16 Clinical Cases in Psychiatry & Behavioral Medicine
✨ By Didactic Med ✨
A 34-year-old woman presents with 6 weeks of persistent sadness, loss of interest in activities she previously enjoyed, difficulty sleeping (waking at 3 AM unable to return to sleep), decreased appetite with 10-lb weight loss, fatigue, difficulty concentrating at work, and feelings of worthlessness. She denies suicidal ideation but states she "wouldn't mind if she didn't wake up." She has withdrawn from friends and family.
Appears tired, psychomotor retardation present. Affect flat with constricted range. Speech soft and slow. Denies hallucinations or delusions. PHQ-9 score: 21 (severe).
SSRIs are first-line treatment for Major Depressive Disorder per APA and NICE guidelines due to their favorable safety profile, tolerability, and efficacy. Sertraline specifically has good evidence for depression and anxiety comorbidity.
DSM-5 Criteria: ≥5 symptoms for ≥2 weeks including depressed mood OR anhedonia. APA 2023: SSRIs/SNRIs first-line. Consider CBT adjunctively. Treatment for 4-9 months after remission. Passive suicidal ideation requires safety planning.
A 28-year-old software engineer presents with 8 months of "constant worrying" about work performance, finances, health, and relationships. He reports muscle tension, restlessness, difficulty falling asleep, irritability, and poor concentration. The worrying is difficult to control and occurs more days than not. He denies panic attacks, specific phobias, or traumatic events. Caffeine intake is high (6 cups/day).
Alert, appears tense, fidgeting throughout interview. Speech normal rate. Mood "anxious." Thought process linear but ruminative. GAD-7 score: 16 (severe anxiety). No suicidal ideation.
SSRIs (escitalopram, sertraline) and SNRIs (duloxetine, venlafaxine) are first-line pharmacotherapy for GAD. Benzodiazepines are reserved for short-term use or acute exacerbations due to dependence risk. Buspirone is an alternative but often less effective as monotherapy.
DSM-5: Excessive anxiety/worry for ≥6 months + ≥3 somatic symptoms. APA/CANMAT 2023: SSRIs/SNRIs first-line. CBT equally effective. Address modifiable factors (caffeine, sleep hygiene). Response typically 4-6 weeks.
A 22-year-old male college student is brought by his parents after a 4-month decline. He believes the FBI is monitoring him through his phone and TV. He hears voices commenting on his actions and occasionally commanding him. He has become socially withdrawn, stopped attending classes, neglects hygiene, and his speech is tangential. There is no substance use. Family history: schizophrenia in paternal uncle.
Poor hygiene, guarded. Flat affect. Speech disorganized with loose associations. Paranoid delusions present. Auditory hallucinations (command type). Insight poor. Judgment impaired.
Second-generation antipsychotics (SGAs) like risperidone, olanzapine, or aripiprazole are first-line due to lower risk of extrapyramidal symptoms and tardive dyskinesia compared to FGAs. Clozapine is reserved for treatment-resistant cases (failed ≥2 adequate antipsychotic trials).
DSM-5: ≥2 symptoms (delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, negative symptoms) for ≥1 month; continuous disturbance ≥6 months. APA 2024: SGAs preferred first-line. LAI formulations reduce relapse. Monitor metabolic parameters.
A 29-year-old woman is brought to the ED by police after being found directing traffic at 3 AM. She has slept only 2 hours/night for the past week, spent $15,000 on a "business venture," speaks rapidly, and believes she has special powers to "heal the world." She has a history of a depressive episode 2 years ago. She denies substance use. Current episode began 10 days ago.
Hyperactive, intrusive, poor boundaries. Euphoric mood, expansive affect. Pressured speech with flight of ideas. Grandiose delusions. Distractible. Poor insight. Impaired judgment.
Acute mania treatment per CANMAT/ISBD guidelines combines a mood stabilizer (lithium or valproate) with an atypical antipsychotic for faster symptom control. Antidepressants are contraindicated in acute mania (risk of cycling). Hospitalization is indicated given severity.
DSM-5: Manic episode = elevated/irritable mood + ≥3 DIGFAST symptoms for ≥1 week with functional impairment. CANMAT/ISBD 2024: Combination therapy more effective than monotherapy for acute mania. Lithium level target 0.8-1.2 mEq/L acutely. Discontinue antidepressants.
A 32-year-old woman presents to the ED with her third episode this month of sudden-onset chest tightness, palpitations, shortness of breath, diaphoresis, trembling, and intense fear of dying lasting 15-20 minutes. Between episodes, she constantly worries about having another attack and avoids crowded places. Cardiac workup negative. Thyroid normal. She has started avoiding driving alone.
