USMLE Step 2 Quiz: Mood And Anxiety Disorders

A 48-year-old man with a history of bipolar I disorder, well-controlled on lithium for the past 5 years, presents for a routine follow-up. He reports his mood has been stable. He has no complaints. As part of his ongoing management, routine laboratory monitoring is performed. His creatinine has increased from 1.0 mg/dL to 1.8 mg/dL over the past year.

Which of the following is the most appropriate next step in management?

A 21-year-old woman presents to the student health center with fatigue and poor concentration for the past 2 months. She feels sad most days and has lost interest in her usual social activities. Her symptoms began shortly after she failed an important examination and was placed on academic probation. She feels overwhelmed and guilty about her academic standing. She is sleeping more than usual but her appetite is unchanged. She denies suicidal ideation.

Which diagnosis best accounts for her symptoms?

A 33-year-old woman with a diagnosis of generalized anxiety disorder (GAD) has not responded to a trial of sertraline. She is now starting cognitive-behavioral therapy (CBT).

Which of the following is a core component of CBT for GAD?

A 68-year-old man presents with his daughter, who is concerned about his mood. For the past 3 months, since the death of his wife of 45 years, he has been sad and tearful. He talks frequently about his wife and looks at old photo albums. He has lost some weight and has trouble sleeping. However, he continues to meet his friends for coffee, enjoys spending time with his grandchildren, and says, 'I miss her terribly, but I know I have to keep going.' He denies feelings of worthlessness, guilt, or suicidal ideation. His mood tends to improve when he is with family.

Which of the following is the most appropriate characterization of this patient's condition?

A 35-year-old man presents with a 3-year history of a depressed mood that is present 'most of the day, more days than not.' He reports chronic fatigue, low self-esteem, and difficulty making decisions, but he has been able to maintain his job and social relationships. He denies any periods of anhedonia or significant weight changes. He has never had a period of elevated mood. His symptoms do not meet the full criteria for a major depressive episode.

What is the most likely diagnosis?

A 45-year-old woman presents to her primary care physician with a 6-month history of feeling 'down' and 'empty.' She reports losing interest in her hobbies, including gardening and reading. She has difficulty falling asleep most nights, feels fatigued throughout the day, and has lost 8 lb (3.6 kg) without trying. She expresses feelings of worthlessness and has trouble concentrating at her job as an accountant. She denies any history of elevated or irritable moods. Her medical history is noncontributory, and she takes no medications. A mental status examination reveals a sad affect and psychomotor slowing. She denies suicidal ideation.

What is the most likely diagnosis?

A 22-year-old man is brought to the emergency department by his roommates. For the past week, he has been sleeping only 2-3 hours per night but reports feeling 'energetic' and 'unstoppable.' He has been talking rapidly and moving from one idea to another, making it difficult for others to follow his conversation. He recently spent his entire student loan disbursement on a sports car and has been making grandiose plans to start a multinational tech company. He is irritable and agitated when his roommates express concern. He has no prior psychiatric history. Urine toxicology is negative.

What is the most likely diagnosis?

A 34-year-old woman presents for evaluation of recurrent mood swings. She reports a 2-month period of depression where she felt hopeless, had low energy, and struggled to get out of bed. She is currently feeling 'better than usual.' For the past 5 days, she has been sleeping 4 hours a night but feels rested. She has been highly productive at work, reorganized her entire home, and feels very confident and talkative. She denies any risky behaviors or significant functional impairment during these 'up' periods. She has never been hospitalized for psychiatric reasons. She reports several similar depressive episodes in the past.

What is the most likely diagnosis?

A 31-year-old man with a new diagnosis of major depressive disorder is being started on pharmacotherapy. He has no other medical conditions and takes no other medications. He expresses concern about potential side effects, particularly sexual dysfunction and weight gain. He would prefer a medication with a favorable side effect profile in these areas.

Which of the following is the most appropriate initial medication for this patient?

A 25-year-old woman presents to her physician after being treated for a first episode of major depression with citalopram for the past 4 weeks. She states, 'The medicine is working too well!' For the past 4 days, she has felt 'on top of the world,' has boundless energy despite sleeping only 3 hours per night, and has been much more talkative and outgoing than usual. She impulsively booked a non-refundable trip to Europe that she cannot afford. Her psychiatrist should now consider which underlying diagnosis?

Which of the following is the most likely underlying diagnosis revealed by this presentation?

A 19-year-old college student reports an intense and persistent fear of giving presentations in class. He worries for weeks in advance, and during presentations, he experiences a racing heart, sweating, and trembling. He fears that he will humiliate himself by saying something foolish or showing his anxiety. Because of this fear, he has dropped two classes that required oral presentations. He is comfortable in one-on-one conversations with friends.

What is the most likely diagnosis?

A 52-year-old man is diagnosed with moderate major depressive disorder. He is started on escitalopram. He returns for follow-up in 6 weeks and reports a significant improvement in his mood, energy, and sleep. He asks how long he should continue taking the medication.

Which of the following is the most appropriate recommendation for the duration of antidepressant therapy?

A 30-year-old musician presents with debilitating anxiety that occurs only when he is scheduled to perform on stage. He feels perfectly fine during rehearsals and in his daily life. However, before a concert, he develops severe tremors, palpitations, and sweating, which interfere with his ability to play his instrument. He is seeking a medication to use only on performance days.

Which of the following is the most appropriate medication for this patient's condition?

A 29-year-old woman is diagnosed with panic disorder. She has a history of substance use disorder and is reluctant to take medications with abuse potential. She expresses interest in a non-pharmacologic treatment. She wants the most effective and evidence-based therapy for her condition.

Which of the following is the most appropriate recommendation?

A 38-year-old man with bipolar I disorder is brought to the clinic by his wife due to a severe depressive episode. He has profound anhedonia, hypersomnia, and suicidal ideation. He is currently maintained on lithium with a therapeutic level. The physician decides to add another medication to treat the acute bipolar depression.

Which of the following medications, when added to lithium, would be the most appropriate treatment for this patient's acute depressive episode?

A 24-year-old woman is being evaluated for depression. She reports a history of several depressive episodes since her late teens. When discussing her history, she mentions a period during her first year of college when she was 'the life of the party,' felt extremely happy, needed very little sleep, and was highly productive, but her friends never expressed concern about her behavior.

To differentiate between unipolar depression and bipolar disorder, which of the following is the most important question to ask regarding that period in college?

A 55-year-old man with a history of hypertension and hyperlipidemia is diagnosed with major depressive disorder. He also complains of neuropathic pain in his feet due to type 2 diabetes. He is seeking a single medication that could potentially help with both his depression and his pain.

Which of the following medications would be the most appropriate choice for this patient?

A 42-year-old woman is diagnosed with major depressive disorder with atypical features. Her symptoms include mood reactivity (mood brightens in response to positive events), hypersomnia, a heavy, leaden feeling in her arms and legs, and significant weight gain. She has not responded to two separate trials of SSRIs.

Which of the following medication classes has historically shown particular efficacy for treatment-resistant depression with atypical features?

A 66-year-old woman with a history of coronary artery disease and a recent myocardial infarction is diagnosed with major depressive disorder. The physician plans to start an antidepressant.

Which of the following antidepressants is considered the safest and best-studied option in patients with recent cardiovascular events?

A 28-year-old man with bipolar I disorder has been successfully maintained on valproic acid. He and his wife are now planning to conceive a child. He asks about the risks of his medication during pregnancy.

Which of the following birth defects is most specifically associated with in utero exposure to valproic acid?