nutrition → ECT indicated)
- Note: Indications for ECT in depression:
○ Treatment-resistant depression
○ Severe or psychotic depression
○ Urgent need for rapid symptom control (e.g., suicide risk, refusal to eat) - Safe in pregnancy and elderly
16. A 40-year-old man develops marked anxiety and trouble concentrating at work within 2 months after losing his job. He reports feeling overwhelmed and tearful but denies persistent sadness or suicidal thoughts. What is the diagnosis?
➔ Adjustment disorder (Emotional distress + functional impairment after identifiable stressor, but no full psychiatric disorder → Adjustment disorder)
- Note: Usually self-limited once stressor resolves (within 6 months)
- May be associated with anxiety or depression
- Treated with brief supportive psychotherapy + pharmacotherapy if needed for symptoms
17. A 34-year-old woman with newly diagnosed systemic lupus erythematosus presents with low mood, fatigue, hypersomnia, and anhedonia. Symptoms began 3 weeks after starting high-dose prednisone. She has no prior psychiatric history. What is the diagnosis?
➔ Medication-Induced Depressive Disorder (due to prednisone)
- Note: Medication-Induced Depressive Disorder occurs within 1 month of initiating a new drug
- Management → Taper/stop offending drug if possible
○ If drug is essential or symptoms severe → Start SSRI (e.g., citalopram) - Steroid-induced psychiatric symptoms range from mania → depression → psychosis
○ Screen for mood symptoms after initiating high-dose prednisone
18. A 45-year-old woman presents 3 weeks after her husband’s death with sadness, poor sleep, and loss of appetite. She denies suicidal ideation and says the pain “comes in waves” but feels connected to her late husband. What is the next step?
➔ Normalize grief and schedule follow-up (Sadness and neurovegetative symptoms shortly after a loss without functional impairment → think Normal (Uncomplicated) Grief)
- Note: Normal Grief Reaction
→ Sadness, guilt, sleep/appetite changes, preoccupation with deceased
→ Preserved self-esteem
→ Emotions occur in waves → triggered by reminders
→ May have transient hallucinations of the deceased
→ No suicidal ideation or marked functional impairment - Monitor for progression to MDD or suicidal ideation
Don’t Confuse With:
| Disorder | Key Features |
|---|---|
| Prolonged Grief Disorder | Lasts >12 months, causes functional impairment |
| Major Depressive Disorder (MDD) | ≥2 weeks of depressed mood + ≥5 SIGECAPS symptoms; worthlessness, guilt, suicidal ideation common; not tied to a specific loss |
19. A 52-year-old woman continues to experience intense sadness, social withdrawal, and inability to resume daily activities 13 months after the death of her husband. She frequently says she “has no purpose without him” but does not endorse suicidal ideation. What is the most likely diagnosis?
➔ Prolonged Grief Disorder (Persistent grief >12 months with functional impairment → think Pathologic Grief)
- Note: Key Feature is → Significant functional impairment (e.g., can’t return to work or resume relationships)
- Treat with → CBT
- MDD vs Pathologic Grief → MDD involves global anhedonia and negative self-worth VS pathologic grief centers on the loss and yearning for the deceased with relatively preserved self-esteem
20. A 72-year-old man with Parkinson disease presents with low mood, loss of interest in activities, poor sleep, and unintentional weight loss over the past month. He denies suicidal ideation. What is the next step in management?
➔ Start mirtazapine for depression (Depression in Parkinson disease + insomnia + weight loss → mirtazapine is a good choice due to sedating and appetite-stimulating effects)
- Note: Depression is common in Parkinson disease and can worsen motor symptoms
- Mirtazapine is preferred in elderly patients with poor sleep and appetite
- The antidepressant of choice is dependant on the patient symptoms and drug side effect profile (eg. Bupropion use in patient with Sexual dysfunction concern)
21. A 30-year-old woman on fluoxetine for depression reports decreased libido and difficulty achieving orgasm. What is the best management?
➔ Switch to bupropion (Patient taking fluoxetine → most likely has SSRI-Induced Sexual Dysfunction)
- Note: SSRI leads to → ↓ libido, arousal issues, delayed/absent orgasm
- Cause: ↑ Serotonin inhibits sexual function
- If distressing and persistent:
→ Lower SSRI dose (if possible)
→ Switch to antidepressant with lower risk (e.g., bupropion, mirtazapine)
22. A 22-year-old woman with major depressive disorder and a BMI of 19 is being evaluated for pharmacotherapy. She reports frequent episodes of binge eating followed by self-induced vomiting. Which antidepressant is contraindicated?
➔ Bupropion (As it increases seizure risk in patients with eating disorders)
- Note: When to use bupropion for MDD?
