Side Effects May Vary
A 27-year-old patient starts sertraline and returns two weeks later reporting mild nausea and restlessness. What’s your next step?
A. Discontinue sertraline and switch to another SSRI
B. Add a benzodiazepine for short-term symptom relief
C. Reassure the patient that mild side effects are common early in treatment and will likely improve
D. Check serum sertraline levels and adjust the dose accordingly
C
Early SSRI side effects (GI upset, jitteriness, sleep changes) are common in the first 1–2 weeks and typically self-resolve. Supportive counseling and reassurance help with adherence. Dose changes or discontinuation are premature unless side effects are severe or persistent.
A 35-year-old man reports feeling “down” most of the day, nearly every day, for the past 3 months. He has lost interest in hobbies, has insomnia, decreased appetite, low energy, and difficulty concentrating. He denies manic episodes.
Most likely diagnosis:
A. Persistent Depressive Disorder (Dysthymia)
B. Major Depressive Disorder, single episode
C. Bipolar II Disorder
D. Adjustment Disorder with Depressed Mood
B. Major Depressive Disorder, single episode
DSM-5 criteria: ≥5 symptoms for ≥2 weeks, including depressed mood or anhedonia, causing distress or impairment. No history of mania/hypomania.
Persistent Depressive Disorder (Dysthymia)
DSM-5 requires depressed mood most of the day for ≥2 years in adults
Patient’s symptoms are 3 months, so too short
Severity can be less than MDD, but chronicity is key
Bipolar II Disorder
Requires at least one hypomanic episode (elevated or irritable mood for ≥4 days, plus ≥3 additional symptoms)
Patient denies any history of hypomania cannot diagnose bipolar disorder
Adjustment Disorder with Depressed Mood
Usually occurs within 3 months of a stressor
Symptoms are out of proportion to the stressor and resolve within 6 months after the stressor ends
In this case, no specific stressor is mentioned, and symptoms have lasted 3 months with multiple DSM-5 MDD criteria -- meets full criteria for MDD, not adjustment disorder
A patient with panic disorder is advised to intentionally provoke mild dizziness to confront their fear of fainting. This is done gradually and repeatedly. What behavioral strategy is being used?
Exposure Therapy
A 27-year-old woman with a history of bipolar I disorder presents for routine follow-up. She reports sleeping only 3–4 hours per night, feeling “energized,” and starting multiple new projects. She stopped taking lithium 3 weeks ago because she “felt fine.” Her pregnancy test is negative.
Which of the following is the most appropriate next step in pharmacologic management?
A. Restart lithium and monitor serum levels
B. Start fluoxetine for her elevated mood
C. Begin carbamazepine and discontinue lithium permanently
D. Add lorazepam as monotherapy
A. Restart lithium and monitor serum levels
The patient is experiencing hypomanic/manic symptoms after discontinuing a mood stabilizer.
Lithium remains first-line for acute mania and maintenance therapy, provided renal and thyroid function are adequate and pregnancy is excluded.
Fluoxetine (or any antidepressant) risks worsening mania if used without a mood stabilizer.
Carbamazepine is an alternative if lithium is contraindicated but not first-line to replace it in a stable patient.
Lorazepam may help short-term for agitation or insomnia but is not adequate monotherapy.
A 30-year-old woman reports a history of several periods over the past 5 years in which she felt extremely energetic, slept only 3–4 hours per night, talked rapidly, and started multiple projects. These periods lasted about 5 days each and caused some interpersonal stress but did not require hospitalization. She has also had two major depressive episodes, each lasting several weeks.
Which of the following is the most likely diagnosis?
A. Bipolar I Disorder
B. Bipolar II Disorder
C. Cyclothymic Disorder
D. Major Depressive Disorder with Hypomanic Features
B. Bipolar II Disorder Key differentiator here: Patient has hypomania only, not full mania --Bipolar II.
Bipolar I: requires at least one manic episode (≥1 week, causing marked impairment or hospitalization) with or without depressive episodes.
