A 26 year-old female is brought to your office by her husband because he is concerned about her symptoms. For over a year, she has been feeling less interested in things she usually enjoyed before, she is irritable ‘over little things’, she has trouble falling asleep, wakes up too early many nights, she is not eating much at the dinner table, she feels very tired ‘even after dishwashing’, when her husband gets intimate with her, she moves away, she is not able to concentrate or remember things, she expresses thoughts of emptiness and meaninglessness, and her husband is not comfortable to leave her alone at home. These symptoms dominated her life for over a year. But over the last two weeks, she is having outbursts of energy and feeling very active. She sounds so cheerful, optimistic and enthusiastic. She talks for hours without taking a break, moving from one subject to another subject. Her thoughts are difficult to follow. She is driving too fast and going on spending sprees. She sleeps only for a few minutes every night. She gets into fights with their neighbors over petty matters like where they keep their trash bags for removal by the waste disposal crew. She believes that she has ‘minds like an Einstein’ and passes judgments on things that are irrelevant to her. She is drinking too much alcohol ‘to calm herself’. She tells inappropriate jokes in front of children, dresses in inappropriate and colorful clothing; Three days ago, she told her husband that ‘Einstein’s soul is talking to her to explain a new theory of relativity’ to her. She argues that she is smart enough to win a Nobel Prize in Physics. In the morning, she looks too depressed and in the evening she looks like ‘she is over the clouds talking to Einstein’. She urinated in her pants and her husband had to take her to the emergency room. She was hospitalized for two days and was started on medication to calm her down. What is the most likely diagnosis in this patient?

Gayatri is a 42 year-old female brought to your office because she has been acting abnormally for the last three days. Family reports that the patient claims that she is the greatest mathematician ever lived and she taught mathematics to legendary mathematicians such as David Hilbert and Carl Gauss. She sleeps only two or three hours a night, she talks for hours non stop, she is easily distracted and wrings her hands a lot. To diagnose this patient with Bipolar Disorder type I, which of the following is required?

Donald is a 32 year-old male who is brought to your office by his wife for the evaluation of his symptoms which she has been concerned about. He no longer expresses interest or pleasure in things that used to excite him a lot. His work day starts at 9 am and ends at 5 pm. But he loses interest in the work by 11 am. Even taking breaks doesn’t give him relaxation. He is easily distracted from what he is doing. He can’t comfortably sleep through the night. He feels fatigued after doing even simple things. He feels ‘low energy’. He expresses thoughts of emptiness in his life. Just as they were planning to go to see a psychologist for counseling, she noticed some moments of ‘high energy’ in his life. He leaves for office at 6 am and ‘accomplishes a lot’ by staying till 10 pm. He rambles a lot without saying much of substance. He spends a lot of time in online gambling to the point he stops only when his wife scolds him. He defends himself stating, ‘But I don’t waste a lot of money’. These episodes last 4-5 days at a time before he returns to his usual ‘low energy’ levels. He has had five or six such ‘high energy’ episodes over the years. When you asked them “Are you hearing any voices others don’t hear?”, they replied, ‘no’. To the question, “Are you seeing any things others around you don’t see?”, they answered, “no”. To the question, “Are having any thoughts to hurt yourself or others around you?”, he answered, “no”. To the question, “Have you ever been hospitalized for any of these symptoms you’ve described?”, they answered, “no”. To the question, “Are your symptoms impacting your work negativity?”, they answered, “No, not at all. In fact, my boss gave me a raise for working late sometimes to get my projects finished before the deadlines.I’ve never felt so good before in my life.” To the question, “have you tried any medications for your symptoms?”Donald hesitated to reply, looked at his wife and then told you, “to be honest, I got some adderall pills from my sister-in-law two days ago and took them”. Then you asked him, “Did they help you?”. He replied, “No, they made my symptoms worse. My sleep and mood became worse”. In physical examination, you notice that he is wringing his hands frequently. Otherwise his physical examination is normal. What is the most likely diagnosis for Donald?

A 34 year-old female comes to your office for the evaluation of her ongoing medical problems. For the last 6 months, she reports that she is feeling lack of energy, loss of appetite, difficulty concentrating, difficulty remembering, thoughts os suicide, loss of interest in activities which used to give her lots of pleasure and feeling empty and hopeless most of the time. These symptoms only made her pre-existing sleeping difficulties worse. For the last 4 years, she has had a hard time falling asleep at night, waking up during the night, and waking up too early. Of the following, which is the best medication to treat her symptoms?

A 68 year-old male comes to your office to discuss a ‘sensitive issue’. He has been having difficulty to become aroused, sustain arousal and reach an orgasm. His penis feels numbed up soon after he gets an erection. He has been taking fluoxetine for depression for the last three months and his sexual dysfunction has only got worse. He has seizure disorder and takes levetiracetam for it. He would like to get on a different medication for his depression. Of the following, which is a good choice for this individual?