Anxious-appearing, tearful. Describes fear of "losing control" during attacks. No psychosis. Good insight—recognizes attacks may be anxiety-related but fears missing cardiac disease.
Combined SSRI + CBT is the most effective treatment for panic disorder with agoraphobia. CBT (specifically panic-focused CBT with interoceptive exposure) addresses avoidance behaviors and catastrophic misinterpretations. Benzodiazepines can be used short-term but interfere with exposure therapy.
DSM-5: Recurrent unexpected panic attacks + ≥1 month of worry about attacks or maladaptive behavioral change. APA 2024: SSRIs (paroxetine, sertraline) + CBT superior to either alone. Start SSRI low to avoid initial activation anxiety.
A 38-year-old combat veteran presents 18 months after returning from deployment. He reports recurrent nightmares of combat, flashbacks triggered by loud noises, avoidance of news about military conflicts, emotional numbness, hypervigilance, exaggerated startle response, and insomnia. He has become increasingly isolated and reports survivor's guilt. Alcohol use has increased to "help sleep."
Guarded, makes limited eye contact. Hypervigilant (scans room). Restricted affect. Describes feeling "detached" from family. Denies active suicidal ideation but reports passive death wishes. No psychosis.
Trauma-focused psychotherapies (Prolonged Exposure, Cognitive Processing Therapy, EMDR) are first-line treatments for PTSD per VA/DoD and APA guidelines. These have stronger evidence than non-trauma-focused approaches. Pharmacotherapy (sertraline, paroxetine) is second-line or adjunctive.
DSM-5: Exposure to trauma + intrusion, avoidance, negative cognitions, and hyperarousal symptoms >1 month. VA/DoD 2023 & APA: PE, CPT, EMDR strongly recommended. For nightmares: prazosin. Screen for and treat comorbid substance use.
A 25-year-old graduate student reports spending 4+ hours daily on handwashing and cleaning rituals due to fears of contamination. She recognizes the fears are "irrational" but feels intense anxiety if she doesn't complete the rituals. She checks locks 15+ times before leaving home. Her hands are cracked and bleeding from excessive washing. She is failing her coursework due to time spent on rituals.
Anxious, hands visibly excoriated. Good insight—describes obsessions as "ego-dystonic." Thought content focused on contamination. No psychosis, no suicidal ideation. Good judgment regarding need for treatment.
Exposure and Response Prevention (ERP) is the gold-standard psychotherapy for OCD. High-dose SSRIs (often 2-3x typical antidepressant doses; e.g., fluoxetine 60-80mg, sertraline 200mg) are first-line pharmacotherapy. Combination is most effective for moderate-severe OCD.
DSM-5: Obsessions and/or compulsions that are time-consuming (>1 hr/day) or cause significant distress/impairment. APA 2023: ERP is the most effective psychotherapy. SSRIs require higher doses and longer trials (10-12 weeks). Augment with low-dose risperidone if partial response.
A 17-year-old female is brought by her mother for 6-month weight loss (from 130 lbs to 92 lbs at 5'5"). She restricts intake to 500 cal/day, exercises 3 hours daily, and expresses intense fear of gaining weight despite being significantly underweight. She sees herself as "still too fat." Amenorrhea for 4 months. She denies purging behaviors. Cold intolerance, fatigue, and lanugo noted.
K⁺ 3.1 mEq/L, glucose 62 mg/dL, WBC 3.2k, ECG: sinus bradycardia with prolonged QTc (480 ms). Lanugo on arms/back. Dry skin. Mild parotid enlargement.
Medical stabilization is urgent given severe bradycardia (HR <50), hypotension, hypothermia, electrolyte abnormalities, and QTc prolongation. These are markers of medical instability requiring inpatient care. Refeeding must be gradual (risk of refeeding syndrome). No medications are FDA-approved for AN; treatment is nutritional rehabilitation + psychotherapy.
DSM-5: Restriction, low weight, fear of weight gain, body image disturbance. APA 2023: Hospitalize if HR <50, BP <90/60, K⁺ <3, or BMI <15. FBT (Maudsley) first-line for adolescents. Monitor for refeeding syndrome (phosphate, thiamine). Mortality rate ~5-10%.
A 24-year-old woman presents after a superficial wrist laceration following a breakup with her boyfriend of 2 weeks, whom she initially described as "perfect." She reports a pattern of unstable relationships, chronic emptiness, intense fear of abandonment, identity confusion ("I don't know who I am"), impulsive spending, and self-harm since age 15. Multiple prior ED visits for self-harm without suicidal intent. History of childhood emotional abuse.
Dramatic, tearful, then angry during interview (splitting observed). Describes intense anger followed by emptiness. Multiple scars from prior self-harm. Denies current suicidal intent ("I didn't want to die, just stop feeling"). Chronic passive SI. Identity diffusion evident.
