74 interactive clinical cases across 16 specialties.
A 48-year-old woman with GAD and multiple SSRI/SNRI failures is skeptical about buspirone after hearing it 'doesn't work.' This case explores why buspirone's reputation undersells its utility, how to identify ideal candidates, and why dosing and expectation-setting are the difference between success and failure.
A 28-year-old woman is referred after an ER visit where she disclosed intrusive thoughts of harming her infant. She was started on risperidone and referred for 'psychotic features.' This case explores the critical differential between harm OCD and genuine psychosis, and the treatment implications of getting it wrong.
A 29-year-old software engineer turns down a promotion to avoid public speaking. Explore the diagnosis and treatment of social anxiety disorder, distinguish it from introversion and avoidant personality disorder, and learn why SSRI plus CBT with exposure hierarchy is the gold standard.
A 31-year-old software developer presents after his 4th ER visit in 3 months for chest pain, palpitations, and fear of dying — all with negative cardiac workups. Walk through the differential diagnosis, panic disorder criteria, behavioral assessment, and evidence-based treatment planning.
A 42-year-old teacher presents with escalating anxiety, but the tremor, weight loss, and palpitations tell a different story. Learn to distinguish genuine psychiatric illness from medical mimics — and why the labs are never optional.
A 9-year-old boy is brought by his mother to outpatient child psychiatry after she read online that his explosive temper outbursts might be bipolar disorder. His father has Bipolar I. He has comorbid ADHD. The clinical question: Is this pediatric bipolar disorder or the chronic irritability pattern that DSM-5 now calls Disruptive Mood Dysregulation Disorder? The answer determines everything — from medication choices to long-term prognosis to what this mother needs to hear.
A 13-year-old male referred by juvenile probation after his third shoplifting charge presents with a history of ODD, escalating antisocial behavior, animal cruelty, and a chilling absence of remorse. His mother is exhausted and afraid. Walk through the diagnostic evolution from ODD to Conduct Disorder, learn to assess callous-unemotional traits in context, and develop a treatment plan grounded in evidence rather than fear.
A 14-year-old girl referred by her school counselor for increasing absences presents with raw, cracked hands, 90-minute showers, and a mother who has rearranged her entire life to accommodate rituals she believes are 'just anxiety.' This case walks through the diagnosis of contamination OCD in an adolescent, the critical role of family accommodation in maintaining symptoms, first-line treatment with ERP and SSRIs, and the nuances of pediatric prescribing when a parent wants medication to be the whole answer.
A 15-year-old male expelled for fighting arrives with a school-assigned ODD label. But underneath the defiance is a teenager who's stopped sleeping, lost interest in everything he loved, and has a family history no one thought to ask about. Walk through the full evaluation — from referral to treatment plan — and learn why behavior is never the whole story.
A 15-year-old on four medications from three different providers presents with worsening function, significant weight gain, and daytime sedation, prompting a careful reassessment of diagnoses, medication rationale, and a rational deprescribing approach.
An 11-year-old girl with ADHD and anxiety is brought by her mother for an initial psychiatric evaluation. Her parents are divorced with joint legal custody. Mother wants medication started; father is firmly against it. The clinician must navigate parental disagreement, protect the child from triangulation, and determine a path forward -- all while recognizing that legal and institutional requirements vary significantly by jurisdiction and setting.
A 38-year-old man with bipolar I disorder was brought to the ER by police after threatening to jump from a parking garage. He's been in the psychiatric emergency room for 6 hours, he's calmer now, and he wants to go home. He insists the episode is over. His wife is begging you not to let him leave. You have 30 minutes to decide: does he stay voluntarily, leave AMA, or get committed involuntarily?
A 52-year-old divorced accountant presents for a routine follow-up. He's calm, polished, and answers your screening questions perfectly — no suicidal ideation, no plan, no intent. But something doesn't add up. His affect is too calm for someone whose life is falling apart. This case teaches what suicide risk assessment looks like when the patient is managing your impression.
Ava is a 16-year-old established patient being treated for MDD with sertraline 100mg. She's been improving — until a breakup two weeks ago unraveled everything. During a routine follow-up, she discloses suicidal ideation with a specific plan: her mother's leftover hydrocodone. She asks you not to tell her parents. Her mother is in the waiting room. This case walks through principles of crisis assessment, safety planning, confidentiality in minors, lethal means counseling, and disposition — emphasizing clinical reasoning over rigid protocols.
A 22-year-old college student presents with a BMI of 14.8, bradycardia, and electrolyte abnormalities after months of progressive restriction. This case explores the medical urgency of severe anorexia nervosa, refeeding syndrome risk, and why there are no FDA-approved medications for this disorder.