○ Smoking cessation, sexual dysfunction concerns, or weight gain. - When NOT to use bupropion for MDD?
○ Bulimia nervosa or anorexia nervosa → due to ↑ seizure risk.
○ Seizure disorder or predisposition (eg, head trauma, withdrawal states).
23. A 28-year-old woman with social anxiety disorder abruptly stops paroxetine and within days develops flu-like symptoms, dizziness, paresthesia, anxiety, and irritability. What is the diagnosis?
➔ Antidepressant (SSRI) discontinuation syndrome (Caused by abrupt cessation of serotonergic medications, especially SSRIs with short half-life)
- Note: Symptoms include:
○ Flu-like symptoms
○ Neurologic: dizziness, paresthesia (“electric shock” sensations)
○ Psychiatric: anxiety, irritability - Management:
○ Mild cases: supportive care
○ Moderate to severe: resume previous SSRI dose and taper slowly
24. 23-year-old woman is started on an SSRI for moderate depression. After 2 weeks, she reports no improvement in mood and is considering stopping the medication. What is the most appropriate response?
➔ Advise her to continue the medication and reassess in a few weeks (SSRIs take 4–6 weeks to show clinical effect)
- Note: Duration of treatment: Continue for at least 6 months even if symptoms improve to prevent relapse.
25. A 24-year-old woman presents with episodes of elevated mood, decreased need for sleep, increased goal-directed activity, and distractibility lasting over a week. Between episodes, she experiences periods of depression. What is the most likely diagnosis?
➔ Bipolar I disorder (Manic episode ≥1 week + functional impairment ± depressive episodes)
- Note: Mania: Elevated/irritable mood, ↑ energy, ↓ sleep, pressured speech, risky behavior
- Bipolar I: ≥1 manic episode ± depressive episodes
- Bipolar II: ≥1 hypomanic + ≥1 major depressive episode
- Symptoms must cause marked impairment in functioning (Bipolar I)
26. A 27-year-old man with bipolar disorder presents with 6 weeks of low mood, anhedonia, fatigue, and suicidal thoughts after stopping lithium 3 months ago. What is the most appropriate pharmacotherapy?
➔ Resume lithium (As it is a previously effective mood stabilizer)
- Note: Bipolar Disorder Management
○ Acute Mania:
→ Mood stabilizers: Lithium, Valproate, Carbamazepine
→ or Atypical antipsychotics: Quetiapine
○ Maintenance Therapy (after mood stabilization):
→ First-line is → Lithium or Valproate - Avoid antidepressants alone due to → risk of manic switch
27. A 35-year-old woman with bipolar disorder presents with fatigue, weight gain, and a non-tender, diffuse goiter. She has been on lithium for 18 months. Labs reveal elevated TSH and low free T4. What is the cause of her symptoms?
➔ Lithium-induced hypothyroidism (Lithium can impair thyroid function → most commonly hypothyroidism with diffuse, non-nodular goiter)
- Note: Treated with Levothyroxine for hypothyroidism → Continue lithium if otherwise effective
- Other lithium side effects include GI upset, tremor, nephrogenic diabetes insipidus, and teratogenicity (Ebstein anomaly).
- USMLE Tip:
→ Check baseline and periodic thyroid function (TSH) in all patients on lithium
→ Don’t stop lithium—manage thyroid issue separately
28. A 28-year-old man with bipolar disorder is brought to the emergency department with confusion, coarse tremors, and vomiting. He recently started taking NSAIDs for back pain. His lithium level is 3.0 mEq/L. What is the next step in management?
➔ Initiate hemodialysis (Severe lithium toxicity with neurologic symptoms and level >2.5 → requires dialysis)
- Note: Lithium toxicity can be precipitated by volume depletion, NSAIDs, ACE inhibitors, or thiazide diuretics
- Acute toxicity symptoms → GI (nausea, vomiting, diarrhea), neurologic signs (tremor, confusion, ataxia, seizures).
- Treatment: Discontinue lithium immediately, supportive treatment
○ Hemodialysis if:
○ Lithium level > 2.5 mEq/L with symptoms
○ or any level > 4.0 mEq/L, even without symptoms
29. A 30-year-old woman on valproic acid for bipolar disorder develops easy bruising and petechiae. What is the most appropriate next step?
➔ Check platelet count (Consider decreasing or discontinuing valproic acid if thrombocytopenia is confirmed)
- Note: Valproic Acid Adverse Effects:
○ Common: GI distress, sedation, tremor, weight gain
○ Hematologic: Leukopenia, thrombocytopenia → monitor platelet count if bleeding symptoms occur
○ Hepatic: hepatotoxicity → monitor liver function tests regularly
○ Pancreatitis - Management: If thrombocytopenia or hepatotoxicity develops, reduce dose or discontinue the medication. If pancreatitis developed → stop immediately
30. A 26-year-old woman with bipolar disorder started on lamotrigine. Two weeks later, she developed a fever and a widespread erythematous rash. What is the cause?
