Mood And Anxiety Disorders - USMLE Step 2

1. What is the most likely diagnosis?
   Answer: Social anxiety disorder The patient's symptoms are characteristic of Social Anxiety Disorder (Social Phobia). He has a marked fear of one or more social or performance situations (giving presentations) in which he is exposed to possible scrutiny by others. He fears he will act in a way that will be embarrassing or humiliating. This fear is causing him to avoid these situations, leading to academic impairment. His comfort in non-performance social situations is also typical. * A) Agoraphobia: This is a fear of situations where escape might be difficult or help unavailable, typically involving places like crowds, public transportation, or open spaces. * B) Generalized anxiety disorder: This involves excessive worry about a number of events or activities, not specifically focused on social performance. * C) Panic disorder: This diagnosis requires recurrent, unexpected panic attacks. The patient's anxiety and panic-like symptoms are specifically triggered by a social performance situation.
2. Which of the following antidepressants is considered the safest and best-studied option in patients with recent cardiovascular events?
   Answer: Sertraline Sertraline is the most well-studied and safest antidepressant for patients with recent myocardial infarction or other significant cardiac disease. Large-scale trials (e.g., SADHART-CHF) have demonstrated its safety and efficacy in this population without increasing the risk of adverse cardiovascular events. * A) Citalopram: At doses above 20 mg/day in older adults (or 40 mg/day in younger adults), citalopram carries a risk of QT interval prolongation, which is a concern in patients with heart disease. * B) Venlafaxine: As an SNRI, venlafaxine can cause a dose-dependent increase in blood pressure and heart rate, which may be detrimental in patients with coronary artery disease. * C) Amitriptyline: Tricyclic antidepressants are relatively contraindicated in patients with heart disease due to their potential to cause conduction delays, arrhythmias, and orthostatic hypotension.
3. Which of the following is the most likely diagnosis?
   Answer: Generalized anxiety disorder The patient's presentation of excessive, uncontrollable worry about multiple issues for at least six months, accompanied by physical symptoms (muscle tension, sleep disturbance) and cognitive symptoms (difficulty concentrating), is characteristic of Generalized Anxiety Disorder (GAD). * A) Panic disorder: This is characterized by recurrent, unexpected panic attacks and persistent concern about having more attacks. * C) Social anxiety disorder: This involves a marked fear of social situations where the individual might be scrutinized by others. This patient's worry is more global and not limited to social contexts. * D) Adjustment disorder with anxiety: This is diagnosed when anxiety symptoms develop in response to an identifiable stressor within 3 months. The patient's symptoms are chronic (1 year) and not tied to a specific recent event.
4. To differentiate between unipolar depression and bipolar disorder, which of the following is the most important question to ask regarding that period in college?
   Answer: Did this period of elevated mood last for at least four consecutive days? The key feature distinguishing a hypomanic episode (required for a Bipolar II diagnosis) from normal mood fluctuations is the duration of symptoms. According to DSM-5 criteria, a hypomanic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood and increased energy lasting at least 4 consecutive days and present most of the day, nearly every day. Asking about the duration is critical to determine if this past episode meets the criteria for hypomania. * A) Changes in appetite: This is a non-specific symptom that can occur in various conditions. * C) Feeling more creative: While increased creativity can be part of a hypomanic episode, it is not a core diagnostic criterion like duration. * D) Family history: While important for assessing risk, it does not confirm the diagnosis in the patient herself. The patient's direct symptom history is paramount.
5. Which diagnosis best accounts for her symptoms?
   Answer: Major depressive disorder Although the symptoms are linked to a stressor (failing an exam), they meet the full criteria for a major depressive episode (MDE). She has at least five of the required symptoms (depressed mood, anhedonia, fatigue, poor concentration, hypersomnia) for a duration of two months, causing significant distress. When the full criteria for MDE are met, the diagnosis is Major Depressive Disorder, even if it was precipitated by a stressor. Adjustment disorder is diagnosed only when the criteria for another mental disorder are not met. * A) Adjustment disorder with depressed mood: This diagnosis is not made if the symptom presentation meets the criteria for a major depressive episode. * C) Unspecified anxiety disorder: The primary symptoms described are depressive, not anxious. * D) Normal stress reaction: While stress is present, the severity and number of symptoms, along with the duration, suggest a clinical disorder rather than a normal reaction.
