USMLE Step 2 Quiz: Mood And Anxiety Disorders

What this quiz covers

This quiz focuses on Mood And Anxiety Disorders, giving you a quick way to practice the rules, question types, and explanations that matter most for USMLE Step 2.

How to use this quiz

Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

Question 1

1. Increase the dose of lithium for better mood stabilization
2. Discontinue lithium and start valproic acid (correct answer)
3. Add an ACE inhibitor to protect the kidneys
4. Recheck creatinine in 6 months

Explanation: Long-term lithium use can cause chronic kidney disease, specifically chronic tubulointerstitial nephropathy, and nephrogenic diabetes insipidus. A significant and progressive rise in creatinine is a sign of lithium-induced nephrotoxicity. The most appropriate step is to discontinue the offending agent and switch to an alternative mood stabilizer, such as valproic acid or lamotrigine, to prevent further renal damage while maintaining mood stability.

• A) Increase the dose of lithium: This would worsen the renal toxicity.
• C) Add an ACE inhibitor: While ACE inhibitors are used in some forms of chronic kidney disease, the primary intervention for drug-induced nephropathy is to stop the causative drug.
• D) Recheck creatinine in 6 months: This would be an inappropriate delay in management, allowing for further irreversible kidney damage.

Question 2

1. Adjustment disorder with depressed mood
2. Major depressive disorder (correct answer)
3. Unspecified anxiety disorder
4. Normal stress reaction

Explanation: Although the symptoms are linked to a stressor (failing an exam), they meet the full criteria for a major depressive episode (MDE). She has at least five of the required symptoms (depressed mood, anhedonia, fatigue, poor concentration, hypersomnia) for a duration of two months, causing significant distress. When the full criteria for MDE are met, the diagnosis is Major Depressive Disorder, even if it was precipitated by a stressor. Adjustment disorder is diagnosed only when the criteria for another mental disorder are not met.

• A) Adjustment disorder with depressed mood: This diagnosis is not made if the symptom presentation meets the criteria for a major depressive episode.
• C) Unspecified anxiety disorder: The primary symptoms described are depressive, not anxious.
• D) Normal stress reaction: While stress is present, the severity and number of symptoms, along with the duration, suggest a clinical disorder rather than a normal reaction.

Question 3

1. Analysis of childhood experiences and unconscious conflicts
2. Practicing acceptance of anxious thoughts without judgment
3. Identifying and challenging cognitive distortions related to worry (correct answer)
4. Prescribing anxiolytic medication to use during therapy sessions

Explanation: A central tenet of cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) is cognitive restructuring. This involves helping the patient identify maladaptive or distorted thoughts (e.g., catastrophizing, probability overestimation) that fuel their chronic worry and then challenging and replacing these thoughts with more realistic and balanced alternatives. This, combined with behavioral techniques like relaxation training, forms the core of CBT for GAD.

• A) Analysis of childhood experiences: This is characteristic of psychodynamic or psychoanalytic therapy, not CBT.
• B) Practicing acceptance: This is a core component of Acceptance and Commitment Therapy (ACT) and mindfulness-based approaches, which are distinct from traditional CBT.
• D) Prescribing medication: This is not a component of psychotherapy, which is delivered by a therapist who may or may not have prescribing authority.

Question 4

1. Major depressive disorder
2. Normal bereavement (correct answer)
3. Persistent depressive disorder
4. Adjustment disorder with depressed mood

Explanation: This patient's symptoms are consistent with a normal grief reaction (bereavement). Although he has some symptoms that overlap with depression (sadness, sleep and appetite changes), key features point away from a major depressive episode. He maintains an interest in activities and social connections, his mood improves with social contact, and he does not have pervasive feelings of worthlessness, hopelessness, or suicidal ideation. His sadness is focused on the loss of his wife. While major depression can occur during bereavement, this patient's presentation is more consistent with a non-pathological grief process.