➔ Lamotrigine-induced Stevens-Johnson Syndrome (SJS) (Serious skin reaction associated with lamotrigine, especially during early use or rapid dose escalation)
- Note: Other adverse effects: headache, nausea, dizziness, diplopia
- Discontinue immediately if a rash develops.
Anxiety & Related Disorders
31. A 32-year-old woman presents with sudden episodes of palpitations and chest tightness. All workups, including ECG and labs, have been normal. She now avoids situations for fear of another episode. What is the diagnosis?
➔ Panic Disorder (Recurrent, unexpected panic attacks + persistent fear of future attacks → think Panic Disorder)
- Note: First-time episodes should still be medically evaluated to rule out organic causes (arrhythmia, hyperthyroidism, pheochromocytoma, etc.)
- Treatment of Panic Disorder:
→ First-line: CBT + SSRIs/SNRIs
→ Benzodiazepines: Short-term only for acute management
Differentiate from:
→ Specific Phobia: Triggered by a specific object/situation → treat by CBT with exposure therapy
→ Social Anxiety (social phobia): Triggered by excessive fear of embarrassment or rejection in social and/or performance situations → treated by CBT, SSRIs; beta-blockers (for performance only anxiety).
→ Somatic Symptom Disorder: Persistent physical symptoms + excessive thoughts/behaviors
32. A 19-year-old college student reports intense anxiety, racing heart, and sweating before giving class presentations. He avoids speaking during group projects and has skipped several required presentations. What is the most appropriate management?
➔ Prescribe propranolol before performance (Symptoms suggestive of Social Anxiety Disorder – performance subtype)
- Note: Treatment of Social Anxiety Disorder:
→ First-line:
○ CBT (with exposure therapy)
○ SSRIs/SNRIs for moderate/severe cases
→ Performance-only subtype:
○ Propranolol (or benzo) as needed for short-term use
33. A 30-year-old woman presents with persistent, excessive worry about multiple aspects of her life, including her job and finances for the past 7 months. She reports difficulty sleeping and irritability. What is the initial treatment approach?
➔ Cognitive behavioral therapy (CBT) and/or SSRIs (Those are first-line treatments for generalized anxiety disorder)
- Note: For GAD → always look for chronic, uncontrolled worry plus multiple somatic/cognitive symptoms lasting ≥6 months, and start with CBT and/or SSRIs.
- Avoid benzodiazepines long-term due to dependency risk.
34. A 22-year-old college student reports repetitive handwashing for several hours each day. He says he fears contamination and feels compelled to wash to ease his anxiety. He recognizes this behavior is excessive but is unable to stop. What is the first-line treatment?
➔ Cognitive Behavioral Therapy (CBT) with exposure and response prevention (symptoms suggestive of OCD)
- Note: Key feature → Patient often has insight (knows thoughts/behaviors are irrational)
- Treated with CBT (exposure and response prevention), High-dose SSRIs
Do not confuse with:
Obsessive-Compulsive Personality Disorder (OCPD), a personality disorder involving rigid perfectionism and control that the patient does not see as problematic (ego-syntonic), unlike the distressing, ego-dystonic nature of OCD.
35. A 28-year-old woman involved in a serious car accident 2 weeks ago reports nightmares, hypervigilance, irritability, and avoids driving. She feels detached from others and has increased her alcohol intake. What is the next step in management?
➔ Trauma-focused CBT (Nightmares + hypervigilance + irritability + within 3 days to 1 month after trauma →Think Acute stress disorder → avoid starting medications → as trauma-focused CBT is first line)
- Note: Keywords: Hyperarousal + Avoidance of trauma reminders + Re-experiencing (nightmares, flashbacks) + Distress/mood changes. (HARD)
Differentiate from:
| Disorder | Key Features | Duration |
|---|---|---|
| PTSD | Same symptom clusters | >1 month |
| Adjustment Disorder | Disproportionate response to stressor; no flashbacks or hypervigilance | <6 months |
| Substance Use | Symptoms solely due to intoxication/withdrawal | Timeline + context help clarify |
36. A 24-year-old woman presents to the emergency department after a sexual assault. She is tearful, withdrawn, and disoriented. What is the next step in management?
➔ Ensure safety, provide emergency contraception, STI prophylaxis, and psychological support (Initial care focuses on physical and emotional safety + medical/legal needs)
- Note: Management is supportive and nonjudgmental — do not push for detailed history initially; let the patient lead.
