USMLE Step 3 Quiz
Practice Chronic Psychiatric Disease Management in USMLE Step 3 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 combat veteran has been treated for post-traumatic stress disorder (PTSD) for the past 18 months. He completed a full course of Cognitive Processing Therapy (CPT) and has been maintained on sertraline 150 mg daily. For the past year, he has had minimal PTSD symptoms, is working full-time, and has re-engaged with his family. He asks how much longer he needs to take the sertraline.
What is the most appropriate recommendation regarding the duration of his pharmacotherapy?
This quiz focuses on Chronic Psychiatric Disease Management, giving you a quick way to practice the rules, question types, and explanations that matter most for USMLE Step 3.
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 combat veteran has been treated for post-traumatic stress disorder (PTSD) for the past 18 months. He completed a full course of Cognitive Processing Therapy (CPT) and has been maintained on sertraline 150 mg daily. For the past year, he has had minimal PTSD symptoms, is working full-time, and has re-engaged with his family. He asks how much longer he needs to take the sertraline.
What is the most appropriate recommendation regarding the duration of his pharmacotherapy?
Explanation: When you encounter PTSD medication management questions, focus on the evidence-based guidelines for maintenance therapy duration, especially in patients who've achieved stability through combined treatment approaches. This veteran represents an ideal treatment response - he's completed evidence-based psychotherapy (CPT), achieved symptom remission on sertraline, and maintained functional recovery for a full year. Current PTSD treatment guidelines recommend continuing effective pharmacotherapy for at least 12 months after achieving symptom stability before considering discontinuation. This approach minimizes relapse risk while the patient consolidates therapeutic gains. Option D is correct because it follows established guidelines: maintain stable patients on effective medication for at least 12 months post-stabilization before attempting a gradual taper. This patient has been stable for one year, so continuing for "at least another 12 months" ensures adequate consolidation time. Option A is overly conservative - indefinite treatment isn't necessary for all PTSD patients, especially those with good psychotherapy response and stable remission. Option B ignores the synergistic relationship between psychotherapy and pharmacotherapy; completing CPT doesn't eliminate the need for continued medication stabilization. Option C proposes premature discontinuation with inadequate tapering time - stopping effective PTSD medication after only one year of stability significantly increases relapse risk, and 2-4 weeks is too rapid for safe sertraline discontinuation. Remember: PTSD medication decisions should balance relapse prevention with treatment burden. Stable patients need at least 12 months of continued pharmacotherapy before considering discontinuation, regardless of psychotherapy completion.
A 28-year-old man with a 7-year history of schizophrenia, paranoid type, is brought to the clinic by his case manager due to concerns about medication nonadherence. The patient has been hospitalized twice in the past year for psychotic relapses after discontinuing his oral risperidone. He agrees to transition to a long-acting injectable (LAI) formulation. The physician decides to start risperidone microspheres for intramuscular injection, which is administered every 2 weeks.
Which of the following is the most appropriate management plan regarding his antipsychotic medication during the transition period?
Explanation: The correct answer is C. Risperidone long-acting injectable microspheres (Risperdal Consta) has a delayed onset of action, as the medication is slowly released from the microspheres. Therapeutic plasma concentrations are not reached for approximately 3 weeks after the initial injection. Therefore, oral antipsychotic supplementation (in this case, the patient's current oral risperidone) must be continued for the first 3 weeks to ensure continuous therapeutic coverage and prevent relapse.
A 34-year-old man is being treated for his third lifetime episode of major depressive disorder. He has been taking sertraline 200 mg daily for the past 10 weeks. He reports some improvement in his energy and appetite but continues to feel significant anhedonia, low mood, and feelings of worthlessness. His PHQ-9 score has decreased from 22 to 15. He has no history of mania or psychosis.
Which of the following is the most appropriate next step in managing this patient's depression?
Explanation: The correct answer is B. This patient has had a partial response to an adequate trial (sufficient dose and duration) of an SSRI. In cases of partial response, augmentation is often more effective than switching to another agent within the same class. Atypical antipsychotics like aripiprazole, quetiapine, and brexpiprazole are FDA-approved and evidence-based augmentation agents for major depressive disorder. Switching to another SSRI (A) is a reasonable strategy but generally reserved for non-response or intolerance. Increasing sertraline beyond its maximum recommended dose of 200 mg (C) is not evidence-based and increases the risk of side effects. Adding a benzodiazepine (D) does not target core depressive symptoms and is inappropriate for long-term management.