• A) Major depressive disorder: This diagnosis would be considered if the patient had more pervasive anhedonia, feelings of worthlessness, or suicidal ideation that are distinct from feelings of loss.
• C) Persistent depressive disorder: This is a chronic condition lasting at least 2 years and would not be diagnosed in this acute context.
• D) Adjustment disorder: While bereavement is a stressor, the term 'normal bereavement' is more specific and appropriate when the reaction is non-pathological and consistent with a typical grief response.

Question 5

1. Major depressive disorder, in partial remission
2. Cyclothymic disorder
3. Persistent depressive disorder (dysthymia) (correct answer)
4. Adjustment disorder with chronic depressed mood

Explanation: Persistent depressive disorder (dysthymia) is characterized by a chronically depressed mood for at least two years in adults. The patient must have two or more additional depressive symptoms (e.g., fatigue, low self-esteem, poor concentration). This patient's long-standing, less severe depressive symptoms that have not met the criteria for a major depressive episode are classic for this diagnosis.

• A) Major depressive disorder: This requires five or more symptoms, including depressed mood or anhedonia, causing significant impairment for at least two weeks. This patient's symptoms are less severe and more chronic.
• B) Cyclothymic disorder: This involves at least two years of fluctuating hypomanic and depressive symptoms that do not meet full criteria for an episode. This patient has no history of hypomanic symptoms.
• D) Adjustment disorder: This is a reaction to a specific stressor and would not typically last for three years.

Question 6

1. Adjustment disorder with depressed mood
2. Major depressive disorder (correct answer)
3. Persistent depressive disorder
4. Bipolar II disorder

Explanation: The patient meets the diagnostic criteria for major depressive disorder (MDD). She has experienced at least five depressive symptoms (depressed mood, anhedonia, sleep disturbance, fatigue, weight loss, feelings of worthlessness, decreased concentration) for a period longer than two weeks, causing significant functional impairment. The absence of any history of manic or hypomanic episodes makes MDD the most likely diagnosis.

• A) Adjustment disorder with depressed mood: This is diagnosed when emotional or behavioral symptoms develop in response to an identifiable stressor within 3 months of its onset. The symptoms in this vignette are not linked to a specific stressor and have lasted for 6 months, making MDD more likely.
• C) Persistent depressive disorder (dysthymia): This is characterized by a chronic depressed mood for at least two years, with fewer and less severe symptoms than MDD. This patient's symptoms are more severe and have a duration of 6 months.
• D) Bipolar II disorder: This diagnosis requires at least one hypomanic episode and at least one major depressive episode. The patient explicitly denies any history of elevated or irritable moods.

Question 7

1. Schizophreniform disorder
2. Bipolar I disorder (correct answer)
3. Cyclothymic disorder
4. Attention-deficit/hyperactivity disorder

Explanation: The patient is exhibiting classic symptoms of a manic episode, including elevated/irritable mood, decreased need for sleep, grandiosity, flight of ideas, and engagement in high-risk behaviors (impulsive spending). A single manic episode is sufficient for the diagnosis of Bipolar I disorder. The symptoms are causing significant functional impairment and require intervention.

• A) Schizophreniform disorder: This diagnosis requires psychotic symptoms like delusions, hallucinations, or disorganized speech for at least one month but less than six months. While grandiosity can be delusional, the primary presentation is a mood disturbance.
• C) Cyclothymic disorder: This involves at least two years of numerous periods with hypomanic and depressive symptoms that do not meet the criteria for a full episode. This patient is experiencing a full manic episode.
• D) Attention-deficit/hyperactivity disorder (ADHD): While ADHD can involve hyperactivity and impulsivity, the symptoms are chronic and developmental, not episodic. The acute onset, decreased need for sleep, and grandiosity are characteristic of mania, not ADHD.

Question 8

1. Bipolar I disorder
2. Major depressive disorder with anxious distress
3. Bipolar II disorder (correct answer)
4. Cyclothymic disorder

Explanation: This patient's history is consistent with Bipolar II disorder, which is characterized by at least one hypomanic episode and at least one major depressive episode. Her current state (elevated mood, increased energy, decreased need for sleep, increased productivity for 5 days) meets the criteria for a hypomanic episode, which, by definition, does not cause marked impairment or require hospitalization. She also has a clear history of a major depressive episode.

