A 23-year-old man presents to an outpatient psychiatrist complaining of anxiety and a persistent feeling that “something terrible will happen to my family.” He describes 1 year of vague, disturbing thoughts about his family members contracting a “horrible disease” or dying in an accident. He believes that he can prevent these outcomes by washing his hands of “the contaminants” any time that he touches something and by performing praying and counting rituals each time that he has unwanted, disturbing thoughts. The thoughts and rituals have become more frequent recently, making it impossible for him to work, and he expresses feeling deeply embarrassed by them. Which of the following is the most effective treatment for this patient's disorder?

Cognitive behavioral therapy and fluoxetine

Psychodynamic psychotherapy and citalopram

Cognitive behavioral therapy and haloperidol

Cognitive behavioral therapy and clonazepam

Psychodynamic psychotherapy and aripiprazole

A 29-year-old woman presents to her primary care physician because she has been experiencing episodes of intense fear. Specifically, she says that roughly once per week she will feel an intense fear of dying accompanied by chest pain, lightheadedness, sweating, and palpitations. In addition, she will feel as if she is choking which leads her to hyperventilate. She cannot recall any trigger for these episodes and is afraid that they will occur while she is driving or working. In order to avoid this possibility, she has been getting rides from a friend and has been avoiding interactions with her coworkers. These changes have not stopped the episodes so she came in for evaluation. This patient's disorder is most likely genetically associated with a personality disorder with which of the following features?

Submissive, clingy, and low self-confidence

Criminality and disregard for rights of others

Eccentric appearance and magical thinking

Grandiosity, entitlement, and need for admiration

Social withdrawal and limited emotional expression

An 11-year-old boy’s parents brought him to a psychologist upon referral from the boy’s school teacher. The boy frequently bullies his younger classmates despite having been punished several times for this. His mother also reported that a year prior, she received complaints that the boy shoplifted from local shops in his neighborhood. The boy frequently stays out at night despite strict instructions by his parents to return home by 10 PM. Detailed history reveals that apart from such behavior, he is usually not angry or irritable. Although his abnormal behavior continues despite warnings and punishments, he neither argues with his parents nor teachers and does not display verbal or physical aggression. Which of the following is the most likely diagnosis?

Attention-deficit/hyperactivity disorder, hyperactivity-impulsivity type

Disruptive mood dysregulation disorder

Intermittent explosive disorder

A previously healthy 36-year-old man is brought to the physician by a friend because of fatigue and a depressed mood for the past few weeks. During this time, he has not been going to work and did not show up to meet his friends for two bowling nights. The friend is concerned that he may lose his job. He spends most of his time alone at home watching television on the couch. He has been waking up often at night and sometimes takes 20 minutes to go back to sleep. He has also been drinking half a pint of whiskey per day for 1 week. His wife left him 4 weeks ago and moved out of their house. His vital signs are within normal limits. On mental status examination, he is oriented to person, place and time. He displays a flattened affect and says that he “doesn't know how he can live without his wife.” He denies suicidal ideation. Which of the following is the next appropriate step in management?

Initiate cognitive behavioral therapy

Prescribe a short course of alprazolam

Prescribe a short course of duloxetine

A 36-year-old woman complains of difficulty falling asleep over the past 4 months. On detailed history taking, she says that she drinks her last cup of tea at 8:30 p.m. before retiring at 10:30 p.m. She then watches the time on her cell phone on and off for an hour before falling asleep. In the morning, she is tired and makes mistakes at work. Her husband has not noticed excessive snoring or abnormal breathing during sleep. Medical history is unremarkable. She has smoked 5–7 cigarettes daily for 7 years and denies excess alcohol consumption. Her physical examination is normal. Which of the following is the best initial step in the management of this patient’s condition?