- Arrange follow-up for PTSD/depression screening
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Personality Disorders
37. A 30-year-old man prefers to live alone, avoids all social contact, and shows no interest in romantic relationships. What is the diagnosis?
➔ Schizoid Personality Disorder (Persistent detachment from social relationships + limited emotional expression + no desire for intimacy → think Schizoid Personality Disorder)
- Note: In Schizoid personality : the patient has Social withdrawal, doesn’t want an emotional relationship VS Avoidant personality: the Patient wants relationships but fears rejection.
- Psychotherapy is the main treatment for both Schezoid and avoidant personality disorders.
38. A 25-year-old man wears strange clothing, claims magical powers, and speaks in an odd, tangential manner. He has no close friends and lives a socially isolated life. What is the diagnosis?
➔ Schizotypal Personality Disorder (Social isolation + eccentric behavior + odd beliefs and speech patterns → think Schizotypal Personality Disorder)
- Note: A key feature is wearing weird clothes.
- Schizotypal (weird + magical thinking) vs Schizoid (emotionally flat + no magical beliefs)
39. A 19-year-old man is arrested for theft and assault. He shows no remorse and has a history of conduct disorder as a child. What is the diagnosis?
➔ Antisocial Personality Disorder ( ≥18 years old + history of Conduct Disorder before age 15 + violation of others’ rights/lack of remorse → Think ASPD)
- Note: If a patient presets with these symptoms but <18 years → Think Conduct Disorder
- Low Serotonin/ high dopamine → impulsivity, aggression.
40. A 21-year-old woman with a history of emotional instability, intense fear of abandonment, and recurrent self-injury presents for psychiatric evaluation. She has a pattern of unstable relationships. What is the next step in management?
➔ Initiate Dialectical Behavior Therapy (DBT) (First-line treatment for Borderline Personality Disorder)
- Note: It is marked by emotional dysregulation, impulsivity, fear of abandonment, and self-harm.
- Splitting is a common defense mechanism — patients view others as either all good or all bad, leading to unstable relationships.
41. A 60-year-old man recently diagnosed with pancreatic cancer insists, “The doctors are wrong — I feel fine, and there’s no way I have cancer.” He refuses to schedule further treatment. What is the most likely defense mechanism involved?
➔ Denial (Blocking external reality from conscious awareness to avoid painful emotions → think Denial)
Differentiate From:
| Defense Mechanism | Key Features |
|---|---|
| Rationalization | Patient with cancer says, “It’s probably just stress — I’ve been overworked” |
| Projection | Patient says, “My doctor seems scared — I think he’s not telling me the truth” |
| Intellectualization | Patient discusses survival statistics in detail without expressing any emotion |
| Splitting | Seeing people as all good or all bad — common in Borderline Personality Disorder (e.g., “My doctor is the best, but the nurse is completely incompetent.”) |
| Fixation | An adult becomes overly dependent on parents or clings to childish routines under stress. |
| Displacement | A man angry at his boss yells at his children when he gets home. |
42. An aggressive child starts playing competitive sports and channels their energy into winning games. What defense mechanism is this?
➔ Sublimation (Aggressive impulses redirected into socially acceptable activities → think Sublimation)
- Note: Common scenario: aggressive child → does sports.
43. A man is angry at his boss but avoids confrontation. Later, he comes home and yells at his children for minor issues. What defense mechanism is this?
➔ Displacement (Shifting emotions from a threatening target to a safer substitute → think Displacement)
- Note: Common example: anger at authority → redirected to family
- Different from projection (attributing feelings to others)
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Other Psychiatric Disorders
44. A 16-year-old girl with BMI 15, amenorrhea, bradycardia, and lanugo is brought by her mother for weight loss. She denies the severity and still wants to lose more weight.
What is the complication?
➔ Osteoporosis (Symptoms suggestive of Anorexia Nervosa → As Malnutrition → leads to ↓ GnRH → leads to ↓ estrogen→ leads to Osteoporosis)
- Note: Key clues → BMI <18.5 + denial of severity + Amenorrhea + Bradycardia + Lanugo (fine body hair)
- Other Complications include → Electrolyte imbalance (↓K⁺, ↓Na⁺), arrhythmia
- Treatment:
○ Nutritional rehab + CBT + Olanzapine (if severe)
○ Hospitalize if unstable vitals, arrhythmia
Eating Disorders
| Disorder | Key Feature | BMI | Treatment |
|---|---|---|---|
| Anorexia Nervosa | Restriction + fear of weight gain | ↓ (<18.5) | Nutritional rehab + CBT |
| Bulimia Nervosa | Binge/purge behavior | Normal/↑ | CBT + SSRI |
| Binge Eating | Binge eating without compensation | ↑ | CBT, SSRIs, lisdexamfetamine |
45. A 24-year-old woman with a history of intense fear of gaining weight presents with fatigue, muscle weakness, and constipation. She admits to frequent use of laxatives to “stay thin.” Labs show hypokalemia. What is the most likely cause of her electrolyte abnormality?