• A) Bipolar I disorder: This diagnosis requires a history of at least one full manic episode, which involves more severe symptoms and significant functional impairment or hospitalization. This patient's 'up' periods are hypomanic.
• B) Major depressive disorder with anxious distress: This describes MDD with features of anxiety, but does not account for the distinct episodes of elevated mood and energy.
• D) Cyclothymic disorder: This involves chronic (at least 2 years) mood fluctuations with periods of hypomanic and depressive symptoms that do not meet the full criteria for an episode. This patient has experienced a full major depressive episode.

Question 9

1. Sertraline
2. Mirtazapine
3. Bupropion (correct answer)
4. Amitriptyline

Explanation: Bupropion is an antidepressant that primarily inhibits the reuptake of norepinephrine and dopamine. It is unique among antidepressants for its lack of serotonergic activity, which means it is not typically associated with sexual dysfunction or weight gain. Given the patient's specific concerns, it is an excellent first-line choice.

• A) Sertraline: As a selective serotonin reuptake inhibitor (SSRI), sertraline is a common first-line treatment for depression but is frequently associated with sexual side effects.
• B) Mirtazapine: This medication often causes sedation and significant weight gain due to its antihistaminic effects, making it a poor choice for this patient.
• D) Amitriptyline: This is a tricyclic antidepressant (TCA) that is no longer considered first-line due to its significant side effect profile (anticholinergic effects, cardiotoxicity in overdose) and potential for weight gain.

Question 10

1. Serotonin syndrome
2. Antidepressant discontinuation syndrome
3. Bipolar disorder (correct answer)
4. Substance-induced mood disorder

Explanation: The development of a manic or hypomanic episode during antidepressant treatment is a key indicator of an underlying bipolar disorder. Antidepressant monotherapy can precipitate a switch from depression to mania in susceptible individuals. The patient's symptoms of elevated mood, decreased need for sleep, increased talkativeness, and impulsive behavior meet the criteria for a manic or hypomanic episode, unmasking a bipolar diathesis.

• A) Serotonin syndrome: This is a life-threatening condition characterized by autonomic instability, altered mental status, and neuromuscular hyperactivity (e.g., hyperreflexia, myoclonus). This patient's symptoms are consistent with a manic switch, not serotonin syndrome.
• B) Antidepressant discontinuation syndrome: This occurs upon cessation of an antidepressant and typically involves flu-like symptoms, insomnia, and sensory disturbances.
• D) Substance-induced mood disorder: There is no information in the vignette to suggest substance use is causing her symptoms.

Question 11

1. Agoraphobia
2. Generalized anxiety disorder
3. Panic disorder
4. Social anxiety disorder (correct answer)

Explanation: The patient's symptoms are characteristic of Social Anxiety Disorder (Social Phobia). He has a marked fear of one or more social or performance situations (giving presentations) in which he is exposed to possible scrutiny by others. He fears he will act in a way that will be embarrassing or humiliating. This fear is causing him to avoid these situations, leading to academic impairment. His comfort in non-performance social situations is also typical.

• A) Agoraphobia: This is a fear of situations where escape might be difficult or help unavailable, typically involving places like crowds, public transportation, or open spaces.
• B) Generalized anxiety disorder: This involves excessive worry about a number of events or activities, not specifically focused on social performance.
• C) Panic disorder: This diagnosis requires recurrent, unexpected panic attacks. The patient's anxiety and panic-like symptoms are specifically triggered by a social performance situation.

