Step 3 · 4–6%

Behavioral Health

Mood, anxiety, psychosis, substance use and safety, with the first drug and its monitoring.

Depression & suicide risk

Screen, treat to remission with an adequate trial, know when to switch or augment, and match suicide-risk findings to the right level of care.

Rules to know

Routine adult or adolescent visit → screen for depression (PHQ-2, then PHQ-9 if positive), including pregnancy and postpartum, with a system to treat and follow up
Low mood or anhedonia for ≥ 2 weeks → major depression if ≥ 5 symptoms with impairment; ask about mania, substances and suicide; check TSH
Mild depression → psychotherapy (CBT) or an antidepressant; moderate to severe → antidepressant plus psychotherapy
Choosing a first antidepressant → SSRI (sertraline, escitalopram), SNRI, bupropion or mirtazapine by side effects, interactions, prior response and cost
Depression with sexual side-effect worries, fatigue or smoking → bupropion; avoid with a seizure disorder or eating disorder
Older adult with depression, insomnia and weight loss → mirtazapine at bedtime
Antidepressant just started → follow up within 2–4 weeks; under age 25, watch closely for new suicidal thinking (boxed warning)
Little response after 4–8 weeks at an adequate dose → raise the dose, switch, or augment with aripiprazole, lithium, bupropion or psychotherapy
Remission after a first episode → continue the antidepressant 6–12 months; ≥ 3 episodes → long-term maintenance
Failure of ≥ 2 adequate antidepressant trials → treatment-resistant depression; esketamine nasal spray with 2-h observation, TMS or ECT
Depression with psychotic features → antidepressant plus antipsychotic, or ECT
Depression with catatonia, refusal to eat or drink, or imminent suicide risk → ECT
SSRI adverse effects → nausea, sexual dysfunction, bleeding with NSAIDs or anticoagulants, hyponatremia in older adults; citalopram capped at 20 mg after 60 for QT
Abrupt stop of paroxetine or venlafaxine → discontinuation syndrome (dizziness, irritability, shock-like sensations); taper over weeks
Depression recurring every winter → morning bright light therapy, with an SSRI or bupropion
Depressed mood most days for ≥ 2 years → persistent depressive disorder; SSRI plus psychotherapy
Grief after a death → normal grief comes in waves tied to reminders with self-worth intact; full depression criteria → treat as depression
Intense yearning and preoccupation > 12 months after a death → prolonged grief disorder; grief-focused psychotherapy
Mood symptoms in the luteal phase that clear with menses → PMDD; confirm with 2 cycles of daily ratings; SSRI daily or luteal-only, or a drospirenone pill
Tearfulness peaking a few days postpartum, gone by 2 weeks → postpartum blues; reassure and recheck
Postpartum depression → psychotherapy and an SSRI (sertraline fits breastfeeding); zuranolone 14-day course is an option, no driving for 12 h after each dose
Postpartum confusion, hallucinations or bizarre thinking → postpartum psychosis; emergency admission, assess risk to the infant, antipsychotic and often lithium
Depression in an older adult → low-dose sertraline or escitalopram, check sodium; avoid tricyclics and paroxetine
Any depressed patient → ask directly about suicidal thoughts, plan, intent, means (especially firearms) and past attempts; asking does not raise risk
Suicidal thoughts with plan, intent or recent attempt → emergency psychiatric admission (also for psychosis or inability to stay safe), involuntary if refused; constant observation, remove hazards
Suicidal thoughts without intent, with supports → written safety plan, lethal means counseling (firearms stored away from home), 988 crisis line, follow-up within days
Strongest suicide risk factors → prior attempt, firearm access, older male, recent psychiatric discharge, substance use, hopelessness, chronic pain or illness, living alone
Intentional overdose → medical stabilization first; acetaminophen and salicylate levels every time; psychiatric evaluation once medically cleared
Recurrent suicidal behavior → lithium lowers suicide in mood disorders; clozapine lowers it in schizophrenia

Traps that cost points

A no-suicide contract instead of a safety plan→ Contracts do not prevent suicide and give false reassurance; write a safety plan together, restrict lethal means and arrange close follow-up.
Starting an antidepressant without asking about past highs→ Unrecognized bipolar disorder can switch into mania; ask about prior manic symptoms and family history first.
Switching antidepressants after 2 weeks without benefit→ Full effect takes 4–8 weeks at an adequate dose; optimize the dose first unless side effects are intolerable.
Stopping the antidepressant once mood recovers→ Stopping early sharply raises relapse; continue at least 6–12 months after remission and then taper.
Skipping the suicide question to avoid planting the idea→ Direct questions do not increase risk and often bring relief; ask every patient with depression.
Letting a high-risk patient go home first to collect belongings→ Imminent risk requires continuous observation until psychiatric evaluation; use an involuntary hold if needed.
Paroxetine as first choice in pregnancy or old age→ It is tied to early-pregnancy cardiac defects and is strongly anticholinergic; sertraline is a better fit.
Outpatient follow-up for postpartum psychosis→ It carries risk of suicide and infant harm and often heralds bipolar disorder; admit and treat urgently.