Bipolar II: requires at least one hypomanic episode (≥4 days, not causing marked impairment or hospitalization) and at least one major depressive episode.
Cyclothymic Disorder: chronic (≥2 years) subthreshold hypomanic and depressive symptoms, never meeting full criteria for MDE or mania.
A patient is advised to avoid caffeine and stimulants and maintain regular sleep and exercise to reduce baseline anxiety. What category of strategies does this represent?
Lifestyle interventions
A 34-year-old woman presents with a 6-month history of excessive worry about work and home responsibilities. She reports difficulty sleeping, muscle tension, and frequent irritability. She denies panic attacks or suicidal thoughts. Her past medical history is unremarkable.
Which of the following is the most appropriate first-line treatment?
A. Alprazolam as needed
B. Cognitive-behavioral therapy (CBT)
C. Hydroxyzine daily
D. Amitriptyline
B. Cognitive-behavioral therapy (CBT)
CBT is first-line for generalized anxiety disorder (GAD) and other chronic anxiety disorders.
SSRIs or SNRIs are first-line pharmacologic options if therapy alone is insufficient.
Benzodiazepines (e.g., alprazolam) are second-line due to dependency risk.
Hydroxyzine can be used short-term for anxiety, but evidence for long-term efficacy is limited.
Amitriptyline is not a first-line treatment for GAD.
A 29-year-old man reports recurrent unexpected episodes of intense fear, palpitations, sweating, shortness of breath, and fear of dying. Attacks occur suddenly and unpredictably. He now avoids elevators and crowded areas due to fear of another attack.
Most likely diagnosis:
A. Agoraphobia
B. Panic Disorder
C. Social Anxiety Disorder
D. Generalized Anxiety Disorder
B. Panic Disorder
DSM-5 requires recurrent unexpected panic attacks and ≥1 month of concern about future attacks or behavior change.
A patient struggling with low motivation is encouraged to schedule one enjoyable activity per day, even if it feels difficult. What is this intervention called?
Behavioral Activation
A 32-year-old woman with a history of major depressive episodes presents with a 2-week history of elevated mood, decreased need for sleep, rapid speech, and distractibility. She has no history of substance use.
Which is the most appropriate next step?
A. Start an SSRI immediately
B. Begin cognitive behavioral therapy only
C. Evaluate for bipolar disorder and consider mood stabilizer
D. Reassure her and follow up in 1 month
C. Evaluate for bipolar disorder and consider mood stabilizer
Symptoms of mania or hypomania (elevated mood, decreased need for sleep, distractibility) require careful evaluation for bipolar disorder. Initiating an antidepressant alone can trigger or worsen mania. Mood stabilizers or atypical antipsychotics are first-line treatment for acute mania/hypomania.
Which of the following bipolar disorders can be diagnosed in a patient who has never experienced a major depressive episode?
A. Bipolar I Disorder
B. Bipolar II Disorder
C. Cyclothymic Disorder
D. Major Depressive Disorder with Mixed Features
A. Bipolar I Disorder: Requires at least one manic episode, but depressive episodes are not required for diagnosis. Some patients may never experience a major depressive episode.
Bipolar II Disorder: Requires at least one hypomanic episode AND at least one major depressive episode; depressive episode is necessary.
Cyclothymic Disorder: Requires ≥2 years of subthreshold hypomanic and depressive symptoms, never meeting criteria for full MDE or mania.
MDD with Mixed Features: Not bipolar; hypomanic symptoms occur only during depressive episodes, never stand-alone.
Key clinical pearl:If a patient presents with a full manic episode but no history of depression, the diagnosis is Bipolar I.
A patient with bipolar disorder has frequent relapses due to poor medication adherence. You provide education on early warning signs, triggers, and sleep hygiene. Which intervention is this?
Psychoeducation
A patient has a panic attack in the clinic. She is alert but reports shortness of breath, palpitations, and fear of dying.