Question 12

1. Taper and discontinue the medication now that he is feeling better
2. Continue the medication for another 4-8 weeks, then taper off
3. Continue the medication at the same dose for at least 6-12 months (correct answer)
4. Continue the medication indefinitely for lifelong prophylaxis

Explanation: Standard guidelines for the treatment of a single episode of major depressive disorder recommend a continuation phase of treatment. After a patient achieves remission (significant improvement or absence of symptoms), the antidepressant should be continued at the full therapeutic dose for at least 6 to 12 months to prevent relapse. Discontinuing medication too early is a major risk factor for recurrence of the depressive episode.

• A) Taper and discontinue the medication now: This is premature and carries a high risk of relapse.
• B) Continue for another 4-8 weeks: This is too short for the continuation phase and is insufficient to consolidate the treatment response.
• D) Continue indefinitely: Lifelong maintenance therapy is typically reserved for patients with recurrent (e.g., 3 or more) major depressive episodes, chronic depression, or severe episodes.

Question 13

1. Sertraline daily
2. Lorazepam as needed before performances
3. Propranolol as needed before performances (correct answer)
4. Buspirone daily

Explanation: This patient has performance-only social anxiety disorder. The most appropriate treatment for this condition is a beta-blocker, such as propranolol, taken about an hour before the performance. Beta-blockers are effective at controlling the peripheral autonomic symptoms of anxiety (e.g., tremors, palpitations, sweating) without causing cognitive slowing or sedation, which is crucial for a performing musician.

• A) Sertraline daily: An SSRI is a first-line treatment for generalized social anxiety disorder, but it is not ideal for infrequent performance anxiety as it requires daily dosing and takes weeks to become effective.
• B) Lorazepam as needed: A benzodiazepine would be effective at reducing anxiety but is generally avoided in this context due to the risk of sedation, cognitive impairment, and ataxia, which could impair musical performance. There is also a risk of dependence.
• D) Buspirone daily: Buspirone is used for generalized anxiety disorder and is not effective for acute, situational anxiety.

Question 14

1. Psychoanalytic psychotherapy
2. Supportive group therapy
3. Cognitive-behavioral therapy (correct answer)
4. Mindfulness-based stress reduction

Explanation: Cognitive-behavioral therapy (CBT) is the most effective and well-established first-line psychotherapy for panic disorder. CBT for panic disorder typically involves psychoeducation, cognitive restructuring to challenge catastrophic interpretations of physical sensations, and interoceptive exposure to feared bodily sensations to reduce anxiety.

• A) Psychoanalytic psychotherapy: This form of therapy focuses on unconscious conflicts and is not considered a first-line, evidence-based treatment for panic disorder.
• B) Supportive group therapy: While potentially helpful, it is not as targeted or effective as CBT for the core symptoms of panic disorder.
• D) Mindfulness-based stress reduction: While mindfulness can be a useful adjunct, it is not considered the primary, most effective standalone psychotherapy for panic disorder compared to CBT.

Question 15

1. Sertraline
2. Bupropion
3. Quetiapine (correct answer)
4. Alprazolam

Explanation: The treatment of bipolar depression requires agents that are effective for depression without inducing mania. Antidepressant monotherapy is contraindicated due to the risk of precipitating a manic switch. First-line, evidence-based treatments for acute bipolar depression include second-generation antipsychotics like quetiapine and lurasidone, or the olanzapine-fluoxetine combination. Quetiapine has robust evidence for efficacy in treating bipolar depression, both as monotherapy and as an adjunct to mood stabilizers like lithium.

• A) Sertraline & B) Bupropion: Adding an antidepressant (like an SSRI or bupropion) to a mood stabilizer is a second-line strategy and carries a risk of inducing mania, even with a mood stabilizer on board. They are not first-line choices.
• D) Alprazolam: A benzodiazepine may help with associated anxiety or insomnia but does not treat the core depressive symptoms of bipolar disorder.

Question 16

1. Did you experience any changes in your appetite or weight?
2. Did this period of elevated mood last for at least four consecutive days? (correct answer)
3. Did you feel more creative than usual during this time?
4. Did you have a family history of similar mood episodes?