➔ GI K⁺ loss (due to Laxative abuse in Anorexia Nervosa or Bulimia)
- Note: Key Electrolyte Effects:
○ Hypokalemia
○ Hypochloremia, and metabolic alkalosis, especially in patients who induce vomiting (loss of gastric HCL)
○ When laxatives are overused, either metabolic alkalosis or non–anion gap metabolic acidosis can occur (secondary to the loss of bicarbonate in the stool)
46. A 24-year-old woman with anorexia nervosa presents with hypokalemia and metabolic alkalosis. She reports chronic laxative use and occasional vomiting. What is the next best step in management?
➔ Stop purging behaviors and begin CBT + nutritional rehabilitation (Electrolyte imbalance due to eating disorder → requires behavioral and medical management)
- Note: Severe cases may require IV fluids + electrolyte replacement
- Monitor for refeeding syndrome in malnourished patients
- Always screen for eating disorders in young women with hypokalemia or acid–base disturbances
47. A 22-year-old woman with severe anorexia nervosa is hospitalized for nutritional rehabilitation. Two days after starting high-calorie refeeding, she develops weakness, arrhythmia, and confusion. Labs show hypophosphatemia. What is the diagnosis?
➔ Refeeding syndrome (Electrolyte shifts + hypophosphatemia after refeeding → classic for refeeding syndrome)
- Note: Caused by → Sudden ↑ insulin after refeeding (esp. carbs) → causes cellular uptake of electrolytes
- Key lab findings: ↑ Insulin, ↓ Thiamine↓ Phosphate (most hallmark), ↓ Potassium, ↓ Magnesium
- Management:
○ Slowly reintroduce nutrition
○ Aggressively monitor and replace phosphate, K⁺, Mg²⁺, and thiamine
○ Monitor ECG
48. A 30-year-old woman has recurrent diarrhea despite multiple negative workups. Her stool tests positive for phenolphthalein. She frequently visits different doctors. What is the next step in management?
➔ Perform a careful review of prior medical records and Regular follow-up with one physician. (Symptoms suggestive of Factitious Disorder)
- Note: Key Features:
○ Motivation: Primary gain (assume sick role, get care)
○ Often associated with early trauma, abuse, or neglect - Treatment:
○ Regular follow-up with one physician
○ Avoid unnecessary tests/interventions
○ Maintain a non-confrontational, therapeutic alliance
Don’t Confuse With:
- Somatic Symptom Disorder: Symptoms are real & distressing, not intentionally produced
- Malingering: Intentional production of symptoms for secondary gain (money, drugs, avoiding work).
49. A young woman develops sudden paralysis of her legs following a traumatic breakup. The neurological exam is normal, and she seems unconcerned by the symptoms. What is the diagnosis?
➔ Conversion Disorder (Look for neurologic symptoms incompatible with medical findings plus a recent stressor → Conversion disorder)
- Note: A key feature is “La belle indifférence” (lack of concern for symptoms).
- Treatment: Education about the disorder and Cognitive-behavioral therapy (CBT)
Differentiate from:
- Somatic Symptom Disorder: Patient has distressing somatic symptoms → treat with regular scheduled visits, CBT
- Illness Anxiety Disorder: Preoccupation with having a serious illness despite reassurance → treat with CBT
50. A 22-year-old woman has seizure-like episodes with eye closure, preserved awareness, and no postictal confusion. EEG is normal. What is the diagnosis?
➔ Psychogenic Nonepileptic Seizures (PNES) (Functional neurologic symptoms mimicking seizures without EEG findings)
- Note: Type of Conversion Disorder
- Key clues: Eyes closed, no postictal state, normal EEG, triggered by stress
- Treatment: Education + CBT
51. A 22-year-old college student reports excessive daytime sleepiness despite sleeping 8–9 hours nightly. He recently experienced brief muscle weakness triggered by laughter and had vivid hallucinations while falling asleep. What is the diagnosis?
➔ Narcolepsy (Excessive daytime sleepiness + cataplexy/hallucinations/sleep paralysis → think narcolepsy)
- Note: Cataplexy is → Sudden loss of muscle tone triggered by emotion
- Narcolepsy
→ Caused by loss of orexin (hypocretin)-producing neurons in lateral hypothalamus
→ Diagnosis: Clinical + multiple sleep latency test (MSLT) or low CSF orexin-A - Treated with maintaining a regular sleep schedule, avoidance of daytime naps
○ Modafinil is → first-line for daytime sleepiness
52. An 87-year-old man reports mild forgetfulness over the past 6 months. He occasionally misplaces keys and forgets grocery items without a list, but he remains socially and cognitively active. What is the explanation for these findings?
