USMLE Step 2 Quiz
Practice Mood And Anxiety Disorders in USMLE Step 2 with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.
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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?
This quiz focuses on Mood And Anxiety Disorders, giving you a quick way to practice the rules, question types, and explanations that matter most for USMLE Step 2.
Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.
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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: 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 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?
Explanation: Valproic acid is a known teratogen and is strongly associated with an increased risk of neural tube defects (e.g., spina bifida) when used during the first trimester of pregnancy. For this reason, women of childbearing potential on valproate should be counseled on effective contraception and folate supplementation, and alternative medications should be considered prior to conception.