USMLE Step 2 Quiz
Practice Psychotic 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 25-year-old woman is brought to the emergency department by her family due to a 2-week history of acute-onset bizarre behavior, disorganized speech, and auditory hallucinations. Her symptoms began shortly after she was unexpectedly fired from her job. Her family reports no prior psychiatric history or substance use. She is oriented to person and place but not time. Her reality testing is poor.
What is the most likely diagnosis?
This quiz focuses on Psychotic 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 25-year-old woman is brought to the emergency department by her family due to a 2-week history of acute-onset bizarre behavior, disorganized speech, and auditory hallucinations. Her symptoms began shortly after she was unexpectedly fired from her job. Her family reports no prior psychiatric history or substance use. She is oriented to person and place but not time. Her reality testing is poor.
What is the most likely diagnosis?
Explanation: The patient's acute onset of psychotic symptoms (hallucinations, disorganized speech) lasting for 2 weeks in the context of a significant psychosocial stressor is characteristic of brief psychotic disorder. By definition, the symptoms last from one day to one month, with an eventual full return to premorbid functioning.
A 55-year-old accountant has the fixed, unshakeable belief that his wife is having an affair. This belief has persisted for over a year, despite his wife's protestations and a lack of any concrete evidence. He has hired private investigators twice, both of whom found no proof of infidelity. Apart from this specific belief and its ramifications (e.g., arguing with his wife), his functioning is unimpaired. He continues to excel at his job and maintains his friendships. He denies any hallucinations, disorganized thoughts, or negative symptoms.
What is the most likely diagnosis?
Explanation: This patient's presentation is classic for delusional disorder. The key features are one or more non-bizarre delusions (in this case, jealous type) that persist for at least one month, without the other psychotic symptoms seen in schizophrenia (e.g., hallucinations, disorganized speech). Crucially, functioning outside the impact of the delusion is not markedly impaired.
A 30-year-old woman with a history of psychosis is evaluated. Over the past year, she has experienced continuous auditory hallucinations and persecutory delusions. During this time, she also had a distinct 3-month period of severe depression with anhedonia, hopelessness, and suicidal ideation. Outside of this depressive episode, her psychotic symptoms have remained present. Her medical history is otherwise unremarkable.
What is the most likely diagnosis?
Explanation: Schizoaffective disorder is diagnosed when a patient meets the criteria for a major mood episode (depressive or manic) that occurs concurrently with the active-phase symptoms of schizophrenia. The key diagnostic feature is the presence of delusions or hallucinations for at least 2 weeks in the absence of a major mood episode during the lifetime duration of the illness. This patient has persistent psychosis with a superimposed major depressive episode, fitting the criteria for schizoaffective disorder.
A 24-year-old man is brought to the emergency department by police for bizarre and aggressive behavior in public. He is extremely agitated and paranoid, believing that insects are crawling under his skin. On physical examination, he is diaphoretic and has dilated pupils. His heart rate is 130/min and his blood pressure is 160/95 mmHg. Numerous excoriations are noted on his arms and face, and he has significant dental erosion and decay.
The patient's psychotic symptoms are most likely caused by intoxication with which of the following substances?
Explanation: This clinical picture is classic for methamphetamine-induced psychosis. Key features include paranoia, agitation, sympathetic hyperactivity (tachycardia, hypertension, mydriasis, diaphoresis), and tactile hallucinations (formication, or the sensation of bugs crawling on the skin). The skin excoriations from picking at these perceived bugs and the poor dental hygiene ('meth mouth') are also highly suggestive.
A 21-year-old man presents to his primary care physician with a 2-month history of new-onset paranoid delusions and auditory hallucinations. He has no prior psychiatric history and this is his first episode of psychosis. He denies any recent trauma or significant stressors. A physical examination, including a neurologic exam, is within normal limits. His vital signs are stable.
In addition to a comprehensive psychiatric history, which of the following is the most important initial step in the diagnostic workup?