Substance use disorders

In the Brain

Screen everyone, treat withdrawal safely, and offer medication for alcohol, opioid and tobacco use disorders the same day.

Rules to know

Every adult → screen for unhealthy alcohol use (AUDIT-C or one heavy-drinking-day question); positive → brief intervention and assess for use disorder
Adolescent at a routine visit → confidential substance screen (CRAFFT); brief counseling and follow-up
Last drink timing in alcohol withdrawal → tremor and anxiety 6–24 h, seizures and hallucinosis 12–48 h, delirium tremens 48–96 h
Alcohol withdrawal → symptom-triggered benzodiazepine by CIWA-Ar score; diazepam or chlordiazepoxide, lorazepam if liver failure or frail
Withdrawal needing admission → prior delirium tremens or withdrawal seizure, severe symptoms, serious illness, pregnancy, unable to take oral meds, no support
Delirium tremens or withdrawal despite high benzodiazepine doses → ICU, phenobarbital or propofol; dexmedetomidine only as an add-on
Alcohol withdrawal seizure → benzodiazepine; no long-term antiseizure drug
Moderate to severe alcohol use disorder → naltrexone or acamprosate plus counseling and mutual-help groups
Naltrexone → not with any opioid use (precipitates withdrawal) or acute liver failure; acamprosate fits liver disease but needs renal dosing
Disulfiram → only for motivated patients with supervised dosing; avoid with heart disease or psychosis
Opioid overdose with pinpoint pupils and slow breathing → ventilate and give naloxone; small IV doses in dependent patients; observe longer after long-acting opioids
Sedation persisting after naloxone with good breathing → co-ingestant such as xylazine or a sedative; support airway and breathing
Opioid use disorder → offer buprenorphine or methadone, which cut overdose death; any clinician with schedule III DEA registration can prescribe buprenorphine
Starting buprenorphine → wait for moderate withdrawal (COWS ≥ 8–12), about 12–24 h after short-acting opioids; after fentanyl consider a low-dose overlapping start
Opioid use disorder seen in the ED → start buprenorphine there and link to ongoing treatment
Methadone for opioid use disorder → dispensed through an opioid treatment program; watch QT and drug interactions
Extended-release naltrexone → only after 7–10 days opioid-free; lost tolerance raises overdose risk on relapse
Opioid use disorder, high-dose opioids, or opioid plus benzodiazepine → prescribe naloxone and teach household members
Pregnant with opioid use disorder → buprenorphine or methadone rather than detoxification; plan newborn withdrawal monitoring
Patient on buprenorphine needing surgery or acute pain care → continue it, add multimodal analgesia and short-acting full agonists if needed
Opioid withdrawal: yawning, dilated pupils, rhinorrhea, gooseflesh, diarrhea → uncomfortable, not dangerous; buprenorphine or methadone, clonidine or lofexidine for symptoms
Smoker → advise quitting at every visit; varenicline or combination nicotine replacement (patch plus short-acting) with counseling; bupropion as alternative
Varenicline → nausea and vivid dreams; safe with psychiatric illness; lower the dose in severe kidney disease
Pregnant smoker → behavioral counseling first; nicotine replacement if counseling alone fails
Cocaine or methamphetamine with chest pain, agitation, hypertension, hyperthermia → benzodiazepines first; aspirin and nitrates for chest pain; avoid acute beta-blockers
Stimulant use disorder → contingency management and CBT; no FDA-approved medication
Stimulant crash with sleepiness, hunger and dysphoria → supportive care; screen for suicidal thinking
Daily cannabis user with cyclic vomiting eased by hot showers → cannabinoid hyperemesis; stop cannabis; haloperidol or topical capsaicin for attacks
Agitation, violence, vertical and horizontal nystagmus, hyperthermia → phencyclidine; benzodiazepines, quiet room, check CK
MDMA use with confusion or seizure → check sodium (hyponatremia), temperature and serotonin toxicity; cool, benzodiazepines
Long-term benzodiazepine or barbiturate user stopping abruptly → withdrawal seizures and death possible; taper with a long-acting agent; avoid flumazenil
Urine opiate immunoassay → misses fentanyl, methadone, oxycodone and buprenorphine; confirm unexpected results with mass spectrometry before acting

Traps that cost points

Dextrose before thiamine in a malnourished drinker→ Glucose can precipitate Wernicke encephalopathy; give IV thiamine first or together.
Long-term antiseizure drug after an alcohol withdrawal seizure→ The seizure is provoked; treat withdrawal with benzodiazepines and address drinking.
Requiring a waiver or special certification before prescribing buprenorphine→ The federal waiver ended in 2023; any clinician with appropriate DEA registration may prescribe it.
Starting buprenorphine while the patient still looks comfortable→ Buprenorphine displaces full agonists and precipitates withdrawal; wait for objective withdrawal or use a low-dose start.
Naltrexone for an alcohol patient also taking opioids→ It blocks opioid analgesia and triggers withdrawal; choose acamprosate or treat the opioid use first.
Detoxifying a pregnant patient off opioids→ Withdrawal raises relapse and overdose risk; maintenance buprenorphine or methadone is standard care.
Metoprolol for a hypertensive tachycardic cocaine user→ Benzodiazepines treat the sympathetic surge; give nitrates or a calcium-channel blocker for persistent hypertension.
Firing a patient whose urine screen shows an unexpected drug→ Immunoassays give false results; confirm with mass spectrometry and discuss before changing care.
Recommending e-cigarettes as the first quit tool→ They are not an approved cessation therapy; offer varenicline or combination nicotine replacement with counseling.