6. Which of the following is the most likely diagnosis?
   Answer: Panic disorder The patient is experiencing recurrent, unexpected panic attacks, which are discrete periods of intense fear with multiple physical and cognitive symptoms. Her presentation is also characterized by persistent concern about having additional attacks and a significant maladaptive change in behavior (avoidance) related to the attacks. This combination is diagnostic of Panic Disorder. * A) Generalized anxiety disorder: This involves chronic, pervasive worry about multiple life domains, not discrete, intense attacks. * B) Specific phobia: This involves fear of a specific object or situation. While she is avoiding the library, the fear is of having another panic attack, not of the library itself. The attacks are also unexpected and not limited to a specific trigger. * C) Social anxiety disorder: This is a fear of social or performance situations. The patient's panic attacks are not specifically triggered by social scrutiny.
7. Which of the following is the most appropriate initial medication for this patient?
   Answer: Bupropion Bupropion is an antidepressant that primarily inhibits the reuptake of norepinephrine and dopamine. It is unique among antidepressants for its lack of serotonergic activity, which means it is not typically associated with sexual dysfunction or weight gain. Given the patient's specific concerns, it is an excellent first-line choice. * A) Sertraline: As a selective serotonin reuptake inhibitor (SSRI), sertraline is a common first-line treatment for depression but is frequently associated with sexual side effects. * B) Mirtazapine: This medication often causes sedation and significant weight gain due to its antihistaminic effects, making it a poor choice for this patient. * D) Amitriptyline: This is a tricyclic antidepressant (TCA) that is no longer considered first-line due to its significant side effect profile (anticholinergic effects, cardiotoxicity in overdose) and potential for weight gain.
8. Which of the following medications, when added to lithium, would be the most appropriate treatment for this patient's acute depressive episode?
   Answer: Quetiapine The treatment of bipolar depression requires agents that are effective for depression without inducing mania. Antidepressant monotherapy is contraindicated due to the risk of precipitating a manic switch. First-line, evidence-based treatments for acute bipolar depression include second-generation antipsychotics like quetiapine and lurasidone, or the olanzapine-fluoxetine combination. Quetiapine has robust evidence for efficacy in treating bipolar depression, both as monotherapy and as an adjunct to mood stabilizers like lithium. * A) Sertraline & B) Bupropion: Adding an antidepressant (like an SSRI or bupropion) to a mood stabilizer is a second-line strategy and carries a risk of inducing mania, even with a mood stabilizer on board. They are not first-line choices. * D) Alprazolam: A benzodiazepine may help with associated anxiety or insomnia but does not treat the core depressive symptoms of bipolar disorder.
9. Which of the following medication classes has historically shown particular efficacy for treatment-resistant depression with atypical features?
   Answer: Monoamine oxidase inhibitors While SSRIs are first-line for major depressive disorder, including the atypical subtype, monoamine oxidase inhibitors (MAOIs) like phenelzine have been shown to be particularly effective for depression with atypical features, especially in cases that are resistant to other treatments. Atypical features (mood reactivity, hypersomnia, hyperphagia, leaden paralysis, interpersonal rejection sensitivity) are considered a potential predictor of a favorable response to MAOIs. * A) Benzodiazepines: These are anxiolytics and are not effective as primary treatment for depression. * B) Typical antipsychotics: These are not used to treat depression and can have significant side effects. * D) Tricyclic antidepressants (TCAs): While effective for depression, TCAs are generally considered less effective than MAOIs for the atypical subtype.
10. Which of the following is a core component of CBT for GAD?
    Answer: Identifying and challenging cognitive distortions related to worry A central tenet of cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) is cognitive restructuring. This involves helping the patient identify maladaptive or distorted thoughts (e.g., catastrophizing, probability overestimation) that fuel their chronic worry and then challenging and replacing these thoughts with more realistic and balanced alternatives. This, combined with behavioral techniques like relaxation training, forms the core of CBT for GAD. * A) Analysis of childhood experiences: This is characteristic of psychodynamic or psychoanalytic therapy, not CBT. * B) Practicing acceptance: This is a core component of Acceptance and Commitment Therapy (ACT) and mindfulness-based approaches, which are distinct from traditional CBT. * D) Prescribing medication: This is not a component of psychotherapy, which is delivered by a therapist who may or may not have prescribing authority.