Explanation: For any patient presenting with a first episode of psychosis, it is crucial to rule out medical and substance-induced causes. A standard initial workup includes a complete physical and neurologic exam, basic laboratory tests (e.g., CBC, electrolytes, BUN, creatinine, LFTs, TSH), and a urine toxicology screen to rule out substance-induced psychotic disorder. This ensures that a treatable underlying condition is not missed before diagnosing a primary psychotic disorder.
A 34-year-old man with a 10-year history of schizophrenia has had four hospitalizations in the past two years due to psychotic relapses. Each relapse was preceded by him discontinuing his oral olanzapine. During a clinic visit, he acknowledges that he has difficulty remembering to take his medication every day but is willing to consider other options to prevent future hospitalizations. His positive symptoms are currently controlled.
Which of the following interventions would be most effective in reducing this patient's risk of relapse?
Explanation: For patients with schizophrenia who have a history of nonadherence to oral medication, long-acting injectable (LAI) antipsychotics are the most effective strategy for improving adherence and reducing relapse rates. An LAI, such as paliperidone palmitate or aripiprazole lauroxil, is administered every few weeks to months, bypassing the need for daily oral dosing.
A 42-year-old man with chronic schizophrenia is maintained on a stable dose of risperidone. His auditory hallucinations are no longer present, and his paranoid thoughts have resolved. However, he continues to struggle with a profound lack of motivation, inability to experience pleasure, and a blunted affect. These negative symptoms significantly impair his ability to maintain relationships and employment.
Which of the following is the most effective intervention for these persistent symptoms?
Explanation: While antipsychotic medications are effective for the positive symptoms of schizophrenia, they have limited efficacy for negative symptoms (avolition, anhedonia, flat affect, etc.). Evidence-based psychosocial interventions, such as social skills training, supported employment, and cognitive-behavioral therapy for psychosis, are the most effective treatments for improving functional outcomes and addressing persistent negative symptoms.
A 23-year-old man with a first psychotic episode is started on haloperidol in the hospital. On the third day of treatment, he complains of a stiff neck and is observed to have a sustained, painful, upward deviation of his eyes and twisting of his neck to one side. He is in significant distress.
Which of the following is the most appropriate immediate treatment?
Explanation: The patient is experiencing an acute dystonic reaction, a type of extrapyramidal side effect (EPS) common with high-potency first-generation antipsychotics like haloperidol. The symptoms include oculogyric crisis (upward eye deviation) and torticollis (neck twisting). The treatment of choice is an intramuscular injection of an anticholinergic agent like benztropine or an antihistamine with anticholinergic properties like diphenhydramine, which provides rapid relief.
A 58-year-old man with chronic schizophrenia has been treated with risperidone 6 mg/day for the past five years. His wife brings him to the clinic because she has noticed he has become progressively slower, has a tremor in his hands at rest, and walks with a shuffling gait. On examination, you note a masked facies, cogwheel rigidity, and a resting pill-rolling tremor.
Which of the following is the most appropriate management step?
Explanation: The patient is exhibiting signs of drug-induced parkinsonism, a common extrapyramidal side effect of antipsychotics with potent D2 receptor blockade, like risperidone. The symptoms include bradykinesia, rigidity, and tremor. The most appropriate management options are to lower the dose of the antipsychotic, switch to an agent with a lower risk of EPS (e.g., quetiapine), or add an anticholinergic medication like benztropine or amantadine. Adding benztropine is a common and effective initial strategy.
A 65-year-old woman with a 20-year history of schizoaffective disorder, treated for many years with haloperidol, presents for a follow-up visit. Her daughter expresses concern about new, involuntary movements she has been making for the past few months. On examination, the patient exhibits repetitive, choreoathetoid movements of her mouth and tongue, including lip-smacking and facial grimacing. She seems unaware of the movements.
Which of the following is the most appropriate next step in management?