DBT is the gold-standard treatment for BPD with strong evidence for reducing self-harm, suicidal behavior, and ED visits. It combines individual therapy + skills group (mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness). Medications are adjunctive for specific symptoms, not core treatment.
DSM-5: ≥5 of 9 criteria (abandonment fears, unstable relationships, identity disturbance, impulsivity, self-harm, affective instability, emptiness, anger, dissociation/paranoia). APA & NICE: Psychotherapy (DBT, MBT, TFP) is primary. Avoid polypharmacy. Benzodiazepines generally contraindicated. Short-term hospitalization only for imminent safety concerns.
A 30-year-old man presents for evaluation of "focus problems." He reports lifelong difficulty sustaining attention in meetings, frequently loses items, procrastinates, and struggles to complete projects. He often interrupts others and feels restless. Childhood history reveals similar symptoms, poor grades despite "being smart," and comments from teachers about not reaching his potential. Two recent jobs lost due to missed deadlines. No substance use.
Restless, fidgety throughout interview. Frequently interrupts. Loses track of questions. Speech pressured but coherent. Mood "frustrated." Insight good—recognizes pattern affecting his life. No psychosis.
Stimulants (methylphenidate, amphetamines) are first-line for adult ADHD with the strongest efficacy data. Effect sizes ~0.9 vs ~0.6 for non-stimulants. Atomoxetine, bupropion, and viloxazine are alternatives if stimulants are contraindicated or not tolerated. Always assess for substance use history and cardiac risk.
DSM-5: ≥5 inattention and/or hyperactivity-impulsivity symptoms, onset before age 12, present in ≥2 settings. NICE 2024 & CADDRA: Stimulants first-line in adults. Monitor BP/HR. Combine with psychoeducation, CBT for ADHD, organizational coaching. No routine cardiac testing unless risk factors present.
A 26-year-old man presents at his girlfriend's urging because he "doesn't get social cues." He has had difficulty maintaining friendships lifelong, prefers routines (eats same lunch daily for 10 years), has intense interest in train schedules (can recite entire regional timetables), and becomes distressed when plans change. He avoids eye contact, speaks in a monotone, and struggles to understand sarcasm. Employed as a data analyst (excellent attention to detail).
Limited eye contact. Flat affect, monotone speech. Detailed responses about special interests with difficulty changing topics. Literal interpretation of idioms. Good factual memory. Difficulty describing emotions ("alexithymia-like").
There is no medication to treat core ASD symptoms. Management focuses on psychoeducation (understanding the diagnosis), social skills training, occupational support/accommodations, and treating co-occurring conditions (anxiety in 40%, depression in 30%). Validate strengths. Connect with ASD community resources.
DSM-5: Persistent deficits in social communication/interaction + restricted, repetitive behaviors, with symptoms present in early development. NICE 2021: Diagnosis by experienced multidisciplinary team. Support employment/relationships. Treat comorbidities (SSRIs for anxiety/OCD, stimulants for ADHD). Antipsychotics only for irritability/aggression, not core symptoms.
A 52-year-old man presents 36 hours after his last drink (1 pint of vodka daily for 15 years). He reports tremor, diaphoresis, anxiety, nausea, and insomnia. He had a seizure during a prior attempt to quit. He drinks despite liver problems (AST/ALT elevated), a DUI, and his wife threatening to leave. He has tried to cut down multiple times but experiences cravings and withdrawal. CIWA-Ar score: 18.
Visible tremor. Diaphoretic. Oriented but anxious. AST 142, ALT 78 (AST:ALT >2:1). MCV elevated. No asterixis. AUDIT-C: 11 (severe AUD).
Benzodiazepines (chlordiazepoxide, diazepam, lorazepam) are first-line for alcohol withdrawal to prevent seizures and delirium tremens. Thiamine (IV/IM first) prevents Wernicke encephalopathy. Symptom-triggered protocols (using CIWA-Ar) reduce total benzodiazepine dose and duration. History of withdrawal seizures increases DT risk.
DSM-5 AUD: ≥2 of 11 criteria in 12 months. ASAM 2024: Thiamine before glucose. CIWA-Ar >8-10 warrants pharmacotherapy. After stabilization: naltrexone or acamprosate for relapse prevention. Consider gabapentin as adjunct. Disulfiram only if highly motivated with close monitoring.
A 28-year-old man presents requesting help to stop using heroin. He started with prescription opioids after a sports injury 5 years ago, transitioned to heroin 2 years ago due to cost. He uses IV heroin daily, has had two non-fatal overdoses, and recently started using fentanyl-contaminated supply. He has lost his job, his family relationships are strained, and he wants to "get his life back." He is in early withdrawal.