Anxiety, trauma & obsessive-compulsive disorders

In the Brain

Therapy and SSRIs come first; benzodiazepines are a short bridge at most, and medical causes are checked once, not endlessly.

Rules to know

Excessive worry most days for ≥ 6 months → GAD when hard to control with tension and poor sleep; CBT and/or SSRI or SNRI (escitalopram, sertraline, venlafaxine, duloxetine)
GAD needing another option → buspirone (no dependence, slow onset) or pregabalin; hydroxyzine for short-term relief
Sudden surges of fear with palpitations, dyspnea and dread → panic attack; first episode gets ECG, glucose, TSH and cardiac evaluation if risk factors
Recurrent unexpected panic attacks with ≥ 1 month of worry or avoidance → panic disorder; CBT and an SSRI started low and raised slowly
Severe panic while the SSRI starts working → scheduled benzodiazepine for a few weeks, then taper
Fear of scrutiny with avoidance of social situations → social anxiety disorder; CBT, SSRI or SNRI
Anxiety only before performances or speeches → propranolol 30–60 minutes beforehand
Fear of one object or situation → specific phobia; exposure-based CBT; medication not first-line
Intrusions, avoidance, negative mood and hyperarousal ≥ 1 month after trauma → PTSD; trauma-focused therapy (prolonged exposure, cognitive processing, EMDR) first
PTSD medication → sertraline, paroxetine or venlafaxine; avoid benzodiazepines
PTSD nightmares despite treatment → prazosin can be tried; watch for orthostatic hypotension
Trauma symptoms from 3 days to 1 month afterward → acute stress disorder; trauma-focused CBT; avoid benzodiazepines and single-session debriefing
Distress out of proportion within 3 months of a stressor → adjustment disorder; brief supportive or problem-solving therapy
Intrusive unwanted thoughts with time-consuming rituals → OCD; exposure and response prevention plus an SSRI at higher doses for 8–12 weeks
OCD not responding to two SSRIs → clomipramine, or augment with aripiprazole or risperidone
Distressing intrusive thoughts of harming the baby, which she avoids → postpartum OCD, not psychosis; exposure therapy and SSRI
Preoccupation with a perceived flaw, repeated mirror checking → body dysmorphic disorder; SSRI plus CBT; cosmetic procedures do not help
Hair pulling or skin picking causing damage → trichotillomania or excoriation disorder; habit reversal training
Child refusing school with distress when apart from parents → separation anxiety; CBT with prompt school return, SSRI if severe
Child who speaks at home but not at school > 1 month → selective mutism; CBT, SSRI if severe
Anxious child or teen → CBT first; CBT plus sertraline works best when moderate to severe
New anxiety in midlife or later → look for hyperthyroidism, arrhythmia, hypoglycemia, pheochromocytoma, caffeine, stimulants, steroids or withdrawal
Perioral tingling and carpal spasm with anxious fast breathing → hyperventilation; slow breathing and reassurance after hypoxia, PE and asthma are excluded
Long-term benzodiazepine user wanting to stop → slow taper, often 5–10% of the dose every 2–4 weeks, adjusted to symptoms; abrupt stop risks seizures
Benzodiazepine prescribing → avoid in older adults (falls, delirium), with opioids or alcohol, and in substance use disorders
Anxiety screening → adults through age 64 and children 8–18 with a brief tool such as GAD-7

Traps that cost points

Long-term benzodiazepine as first-line for GAD→ Dependence, falls and cognitive effects outweigh benefit; use CBT and SSRIs or SNRIs.
Buspirone as needed for a panic attack→ Buspirone takes weeks and does not abort panic; treat panic disorder with CBT and an SSRI.
Repeating full cardiac workups at each panic visit→ Once medical causes are reasonably excluded, repeated testing reinforces illness fears; commit to panic treatment.
Benzodiazepines for PTSD or acute stress→ They worsen PTSD outcomes and risk dependence; use trauma-focused therapy and SSRIs.
Low-dose SSRI for 4 weeks in OCD, then calling it failure→ OCD needs higher doses for 8–12 weeks plus exposure and response prevention.
Group debriefing right after a traumatic event→ Single-session debriefing does not prevent PTSD and may worsen it; offer support and screen later.
Daily medication for a simple specific phobia→ Exposure therapy works best; drugs add little.
Treating postpartum intrusive harm thoughts as psychosis→ Ego-dystonic thoughts she resists are OCD with low risk of acting; reassure, treat with ERP and SSRI.

