A 23-year-old man presents to the emergency department with a chief complaint of being assaulted on the street. The patient claims that he has been followed by the government for quite some time and that he was assaulted by a government agent but was able to escape. He often hears voices telling him to hide. The patient has an unknown past medical history and admits to smoking marijuana frequently. On physical exam, the patient has no signs of trauma. When interviewing the patient, he is seen conversing with an external party that is not apparent to you. The patient states that he is afraid for his life and that agents are currently pursuing him. What is the best initial response to this patient’s statement?

It sounds like you have been going through some tough experiences lately.

I think you are safe from the agents here.

You have a mental disorder but don’t worry we will help you.

I don’t think any agents are pursuing you.

What medications are you currently taking?

A 19-year-old woman comes to the physician because of a 2-day history of difficulty sleeping. She worries that the lack of sleep will ruin her career prospects as a model. She has been coming to the physician multiple times over the past year for minor problems. She is dressed very extravagantly and flirts with the receptionist. When she is asked to sit down in the waiting room, she begins to cry and says that no one listens to her. When she is called to the examination room, she moves close to the physician, repeatedly intends to touch his cheek, and makes inappropriate comments. She does not have a history of self-harm or suicidal ideation. Which of the following is the most likely diagnosis?

Histrionic personality disorder

Schizotypal personality disorder

Borderline personality disorder

Narcissistic personality disorder

A 38-year-old man comes to the physician because of persistent sadness and difficulty concentrating for the past 6 weeks. During this period, he has also had difficulty sleeping. He adds that he has been “feeling down” most of the time since his girlfriend broke up with him 4 years ago. Since then, he has only had a few periods of time when he did not feel that way, but none of these lasted for more than a month. He reports having no problems with appetite, weight, or energy. He does not use illicit drugs or alcohol. Mental status examination shows a depressed mood and constricted affect. Which of the following is the most likely diagnosis?

Adjustment disorder with depressed mood

A 15-year-old female presents to her family physician for an annual school physical exam and check-up. She is accompanied by her mother to the visit and is present in the exam room. The patient has no complaints, and she does not have any past medical problems. She takes no medications. The patient reports that she remains active, exercising 5 times a week, and eats a healthy and varied diet. Which of the following would be the best way for the physician to obtain a more in-depth social history, including sexual history and use of alcohol, tobacco, or recreational drugs?

Ask the mother to step outside into the hall for a portion of the visit

Disallow the mother to be present in the examination room throughout the entirety of the visit

Give the patient a social history questionnaire to fill out in the exam room

Ask the patient the questions directly, with her mother still in the exam room

Speak softly to the patient so that the mother does not hear and the patient is not embarrassed

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 42-year-old female presents to her primary care provider for an annual checkup. She reports feeling sad over the past few months for no apparent reason. She has lost interest in swimming, which she previously found enjoyable. Additionally, she has had trouble getting a full night’s sleep and has had trouble concentrating during the day. She has lost 15 pounds since her last visit one year prior. Which of the following sets of neurotransmitter levels is associated with this patient’s condition?

Decreased norepinephrine, decreased serotonin, decreased dopamine

Decreased acetylcholine, normal serotonin, normal dopamine

Decreased GABA, decreased acetylcholine, increased dopamine

Increased norepinephrine, decreased serotonin, decreased GABA

Increased acetylcholine, increased serotonin, decreased dopamine

A 27-year-old woman with cystic fibrosis comes to the physician for a follow-up examination. She has been hospitalized frequently for pneumonia and nephrolithiasis and is on chronic antibiotic therapy for recurrent sinusitis. The patient and her husband would like to have a child but have been unable to conceive. She feels that she can never achieve a full and happy life due to her disease and says that she is “totally frustrated” with the barriers of her illness. Although her family is supportive, she doesn't want to feel like a burden and tries to shield them from her struggles. Which of the following is the most appropriate statement by the physician?