A 41-year-old man is referred for depression. His BMI is 38. He's been told to lose weight by every doctor he's seen for the past decade. Nobody has ever asked him how he eats — not what he eats, but how. He describes episodes of rapid, out-of-control eating followed by overwhelming shame and disgust. He doesn't purge. He's never heard the term 'binge eating disorder.' He thought this was just a willpower problem.
A 27-year-old dental hygienist is referred by her dentist — not her PCP — after he noticed enamel erosion patterns consistent with self-induced vomiting. She presents for 'depression and anxiety,' makes no mention of eating, and looks completely healthy. Her BMI is 22. The eating disorder is invisible unless you know where to look, and she's counting on you not looking.
A 78-year-old man is two days post hip surgery and 'not making sense' according to the surgical team. They want you to start an antipsychotic so he'll stop pulling at his IV lines. His daughter says he was 'a little forgetful' before admission but nothing like this. You're the psychiatry consult. The surgical team wants a quick fix. The family wants to know if this is Alzheimer's. Neither question has the answer they're hoping for.
A 74-year-old retired ICU nurse hasn't left her house in three months. She says it's because of her knees, her vertigo, and the ice outside. Her PCP thinks it's anxiety. She has a PRN alprazolam prescription she's been using daily. Everyone is treating pieces of this — nobody is seeing the whole picture.
A 72-year-old retired schoolteacher is brought in by her daughter who suspects Alzheimer's disease. Cognitive symptoms emerged suddenly after the death of her husband. Can you distinguish pseudodementia from true dementia — and give this patient the diagnosis she actually deserves?
An 81-year-old widow with mild cognitive impairment wants to sell her house and give the proceeds to her church. Her adult children are convinced she's being manipulated and want you to declare her incompetent. She's sitting in front of you, sharp-eyed and annoyed, telling you this is her money and her decision. This case teaches what capacity actually means — and what it doesn't.
A 38-year-old high school teacher with bipolar II has failed lamotrigine and valproate and is now a candidate for lithium, but his previous provider hesitated and the patient fears 'being poisoned by a metal.' Navigate the evidence, the workup, the conversation, and the long-term monitoring plan.
A 34-year-old man on sertraline 100mg for MDD presents with sexual dysfunction, emotional blunting, weight gain, and bruxism. His depression improved significantly, but side effects are affecting his quality of life. Navigate the decision between managing side effects, augmenting, and switching medications.
A 58-year-old woman presents to your practice after her previous psychiatrist retired. She has been stable on alprazolam 1mg TID for 12 years. Guidelines say taper, but the evidence for forced tapering in stable patients is more nuanced than it appears. Can you assess the individual, weigh the actual risks, and navigate this with the patient rather than at her?
A patient on lamotrigine calls in a panic about a new rash, requiring the clinician to differentiate a benign drug rash from potentially life-threatening Stevens-Johnson Syndrome and make a time-sensitive clinical decision.
A 62-year-old woman arrives on seven psychotropic medications from multiple providers. She's fatigued, cognitively foggy, gaining weight, and falling. Can you untangle the prescribing cascade, identify what to stop, and build a rational deprescribing plan without destabilizing her?
A 44-year-old yoga instructor with bipolar II disorder, stable on lithium and quetiapine for three years, requests complete psychiatric medication discontinuation after embracing holistic wellness practices. The clinician must balance respect for patient autonomy with the duty to inform about serious risks — including the specific dangers of lithium discontinuation.
A 42-year-old school psychologist with bipolar II disorder, stable for 18 months on lamotrigine and quetiapine, requests medication simplification due to weight gain, morning grogginess, and emerging metabolic concerns. The clinician must weigh the legitimate burden of long-term side effects against the risk of destabilizing a patient who is doing well — navigating a clinical space where guidelines offer little guidance and the art of psychiatry matters most.
A 58-year-old retired firefighter presents 6 weeks after an anterior wall STEMI with apathy, insomnia, weight loss, and passive suicidal ideation. His cardiologist referred him because his wife reports he 'isn't himself.' This case explores the distinction between adjustment disorder and MDD in the post-MI context, cardiac-safe antidepressant selection, critical drug interactions, and the evidence that untreated depression is an independent cardiac risk factor.
A 67-year-old retired engineer presents 14 months after his wife's death with persistent depressive symptoms, raising the question of whether this represents prolonged grief disorder, bereavement-triggered MDD, or a longer-than-typical but normal grief process.
