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.

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.

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.

Persistent depressive disorder (dysthymia) is characterized by a chronically depressed mood for at least two years in adults. The patient must have two or more additional depressive symptoms (e.g., fatigue, low self-esteem, poor concentration). This patient's long-standing, less severe depressive symptoms that have not met the criteria for a major depressive episode are classic for this diagnosis.

• A) Major depressive disorder: This requires five or more symptoms, including depressed mood or anhedonia, causing significant impairment for at least two weeks. This patient's symptoms are less severe and more chronic.
• B) Cyclothymic disorder: This involves at least two years of fluctuating hypomanic and depressive symptoms that do not meet full criteria for an episode. This patient has no history of hypomanic symptoms.
• D) Adjustment disorder: This is a reaction to a specific stressor and would not typically last for three years.

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.

The patient is exhibiting classic symptoms of a manic episode, including elevated/irritable mood, decreased need for sleep, grandiosity, flight of ideas, and engagement in high-risk behaviors (impulsive spending). A single manic episode is sufficient for the diagnosis of Bipolar I disorder. The symptoms are causing significant functional impairment and require intervention.

• A) Schizophreniform disorder: This diagnosis requires psychotic symptoms like delusions, hallucinations, or disorganized speech for at least one month but less than six months. While grandiosity can be delusional, the primary presentation is a mood disturbance.
• C) Cyclothymic disorder: This involves at least two years of numerous periods with hypomanic and depressive symptoms that do not meet the criteria for a full episode. This patient is experiencing a full manic episode.
• D) Attention-deficit/hyperactivity disorder (ADHD): While ADHD can involve hyperactivity and impulsivity, the symptoms are chronic and developmental, not episodic. The acute onset, decreased need for sleep, and grandiosity are characteristic of mania, not ADHD.

This patient's history is consistent with Bipolar II disorder, which is characterized by at least one hypomanic episode and at least one major depressive episode. Her current state (elevated mood, increased energy, decreased need for sleep, increased productivity for 5 days) meets the criteria for a hypomanic episode, which, by definition, does not cause marked impairment or require hospitalization. She also has a clear history of a major depressive episode.

• A) Bipolar I disorder: This diagnosis requires a history of at least one full manic episode, which involves more severe symptoms and significant functional impairment or hospitalization. This patient's 'up' periods are hypomanic.
• B) Major depressive disorder with anxious distress: This describes MDD with features of anxiety, but does not account for the distinct episodes of elevated mood and energy.
• D) Cyclothymic disorder: This involves chronic (at least 2 years) mood fluctuations with periods of hypomanic and depressive symptoms that do not meet the full criteria for an episode. This patient has experienced a full major depressive episode.

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.

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.

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.