I understand that living with cystic fibrosis is not easy. You are not alone in this. I would like to recommend a support group.

You should educate yourself about your disease or condition using credible, current sources. Knowledge can help dispel fear and anxiety.

I see that you are frustrated, but this illness has its ups and downs. I am sure you will feel much better soon.

I understand your frustration with your situation. I would like to refer you to a therapist.

I think it's really important that you talk to your family more about this. I'm sure they can help you out.

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 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 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

Cultural aspects of mood disorders for USMLE Step 2 CK: High-Yield Psychiatry Lessons

Cultural Frameworks - It's a Small World

Somatic Symptom Focus: Many cultures (e.g., Asian, Latin American) express distress through physical symptoms (somatization) rather than emotional language.
- Examples: "nerves" (ataques de nervios), "heaviness," "imbalance."
Culture-Bound Syndromes: Presentations of mood disturbances may fit specific cultural syndromes.
- Ataque de nervios: Common in Latin Caribbean groups; includes trembling, heart palpitations, and a sense of being out of control.
- Susto (Latin America): Illness attributed to a frightening event, causing the soul to leave the body.

⭐ In many non-Western cultures, inquiries about mood should be supplemented with questions about physical symptoms like fatigue, pain, or sleep disturbances, as these are often the primary complaint.

Symptom Expression - Not Just Feeling Blue

Cultural background profoundly shapes how patients experience and report depressive symptoms, often de-emphasizing affective components in favor of physical ones.
Somatization is a key feature: psychological distress is channeled into and expressed through physical symptoms.
- Instead of reporting sadness, patients may present with chief complaints of headaches, fatigue, palpitations, or chronic pain.
- This is more prevalent in cultures where overt emotional expression is stigmatized or less accepted.
Culture-Bound Presentations:
- Latinx cultures: Ataque de nervios ("attack of nerves") involves intense emotional upset, aggression, and seizure-like or fainting episodes.
- Asian cultures: Diagnoses like Neurasthenia (神经衰弱, shénjīng shuāiruò) emphasize physical and mental fatigue over depressed mood.

⭐ Exam Favorite: When a patient from a non-Western culture presents with multiple, vague somatic complaints that lack a clear medical etiology, maintain a high index of suspicion for an underlying mood disorder like Major Depressive Disorder (MDD).

Treatment & Barriers - Bridging the Divide

Core Barriers to Care:
- Stigma & Shame: Prevents individuals from seeking help, fearing social or family rejection.
- Mistrust of Healthcare: Often rooted in historical injustices (e.g., Tuskegee study) or personal experiences of discrimination.
- Language Differences: Use of non-professional interpreters (e.g., family) can lead to miscommunication and diagnostic errors.
- Divergent Explanatory Models: Patients may attribute symptoms to spiritual or social causes, not a medical illness.
Bridging the Divide - Key Strategies:
- Cultural Humility: A lifelong commitment to self-evaluation and redressing power imbalances.
- Patient-Centered Tools: Employ the Cultural Formulation Interview (CFI) from DSM-5.
- Integrated Care: Co-locating mental health services within primary care settings.

⭐ High-Yield: The Cultural Formulation Interview (CFI) is a standardized, 16-question tool in DSM-5 designed to help clinicians understand a patient's cultural background and its impact on their clinical presentation and care. It is essential for building a therapeutic alliance.

High-Yield Points - ⚡ Biggest Takeaways

Depression often presents with somatic symptoms (e.g., fatigue, pain) in Asian and Hispanic cultures, not sadness.

Cultural stigma is a primary barrier to seeking care, leading to delayed diagnosis and treatment.

Be aware of culture-bound syndromes like ataque de nervios (Hispanic) which can overlap with mood disorders.

Misdiagnosis is a major risk without considering the patient's cultural context and communication style.

Native Americans/Alaska Natives have ↑ rates of depression and suicide, linked to historical trauma.

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