A 35-year-old IT project manager presents for an 8-week follow-up on sertraline 100mg for MDD. His depression has clearly improved (PHQ-9: 19 to 9), but he reports new-onset irritability, emotional volatility, and anger outbursts that are damaging his marriage and his relationship with his 6-year-old son. Navigate the differential diagnosis of SSRI-associated irritability — including emotional blunting, residual depression, akathisia, and emerging bipolarity — and develop a treatment plan that addresses both the pharmacological and relational dimensions of the problem.
A 44-year-old middle school history teacher presents for a 12-week follow-up on sertraline. His PHQ-9 has dropped from 21 to 11 — a meaningful improvement, but he remains symptomatic with prominent anhedonia and says he is 'going through the motions.' This case explores the clinical challenge of partial response in depression: when to optimize the current regimen, when to augment, when to switch, and why remission — not merely response — must be the treatment target. Most real patients live in this 'almost better' zone, and how you navigate it determines whether they recover or relapse.
A 38-year-old graphic designer returns for a 2-week follow-up after starting escitalopram for MDD. She reports feeling 'amazing' — but sleeping 4-5 hours, starting multiple new projects, and talking faster than usual. Is this a genuine antidepressant response, SSRI activation syndrome, or emerging hypomania? Navigate the differential, medication decisions, and the difficult conversation with a patient who finally feels good.
A 48-year-old CPA presents frustrated after two 'failed' antidepressant trials. Walk through the systematic approach to treatment-resistant depression — verifying adequate trials, optimization, augmentation strategies, and advanced therapies.
A 21-year-old college junior presents with insomnia and academic failure. But the real diagnosis is hiding in the history. Walk through the full evaluation from presentation to follow-up.
A 36-year-old litigation attorney is brought to your clinic by his terrified law partner. He hasn't slept in five days, spent $40,000 on crypto, and stopped his lithium six weeks ago because he's 'cured.' Navigate the hospitalization decision, acute stabilization, and discharge planning for full-blown mania with psychotic features.
A 55-year-old long-haul truck driver is referred after 14 months of unexplained chronic pain, fatigue, GI complaints, and headaches. His medical workup is entirely negative, his PCP is frustrated, and Frank insists he's not depressed — he's sick. Learn to recognize depression when it speaks through the body, and how to meet a skeptical patient where he is.
A 33-year-old male EMT is referred for "bipolar not responding to treatment" after 6 months on lamotrigine. His "mood swings" don't follow bipolar patterns — they're rapid, reactive, and interpersonally driven. Navigate the critical differential between Bipolar II and Borderline Personality Disorder in a male patient, and learn why getting this wrong means treating the wrong diagnosis.
A 34-year-old teacher presents with 3 months of worsening fatigue, anhedonia, and difficulty concentrating. Walk through the initial psychiatric evaluation, differential diagnosis, and treatment planning.
A 29-year-old elementary school teacher presents proactively in early October, reporting four consecutive years of winter depressive episodes with full summer remission. She wants to prevent this year's episode before it takes hold. Navigate the diagnostic criteria for the seasonal pattern specifier, differentiate from other causes of winter worsening, and build a preventive treatment plan using light therapy, chronotherapy, and the only FDA-approved antidepressant for seasonal depression prevention.
A 29-year-old software engineer presents with well-established ADHD-inattentive type and co-occurring generalized anxiety disorder, raising the question of which condition to treat first and how to navigate medication choices when treatments for one may complicate the other.
A 39-year-old corporate attorney and law firm partner presents with 6 months of progressive concentration difficulties, exhaustion, emotional flatness, and a sense that her brain 'stopped working.' Her PCP referred her after a positive ADHD screen she requested based on social media content. Navigate the increasingly common clinical challenge of distinguishing late-unmasked ADHD from occupational burnout and depression with prominent cognitive symptoms.
A 31-year-old high school science teacher and assistant basketball coach with ADHD predominantly inattentive presents after 10 weeks on atomoxetine 80mg with minimal response. The case navigates diagnostic verification, sleep deprivation as a confound, weight-based dose optimization, addressing stigma-driven stimulant avoidance, and the practical pharmacology of transitioning from a non-stimulant to a stimulant regimen.
A 28-year-old social media manager with a prior BPD diagnosis presents questioning whether she actually has ADHD — or both. She describes rapid mood shifts lasting minutes (not days), intense rejection sensitivity, chronic disorganization, and emotional outbursts she can't control. Navigate one of the highest-stakes differential diagnoses in young women: ADHD emotional dysregulation vs. BPD vs. comorbid ADHD + BPD, where the treatment trajectories diverge dramatically and getting it wrong in either direction causes harm.