A 31-year-old woman with bipolar II disorder and a history of severe depressive episodes is being started on lamotrigine for maintenance therapy. She is currently taking valproic acid 500 mg twice daily, which has been helpful for hypomania but not for her depression. The physician plans to cross-taper the medications.
Which of the following is the most appropriate initial dosing and titration schedule for lamotrigine in this patient?
Explanation: The correct answer is B. Valproic acid significantly inhibits the metabolism of lamotrigine, more than doubling its serum concentration. To reduce the risk of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN), a much slower titration schedule is required when lamotrigine is co-administered with valproate. The recommended starting dose is 25 mg every other day for two weeks. The standard titration (A) is for lamotrigine monotherapy. A faster titration (C, D) would be used with an enzyme-inducing medication (like carbamazepine) but would be extremely dangerous in this patient taking valproate, markedly increasing the risk of a life-threatening rash.
A 76-year-old woman with generalized anxiety disorder and osteoarthritis has been taking lorazepam 1 mg three times daily for the past 8 years. Her primary care physician is concerned about the risks of long-term benzodiazepine use, including cognitive impairment and falls, and the patient agrees to attempt discontinuation. She has tried to stop on her own in the past but experienced severe anxiety and insomnia.
What is the most appropriate strategy for discontinuing lorazepam in this patient?
Explanation: The correct answer is B. Long-term, high-dose benzodiazepine use requires a very slow taper to minimize withdrawal symptoms. A direct taper of a short-acting agent like lorazepam can be difficult due to significant inter-dose rebound anxiety. The preferred method is to switch the patient to an equivalent dose of a long-acting benzodiazepine, such as diazepam or clonazepam. The long half-life of these agents provides a smoother, more gradual decline in blood levels, making the taper more tolerable. A 25% per week taper (A) is too rapid for long-term use. Abrupt cessation (C) can cause severe, life-threatening withdrawal. Switching to another short-acting agent like alprazolam (D) would not facilitate the taper.
A 42-year-old man with opioid use disorder is stable on sublingual buprenorphine/naloxone 16 mg/4 mg daily. He is scheduled for an elective cholecystectomy in two weeks. His surgeon calls you, his primary care physician, to ask for guidance on managing his buprenorphine around the time of the procedure to ensure adequate postoperative pain control.
Which of the following is the most appropriate recommendation for this patient's perioperative management?
Explanation: The correct answer is C. Management of buprenorphine in the perioperative period requires careful coordination. Buprenorphine is a partial mu-opioid agonist with high receptor affinity, which can interfere with the efficacy of full agonist opioids used for analgesia. While continuing it (A) is one strategy ('continue and override'), a common and effective approach involves holding the buprenorphine for a short period (24-72 hours) before surgery to allow full agonists to work. This must be paired with a robust multimodal pain plan (e.g., regional anesthesia, NSAIDs, acetaminophen) and close monitoring. Stopping it for a prolonged period (B) dramatically increases the risk of withdrawal and relapse. Transitioning to methadone (D) is a complex process not indicated for routine elective surgery.
A 24-year-old man with schizoaffective disorder has been treated with olanzapine 20 mg daily for the past 18 months. His psychotic and mood symptoms are well-controlled. At his annual physical exam, his BMI is 34 kg/m², up from 27 kg/m² at the start of treatment. Laboratory studies show a fasting glucose of 135 mg/dL and a triglyceride level of 250 mg/dL. He has been receiving lifestyle counseling with minimal effect.
Which of the following is the most appropriate change to his medication regimen?
Explanation: The correct answer is C. Olanzapine is associated with a high risk of metabolic side effects, including significant weight gain, hyperglycemia, and dyslipidemia. This patient has developed iatrogenic metabolic syndrome. While metformin (A) can be a helpful adjunct, the primary intervention should be to address the offending agent. The most appropriate step is to switch the patient to an antipsychotic with a lower metabolic risk profile, such as ziprasidone, aripiprazole, or lurasidone. Increasing the olanzapine dose (B) would likely worsen the metabolic issues. Bariatric surgery (D) is a significant intervention that may be considered later, but a medication change should be attempted first.
