A mental health volunteer is interviewing locals as part of a community outreach program. A 46-year-old man discloses that he has felt sad for as long as he can remember. He feels as though his life is cursed and if something terrible can happen to him, it usually will. He has difficulty making decisions and feels hopeless. He also feels that he has had worsening suicidal ideations, guilt from past problems, decreased energy, and poor concentration over the past 2 weeks. He is otherwise getting enough sleep and able to hold a job. Which of the following statement best describes this patient's condition?

The patient has double depression.

The patient may have symptoms of mania or psychosis.

The patient is likely to show anhedonia.

The patient likely has paranoid personality disorder.

The patient should be started on an SSRI.

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

"Can you tell me more about the symptoms you have been experiencing?"

"Does the diarrhea typically precede the constipation, or vice-versa?"

"Is the diarrhea foul-smelling?"

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

"Are the symptoms worse in the morning or at night?"

A 24-year-old woman presents to her primary care physician for a wellness exam. She currently has no acute concerns but has been feeling hopeless, has a poor appetite, difficulty with concentration, and trouble with sleep. She says that she has poor self-esteem and that her symptoms have been occurring for the past 3 years. She has had moments where she felt better, but it lasted a few weeks out of the year. She currently lives alone and does not pursue romantic relationships because she feels she is not attractive. She has a past medical history of asthma. Her mother is alive and healthy. Her father committed suicide and suffered from major depressive disorder. On physical exam, the patient has a gloomy demeanor and appears restless and anxious. Which of the following is the most likely diagnosis?

Disruptive mood dysregulation disorder

A 19-year-old female college student is brought into the emergency department by her boyfriend. The boyfriend reports that the patient got caught stealing from the company she works for and subsequently got fired. The boyfriend received a text that evening saying “I’ll miss you.” When he arrived at her dorm room, the patient was slumped in the shower covered in blood. The patient agreed to be driven to the emergency room. When asked about what happened, the patient replies “I just want out of this life.” The patient has bipolar disorder, and takes lithium as prescribed. She has a psychiatrist she sees every week, which the boyfriend confirms. She has never had a prior suicide attempt nor has she ever been hospitalized for a psychiatric disorder. The patient’s vitals are stable. Upon physical examination, a 4 centimeter vertical incision is noted on the patient’s left forearm. During the patient’s laceration repair, she asks if she will be admitted. She states, “these ups and downs are common for me, but I feel better now.” She verbalizes that she understands that she overreacted. She asks to go home, and her boyfriend insists that he will stay with her. They both confirm that neither of them have guns or know any peers with access to guns. Which of the following is the most appropriate management for the patient?

Involuntarily admit the patient

Have the patient sign a suicide contract before discharge

Set up a next-day appointment with the patient’s psychiatrist

Discontinue lithium and start valproate

A 48-year-old woman is brought to the emergency department by her family at her psychiatrist's recommendation. According to her family, she has been more restless than her baseline over the past week. The patient herself complains that she feels her mind is racing. Her past medical history is significant for bipolar disorder on lithium and type 1 diabetes mellitus. The family and the patient both assert that the patient has been taking her medications. She denies any recent illness or sick contacts. The patient's temperature is 100°F (37.8°C), blood pressure is 100/60 mmHg, pulse is 130/min, and respirations are 20/min. She appears diaphoretic, and her cardiac exam is notable for an irregularly irregular rhythm with a 2/6 early systolic murmur. Blood counts and metabolic panel are within normal limits. The patient's lithium level is within therapeutic range. Which of the following laboratory tests would be the most useful to include in the evaluation of this patient?

Thyroid stimulating hormone and free thyroxine levels

Thyroid stimulating hormone and total thyroxine levels

Thyrotropin-releasing hormone stimulation test

Triiodothyronine and thyroxine levels

Bipolar I disorder diagnostic criteria for USMLE Step 2 CK: High-Yield Psychiatry Lessons

Manic Episode Criteria - The Core Requirement

A distinct period of abnormally and persistently elevated, expansive, or irritable mood and increased goal-directed activity or energy.

Duration: Lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
Symptom Threshold: ≥3 of the following symptoms are present to a significant degree (≥4 if the mood is only irritable).
- 📌 Mnemonic: DIG FAST
  - Distractibility
  - Indiscretion / Impulsivity (high-risk activities)
  - Grandiosity or inflated self-esteem
  - Flight of ideas or racing thoughts
  - Activity ↑ (goal-directed)
  - Sleep ↓ (decreased need)
  - Talkativeness (pressured speech)
Severity: The mood disturbance is severe enough to cause marked impairment in social/occupational functioning, necessitate hospitalization, or includes psychotic features.

⭐ A single manic episode is sufficient to diagnose Bipolar I Disorder. A history of major depressive episodes is a common feature but is not required for diagnosis.

Episode Comparison - Mania vs. The Rest

Feature	Manic Episode	Hypomanic Episode	Major Depressive Episode
Duration	≥ 1 week (or any if hospitalized)	≥ 4 consecutive days	≥ 2 weeks
Impairment	Marked social/occupational impairment	Unequivocal change, NOT marked	Significant distress or impairment
Psychosis	May be present	By definition, absent	May be present
Hospitalization	May necessitate	By definition, no	May be required

-   **D**istractibility
-   **I**mpulsivity / Indiscretion
-   **G**randiosity
-   **F**light of ideas
-   **A**ctivity (goal-directed) ↑
-   **S**leep need ↓
-   **T**alkativeness (pressured speech)

⭐ A single manic episode is sufficient to diagnose Bipolar I Disorder, even without a prior major depressive episode.

Diagnostic Specifiers - Adding Clinical Detail

With Anxious Distress: Presence of at least two anxiety symptoms during a mood episode.
With Mixed Features: Criteria are met for a manic or hypomanic episode, with at least three depressive symptoms present nearly every day.
With Rapid Cycling: At least four mood episodes (manic, hypomanic, or major depressive) within a 12-month period.
With Psychotic Features: Delusions or hallucinations are present.
- Mood-congruent: Content is consistent with the typical themes of the mood episode.
- Mood-incongruent: Content does not align with the mood.
With Peripartum Onset: Onset occurs during pregnancy or within the four weeks following delivery.

⭐ Rapid cycling is more common in women, may be associated with hypothyroidism, and often carries a poorer prognosis.

The cornerstone of Bipolar I is at least one lifetime manic episode.

Manic episodes are defined by an elevated, expansive, or irritable mood lasting at least 1 week or requiring hospitalization.

Diagnosis requires ≥3 DIGFAST symptoms (or ≥4 if the mood is only irritable).

The mood disturbance must cause marked impairment in social or occupational functioning.

Major depressive episodes are common but not required for diagnosis.

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