Continuous positive airway pressure

An 11-year-old girl is brought to her primary care physician by her mother with complaints of constant lower abdominal pain and foul-smelling urine for the past 2 days. The patient has had several previous episodes of simple urinary tract infections in the past. Her vitals signs show mild tachycardia without fever. Physical examination reveals suprapubic tenderness without costovertebral angle tenderness on percussion. Urinalysis reveals positive leukocyte esterase and nitrite. Further questioning reveals that the patient does not use the school toilets and holds her urine all day until she gets home. When pressed further, she gets teary-eyed and starts to cry and complains that other girls will make fun of her if she uses the bathroom and will spread rumors to the teachers and her friends. She reports that though this has never happened in the past it concerns her a great deal. Which of the following is the most likely diagnosis for this patient?

Social anxiety disorder, performance only

Specific phobias for USMLE Step 2 CK: High-Yield Psychiatry Lessons

Diagnosis & Criteria - What Scares You?

DSM-5 Criteria: Marked, persistent fear (>6 months) about a specific object or situation.
- The phobic stimulus almost always provokes an immediate anxiety response.
- The stimulus is actively avoided or endured with intense fear.
- Fear is out of proportion to the actual danger.
- Causes clinically significant distress or impairment in social or occupational functioning.
Specifiers:
- Animal (e.g., spiders, insects, dogs)
- Natural Environment (e.g., heights, storms, water)
- Blood-Injection-Injury (B-I-I)
- Situational (e.g., airplanes, elevators, enclosed places)

Common Phobias Illustrated

⭐ The Blood-Injection-Injury (B-I-I) type is unique, often causing an initial brief tachycardia followed by a vasovagal faint (bradycardia, hypotension), unlike the pure sympathetic arousal in other phobias.

Phobia Subtypes - Name Your Nemesis

Subtype	Examples	Clinical Pearl
Animal	Spiders (arachnophobia), insects, dogs	Most common specific phobia subtype.
Natural Environment	Heights (acrophobia), storms, water	Onset is typically in childhood.
Blood-Injection-Injury (BII)	Needles, invasive medical procedures	Unique biphasic cardiovascular response.
Situational	Airplanes, elevators, enclosed spaces	Tends to have a bimodal age of onset.
Other	Choking, vomiting, loud sounds	A residual category for fears not covered above.

Etiology & Epidemiology - Roots of Dread

Epidemiology:
- Lifetime prevalence: ~12.5%.
- F:M ratio is 2:1.
- Onset: Bimodal peaks in childhood (e.g., animals) & early adulthood (e.g., situational).
Etiology:
- Genetic: Familial aggregation is common.
- Behavioral (Learning):
  - Direct conditioning (traumatic event).
  - Vicarious acquisition (observing fear).
  - Informational transmission (being told of danger).
- Neurobiological: Key roles for amygdala & insula hyperactivity.

⭐ The most common type of specific phobia is animal-related, but the most common presenting phobia in clinical practice is situational (e.g., flying, elevators).

Amygdala fear circuit and its regulation

Treatment - Facing the Fear

First-line: Cognitive Behavioral Therapy (CBT) with exposure is the most effective treatment.
Exposure Therapy: Involves gradual, repeated exposure to the phobic stimulus until the anxiety response diminishes (habituation).
- Systematic Desensitization: Pairs exposure with relaxation techniques.
- Flooding: Intense, prolonged exposure without relaxation.

⭐ Exam Favorite: Unlike most other anxiety disorders (GAD, Panic Disorder), SSRIs are NOT first-line for specific phobias. CBT with exposure therapy has superior efficacy.

High‑Yield Points - ⚡ Biggest Takeaways

Marked and persistent fear (>6 months) of a specific object or situation that is out of proportion to the actual danger.

The phobic stimulus provokes immediate anxiety and is actively avoided or endured with intense distress.

Must cause clinically significant distress or social/occupational impairment.

Best initial therapy is Cognitive-Behavioral Therapy (CBT) with exposure therapy.

Benzodiazepines can be used for situational-only phobias (e.g., flying) but are not first-line for chronic treatment.

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