A 33-year-old woman is brought to the physician by her husband because of persistent sadness for the past 2 months. During this period, she also has had difficulty sleeping and an increased appetite. She had similar episodes that occurred 2 years ago and 9 months ago that each lasted for 4 months. Between these episodes, she reported feeling very energetic and rested after 3 hours of sleep. She often went for long periods of time without eating. She works as a stock market trader and received a promotion 5 months ago. She regularly attends yoga classes on the weekends with her friends. On mental status examination, she has a blunted affect. She denies suicidal thoughts and illicit drug use. Which of the following is the most likely diagnosis?

Major depressive disorder with seasonal pattern

Major depressive disorder with atypical features

A 24-year-old male comes into the psychiatric clinic complaining of consistent sadness. He endorses feelings of worthlessness, anxiety, and anhedonia for the past couple months but denies feeling suicidal. He further denies any past episodes of feeling overly energetic with racing thoughts. Confident of the diagnosis, you recommend frequent talk therapy along with a long-term prescription of a known first-line medication for this disorder. What is the drug and what are some of the most frequently encountered side effects?

Selective serotonin reuptake inhibitor; anorgasmia, insomnia

Selective serotonin reuptake inhibitor; hypomania, suicidal thoughts

Tricyclic antidepressants; hypomania, suicidal thoughts

Monoamine oxidase inhibitors; Orthostatic hypotension, weight gain

Tricyclic antidepressants; Orthostatic hypotension, anticholinergic effects

A 19-year-old woman presents to an outpatient psychiatrist after 2 weeks of feeling “miserable.” She has been keeping to herself during this time with no desire to socialize with her friends or unable to enjoy her usual hobbies. She also endorses low energy, difficulty concentrating and falling asleep, and decreased appetite. You diagnose a major depressive episode but want to screen for bipolar disorder before starting her on an anti-depressant. Which of the following cluster of symptoms, if previously experienced by this patient, would be most consistent with bipolar I disorder?

Impulsivity, insomnia, increased energy, irritability, and auditory hallucinations for 2 weeks

Insomnia, anxiety, nightmares, and flashbacks for 6 months

Elevated mood, insomnia, distractibility, and flight of ideas for 5 days

Impulsivity, rapid mood swings, intense anger, self-harming behavior, and splitting for 10 years

Auditory hallucinations, paranoia, and disorganized speech for 2 weeks

A 23-year-old woman is brought to the physician by her father because of irritability, mood swings, and difficulty sleeping over the past 10 days. A few days ago, she quit her job and spent all of her savings on supplies for a “genius business plan.” She has been energetic despite sleeping only 1–2 hours each night. She was diagnosed with major depressive disorder 2 years ago. Mental status examination shows pressured speech, a labile affect, and flight of ideas. Throughout the examination, she repeatedly states “I feel great, I don't need to be here.” Urine toxicology screening is negative. Which of the following is the most likely diagnosis?

Attention-deficit hyperactivity disorder

A 27-year-old woman is brought to the office at the insistence of her fiancé to be evaluated for auditory hallucinations for the past 8 months. The patient’s fiancé tells the physician that the patient often mentions that she can hear her own thoughts speaking aloud to her. The hallucinations have occurred intermittently for at least 1-month periods. Past medical history is significant for hypertension. Her medications include lisinopril and a daily multivitamin both of which she frequently neglects. She lost her security job 7 months ago after failing to report to work on time. The patient’s vital signs include: blood pressure 132/82 mm Hg; pulse 72/min; respiratory rate 18/min, and temperature 36.7°C (98.1°F). On physical examination, the patient has a flat affect and her focus fluctuates from the window to the door. She is disheveled with a foul smell. She has difficulty focusing on the discussion and does not quite understand what is happening around her. A urine toxicology screen is negative. Which of the following is the correct diagnosis for this patient?

Schizotypal personality disorder

Mixed features specification for USMLE Step 2 CK: High-Yield Psychiatry Lessons

Mixed Features Specifier - Manic-Depressive Mashup

Core Concept: Full criteria are met for a mood episode (manic, hypomanic, or depressive) while simultaneously showing symptoms from the opposite pole.
DSM-5 Criteria:
- For a Manic or Hypomanic Episode: Must have at least 3 symptoms of depression (e.g., dysphoria, anhedonia, psychomotor retardation).
- For a Major Depressive Episode: Must have at least 3 symptoms of mania/hypomania (e.g., elevated mood, grandiosity, flight of ideas, increased activity).

Venn diagram: Bipolar mixed episode symptoms

⭐ Mixed features are associated with a significantly higher suicide risk and often have a poorer response to lithium monotherapy, frequently requiring valproate or atypical antipsychotics.

Clinical Picture - Emotional Rollercoaster Wreck

Patient experiences a chaotic, simultaneous blend of manic and depressive symptoms.
Core feature: High energy paired with negative mood (dysphoric mania) or low energy with agitated thoughts (depressive mixed state).
Common presentation:
- Mood: Extreme irritability, anxiety, emotional lability.
- Cognition: Racing thoughts, distractibility, but with depressive themes (guilt, worthlessness).
- Behavior: Psychomotor agitation, impulsivity, sleep disturbances (insomnia).

⭐ High-Yield: Suicide risk is significantly higher in mixed episodes than in pure mania or depression due to the combination of depressive hopelessness and manic energy/impulsivity.

The Mimics - Not Just Bipolar

Schizoaffective Disorder: Key is psychosis occurring in the absence of mood episodes.
MDD with Mixed Features: A primary depressive episode with some sub-threshold hypomanic/manic symptoms.
Anxiety Disorders: Can mimic agitation, irritability, and racing thoughts.
Substance/Medication-Induced: Always rule out stimulants (cocaine, amphetamines), corticosteroids, or activating antidepressants.
Borderline Personality Disorder (BPD): Look for chronic, pervasive instability in relationships and self-image, rather than distinct mood episodes.

⭐ Exam Favorite: To diagnose Schizoaffective Disorder, delusions or hallucinations must be present for ≥2 weeks in the absence of a major mood episode during the illness's lifetime.

Treatment Strategy - Calming the Storm

Primary Goal: Stabilize mood by concurrently targeting both manic and depressive symptoms.
First-line: Atypical (second-generation) antipsychotics (e.g., olanzapine, risperidone, quetiapine, aripiprazole) are often initiated first due to rapid action.
Adjunct/Alternative: Mood stabilizers like Valproate or Lithium are cornerstone therapies.
⚠️ AVOID antidepressant monotherapy due to the high risk of precipitating or worsening mania.

⭐ Valproic acid is often considered more effective than lithium for the treatment of mixed episodes and rapid-cycling bipolar disorder.

A "mixed features" specifier is applied when a patient meets full criteria for a manic/hypomanic episode AND simultaneously has ≥3 depressive symptoms.

It can also apply to a major depressive episode with ≥3 manic/hypomanic symptoms.

These concurrent symptoms must be present nearly every day during the episode.

This specifier indicates a worse prognosis, higher suicide risk, and greater functional impairment.

Crucially, antidepressant monotherapy is contraindicated as it can worsen manic symptoms.

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