A 26-year-old woman with a long-standing diagnosis of borderline personality disorder calls her primary care clinic in tears. She states that her partner made a comment about her being 'too sensitive,' and she is now experiencing intense suicidal ideation. She demands an 'emergency prescription' for an antianxiety medication and says she will cut herself if she doesn't get it. She has a crisis plan in place with her therapist that she has used before.
Which of the following is the most appropriate immediate response by the physician?
Explanation: The correct answer is C. The cornerstone of managing borderline personality disorder (BPD) is skills-based psychotherapy (like DBT). A key principle is to avoid reinforcing maladaptive behaviors (e.g., threats of self-harm to obtain medication). The most appropriate response is to validate the patient's emotional pain while simultaneously empowering her to use her previously learned coping skills and crisis plan. Prescribing a benzodiazepine (A) can be dangerous, reinforce dysfunctional behavior, and increase disinhibition. While an ED visit (B) may become necessary if she cannot ensure her safety, the first step is to encourage the use of her established plan. Reactive medication changes (D) are generally ineffective for BPD traits and can destabilize the treatment frame.
A 28-year-old woman with a history of bipolar I disorder, characterized by severe manic episodes with psychosis, is stable on valproic acid 1000 mg daily. Her mood has been euthymic for three years. She and her husband now wish to conceive a child. She is seeking preconception counseling.
What is the most appropriate recommendation regarding her mood stabilizer?
Explanation: When you encounter preconception counseling questions involving psychiatric medications, you need to balance maternal mental health stability against teratogenic risks while considering safer alternatives. Valproic acid poses significant teratogenic risks, including neural tube defects (1-2% risk), facial dysmorphism, and cognitive impairment in exposed children. For a woman planning pregnancy, continuing valproic acid is inappropriate despite her current stability. The goal is transitioning to a safer mood stabilizer before conception while maintaining psychiatric stability. Lamotrigine represents the safest mood stabilizer option during pregnancy, with minimal teratogenic risk and effectiveness for bipolar disorder maintenance. A gradual cross-taper allows for smooth transition while monitoring for mood destabilization, making option D correct. Option A is dangerous because while folic acid reduces neural tube defect risk, it doesn't eliminate valproic acid's other teratogenic effects, and continuing this high-risk medication is unjustifiable when safer alternatives exist. Option B fails to recognize that untreated bipolar disorder during pregnancy carries substantial risks including poor prenatal care, substance abuse, and postpartum psychosis. Abrupt discontinuation also risks severe mood episodes. Option C contains a critical misconception - lithium does carry fetal risks, particularly Ebstein's anomaly (though the risk is lower than previously thought, around 0.05-0.1%). While lithium might be considered, lamotrigine remains the preferred first-line option. Remember: In psychiatric preconception counseling, never choose "stop everything" or continue high-risk medications. Look for the safest effective alternative with proper transition planning.
A 25-year-old graduate student with obsessive-compulsive disorder has been treated with fluoxetine for the past 16 weeks. The dose was gradually increased and has been at 80 mg daily for the past 8 weeks. He has also been engaged in weekly exposure and response prevention (ERP) therapy. Despite these interventions, he continues to spend 3-4 hours per day on compulsive rituals and experiences significant distress. His symptoms remain severe.
Which of the following is the most appropriate next pharmacologic step?
Explanation: The correct answer is B. This patient has treatment-resistant OCD, defined as a failure to respond to an adequate trial of a first-line agent (an SSRI at maximum tolerated dose for at least 8-12 weeks) plus ERP. The most evidence-based next step is to augment the SSRI with an atypical antipsychotic, such as risperidone or aripiprazole. Switching to clomipramine (A), a tricyclic antidepressant, is another option, but augmentation is often preferred to preserve the partial response from the SSRI. Increasing the fluoxetine dose beyond the typical maximum (C) is not evidence-based. Augmentation with buspirone (D) has limited evidence for OCD.
A 52-year-old man with bipolar I disorder is maintained on lithium 900 mg daily with a therapeutic serum level of 0.9 mEq/L. He has been euthymic for over a year. He presents to his primary care physician with a 6-week history of worsening fatigue, anhedonia, hypersomnia, and a 10-lb weight gain. He denies mood elevation, increased energy, or racing thoughts. He has a PHQ-9 score of 18, indicating moderate-to-severe depression.
Which of the following is the most appropriate addition to his lithium regimen?