11. Which of the following is the most appropriate recommendation for the duration of antidepressant therapy?
    Answer: Continue the medication at the same dose for at least 6-12 months Standard guidelines for the treatment of a single episode of major depressive disorder recommend a continuation phase of treatment. After a patient achieves remission (significant improvement or absence of symptoms), the antidepressant should be continued at the full therapeutic dose for at least 6 to 12 months to prevent relapse. Discontinuing medication too early is a major risk factor for recurrence of the depressive episode. * A) Taper and discontinue the medication now: This is premature and carries a high risk of relapse. * B) Continue for another 4-8 weeks: This is too short for the continuation phase and is insufficient to consolidate the treatment response. * D) Continue indefinitely: Lifelong maintenance therapy is typically reserved for patients with recurrent (e.g., 3 or more) major depressive episodes, chronic depression, or severe episodes.
12. Which of the following medications would be the most appropriate choice for this patient?
    Answer: Duloxetine Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI) that is FDA-approved for the treatment of major depressive disorder, generalized anxiety disorder, and several pain conditions, including diabetic peripheral neuropathy. Its dual mechanism of action on both serotonin and norepinephrine pathways is thought to contribute to its analgesic effects. This makes it an ideal choice for a patient with comorbid depression and neuropathic pain. * A), C), & D): Fluoxetine, escitalopram, and sertraline are all selective serotonin reuptake inhibitors (SSRIs). While effective for depression, they are not considered first-line treatments for neuropathic pain and are less likely to provide the dual benefit this patient is seeking.
13. Which of the following is the most appropriate medication for this patient's condition?
    Answer: Propranolol as needed before performances This patient has performance-only social anxiety disorder. The most appropriate treatment for this condition is a beta-blocker, such as propranolol, taken about an hour before the performance. Beta-blockers are effective at controlling the peripheral autonomic symptoms of anxiety (e.g., tremors, palpitations, sweating) without causing cognitive slowing or sedation, which is crucial for a performing musician. * A) Sertraline daily: An SSRI is a first-line treatment for generalized social anxiety disorder, but it is not ideal for infrequent performance anxiety as it requires daily dosing and takes weeks to become effective. * B) Lorazepam as needed: A benzodiazepine would be effective at reducing anxiety but is generally avoided in this context due to the risk of sedation, cognitive impairment, and ataxia, which could impair musical performance. There is also a risk of dependence. * D) Buspirone daily: Buspirone is used for generalized anxiety disorder and is not effective for acute, situational anxiety.
14. Which of the following psychotherapies would be most appropriate to address her specific interest?
    Answer: Interpersonal psychotherapy Interpersonal psychotherapy (IPT) is an evidence-based, time-limited therapy for depression that focuses on the connection between mood and interpersonal relationships. It helps patients identify and address problems in one of four areas: grief, interpersonal role disputes, role transitions, or interpersonal deficits. Given the patient's specific interest in understanding how her relationships and social roles affect her mood, IPT is an ideal fit. * B) Dialectical behavior therapy (DBT): This is primarily used for borderline personality disorder and focuses on emotional regulation, mindfulness, and distress tolerance. * C) Exposure and response prevention (ERP): This is the first-line treatment for obsessive-compulsive disorder. * D) Psychodynamic psychotherapy: While it also explores relationships, it is typically longer-term and focuses more on unconscious conflicts and early life experiences rather than current interpersonal problems.
15. Which of the following is the most appropriate next step in management?
    Answer: Discontinue lithium and start valproic acid Long-term lithium use can cause chronic kidney disease, specifically chronic tubulointerstitial nephropathy, and nephrogenic diabetes insipidus. A significant and progressive rise in creatinine is a sign of lithium-induced nephrotoxicity. The most appropriate step is to discontinue the offending agent and switch to an alternative mood stabilizer, such as valproic acid or lamotrigine, to prevent further renal damage while maintaining mood stability. * A) Increase the dose of lithium: This would worsen the renal toxicity. * C) Add an ACE inhibitor: While ACE inhibitors are used in some forms of chronic kidney disease, the primary intervention for drug-induced nephropathy is to stop the causative drug. * D) Recheck creatinine in 6 months: This would be an inappropriate delay in management, allowing for further irreversible kidney damage.