Psychosis & antipsychotic safety

In the Brain

Exclude medical and drug causes, choose an antipsychotic by side effects, monitor metabolic and movement risks, and recognize NMS, serotonin syndrome and catatonia.

Rules to know

First-episode psychosis → CBC, CMP, glucose, TSH, HIV, syphilis, urine drug screen, pregnancy test; MRI if neurologic signs or atypical course
Psychosis with disorientation, fluctuating attention or abnormal vitals → delirium or encephalitis until proven otherwise; LP or EEG as indicated
Psychosis < 1 month with full recovery → brief psychotic disorder; 1–6 months → schizophreniform; ≥ 6 months → schizophrenia
Psychosis persisting ≥ 2 weeks without mood symptoms → schizoaffective disorder when mood episodes fill most of the illness
Fixed nonbizarre false belief ≥ 1 month, otherwise functioning → delusional disorder; antipsychotic and supportive therapy; neither argue nor agree
Schizophrenia → second-generation antipsychotic chosen by side effects, 4–6 week trial, long-term continuation plus family education and supported employment
Relapses from missed doses → long-acting injectable antipsychotic
Two failed antipsychotic trials, or persistent suicidality in schizophrenia → clozapine
Clozapine → ANC before starting and on schedule (weekly at first); myocarditis in first 2 months; seizures; severe constipation; drooling
Clozapine patient who stops smoking → levels rise; lower the dose and check a level
Antipsychotic metabolic monitoring → weight each visit early then quarterly; BP, glucose or A1c and lipids at baseline, 12 weeks, then yearly
Antipsychotic weight gain → switch to aripiprazole, lurasidone or ziprasidone, add metformin, lifestyle program
Galactorrhea, amenorrhea or low libido on risperidone or paliperidone → high prolactin; switch to or add aripiprazole
QT-prolonging antipsychotic with heart disease or other QT drugs → baseline ECG; correct potassium and magnesium
Inner restlessness and pacing days after starting an antipsychotic → akathisia; lower the dose, add propranolol
Orofacial writhing after months of a D2 blocker → tardive dyskinesia; valbenazine or deutetrabenazine, consider clozapine; screen movements every 6–12 months
Fever, lead-pipe rigidity, confusion, unstable vitals, high CK on an antipsychotic → NMS; stop the drug, ICU, cooling, fluids, benzodiazepines; dantrolene or bromocriptine if severe
After NMS resolves → wait ≥ 2 weeks, then a low dose of a lower-potency agent with close monitoring
Agitation, sweating, diarrhea, hyperreflexia, clonus hours after a serotonergic drug → serotonin syndrome; stop agents, benzodiazepines, cooling; cyproheptadine if moderate
Serotonin syndrome triggers → SSRIs or SNRIs combined with MAOIs, linezolid, tramadol, meperidine, methylene blue, dextromethorphan or fentanyl
Mutism, posturing, staring, waxy flexibility → catatonia; IV lorazepam trial, ECT if no response; hold antipsychotics until it lifts
Agitated patient → verbal de-escalation and oral medication first; then IM haloperidol with lorazepam or IM olanzapine; restraint last, with frequent checks
Psychosis after methamphetamine, cannabis, PCP or hallucinogens → substance-induced; benzodiazepines, observe; persisting > 1 month abstinent → primary psychotic disorder
Psychosis with lupus, thyroid disease, HIV, high-dose steroids or levodopa → psychosis due to a medical condition or drug; treat the cause
Psychosis with danger or inability to meet basic needs, refusing care → emergency involuntary hold under state law
Muscarinic agonist xanomeline-trospium → antipsychotic effect without D2 blockade; nausea, constipation, urinary retention; avoid in liver impairment
Pregnant patient stable on an antipsychotic → usually continue it; relapse is the larger risk

Traps that cost points

More haloperidol for a patient who cannot sit still→ Restlessness after starting an antipsychotic is often akathisia; raising the dose worsens it. Lower the dose and add propranolol.
Benztropine for tardive dyskinesia→ Anticholinergics can worsen tardive dyskinesia; use a VMAT2 inhibitor and reduce or switch the antipsychotic.
Restarting the same antipsychotic the day NMS resolves→ Wait at least 2 weeks and use a low dose of a lower-potency agent.
Acetaminophen to treat fever in NMS or serotonin syndrome→ Heat comes from muscle activity; cool externally and sedate, paralyze and intubate if temperature keeps climbing.
Haloperidol for a mute, rigid, posturing patient→ Catatonia can worsen or turn into NMS with antipsychotics; give lorazepam and consider ECT.
Ignoring constipation in a patient on clozapine→ Clozapine slows the gut and can cause fatal ileus; ask every visit and prescribe a bowel regimen.
IM olanzapine together with IM or IV lorazepam→ Combined parenteral use has caused respiratory depression and hypotension; separate them or choose haloperidol with lorazepam.
Diagnosing schizophrenia without a drug screen and medical workup→ Drugs, delirium, encephalitis and endocrine disease can all present as psychosis; screen before labeling.

Bipolar disorder & mood stabilizers

In the Brain

Recognize mania, stop antidepressants, choose a mood stabilizer or antipsychotic, and monitor lithium and valproate safely.