A 26-year-old graduate student requests Adderall by name after trying a friend's prescription. The evaluation reveals a picture that is neither clearly ADHD nor clearly not — the kind of ambiguity where most of these encounters actually land. This case models the systematic approach that serves the patient regardless of which way the diagnosis ultimately falls.
A 41-year-old senior systems engineer is referred by his couples therapist after his wife describes him as 'emotionally absent.' Nathan has never had a psychiatric evaluation but has always known he was 'different.' Walk through the diagnostic reasoning for late-diagnosed autism in adult men, differentiate ASD from schizoid personality disorder, social anxiety, and alexithymia, and build a treatment plan centered on self-understanding, accommodation, and relationship repair.
A 34-year-old marketing director is referred after CBT for anxiety isn't working. She's high-functioning but unraveling — missed deadlines, 47 open browser tabs, and a lifetime of 'not living up to her potential.' Walk through the adult ADHD diagnostic workup, differential diagnosis, and stimulant prescribing.
Derek T. is a 34-year-old software developer with a childhood ADHD diagnosis and a real history of stimulant misuse in college — including snorting Adderall and recreational cocaine use. He has been sober for 6 years and is now functionally impaired at work and home. He is upfront about his history and wants help. This case explores the clinical reasoning behind risk-stratified stimulant prescribing when ADHD is genuine and substance history is real.
A 35-year-old librarian has been in treatment for anxiety and depression for 12 years with no real improvement. She's tried 4 SSRIs, 2 SNRIs, buspirone, and multiple therapists. After reading an article about autism in women, she's requesting an evaluation. Walk through the diagnostic reasoning for late-diagnosed autism in adults, unpack the masking phenomenon, differentiate ASD from look-alike conditions, and build a treatment plan that centers accommodations over medication.
A 22-year-old pre-med student requests an ADHD evaluation, citing classic symptoms and reporting that Adderall she buys from a classmate is the only thing that helps her study. Her presentation is polished and textbook-perfect — but the clinical picture is more complicated than it appears. Walk through the structured assessment that protects both patient and provider.
A 31-year-old woman who is 8 weeks pregnant stopped sertraline 150mg abruptly after a positive pregnancy test and is now experiencing depressive relapse — raising the question of how to navigate the risk-benefit conversation when both treating and not treating carry real consequences.
A 30-year-old woman is brought in by her husband 4 weeks postpartum with persistent crying, insomnia, intrusive thoughts about the baby, and a statement that alarms everyone: "The baby would be better off without me." Navigate the timeline-based differential, risk assessment, and the medication-in-breastfeeding conversation that every perinatal clinician must master.
A 52-year-old man presents requesting an antidepressant after being passed over for a promotion and estranged from his adult son. He's charming, articulate, and flattering — and everything wrong in his life is someone else's fault. The depression is real. But if you miss the personality disorder underneath it, you'll spend years chasing a treatment response that never fully arrives.
A 26-year-old woman presents urgently after an ED discharge for superficial self-harm following a breakup. She's idealizing you, begging you not to hospitalize her, and her treatment history is a trail of burned bridges. Navigate risk assessment, countertransference, medication decisions, and boundary-setting in one of the most clinically challenging presentations in psychiatry.
A 32-year-old man with schizophrenia has failed multiple adequate antipsychotic trials and continues to experience debilitating psychosis. This case explores the rationale, logistics, and clinical considerations involved in initiating clozapine for treatment-resistant schizophrenia.
A 20-year-old computer science major is brought to your clinic by his terrified parents. Over 4-5 months he's withdrawn, stopped showering, and failed his classes. Now he believes the WiFi is monitoring his thoughts and a stranger's voice is narrating his actions. This is what real psychosis looks like — the companion case to the PTSD veteran whose trauma re-experiencing was mistaken for psychosis.
A 24-year-old woman referred from a domestic violence shelter reports hearing a male voice telling her she's worthless. Sometimes it sounds like her childhood abuser — clearly trauma-linked. But sometimes it's a stranger narrating her actions in the third person — which doesn't fit trauma at all. She's paranoid about being followed, but she's also fleeing a violent partner. This case doesn't fit neatly into one box, and the correct clinical position is to sit with that uncertainty rather than force a premature diagnosis.
A 52-year-old man with treatment-resistant MDD developed intense restlessness 3 weeks after aripiprazole augmentation. His previous provider misinterpreted the symptoms as worsening anxiety and increased the dose, making everything worse. Learn to recognize akathisia, avoid the catastrophic error of escalating the offending agent, and manage this common and dangerous side effect.