➔ Normal Aging (Mild memory lapses without functional impairment → think Normal Cognitive Aging → managed with reassurance)
- Note: Normal Changes:
○ Mild decline in memory, and processing speed
○ Occasional forgetfulness (e.g., misplacing items, minor word-finding difficulty) - Key Feature → No impairment in daily functioning, independence preserved
- Protective Factors → Staying cognitively/socially engaged (e.g., reading, socializing)
Differentiate From:
| Condition | Key Features |
|---|---|
| Mild Cognitive Impairment (MCI) | Noticeable cognitive decline, but independent functioning preserved; higher risk of progressing to dementia |
| Dementia (e.g., Alzheimer’s) | Progressive memory loss with functional impairment (e.g., getting lost, poor hygiene) |
USMLE Tip: → Always assess for functional impact when differentiating between normal aging, MCI, and dementia.
53. An 80-year-old hospitalized patient becomes acutely confused, disoriented, and is pulling out IV lines. Vitals are stable, what is the next step in management?
➔ Urine analysis (New-onset Delirium → next step is to look for a source of acute disease (like UTI))
- Note: Acute onset, fluctuating course, impaired attention ± hallucinations → Think Delirium
○ Causes: infection, pain, meds (e.g. opioids), electrolyte imbalance, sleep deprivation - Management:
○ Treat underlying cause (eg, infection, meds)
○ Supportive care: frequent reorientation, promote mobility/sleep, and social support.
○ In severe cases associated with agitation: Short-term haloperidol (first-line antipsychotic)
Don’t confuse with:
→ Dementia: Gradual onset, progressive
→ Psychosis: No fluctuating course, no acute medical trigger
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Psychiatric Emergencies & Substance Use
54. A 21-year-old woman is brought to the ED after collapsing at a music festival. She is confused, tachycardic, diaphoretic, and has a tonic-clonic seizure. Friends say she took “molly.” What is the cause of her symptoms?
➔ Ecstasy (MDMA) intoxication (causes severe hyponatremia (leading to seizure) + autonomic instability)
- Note: Key Effects → ↑ thirst , ↑ energy, Bruxism, agitation, hyperthermia, seizures
Common Substances: Key Features of Intoxication and Withdrawal
| Substance | Intoxication | Withdrawal |
|---|---|---|
| Alcohol | Ataxia, slurred speech | Tremors, seizures, Delirium tremens |
| Benzodiazepines | Ataxia, minor respiratory depression | Seizures, rebound anxiety |
| Opioids | Pinpoint pupils, respiratory depression | Mydriasis, yawning, flu-like symptoms |
| Cocaine | Mydriasis, nasal septum abnormalities, hallucinations (tactile) | Depression, hypersomnia |
| Amphetamines | Meth mites (tactile hallucinations), hyperthermia | “Crash” — depression |
| Cannabis | Euphoria, conjunctival injection, increased appetite | Anxiety, depression |
| LSD | Visual hallucinations, depersonalization | Flashbacks (rare) |
| MDMA (Ecstasy) | Hyperthermia, serotonin syndrome, hyponatremia | Depression, fatigue |
| PCP | Violent behavior, nystagmus (vertical), analgesia | Agitation, anxiety |
| Inhalants | Common in adolescents. Euphoria, disinhibition, slurred speech, rash around mouth | Irritability, headaches |
55. A 40-year-old man presents with sudden severe back pain after lifting a box. He requests opioids, but the exam shows no distress, normal vitals, and full range of motion. Straight leg raise is negative. What is the next best step?
➔ Screen for Substance Use Disorder (Discrepancy between reported pain severity and objective findings + drug-seeking behavior → think Substance Use Disorder)
- Note: Management:
→ Consider prescription monitoring programs (PMPs)
→ Use non-opioid pain control and behavioral support
Don’t Confuse With:
→ Malingering: Intentional symptom exaggeration for external gain (overlaps with SUD but without compulsive use)
56. A 25-year-old man is brought to the ED by police for bizarre behavior and aggression. He is combative, confused, hypertensive, diaphoretic, and has horizontal nystagmus. He stumbles when trying to walk. What is the cause?
➔ PCP Intoxication (aggression + psychosis + nystagmus → think Phencyclidine)
- Note: Trauma is the most common complication
- First step in management is → Chemical sedation (IM benzodiazepines)
57. A 28-year-old man presents with the sensation of insects crawling under his skin and multiple skin excoriations. He appears agitated with dilated pupils, tachycardia, and hypertension. Which substance is responsible?