Rules to know

Elevated or irritable mood with more energy ≥ 1 week, or hospitalized → manic episode, bipolar I (less sleep, grandiosity, pressured speech, risky spending)
Hypomania ≥ 4 days without marked impairment, plus major depression → bipolar II
Mild highs and lows for ≥ 2 years never meeting full episodes → cyclothymic disorder
New mania → stop antidepressants and stimulants; check urine drugs and TSH, review steroids and other medical causes
First manic episode after age 50 → search for a neurologic or medical cause, including brain MRI
Acute mania, mild to moderate → one antipsychotic, lithium or valproate; severe or psychotic → antipsychotic plus lithium or valproate, admit if unsafe
Bipolar depression → quetiapine, lurasidone, cariprazine, lumateperone or olanzapine-fluoxetine; never an antidepressant alone
Bipolar maintenance → lithium first (also lowers suicide); valproate, lamotrigine, quetiapine or aripiprazole as alternatives
Mostly depressive bipolar course → lamotrigine prevents depressive relapse but does not treat acute mania
Before lithium → kidney function, TSH, calcium, pregnancy test; ECG if older or with heart disease
Lithium started or dose changed → trough level 12 h after a dose, about 5 days later; maintenance level about 0.6–1.0
Stable on lithium → level every 3–6 months, kidney function and TSH every 6–12 months, calcium yearly
Lithium plus a thiazide, NSAID, ACE inhibitor, ARB or dehydration → level rises; recheck within about a week
Lithium with coarse tremor, vomiting, diarrhea, ataxia or confusion → toxicity; stop it, IV saline, level; hemodialysis for severe neurologic signs or kidney failure
Lithium-induced hypothyroidism → keep lithium and add levothyroxine
Polyuria and dilute urine on lithium → nephrogenic diabetes insipidus; amiloride, review need for lithium
Valproate → baseline and periodic liver tests and platelets; weight gain, tremor, hair loss, pancreatitis; major teratogen
Lamotrigine missed for ≥ 5 days → restart from the lowest titration dose because of rash risk
Carbamazepine for bipolar disorder → CBC, sodium and liver tests; induces metabolism of other drugs and contraceptives
Bipolar disorder and planning pregnancy → avoid valproate and carbamazepine; lithium can continue with closer levels and fetal echocardiography
≥ 4 mood episodes in a year → rapid cycling; check thyroid, stop antidepressants, optimize mood stabilizer
Mania that starts on an antidepressant and persists after stopping → treat as bipolar disorder

Traps that cost points

Antidepressant monotherapy for bipolar depression→ It can trigger mania or rapid cycling; use quetiapine, lurasidone, cariprazine, lumateperone or lamotrigine.
Drawing a lithium level a few hours after the dose→ Levels are standardized as a 12-h trough; a peak sample overstates the steady level.
Stopping lithium because TSH rose→ Hypothyroidism is easily treated with levothyroxine; lithium's benefit usually outweighs it.
Ibuprofen for back pain in a patient on lithium→ NSAIDs reduce lithium clearance and cause toxicity; prefer acetaminophen or recheck the level closely.
Valproate for a young woman without contraception counseling→ Valproate causes neural tube defects and cognitive harm; choose another agent or ensure reliable contraception.
Abruptly stopping lithium in a stable patient→ Rapid discontinuation brings rebound mania and higher suicide risk; taper over weeks if stopping.
Restarting lamotrigine at the old dose after a week off→ Re-escalate from the lowest dose; a full-dose restart raises the risk of Stevens-Johnson syndrome.

Child & adolescent mental health

In the Brain

Diagnose ADHD from more than one setting, treat by age, refer autism early without waiting, and recognize disruptive behavior patterns.

Rules to know

Inattention or hyperactivity in ≥ 2 settings, onset before 12, ≥ 6 months → ADHD; parent and teacher rating scales; no labs, EEG or imaging
ADHD at age 4–5 → parent training in behavior management first; methylphenidate if not enough
ADHD at age ≥ 6 → stimulant (methylphenidate or amphetamine) plus behavioral and school supports such as an IEP or 504 plan
Child on a stimulant → track height, weight, BP and pulse; ask about appetite, sleep, tics and mood
Before a stimulant → ask about exertional syncope, chest pain and family sudden death; ECG or cardiology only if positive
ADHD with substance misuse risk, tics, or stimulant intolerance → atomoxetine, viloxazine, guanfacine ER or clonidine ER
Atomoxetine → suicidal-thinking warning in youth; guanfacine or clonidine → sedation, rebound hypertension if stopped abruptly
Adult ADHD → symptoms must date back to childhood; screen substance use, prefer long-acting stimulant, check BP
Positive autism screen at 18 or 24 months → refer for diagnostic evaluation and early intervention at once, plus a hearing test
Autism confirmed → applied behavior analysis, speech and occupational therapy; chromosomal microarray and fragile X testing
Autism with severe irritability or aggression → risperidone or aripiprazole with metabolic monitoring
Loss of speech or skills already gained → urgent evaluation; girl with hand-wringing and slowing head growth → Rett syndrome (MECP2)
Speech or language delay → hearing test first
Struggling reader with normal intelligence → specific learning disorder; psychoeducational testing through the school and an IEP
Angry, defiant, argumentative with adults ≥ 6 months → oppositional defiant disorder; parent management training
Cruelty, theft, fire-setting, serious rule-breaking → conduct disorder; family or multisystemic therapy, treat ADHD; risk of adult antisocial personality
Severe temper outbursts ≥ 3 a week with constant irritability, onset before 10 → disruptive mood dysregulation disorder; CBT and parent training; not bipolar
Adolescent depression → yearly screening from age 12; CBT or interpersonal therapy, fluoxetine or escitalopram; watch suicidality closely early on
Withdrawn child who seeks no comfort after severe neglect → reactive attachment disorder; stable caregiver and caregiver-focused therapy
Soiling after age 4 with hard stools → encopresis from constipation; disimpaction, daily polyethylene glycol, scheduled toilet sitting
Short eye openings, smooth philtrum, thin upper lip, growth and learning problems → fetal alcohol spectrum disorder; early intervention services
Intellectual disability without a known cause → chromosomal microarray and fragile X testing, hearing and vision checks

