Clinical Skills

anorexia nervosarefeeding syndromemedical stabilization

Anorexia Nervosa: When the Body Is Failing

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.

Discontinuation SyndromeVenlafaxineSNRIs

Antidepressant Discontinuation Syndrome

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.

LithiumBipolar IIMood Stabilizers

Lithium: The Drug Everyone's Afraid Of

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.

Serotonin SyndromeNeuroleptic Malignant SyndromeMAOI

Serotonin Syndrome vs Neuroleptic Malignant 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.

SSRIsSide EffectsSexual Dysfunction

SSRI Side Effects & The Switch

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.

Tardive DyskinesiaAIMS ExamAntipsychotic Side Effects

Tardive Dyskinesia: The Movement You Almost Missed

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.

NPDNarcissistic Personality DisorderMDD

The Charming Patient Who Blames Everyone Else

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.

acute dystoniahaloperidolextrapyramidal symptoms

The ER Call: Acute Dystonia After Haloperidol

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.

BenzodiazepinesHarm ReductionShared Decision-Making

The Inherited Benzo Patient

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?

intermediate~20 min

The Lamotrigine Rash Call

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.

lamotrigineStevens-Johnson SyndromeSJS

Binge Eating DisorderBEDEating Disorders

The Man Nobody Asked About Food

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.

PolypharmacyDeprescribingPrescribing Cascade

The Messy Med List

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?

intermediate~20 min

The Night Nurse Who Can't Turn Off

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.

Shift WorkCircadian RhythmSleep Disorder

beginner~20 min

The Nurse Who Just Wants to Sleep

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.

InsomniaCBT-ISleep Hygiene

AntipsychoticsMetabolic SyndromeWeight Gain

The Patient Who Gained 30 Pounds

A 32-year-old woman with schizoaffective disorder is psychiatrically stable on olanzapine for the first time in years — but she's gained 30 pounds, her fasting glucose is pre-diabetic, and her mother died of diabetes complications. Walk through metabolic monitoring, the risk-benefit calculus, and the antipsychotic switch decision.

BPDPersonality DisorderCrisis

The Patient Who Splits the Team

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.

Involuntary CommitmentAMADanger to Self

The Patient Who Wants to Leave Against Medical Advice

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?

Bipolar IIMedication DiscontinuationPatient Autonomy

The Patient Who Wants to Stop Everything

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.

Bulimia NervosaEating DisordersNormal Weight

The Patient Whose Dentist Made the Referral

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.

Suicide RiskSafety PlanningRisk Assessment

The Quiet Patient Who Answers Every Question 'Right'

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.

Suicide Risk AssessmentAdolescentSafety Planning

The Routine Follow-Up That Isn't

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.