➔ Methamphetamine intoxication (Tactile hallucinations + sympathomimetic signs → think methamphetamine)
- Note: Oral findings: Chronic use → “Meth mouth” (severe tooth decay, bruxism, dry mouth)
- Treat with → Supportive care, benzodiazepines
58. A 28-year-old man presents with chest pain after using cocaine. Vitals show hypertension and tachycardia. ECG shows ST depressions. What is the initial management?
➔ Benzodiazepines (1st-line for cocaine-induced hypertension & chest pain)
- Note: Complications of Cocaine include
○ MI from coronary vasospasm
○ Intracranial hemorrhage - First-line in management is → Benzodiazepines (↓ sympathetic outflow)
USMLE Tip:
Cocaine + chest pain = NO β-blockers– always start with benzos. (As β-blockers can can lead to unopposed α₁-adrenergic receptor stimulation → causing severe vasoconstriction, hypertension, and possible worsening of myocardial ischemia.)
59. A 15-year-old boy is brought in by his parents due to episodes of dizziness, slurred speech, and a chemical odor on his clothes. He has perioral rash and frequent nosebleeds. What is the cause?
➔ Inhalant abuse (Common in adolescents; signs include CNS depression + chemical odor + perioral rash)
- Note: Commonly abused by adolescents
- Tox screens are often negative.
60. A 32-year-old man is evaluated in the outpatient clinic for irritability, poor concentration, and suspiciousness over the past 3 weeks. He believes his neighbors are “monitoring his every move”. Urine toxicology is positive for amphetamines. Which of the following is the most likely diagnosis?
➔ Substance-Induced Psychotic Disorder (from stimulant intoxication)
- Note: Substance-Induced Psychosis is most common with stimulants → Cocaine, methamphetamine
- Treat with
○ Supportive care
○ Benzodiazepines for agitation
○ Antipsychotics if psychosis severe
Don’t Confuse With:
- Schizophrenia: Chronic symptoms, not substance-linked
- Brief psychotic disorder: No drug trigger, <1 month duration
61. A 60-year-old hospitalized man with a 40-pack-year smoking history becomes irritable, restless, and has difficulty sleeping 2 days after admission. Vitals are normal. What is the next step in management?
➔ Start nicotine replacement therapy (eg, transdermal patch) (New-onset agitation/insomnia in a smoker → think Nicotine Withdrawal)
- Note: First-line in management is → Nicotine replacement (patch, gum, lozenge), bupropion, or varenicline
Don’t Confuse With:
→ Delirium: Altered sensorium, disorientation
→ Benzodiazepine/alcohol withdrawal: Tremors, hallucinations, seizures
62. A chronic alcoholic man presents with confusion, ataxia, and ophthalmoplegia. MRI shows mammillary body atrophy. What is the immediate treatment to prevent progression to irreversible cognitive impairment?
➔ Intravenous thiamine (Vitamin B1) administration (alcoholic + Acute confusion + Ophthalmoplegia + Ataxia → Think Wernicke Encephalopathy)
- Note: MRI Finding → Mammillary body atrophy
- May progress to Wernicke-Korsakoff syndrome (irreversible amnesia + confabulation) if untreated
- Treat with immediate high-dose IV thiamine before glucose administration
63. A 40-year-old man with a history of alcohol use disorder presents requesting help to stop drinking. He reports strong cravings and multiple relapses. What is the best next step in management?
➔ Initiate naltrexone (first-line for alcohol use disorder with cravings)
- Note: Treatment Options for alcohol use disorder:
– First-line:
→ Naltrexone: ↓ craving (opioid antagonist)
↳ Contraindicated if using opioids or liver failure
→ Acamprosate: Maintains abstinence (glutamate modulator)
↳ Safe in liver disease; avoid in renal impairment
– Second-line:
→ Disulfiram: Aversive therapy (causes acetaldehyde buildup)
↳ Must be highly motivated + abstinent
64. A 46-year-old man with alcohol use disorder was admitted for acute pancreatitis. On hospital day 3, he becomes agitated and confused. He reports seeing “spiders on the wall.” What is the next step in management?
➔ Administer intravenous benzodiazepines (Alcoholic patient who has been hospitalized for the past 2 days + agitated and confused → Think Delirium Tremens)
- Note: Delirium Tremens symptoms include:
○ Delirium (confusion, disorientation, fluctuating consciousness)
○ Hallucinations (usually visual)
○ Autonomic instability: ↑HR, ↑BP, hyperthermia
○ Agitation, tremor, seizures - Treat with :
○ Benzodiazepines (For alcohol withdrawal)
○ Supportive with IV fluids and Vitamin supplementation
USMLE Tip:
→ Always administer thiamine before glucose to prevent Wernicke encephalopathy
→ Monitor for hypomagnesemia in alcohol withdrawal: due to poor intake + renal loss
65. A 30-year-old man with schizophrenia presents with confusion, muscle rigidity, fever (39.8°C), and tachycardia after being started on risperidone. Labs show ↑CK and leukocytosis. What is the most likely diagnosis?