Traps that cost points

Diagnosing ADHD from a single teacher report→ Symptoms must impair function in at least two settings; collect parent and teacher scales and check vision, hearing, sleep and mood.
Routine ECG before every stimulant→ A targeted cardiac history is enough; reserve ECG or cardiology for positive findings.
Waiting for a formal autism diagnosis before therapy→ Start early intervention while the diagnostic evaluation is pending; time matters for outcome.
Labeling a chronically irritable child with explosive outbursts as bipolar→ Persistent irritability with outbursts fits disruptive mood dysregulation disorder; mood stabilizers are not first-line.
Stopping a stimulant because tics appeared→ Stimulants rarely cause lasting tics; many children continue with monitoring or add guanfacine.
Behavioral therapy alone for encopresis→ Most encopresis comes from chronic constipation with overflow; clear the impaction and keep stools soft.

Eating disorders

In the Brain

Recognize restriction and purging from the exam and labs, know who needs admission, and match therapy to age and diagnosis.

Rules to know

Restricted intake, low weight, fear of gaining, distorted body image → anorexia nervosa; vitals with orthostatics, ECG, electrolytes, phosphate, glucose
Anorexia exam → bradycardia, hypotension, hypothermia, lanugo, amenorrhea, low bone density, mildly raised liver enzymes; low potassium suggests purging
Eating disorder with unstable vitals → admit: HR < 50 (teen) or < 40 (adult), hypotension, orthostasis, temperature < 35.6 °C, arrhythmia or electrolyte derangement
Severe malnutrition, food refusal or failed outpatient care → inpatient program with a nutrition team managing refeeding risk
Adolescent with anorexia, medically stable → family-based treatment with parents in charge of meals
Adult with anorexia → eating-disorder psychotherapy with nutritional rehabilitation; no medication reliably restores weight
Low bone density in anorexia → weight restoration and return of menses; estrogen pills do not protect bone
Binges with vomiting at normal weight, parotid swelling, knuckle calluses, dental erosion → bulimia nervosa
Self-induced vomiting → hypokalemic hypochloremic metabolic alkalosis, raised amylase; laxative misuse → non-gap metabolic acidosis
Bulimia → eating-disorder CBT plus fluoxetine (60 mg daily)
Eating disorder needing an antidepressant or quit aid → avoid bupropion (seizure risk)
Recurrent loss-of-control binges without purging → binge-eating disorder; CBT; lisdexamfetamine for moderate to severe adult disease
Child restricting foods without body image concern → avoidant/restrictive food intake disorder (texture, fear of choking); specialty feeding therapy
Athlete with low energy intake, amenorrhea, stress fractures → relative energy deficiency in sport; more intake, less training, screen for eating disorder
Teen with type 1 diabetes, weight loss, rising A1c → consider insulin omission to lose weight; screen for eating disorder
Anorexia → high suicide and mortality; screen for suicidality and treat comorbid depression or OCD after weight gain begins
Outpatient anorexia → regular gowned weights, vitals and electrolytes when purging; set clear thresholds for higher care

Traps that cost points

SSRI to treat underweight anorexia→ SSRIs do not restore weight while malnourished; nutrition and psychotherapy come first, SSRIs only for comorbid depression or OCD.
Bupropion for depression in a patient who purges→ Purging and electrolyte shifts raise seizure risk; choose an SSRI such as fluoxetine.
Prescribing estrogen pills for amenorrhea and bone loss in anorexia→ Pills mask amenorrhea without protecting bone; weight restoration is the treatment.
Reassured by a normal BMI in a patient who purges→ Bulimia occurs at normal weight; check potassium, ECG and dental and parotid findings.
Individual therapy alone for a teenager with anorexia→ Family-based treatment has the strongest evidence in adolescents; involve parents.
Outpatient care for a teen with heart rate in the 40s→ Bradycardia with malnutrition signals cardiac risk; admit for monitored refeeding.