Explanation: This patient is presenting with classic signs of tardive dyskinesia (TD), a potentially irreversible movement disorder caused by long-term exposure to dopamine-blocking agents. Management involves discontinuing the offending agent if possible and switching to an antipsychotic with lower TD risk (like clozapine). If symptoms persist or the antipsychotic cannot be stopped, the treatment of choice is a vesicular monoamine transporter 2 (VMAT2) inhibitor, such as valbenazine or deutetrabenazine.
A 30-year-old man with schizophrenia is brought to the emergency department from his group home due to a sudden change in mental status. He was started on fluphenazine two weeks ago. He is now febrile to 40.1°C (104.2°F), confused, and diaphoretic. His blood pressure is 170/110 mmHg and his pulse is 125/min. On physical examination, he has diffuse, severe 'lead-pipe' rigidity. Laboratory results are notable for a creatine kinase level of 20,000 U/L and leukocytosis.
Which of the following is the most critical initial step in this patient's management?
Explanation: This patient's presentation of fever, autonomic instability (hypertension, tachycardia), altered mental status, and severe muscle rigidity ('lead-pipe') in the setting of recent antipsychotic initiation is classic for Neuroleptic Malignant Syndrome (NMS), a medical emergency. The single most important first step is to discontinue the offending antipsychotic agent. This is followed by aggressive supportive care (IV fluids, cooling blankets) and consideration of specific treatments like dantrolene or bromocriptine.
A 28-year-old woman with schizophrenia has been treated with paliperidone for the past year. She presents to her psychiatrist complaining of amenorrhea for the last 6 months and a milky discharge from her breasts. She is concerned and asks what might be causing these symptoms. A pregnancy test is negative.
Which of the following is the most appropriate next step to evaluate her symptoms?
Explanation: The patient's symptoms of amenorrhea and galactorrhea are highly suggestive of hyperprolactinemia, a common side effect of antipsychotics that are potent dopamine D2 receptor antagonists, such as paliperidone and risperidone. The first step in the workup is to confirm the diagnosis by measuring a serum prolactin level.
A 31-year-old woman with bipolar I disorder was started on lurasidone one month ago. She reports that her mood is stable, but she feels an intense inner restlessness and a compulsion to move. She tells you, "I feel like I'm crawling out of my skin and I can't sit still." During the interview, she is constantly shifting in her seat and tapping her feet.
Which of the following is the most appropriate initial pharmacologic treatment for this patient's symptoms?
Explanation: This patient is describing akathisia, an extrapyramidal side effect characterized by a subjective feeling of inner restlessness and objective signs of repetitive movements. It is a common side effect of many antipsychotics. The first-line treatment for akathisia is to reduce the dose of the offending agent if possible. If not, the most effective pharmacologic treatments are beta-blockers (e.g., propranolol), followed by benzodiazepines or anticholinergics.
A 28-year-old man with a known history of schizophrenia is brought to the emergency department by ambulance for acute agitation. He is pacing, yelling, and appears to be responding to internal stimuli. He is uncooperative with attempts at verbal de-escalation and refuses to take any oral medication. He is perceived as a potential danger to himself and the staff.
Which of the following is the most appropriate next step in management?
Explanation: In an acutely agitated and psychotic patient who is uncooperative with oral medication, the standard of care is rapid tranquilization with an intramuscular antipsychotic. A second-generation antipsychotic like olanzapine or ziprasidone, or a first-generation agent like haloperidol, is effective and appropriate. This allows for rapid control of agitation and psychosis.
A 19-year-old college sophomore is brought to the student health center by her roommate, who is concerned about her behavior over the past 3 months. The patient has been spending most of her time in her room, expressing fears that her classmates are plotting against her. She also reports hearing voices whispering her name. Her academic performance has significantly deteriorated. She denies any illicit drug use or significant mood changes such as depression or mania. Her symptoms have been continuous over the 3-month period.
What is the most likely diagnosis?