Explanation: The correct answer is B. The patient is experiencing a breakthrough depressive episode despite being on maintenance lithium. The primary concern in treating bipolar depression is to avoid inducing mania or rapid cycling. Antidepressant monotherapy (A, C) carries a significant risk of this switch and is generally avoided. The evidence-based approach is to add a medication with proven efficacy for bipolar depression. Lurasidone is an atypical antipsychotic that is FDA-approved for this indication. Other options include quetiapine, olanzapine-fluoxetine combination, or cariprazine. Adding another mood stabilizer like valproic acid (D) is an option for prophylaxis but is not a first-line acute treatment for bipolar depression.
A 49-year-old man with a history of severe alcohol use disorder recently completed a 7-day inpatient detoxification. He is highly motivated to remain abstinent and is starting an intensive outpatient program. He has a history of opioid use but has not used opioids in over a year. His liver function tests show AST 65 U/L and ALT 70 U/L (ULN < 40). He has no signs of cirrhosis or hepatic decompensation.
Which of the following medications is most appropriate to offer this patient to help prevent relapse?
Explanation: The correct answer is A. Naltrexone is a first-line, FDA-approved medication for the treatment of alcohol use disorder. It is an opioid antagonist that reduces heavy drinking and cravings. It is contraindicated in patients with acute hepatitis or liver failure, but mild elevations in transaminases, as seen in this patient, are not an absolute contraindication, though monitoring is required. Disulfiram (B) is less effective due to adherence issues and carries risks. Acamprosate (C) is also a first-line option, but naltrexone is particularly effective for patients with high cravings. Chlordiazepoxide (D) is a benzodiazepine used for managing acute alcohol withdrawal, not for long-term relapse prevention.
A 30-year-old woman presents for long-term psychiatric care. Her history is notable for recurrent episodes of major depression, two episodes of euphoric mood with grandiosity and decreased need for sleep lasting 2-3 weeks, and persistent auditory hallucinations that are present both during and between her mood episodes. Her symptoms are currently stable. Her diagnosis is schizoaffective disorder, bipolar type.
Which of the following would be the most appropriate long-term maintenance monotherapy for this patient?
Explanation: When you encounter schizoaffective disorder questions, remember this condition requires treatment for both psychotic symptoms (hallucinations/delusions) and mood episodes. The key is that psychotic symptoms persist even when mood is stable, distinguishing it from mood disorders with psychotic features. For schizoaffective disorder, bipolar type, you need a medication that addresses three components: acute mood stabilization, mood episode prevention, and ongoing psychotic symptoms. Paliperidone (A) is an atypical antipsychotic with demonstrated efficacy for all three aspects. It effectively treats psychotic symptoms while also providing mood stabilization, making it an excellent monotherapy choice for long-term maintenance. Sertraline (B) is an SSRI antidepressant that would address depressive episodes but provides no antipsychotic effect for her persistent hallucinations. Additionally, using an antidepressant alone in bipolar disorder risks triggering manic episodes. Lithium (C) is a classic mood stabilizer excellent for bipolar disorder, particularly manic episode prevention, but it lacks antipsychotic properties. Her persistent auditory hallucinations would remain untreated. Lamotrigine (D) is primarily effective for bipolar depression prevention and offers minimal benefit for manic episodes or psychotic symptoms. It wouldn't address her euphoric episodes or hallucinations adequately. Study tip: For schizoaffective disorder questions, always look for treatments that address both psychotic and mood symptoms simultaneously. Atypical antipsychotics are often the best monotherapy choice because they provide broader symptom coverage than mood stabilizers or antidepressants alone.
A 32-year-old man with panic disorder has been successfully treated with paroxetine 40 mg daily and cognitive-behavioral therapy. He has been free of panic attacks and has had only minimal anticipatory anxiety for the past 15 months. He feels he has 'mastered' his anxiety and would like to try stopping his medication.
Which of the following is the most appropriate counseling to provide this patient?
