A 42-year-old man comes to his outpatient psychiatrist with complaints of a

depressed mood, which he states is identical to depressions he has

experiencedpreviously. He was diagnosed with major depression for the first time 20
years ago. At that time, he was treated with imipramine, up to 150 mg/d, with
goodresults. During a second episode, which occurred 15 years ago, he was treated
with imipramine, and once again his symptoms remitted after 4 to 6 weeks. He
denies illicit drug use or any recent traumatic events. The man states that although
he is sure he is experiencing another major depression, he would like to avoid
imipramine this time because it produced unacceptable side effects such as dry
mouth, dry eyes, and constipation. What is the best therapy? What are the side
effects of the proposed therapy?
A 21-year-old man is brought to the emergency department by the police after
hewas found sitting in the middle of traffic on a busy street. By way of
explanation,the patient states, The voices told me to do it. The patient says that
for the past year he has felt that people are not who they say they are. He began
to isolate himself in his room and dropped out of school. He claims that he hears
voices telling him to do bad things. There are often two or three voices talking,
and they often comment to each other on his behavior. He denies that he currently
uses drugs or alcohol, although he reports that he occasionally smoked marijuana in
the past. He says that he has discontinued this practice over the past 6 months
because he can no longer afford it, and claims that marijuana helped with the
voices. He denies any medical problems and is taking no medication. On a mental
status examination, the patient is noted to be dirty and disheveled, with poor
hygiene. He appears somewhat nervous in his surroundings and paces around the
examination room, always with his back to a wall. He states that his mood is okay.
His affect is congruent, although flat. His speech is of normal rate, rhythm, and
tone. His thought processes are tangential, and loose associations are occasionally
noted. His thought content is positive for delusions and auditory hallucinations. He
denies any suicidal or homicidal ideation. What is the most likely diagnosis for this
patient? What conditions are important to rule out before a diagnosis can be
made? Should this patient be hospitalized?
A 36-year-old woman presents to the emergency department with a chief complaint
of I think Im going crazy. She states that for the past 3 months, she has been
experiencing abrupt episodes of palpitations, sweating, trembling, shortness of
breath, chest pain, dizziness, and feeling as if she is going to die. The first time this
happened she was walking down the street, not thinking about anything in
particular. The episode lasted approximately 15 minutes, although the patient felt
as if it lasted much longer. Since that time she has had similar episodes once or
twice a day that have occurred unexpectedly in different situations. As a result she
finds herself worrying nearly continuously regarding when she will have another
attack. She denies having any other symptoms. She has been to the emergency
department twice in the past 2 weeks, convinced that she is having a heart attack.

However, the results of all her physical and laboratory examinations have been
unremarkable. She denies drug use and drinks alcohol only occasionally. Her
alcohol intake has decreased since the episodes began. Her only medical problem is
a 1-year history of hypothyroidism for which she takes levothyroxine (Synthroid).
What is the differential diagnosis? What is the next diagnostic step?
A 55-year-old woman presents to a psychiatrist with complaints of a depressed
mood for the past 3 months. She notes that her mood has been consistentlylow,
and she describes her recent state as just not me. She has also noticed a
decrease in energy and a weight gain of 6 to 7 lb occurring over the same period of
time, although her appetite has not increased. She has never visited a psychiatrist
before and does not remember ever feeling this depressed for this long before. She
denies any medical problems and takes no medications. Her family history is
positive for schizophrenia in one maternal aunt. On a mental status examination the
patient appears depressed and tired, although she has a normal range of affect. Her
speech is somewhat slowed but otherwise unremarkable. Her thought processes are
linear and logical. She is not suicidal or homicidal and does not report hallucinations
or delusions. Her cognition is grossly intact. Her judgment and impulse control are
not impaired. Her physical examination reveals a blood pressure of 110/70 mm Hg
and a temperature of 98F (36.7C). Her thyroid gland is diffusely enlarged but not
painful. Her heart has a regular rate and rhythm. She has coarse, brittle hair but no
rashes. What is the most likely diagnosis? What is the next diagnostic step