16. What is the most likely diagnosis?
    Answer: Major depressive disorder The patient meets the diagnostic criteria for major depressive disorder (MDD). She has experienced at least five depressive symptoms (depressed mood, anhedonia, sleep disturbance, fatigue, weight loss, feelings of worthlessness, decreased concentration) for a period longer than two weeks, causing significant functional impairment. The absence of any history of manic or hypomanic episodes makes MDD the most likely diagnosis. * A) Adjustment disorder with depressed mood: This is diagnosed when emotional or behavioral symptoms develop in response to an identifiable stressor within 3 months of its onset. The symptoms in this vignette are not linked to a specific stressor and have lasted for 6 months, making MDD more likely. * C) Persistent depressive disorder (dysthymia): This is characterized by a chronic depressed mood for at least two years, with fewer and less severe symptoms than MDD. This patient's symptoms are more severe and have a duration of 6 months. * D) Bipolar II disorder: This diagnosis requires at least one hypomanic episode and at least one major depressive episode. The patient explicitly denies any history of elevated or irritable moods.
17. Which of the following is the most likely underlying diagnosis revealed by this presentation?
    Answer: Bipolar disorder The development of a manic or hypomanic episode during antidepressant treatment is a key indicator of an underlying bipolar disorder. Antidepressant monotherapy can precipitate a switch from depression to mania in susceptible individuals. The patient's symptoms of elevated mood, decreased need for sleep, increased talkativeness, and impulsive behavior meet the criteria for a manic or hypomanic episode, unmasking a bipolar diathesis. * A) Serotonin syndrome: This is a life-threatening condition characterized by autonomic instability, altered mental status, and neuromuscular hyperactivity (e.g., hyperreflexia, myoclonus). This patient's symptoms are consistent with a manic switch, not serotonin syndrome. * B) Antidepressant discontinuation syndrome: This occurs upon cessation of an antidepressant and typically involves flu-like symptoms, insomnia, and sensory disturbances. * D) Substance-induced mood disorder: There is no information in the vignette to suggest substance use is causing her symptoms.
18. Which of the following is the most appropriate recommendation?
    Answer: Cognitive-behavioral therapy Cognitive-behavioral therapy (CBT) is the most effective and well-established first-line psychotherapy for panic disorder. CBT for panic disorder typically involves psychoeducation, cognitive restructuring to challenge catastrophic interpretations of physical sensations, and interoceptive exposure to feared bodily sensations to reduce anxiety. * A) Psychoanalytic psychotherapy: This form of therapy focuses on unconscious conflicts and is not considered a first-line, evidence-based treatment for panic disorder. * B) Supportive group therapy: While potentially helpful, it is not as targeted or effective as CBT for the core symptoms of panic disorder. * D) Mindfulness-based stress reduction: While mindfulness can be a useful adjunct, it is not considered the primary, most effective standalone psychotherapy for panic disorder compared to CBT.
19. Which of the following is the most appropriate characterization of this patient's condition?
    Answer: Normal bereavement This patient's symptoms are consistent with a normal grief reaction (bereavement). Although he has some symptoms that overlap with depression (sadness, sleep and appetite changes), key features point away from a major depressive episode. He maintains an interest in activities and social connections, his mood improves with social contact, and he does not have pervasive feelings of worthlessness, hopelessness, or suicidal ideation. His sadness is focused on the loss of his wife. While major depression can occur during bereavement, this patient's presentation is more consistent with a non-pathological grief process. * A) Major depressive disorder: This diagnosis would be considered if the patient had more pervasive anhedonia, feelings of worthlessness, or suicidal ideation that are distinct from feelings of loss. * C) Persistent depressive disorder: This is a chronic condition lasting at least 2 years and would not be diagnosed in this acute context. * D) Adjustment disorder: While bereavement is a stressor, the term 'normal bereavement' is more specific and appropriate when the reaction is non-pathological and consistent with a typical grief response.
20. Which of the following is the most effective and definitive treatment for this patient's condition?
    Answer: Cognitive-behavioral therapy with systematic desensitization The patient has a specific phobia (arachnophobia). The first-line and most effective treatment for specific phobias is cognitive-behavioral therapy (CBT) that utilizes exposure techniques, such as systematic desensitization or flooding. This involves gradual and repeated exposure to the feared object or situation in a controlled setting until the fear response is extinguished. * A) Pharmacotherapy with an SSRI: Medications are not considered first-line treatment for specific phobias and are generally less effective than exposure therapy. * B) Psychoeducation alone: While a component of therapy, simply providing information is insufficient to overcome the deep-seated fear response. * D) Psychoanalytic therapy: This is not an evidence-based treatment for specific phobias and is less effective and efficient than CBT with exposure.

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