Explanation: When managing panic disorder treatment discontinuation, you must balance the patient's desire for independence with evidence-based tapering practices to prevent relapse and withdrawal symptoms. The correct approach is option A - recommending a very gradual taper over 2-4 months. SSRIs like paroxetine have short half-lives and are particularly associated with discontinuation syndrome, which can include dizziness, flu-like symptoms, and "brain zaps." More importantly, panic disorder has high relapse rates with abrupt medication cessation, even in patients who've been stable. A slow taper allows monitoring for symptom recurrence while minimizing withdrawal effects. Since this patient has strong CBT skills, gradual discontinuation is reasonable to attempt. Option B is too rigid - while panic disorder often requires long-term treatment, indefinite therapy isn't automatically necessary for every patient, especially those with good CBT response and prolonged stability. Option C represents dangerous advice, as immediate cessation risks both withdrawal syndrome and panic symptom recurrence without warning. The one-year stability period, while encouraging, doesn't guarantee sustained remission off medication. Option D suggests replacing a proven treatment with PRN benzodiazepines, which is inappropriate for panic disorder maintenance and risks creating dependence while providing inadequate prophylaxis. Remember for Step 3: Medication discontinuation questions often test your knowledge of tapering schedules and relapse prevention. Always favor gradual approaches for psychiatric medications, especially SSRIs and particularly paroxetine, which has the highest discontinuation syndrome risk among this drug class.
An 82-year-old woman with a history of recurrent major depression, hypertension, type 2 diabetes, and osteoporosis is brought to your office by her daughter due to a 2-month decline in mood, appetite, and energy. She has a history of falls, with a hip fracture 2 years ago. She was previously stable on citalopram, but it was stopped a year ago. Her daughter is requesting to restart an antidepressant.
Which of the following is the most appropriate pharmacologic agent to initiate in this patient?
Explanation: When treating depression in elderly patients, you need to consider both efficacy and safety, particularly focusing on side effects that could worsen existing comorbidities like falls risk, cardiovascular disease, and diabetes. Sertraline (A) is the best choice here because it's a selective serotonin reuptake inhibitor (SSRI) with minimal drug interactions, low anticholinergic effects, and minimal impact on cardiac conduction. It has a favorable side effect profile in the elderly and doesn't significantly affect blood glucose or increase fall risk through sedation or orthostatic hypotension. Paroxetine (B) is problematic because it has the highest anticholinergic activity among SSRIs, which can cause confusion, constipation, urinary retention, and dry mouth in elderly patients. It also has significant drug interactions and can worsen cognitive function. Amitriptyline (C) is a tricyclic antidepressant that's particularly dangerous in the elderly due to strong anticholinergic effects, sedation, orthostatic hypotension, and cardiac conduction abnormalities. Given this patient's fall history and multiple comorbidities, amitriptyline could significantly increase her fall risk and worsen her diabetes management. Mirtazapine (D) causes significant sedation and weight gain, both problematic for this patient. The sedation increases fall risk, while weight gain can worsen diabetes control and mobility issues. Study tip: For elderly depression questions on USMLE Step 3, remember "start low, go slow" with medications that have minimal anticholinergic effects, low fall risk, and few drug interactions. Sertraline and citalopram are typically the safest SSRI choices in geriatric patients.
A 33-year-old man with schizophrenia has been hospitalized for a severe psychotic exacerbation. His past records indicate he was treated for 12 weeks with risperidone up to 8 mg/day with no improvement in his auditory hallucinations or paranoid delusions. Following that, he was switched to aripiprazole 30 mg/day for 16 weeks, again with minimal response. He has no history of substance use or neurologic conditions. He has been adherent to these medication trials.
Which of the following is the most appropriate medication to initiate during this hospitalization?
Explanation: When you encounter a schizophrenia case describing failed trials with multiple antipsychotics, you're likely dealing with treatment-resistant schizophrenia (TRS). The key diagnostic criteria for TRS are: failure to respond to at least two adequate trials of different antipsychotics, each lasting 4-6 weeks at therapeutic doses, with continued psychotic symptoms. This patient clearly meets TRS criteria with failed 12-week risperidone and 16-week aripiprazole trials at appropriate doses, demonstrating persistent auditory hallucinations and paranoid delusions. Clozapine (D) is the gold standard for TRS and the only FDA-approved medication specifically for this indication. It's uniquely effective because it blocks multiple neurotransmitter receptors beyond just dopamine, including serotonin and norepinephrine pathways. Olanzapine (A) is another second-generation antipsychotic, but switching to yet another conventional antipsychotic after two failures rarely provides benefit. Haloperidol (B) is a first-generation antipsychotic that's actually less likely to work than the second-generation agents already tried, plus carries higher risk of extrapyramidal side effects. Ziprasidone (C) is another second-generation antipsychotic with no special indication for treatment-resistant cases. While clozapine requires careful monitoring for potentially serious side effects like agranulocytosis (weekly blood draws initially), neutropenia, and myocarditis, its superior efficacy in TRS makes it the clear choice when other antipsychotics have failed. Study tip: Remember the "rule of twos" for TRS—two failed trials of different antipsychotics automatically points to clozapine as the next step.