Explanation: The key feature distinguishing a hypomanic episode (required for a Bipolar II diagnosis) from normal mood fluctuations is the duration of symptoms. According to DSM-5 criteria, a hypomanic episode is a distinct period of abnormally and persistently elevated, expansive, or irritable mood and increased energy lasting at least 4 consecutive days and present most of the day, nearly every day. Asking about the duration is critical to determine if this past episode meets the criteria for hypomania.

• A) Changes in appetite: This is a non-specific symptom that can occur in various conditions.
• C) Feeling more creative: While increased creativity can be part of a hypomanic episode, it is not a core diagnostic criterion like duration.
• D) Family history: While important for assessing risk, it does not confirm the diagnosis in the patient herself. The patient's direct symptom history is paramount.

Question 17

1. Fluoxetine
2. Duloxetine (correct answer)
3. Escitalopram
4. Sertraline

Explanation: Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI) that is FDA-approved for the treatment of major depressive disorder, generalized anxiety disorder, and several pain conditions, including diabetic peripheral neuropathy. Its dual mechanism of action on both serotonin and norepinephrine pathways is thought to contribute to its analgesic effects. This makes it an ideal choice for a patient with comorbid depression and neuropathic pain.

• A), C), & D): Fluoxetine, escitalopram, and sertraline are all selective serotonin reuptake inhibitors (SSRIs). While effective for depression, they are not considered first-line treatments for neuropathic pain and are less likely to provide the dual benefit this patient is seeking.

Question 18

1. Benzodiazepines
2. Typical antipsychotics
3. Monoamine oxidase inhibitors (correct answer)
4. Tricyclic antidepressants

Explanation: While SSRIs are first-line for major depressive disorder, including the atypical subtype, monoamine oxidase inhibitors (MAOIs) like phenelzine have been shown to be particularly effective for depression with atypical features, especially in cases that are resistant to other treatments. Atypical features (mood reactivity, hypersomnia, hyperphagia, leaden paralysis, interpersonal rejection sensitivity) are considered a potential predictor of a favorable response to MAOIs.

• A) Benzodiazepines: These are anxiolytics and are not effective as primary treatment for depression.
• B) Typical antipsychotics: These are not used to treat depression and can have significant side effects.
• D) Tricyclic antidepressants (TCAs): While effective for depression, TCAs are generally considered less effective than MAOIs for the atypical subtype.

Question 19

1. Citalopram
2. Venlafaxine
3. Amitriptyline
4. Sertraline (correct answer)

Explanation: Sertraline is the most well-studied and safest antidepressant for patients with recent myocardial infarction or other significant cardiac disease. Large-scale trials (e.g., SADHART-CHF) have demonstrated its safety and efficacy in this population without increasing the risk of adverse cardiovascular events.

• A) Citalopram: At doses above 20 mg/day in older adults (or 40 mg/day in younger adults), citalopram carries a risk of QT interval prolongation, which is a concern in patients with heart disease.
• B) Venlafaxine: As an SNRI, venlafaxine can cause a dose-dependent increase in blood pressure and heart rate, which may be detrimental in patients with coronary artery disease.
• C) Amitriptyline: Tricyclic antidepressants are relatively contraindicated in patients with heart disease due to their potential to cause conduction delays, arrhythmias, and orthostatic hypotension.

Question 20

1. Ebstein anomaly
2. Limb defects
3. Neural tube defects (correct answer)
4. Cleft palate

Explanation: Valproic acid is a known teratogen and is strongly associated with an increased risk of neural tube defects (e.g., spina bifida) when used during the first trimester of pregnancy. For this reason, women of childbearing potential on valproate should be counseled on effective contraception and folate supplementation, and alternative medications should be considered prior to conception.

• A) Ebstein anomaly: This cardiac defect is classically associated with first-trimester lithium exposure.
• B) Limb defects: While some anticonvulsants can be associated with skeletal abnormalities, neural tube defects are the most prominent and specific risk with valproate.
• D) Cleft palate: This can be associated with various medications, but is not the most specific or common major malformation linked to valproate.