A 41-year-old man abruptly stopped venlafaxine 225mg after two years of successful MDD treatment and now presents with 'brain zaps,' dizziness, nausea, and emotional lability — raising the question of whether this is a true depressive relapse or antidepressant discontinuation syndrome.
A 45-year-old woman presents with agitation, diaphoresis, tremor, and rigidity after an incomplete cross-taper from venlafaxine to phenelzine with concurrent tramadol use. Learn to differentiate serotonin syndrome from neuroleptic malignant syndrome, identify high-risk drug combinations, and manage these life-threatening medication emergencies.
A 56-year-old woman with stable schizoaffective disorder on long-term haloperidol presents for routine follow-up, where you notice subtle orofacial movements she has dismissed as a nervous habit. This case explores tardive dyskinesia recognition, the AIMS exam, differential diagnosis of movement disorders, and the emerging role of VMAT2 inhibitors — all while navigating the tension between treating a movement disorder and preserving hard-won psychiatric stability.
A 23-year-old man presents to the ER with his neck locked to one side and his eyes rolling upward, 8 hours after receiving IM haloperidol on a psychiatric unit. The nursing staff thinks he's having a seizure. This case covers recognition, acute treatment, risk factors, and the clinical reasoning that prevents it from happening again.
A 34-year-old ICU nurse working permanent night shifts presents with worsening insomnia, irritability, and depressive symptoms. Her PCP started trazodone for sleep, her coworker gave her lorazepam, and she's drinking energy drinks to stay awake at work. Before you treat the mood symptoms, look at the schedule.
A 45-year-old ICU nurse with chronic insomnia requests zolpidem. Explore evidence-based treatment for insomnia, the role of CBT-I as first-line therapy, and how to navigate the 'just give me a pill' conversation with a medically knowledgeable patient.
A 48-year-old elementary school teacher presents with worsening depression despite two adequate SSRI trials. She's exhausted, gaining weight, can't concentrate, and her husband sleeps in the guest room because of her snoring. Before you reach for a third antidepressant, look at what everyone else has missed.
A 41-year-old general contractor self-refers after his wife discovers he's been buying oxycodone from a coworker. What began as a legitimate prescription for a back injury has become severe opioid use disorder. Walk through destigmatization, assessment, MAT selection, buprenorphine induction, and long-term treatment planning.
A 44-year-old man presents requesting alprazolam refills after his previous psychiatrist retired. He's been on escalating doses for 3 years, now taking alprazolam 2mg TID — and sometimes more during stressful weeks. He's not trying to get high. He's terrified of what happens when he runs out. His previous provider kept increasing the dose because nothing else seemed to work, and now you've inherited a patient who is both physiologically dependent and meeting criteria for a use disorder. You can't just refuse to prescribe — but you can't keep doing what was done before.
A 38-year-old pharmaceutical sales rep is referred after a DUI. He drinks 6-8 drinks nightly and endorses significant depressive symptoms. Untangle the classic dual diagnosis question: is this independent MDD driving the drinking, or alcohol-induced depression that will resolve on its own?
A 29-year-old software engineer presents for anxiety treatment. He's bright, functional, and dismissive of any concern about his daily cannabis use — 'it's legal and it's the only thing that helps.' His anxiety is worsening despite (or because of) daily use, and he can't see the connection. This case explores the clinical challenge of cannabis use disorder when the patient doesn't believe it's a problem.
A 31-year-old tow truck driver is brought to the ER by his brother after five days without sleep, paranoid delusions about government tracking, and visual hallucinations. He tests positive for methamphetamine. The clinical question isn't whether meth caused this — it's whether meth is the whole story, and what happens when it clears.
A 32-year-old woman referred for 'treatment-resistant depression' arrives 15 minutes late, avoids eye contact, and gives vague answers. She's been through four providers, three SSRIs, and carries an informal BPD label no one has formally diagnosed. The clinical picture shifts when you stop treating the symptoms on the surface and start wondering what's underneath them.
A 26-year-old graduate student presents for insomnia that started 'a few months ago.' She's controlled, articulate, and wants a sleeping pill. Over the course of the interview, the real reason she can't sleep begins to surface — but only if you create the conditions for it. This case teaches trauma-informed assessment when the patient isn't ready to say the word.
A 28-year-old combat veteran is referred for "auditory hallucinations and paranoid behavior." But the voices have a context, the visions have a trigger, and the paranoia has a reason. Walk through the critical distinction between trauma-driven re-experiencing and true psychosis.