Explanation: This patient presents with classic symptoms of psychosis, including delusions and hallucinations, along with a decline in functioning. The key diagnostic feature is the duration of symptoms. Schizophreniform disorder is diagnosed when symptoms last between one and six months. Since her symptoms have been present for 3 months, this is the most fitting diagnosis.
A 78-year-old resident of a nursing home with a history of moderate Alzheimer dementia is brought to the emergency department for evaluation of new-onset agitation and visual hallucinations that began yesterday. The nursing staff reports that he has been more confused than usual, and his level of awareness seems to fluctuate throughout the day. His vital signs are: temperature 38.5°C (101.3°F), blood pressure 100/60 mmHg, heart rate 110/min, and respirations 20/min. A urinalysis is performed.
The patient's acute change in mental status is most likely due to which of the following?
Explanation: This patient's acute onset of altered mental status, fluctuating course, and attentional deficits, superimposed on a chronic dementia, is characteristic of delirium. The presence of fever, tachycardia, and hypotension strongly suggests an underlying medical cause, such as a urinary tract infection or pneumonia. Differentiating primary psychosis from psychosis secondary to a medical condition is crucial.
A 29-year-old man with schizophrenia continues to experience severe, persistent command hallucinations and persecutory delusions despite compliant, therapeutic trials of both oral risperidone and oral aripiprazole over the past three years. His symptoms cause significant distress and functional impairment, including an inability to work or live independently. His psychiatrist is considering a change in medication.
Which of the following is the most appropriate next step in pharmacologic management?
Explanation: This patient has treatment-resistant schizophrenia (TRS), which is defined as a failure to respond to at least two adequate trials of different antipsychotic medications. Clozapine is the only medication with proven efficacy for TRS and is the standard of care in this situation.
A 22-year-old man is brought to the clinic by his parents due to an 8-month history of behavioral changes. His parents report that he has become increasingly socially withdrawn, his grades in college have declined precipitously, and he has developed odd beliefs, such as thinking that television news anchors are sending him secret messages. The patient states he hears voices that provide a running commentary on his actions. On mental status examination, he has a flat affect and his speech is tangential and difficult to follow. He has no history of substance use, and a urine toxicology screen is negative. Physical examination and basic laboratory studies are unremarkable.
What is the most likely diagnosis?
Explanation: The patient's presentation of positive symptoms (delusions, auditory hallucinations), negative symptoms (flat affect, social withdrawal), and disorganized thought/speech, coupled with a significant decline in functioning for a duration of 8 months, meets the DSM-5 criteria for schizophrenia. The symptoms must be present for at least 6 months for this diagnosis.
A 40-year-old man with schizoaffective disorder has been treated with olanzapine for the past two years. His psychiatric symptoms are well-controlled. During a routine follow-up, his weight is noted to have increased by 15 kg (33 lbs) since starting the medication, and his BMI is now 32 kg/m². His blood pressure is 145/90 mmHg.
Which of the following screening tests is most important to perform at this time?
Explanation: Second-generation antipsychotics, particularly olanzapine and clozapine, are associated with a high risk of metabolic syndrome, which includes weight gain, dyslipidemia, hyperglycemia, and hypertension. Given this patient's significant weight gain and elevated blood pressure, it is essential to screen for the other components of metabolic syndrome by checking a fasting lipid panel and a hemoglobin A1c (or fasting glucose).
A 35-year-old woman with treatment-resistant schizoaffective disorder is initiated on clozapine. Her psychiatrist explains that this medication requires a special monitoring program due to a potentially life-threatening side effect.
Which of the following adverse effects necessitates weekly blood monitoring for the first six months of clozapine therapy?
Explanation: Clozapine carries a risk of severe neutropenia, including agranulocytosis, which can be fatal. Due to this risk, patients taking clozapine must be enrolled in a Risk Evaluation and Mitigation Strategy (REMS) program that requires regular monitoring of the absolute neutrophil count (ANC). Monitoring is weekly for the first 6 months, then bi-weekly for the next 6 months, and monthly thereafter.