Personality, somatic & factitious disorders

In the Brain

Keep care consistent and boundaries clear, treat real distress without needless tests, and separate factitious disorder from malingering.

Rules to know

Unstable relationships, self-image and mood, impulsivity, self-harm, fear of abandonment → borderline personality disorder; dialectical behavior therapy; drugs only for comorbidities
Borderline patient in clinic → regular scheduled visits, clear consistent limits, one coordinating clinician, team huddles to avoid splitting
Deceit and disregard for others after conduct disorder before 15 → antisocial personality disorder in adults
Entitled patient demanding the top doctor and belittling staff → narcissistic personality; acknowledge concerns without confrontation, keep standard care
Dramatic, attention-seeking, flirtatious patient → histrionic personality; keep professional boundaries, use a chaperone
Suspicious patient sure of hidden motives → paranoid personality; explain plans clearly and transparently
Detached loner uninterested in relationships → schizoid personality; odd beliefs and magical thinking → schizotypal personality
Longs for relationships but avoids them fearing rejection → avoidant personality; cannot decide without others → dependent personality
Perfectionism and rigid rules that feel right to the patient → obsessive-compulsive personality, unlike OCD
Distressing physical symptoms with excessive worry and visits ≥ 6 months → somatic symptom disorder; regular scheduled visits with one clinician, limit tests, CBT
Fear of serious illness with few or no symptoms → illness anxiety disorder; scheduled visits, CBT, SSRI; avoid repeated testing
Neurologic deficit inconsistent with anatomy (Hoover sign, give-way weakness) → functional neurological disorder; explain it as real and treatable, PT and CBT
Intentionally produced symptoms without external reward → factitious disorder; nonpunitive team discussion, one clinician, avoid needless procedures
Hypoglycemia with high insulin, low C-peptide, health care worker → injected insulin; consider factitious disorder
Caregiver fabricating or inducing a child's illness → factitious disorder imposed on another; protect the child and report to child protective services
Symptoms feigned for disability, drugs, or avoiding work or jail → malingering; document objective findings neutrally, avoid accusation, do not supply the gain
Memory gaps for personal events after trauma → dissociative amnesia; feeling detached from self with intact reality testing → depersonalization disorder; psychotherapy
Patient reacting to the clinician like a past parent figure → transference; clinician's own strong reaction → countertransference; notice it, keep care steady
Personality disorder with depression or substance use → treat the comorbid condition; avoid benzodiazepines
Recurrent gambling despite losses, chasing losses → gambling disorder; CBT, self-exclusion; ask about dopamine agonists

Traps that cost points

As-needed visits for a patient with somatic symptom disorder→ Unscheduled visits reward symptoms; set regular brief visits with one clinician and review function.
Telling a patient with functional weakness that nothing is wrong→ Symptoms are real and involuntary; give a positive diagnosis and refer for physical therapy and CBT.
Confronting a factitious patient alone and discharging them→ Use a supportive team approach, offer psychiatric care, and coordinate to prevent further harm.
Calling malingering a psychiatric disorder needing therapy→ Malingering is conscious deception for gain; document carefully and decline unsupported requests.
Benzodiazepines for emotional crises in borderline personality disorder→ They increase impulsivity and dependence; use DBT skills and treat comorbid depression.
Different staff giving different answers to a splitting patient→ Agree on one plan and one voice; consistency reduces conflict.
Repeated imaging to reassure a patient with illness anxiety→ Each normal test brings brief relief and more worry; set limits and treat the anxiety.

Sleep disorders

In the Brain

Treat chronic insomnia with CBT-I first, use sleep drugs sparingly, time light and melatonin for circadian problems, and test properly for narcolepsy.

Rules to know

Poor sleep ≥ 3 nights a week for ≥ 3 months with daytime effects → chronic insomnia; sleep diary, look for mood, pain, apnea, restless legs, caffeine, alcohol, drugs
Chronic insomnia → CBT-I first (stimulus control, sleep restriction, cognitive work); sleep hygiene advice alone is not enough
Insomnia needing a drug → short course, lowest dose: orexin antagonist, zolpidem or eszopiclone; low-dose doxepin for early waking
Zolpidem or eszopiclone → stop after any complex sleep behavior such as sleep-driving; lower doses for women and older adults
Older adult with insomnia → CBT-I; avoid benzodiazepines and diphenhydramine; ramelteon or low-dose doxepin if a drug is needed
Sedating drugs for chronic insomnia → trazodone, melatonin, antihistamines and antipsychotics have weak evidence and real harms
Teen unable to fall asleep before 2–3 am → delayed sleep phase if sleep is normal when allowed late; fixed wake time, morning light, low-dose evening melatonin
Older adult sleepy at 7 pm and awake at 3 am → advanced sleep phase; evening bright light
Night-shift worker with insomnia and on-shift sleepiness → shift work disorder; dark quiet daytime sleep, bright light at work, timed naps, modafinil
Eastward jet lag → melatonin at destination bedtime, morning light
Daytime sleepiness → first check sleep duration, apnea risk and sedating medications
Sleep attacks, cataplexy with laughter, sleep paralysis, vivid hallucinations at sleep onset → narcolepsy; overnight polysomnography, then multiple sleep latency test
Before sleep latency testing → stop REM-suppressing antidepressants and stimulants about 2 weeks ahead; ensure adequate sleep
Narcolepsy → scheduled naps, modafinil, armodafinil, solriamfetol, pitolisant or stimulants; cataplexy → oxybate or pitolisant
Modafinil in a woman on hormonal contraception → contraceptive failure risk; use an IUD or added method
Older man acting out dreams, punching or kicking → REM sleep behavior disorder; polysomnography, bedroom safety, melatonin; counsel about later Parkinson or Lewy body disease
Child walking or screaming early in the night without recall → NREM parasomnia; reassure, secure the home, scheduled awakenings if frequent
Frightening dreams with full recall late in the night → nightmare disorder; imagery rehearsal therapy