Rhinorrhea, lacrimation, yawning, piloerection ("goosebumps"), restlessness, GI cramping. Track marks on arms. HIV/HCV testing needed. Motivated for treatment.
Medications for Opioid Use Disorder (MOUD)—buprenorphine or methadone—are first-line and reduce mortality by 50%+. Detoxification alone has extremely high relapse rates (>90%) and increased overdose risk post-detox. Naltrexone is an option only AFTER full opioid withdrawal (7+ days). Provide naloxone for overdose prevention.
SAMHSA/ASAM 2024: MOUD is standard of care. Buprenorphine can be initiated in office (no X-waiver needed since 2023). Methadone via OTP only. Injectable buprenorphine (Sublocade) for adherence concerns. All patients: harm reduction (naloxone, fentanyl test strips), HIV/HCV testing, HBV vaccination.
An 78-year-old woman, hospitalized for hip fracture surgery 2 days ago, is noted by night nursing to be "confused and agitated." She is pulling at her IV, calling for her deceased husband, and is unable to state the date or location. During morning rounds, she is drowsy but arousable. Her daughter reports she was "sharp as a tack" before admission. Medications include oxycodone, diphenhydramine for sleep, and ciprofloxacin for UTI.
CAM positive: acute onset, fluctuating course, inattention (cannot recite months backwards), disorganized thinking. Visual hallucinations (seeing "children in the room"). Waxing/waning alertness. Not at baseline per family. UA shows pyuria.
Delirium treatment focuses on identifying and treating underlying causes (UTI, medications, pain, constipation, hypoxia, metabolic derangements). Discontinue anticholinergics (diphenhydramine), reduce opioids if possible, and use non-pharmacologic interventions first (reorientation, sleep hygiene, mobilization, family presence). Antipsychotics reserved for severe agitation causing harm.
DSM-5: Disturbance in attention/awareness + acute onset/fluctuating course + additional cognitive deficit + not explained by pre-existing neurocognitive disorder. AGS 2023: Antipsychotics do NOT improve delirium outcomes and increase mortality in dementia. Non-pharmacologic approaches (HELP protocol) are cornerstone. Avoid restraints (worsen agitation).
A 72-year-old retired professor is brought by his wife for evaluation of 2 years of progressive memory problems. He repeats questions, forgets appointments, recently got lost driving to a familiar store, and left the stove on twice. His wife manages finances now after he made errors paying bills. He is less engaged socially and has become more passive. There is no history of strokes. Gait and motor function are normal.
Impaired delayed recall (0/5 words at 5 min), impaired visuospatial function (clock drawing abnormal), temporal disorientation. Language and attention relatively preserved. MRI: bilateral hippocampal atrophy. No significant vascular changes.
Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) are first-line for mild-moderate Alzheimer's dementia with modest cognitive/functional benefits. Memantine (NMDA antagonist) is added for moderate-severe disease or used when ChEIs not tolerated. Anti-amyloid therapies (lecanemab, donanemab) now FDA-approved for early AD with confirmed amyloid pathology.
DSM-5: Major NCD with insidious onset, gradual progression, amnesia predominant (hippocampal pattern). AAN/APA 2024: ChEIs first-line; modest benefit. Manage cardiovascular risk factors. Address caregiver burden. Advance care planning early. New: anti-amyloid mAbs if early-stage + amyloid-PET/CSF positive.
A 35-year-old woman with history of psychiatric hospitalizations presents with auditory hallucinations (voices commenting on her actions) and paranoid delusions (neighbors plotting against her) ongoing for 6 months. During this period, she also experienced a 3-week episode of severe depression with anhedonia, hypersomnia, and suicidal ideation. Notably, her psychotic symptoms persisted even after her mood normalized. Her mother has schizophrenia.
Fair hygiene. Guarded, paranoid. Current mood "okay." Affect restricted. Active auditory hallucinations acknowledged. Persecutory delusions persistent. Thought process tangential at times. Partial insight—acknowledges need for medication.
The key differentiator for schizoaffective disorder is that psychotic symptoms (delusions/hallucinations) must be present for ≥2 weeks IN THE ABSENCE of mood episodes during the illness course. In bipolar/depression with psychosis, psychosis occurs ONLY during mood episodes. Treatment combines antipsychotic + mood stabilizer or antidepressant (depressive type).
DSM-5 Criteria: (1) Meets schizophrenia Criterion A, (2) Major mood episode concurrent with active psychosis, (3) Delusions/hallucinations for ≥2 weeks WITHOUT mood episode, (4) Mood symptoms present for majority of total duration. Treatment: SGA (paliperidone FDA-approved for schizoaffective) + mood stabilizer. LAI for adherence. Clozapine if treatment-resistant.