A 45-year-old woman with bipolar I disorder has been maintained on lithium carbonate 450 mg twice daily for the past 5 years. Her mood has been stable with no manic or depressive episodes in over 2 years. She presents for a routine follow-up appointment. Her last lithium level, checked 3 months ago, was 0.8 mEq/L. She has no new complaints.
In addition to a basic metabolic panel and lithium level, which of the following tests is most important to obtain as part of her routine annual monitoring?
Explanation: The correct answer is C. Long-term lithium therapy can cause hypothyroidism in up to one-third of patients, and it can also affect parathyroid function (hyperparathyroidism and hypercalcemia) and renal function (nephrogenic diabetes insipidus, chronic kidney disease). Therefore, routine annual monitoring for a stable patient on chronic lithium therapy should include a TSH level, as well as a basic metabolic panel (to assess renal function and electrolytes) and a lithium level. Liver function tests are necessary for valproate, an ECG may be needed at baseline or with signs of toxicity but not typically annually unless indicated, and a CBC is for carbamazepine.
A 29-year-old woman with recurrent major depressive disorder has been in remission for 9 months on escitalopram 20 mg daily. She reports that her mood is excellent, but she is very distressed by anorgasmia, which began shortly after starting the medication. She states this is causing significant strain in her relationship. She is hesitant to change medications because this is the first one that has worked for her.
Which of the following is the most appropriate next step in management?
Explanation: The correct answer is C. SSRI-induced sexual dysfunction is a common and distressing side effect. For a patient who has responded well to the SSRI and wishes to continue it, augmentation with bupropion is a first-line strategy. Bupropion is a norepinephrine-dopamine reuptake inhibitor that often improves sexual function and can also augment the antidepressant effect. Reassurance (A) is inappropriate as the side effect has persisted for 9 months. Switching to venlafaxine (an SNRI) (B) is unlikely to help, as SNRIs also have high rates of sexual dysfunction. Drug holidays (D) are not recommended for antidepressants with intermediate half-lives like escitalopram and can lead to withdrawal symptoms or breakthrough depression.
A 38-year-old software engineer has been treated for ADHD since college with mixed amphetamine salts, extended-release, 20 mg daily. This has been effective for his inattentive symptoms. At his annual physical, his blood pressure is 150/95 mmHg on multiple readings. He also reports increased anxiety and trouble sleeping. He has no other medical problems and a BMI of 23 kg/m².
Which of the following is the most appropriate next step in managing his ADHD and new-onset symptoms?
Explanation: The correct answer is D. Stimulant medications are known to increase blood pressure, heart rate, anxiety, and insomnia. This patient's new-onset hypertension and anxiety are likely side effects of his long-term stimulant use. The most appropriate step is to address the root cause by switching to a non-stimulant medication for ADHD, such as atomoxetine, viloxazine, or guanfacine/clonidine ER. Simply treating the side effects with other medications (A, B) leads to polypharmacy and does not address the underlying iatrogenic issue. While lifestyle changes (C) are important, the degree of hypertension requires a medication adjustment.
A 62-year-old man with a 30-year history of schizophrenia is managed with haloperidol decanoate injections every 4 weeks. During a routine follow-up, his nurse practitioner notes new, repetitive, involuntary puckering movements of his lips and frequent tongue protrusions. The patient seems unaware of these movements. His psychiatric symptoms are otherwise well-controlled.
Which of the following is the most appropriate next step in management?
Explanation: The correct answer is C. The patient is exhibiting classic signs of tardive dyskinesia (TD), a potentially irreversible hyperkinetic movement disorder caused by long-term exposure to dopamine receptor antagonists. The first steps in management are to reduce the dose of the offending agent or switch to a lower-risk antipsychotic (e.g., a second-generation agent like clozapine or quetiapine) if possible. Additionally, VMAT2 inhibitors like valbenazine or deutetrabenazine are approved for the treatment of TD. Administering an anticholinergic agent like benztropine (A, B) is the treatment for acute dystonia or parkinsonism, but it can worsen TD. The movements are not benign (D) and can be socially stigmatizing and physically uncomfortable.