Traps that cost points

Sleep hygiene handout as the whole treatment for chronic insomnia→ Hygiene alone rarely works; deliver structured CBT-I, including digital programs.
Diphenhydramine for sleep in an older adult→ Anticholinergic effects cause confusion, falls and retention; use CBT-I and safer options.
Melatonin at bedtime for delayed sleep phase→ Shifting the clock needs a small dose several hours before the desired bedtime plus morning light.
Diagnosing narcolepsy from a daytime nap study alone→ Overnight polysomnography must precede the multiple sleep latency test to exclude apnea and sleep loss.
Continuing zolpidem after a sleep-driving episode→ Complex sleep behaviors are a reason to stop permanently.
Clonazepam for dream enactment without discussing prognosis→ Most patients later develop a synucleinopathy; counsel, consider melatonin first, and secure the bedroom.

Sexual health & gender dysphoria

In the Brain

Treat erectile dysfunction as a vascular warning sign, fix drug-related dysfunction, and give gender-diverse patients respectful, evidence-based care.

Rules to know

Erectile dysfunction → check cardiovascular risk (BP, lipids, A1c), medications and mood; morning testosterone if low libido or hypogonadal signs
Erectile dysfunction first-line → PDE5 inhibitor (sildenafil, tadalafil) plus exercise, weight loss and smoking cessation
PDE5 inhibitor with any nitrate or riociguat → contraindicated (severe hypotension); start low and separate from alpha-blockers
Sudden situational erectile dysfunction with normal morning erections → psychogenic; sex therapy or CBT, PDE5 inhibitor can help
PDE5 inhibitor failure → intracavernosal or urethral alprostadil or vacuum device, then penile prosthesis
Erection > 4 h (trazodone, injections, sickle cell disease) → ischemic priapism; emergency aspiration and phenylephrine
Ejaculation within about 1 minute causing distress → premature ejaculation; behavioral techniques, daily or on-demand SSRI, topical anesthetic
Sexual dysfunction on an SSRI → lower dose, switch to bupropion, mirtazapine or vortioxetine, or add bupropion or a PDE5 inhibitor
Drugs causing sexual dysfunction → SSRIs, antipsychotics raising prolactin, beta-blockers, thiazides, finasteride, spironolactone, opioids
Low desire in a woman → review relationship, mood, drugs, pain and menopause status; sex therapy first
Premenopausal woman with distressing low desire → flibanserin (hypotension; avoid alcohol near dosing) or bremelanotide (nausea, brief BP rise)
Pain with penetration or involuntary pelvic floor tightening → genito-pelvic pain/penetration disorder; pelvic floor PT, dilators, CBT
Sexual history → nonjudgmental questions on partners, practices, protection, past STIs and pregnancy plans
Distress from incongruence between gender identity and assigned sex ≥ 6 months → gender dysphoria; gender diversity itself is not a disorder
Transgender or nonbinary patient → use chosen name and pronouns; screen for depression, anxiety, suicidality, substance use and minority stress
Adult seeking gender-affirming hormones → informed consent, confirm persistent dysphoria and capacity, address mental health; monitor per endocrine protocol
Adolescent with gender dysphoria → multidisciplinary specialist assessment; medical options depend on that evaluation and current state law; mental health support throughout
Screening transgender patients → screen the organs present: cervical screening if a cervix, prostate discussion if a prostate, breast screening by tissue and risk

Traps that cost points

Prescribing sildenafil without asking about chest pain or nitrates→ ED often precedes coronary disease; assess cardiac risk and never combine with nitrates.
Testosterone for erectile dysfunction with normal levels→ Testosterone helps only proven hypogonadism; PDE5 inhibitors treat most ED.
Stopping an effective SSRI for sexual side effects without alternatives→ Relapse risk is high; adjust dose, switch to bupropion or add bupropion or a PDE5 inhibitor.
Observing an erection lasting 5 hours→ Ischemic priapism damages tissue within hours; aspirate and give phenylephrine emergently.
Treating gender identity itself as the illness to fix→ Care addresses distress and health needs; conversion efforts harm patients and are not appropriate.
Skipping cervical screening in a transgender man with a cervix→ Screen by anatomy present, using the same intervals as for other patients with a cervix.