➔ Neuroleptic Malignant Syndrome (NMS) (AMS + “lead-pipe” rigidity + fever + autonomic instability after antipsychotics → think NMS)
- Note: Triggered by
→ High-potency antipsychotics (eg, haloperidol)
→ Antiemetics (eg, metoclopramide) - Treatment:
→ Stop antipsychotics immediately
→ Supportive care: IV fluids, cooling blankets
→ Dantrolene or bromocriptine if severe
Don’t Confuse With:
→ Serotonin syndrome: Myoclonus, hyperreflexia, GI symptoms (vs rigidity & hyporeflexia in NMS) → treat with stopping serotonergic agents, give cyproheptadine
→ Malignant hyperthermia: Life-threatening fever and rigidity as a reaction to anesthesia (eg, succinylcholine, volatile gases) during or just after surgery→ Treat with drug discontinuation, and IV Dantrolene
66. A 25-year-old man with schizophrenia is brought to the ED 2 hours after receiving haloperidol for agitation. He has painful neck twisting and upward eye deviation. He is alert, afebrile, and hemodynamically stable. What is the next step in management?
➔ Administer benztropine (Involuntary, painful muscle spasms (e.g., torticollis, oculogyric crisis) → Think Acute dystonic reaction)
- Note: Acute dystonic reaction is triggered by:
○ D2 antagonists (eg, antipsychotics, metoclopramide)
○ Occurs hours to days after drug initiation - Treat with → Diphenhydramine or benztropine (anticholinergics)
USMLE Tip:
→ Extrapyramidal symptoms (EPS) are common with high-potency antipsychotics (e.g., haloperidol)
Extrapyramidal Symptoms
| EPS Type | Key Features | Onset | Treatment |
|---|---|---|---|
| Dystonia | Painful spasms (e.g., torticollis) | Hours–days | Benztropine, diphenhydramine |
| Akathisia | Inner restlessness, pacing | Days–weeks | Propranolol, benzodiazepines |
| Parkinsonism | Bradykinesia, rigidity, resting tremor, masked facies | Weeks–months | Benztropine, amantadine |
| Tardive Dyskinesia | Involuntary movements (e.g., lip smacking) | Months–years | Valbenazine or switch antipsychotic |
67. A 29-year-old woman recently started risperidone for schizophrenia. She now reports tremors, slow movement, and stiffness in her arms. On the exam, she has cogwheel rigidity and bradykinesia. What is the most likely cause of her symptoms?
➔ Medication-induced parkinsonism (Risperidone blocks D2 receptors → ↓ dopamine in nigrostriatal pathway → EPS symptoms)
- Note: Parkinsonism typically occurs days to weeks after initiation
- Treatment:
→ Lower the dose of risperidone
→ Add benztropine or amantadine if needed
→ Switch to an antipsychotic with lower EPS risk (e.g., quetiapine, clozapine) if severe
68. A 19-year-old woman is found confused and delirious after ingesting an unknown number of pills. Vitals show hypotension, and ECG reveals QRS widening. She has dry mucous membranes, flushed skin, and mydriasis. What is the cause?
➔ Tricyclic Antidepressant (TCA) Overdose (Anticholinergic signs + cardiac toxicity → think TCA overdose, especially imipramine, amitriptyline)
- Note: Key Features of TCA overdose:
○ CNS: Confusion, seizures
○ Cardiac: Arrhythmias, widened QRS, prolonged QT,
○ Anticholinergic: Dry mouth, mydriasis, flushed skin, urinary retention, constipation - USMLE Tip: SSRIs are much safer — even in overdose, they rarely cause life-threatening toxicity.
69. A 20-year-old man is brought to the ED after ingesting an unknown quantity of amitriptyline in a suicide attempt. He is drowsy, has dilated pupils, dry skin, and mild hypotension. What is the most appropriate next step in evaluation?
➔ Obtain an ECG (Suspected TCA overdose → must assess for QRS widening and arrhythmias)
- Note: Always check ECG in suspected overdose cases.
- Diagnosis Clue: ECG changes + anticholinergic symptoms
- Treated with → IV sodium bicarbonate (1st line to narrow QRS and prevent arrhythmias), Supportive therapy
🏁 Final Thoughts
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Disclaimer
Version 1.0 August 2025. No part of this document may be reproduced or distributed without written permission. For personal study only. Medical information herein is for educational purposes and does not constitute clinical advice. Always confirm with current guidelines and your institution’s policies.
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