Most appropriate immediate intervention:
A. Administer alprazolam IM
B. Reassure and guide through slow breathing and grounding
C. Order ECG and hospitalize immediately
D. Start long-term SSRI immediately
B. Reassure and guide through slow breathing and grounding
Panic attacks are self-limited; acute management is supportive, teaching coping skills. Pharmacotherapy is for prevention of recurrence, not immediate relief.
A 19-year-old college freshman reports feeling nervous and restless after moving away from home. He has difficulty concentrating but maintains friendships and grades. Symptoms began 3 weeks after the move and have persisted for 2 months.
Most likely diagnosis:
A. Generalized Anxiety Disorder
B. Adjustment Disorder with Anxiety
C. Acute Stress Disorder
D. Persistent Depressive Disorder
Adjustment Disorder with Anxiety
DSM-5: Emotional or behavioral symptoms within 3 months of identifiable stressor; distress exceeds expected reaction but doesn’t meet another disorder’s criteria; resolves within 6 months of stressor ending.
Treatment: supportive or CBT-based psychotherapy; medications only if symptoms persist or are severe.
A patient presents with anxiety exacerbated by insomnia and stimulant use. You first address these physiological contributors before cognitive work. Why?
Underlying medical/lifestyle factors must be stabilized; CBT alone cannot manage somatic triggers.
A 28-year-old man presents to your clinic for follow-up. He reports episodes over the past 4 years where he felt extremely energetic, slept only 2–3 hours per night, talked rapidly, and started multiple projects. Each episode lasted 5–6 days, caused interpersonal conflict, but did not require hospitalization.
He also reports two separate periods of depressed mood over the past 3 years, with anhedonia, fatigue, and poor concentration lasting 3–4 weeks each. He denies alcohol or substance use. His partner reports irritability and impulsive spending during high-energy periods.
Which of the following is TRUE regarding the appropriate management of this patient?
A. Start fluoxetine monotherapy for depressive episodes; psychotherapy is optional.
B. Initiate lithium or lamotrigine for mood stabilization and provide psychoeducation plus CBT.
C. Only recommend CBT for hypomanic episodes; pharmacotherapy is unnecessary.
D. Hospitalization is required for all hypomanic episodes before treatment can begin.
B. Initiate lithium or lamotrigine for mood stabilization and provide psychoeducation plus CBT
Diagnosis
Patient meets Bipolar II Disorder:
Hypomanic episodes ≥4 days, elevated/irritable mood + ≥3 other symptoms, causing interpersonal stress but not hospitalization.
Major depressive episodes ≥2 weeks, causing distress or impairment.
Pharmacologic Interventions
First-line mood stabilizers for Bipolar II:
Lithium: reduces risk of depressive and hypomanic episodes, suicide prevention.
Lamotrigine: effective for bipolar depression prevention; less effect on acute hypomania.
Other options (if needed):
Atypical antipsychotics (e.g., quetiapine) can be used for depressive episodes.
Avoid antidepressant monotherapy: may trigger hypomania.
Behavioral / Psychotherapeutic Interventions
Psychoeducation: teaches recognition of early warning signs of hypomania or depression, importance of sleep hygiene, medication adherence.
Cognitive Behavioral Therapy (CBT): targets depressive cognitions, helps with behavioral activation and emotion regulation.
Family-focused therapy: involves partner/family to manage relational stress and improve support.
Why not the other options
A: Fluoxetine monotherapy → risky; can trigger hypomania.
C: CBT alone is insufficient for mood stabilization in Bipolar II with recurrent depressive episodes.
D: Hospitalization is not required for hypomania unless there is danger to self/others or severe impairment.
Clinical pearl:
Bipolar II is often underdiagnosed because hypomania may feel “normal” to patients. Recognition and combination therapy — mood stabilizer + psychotherapy — is key for long-term functioning and relapse prevention.