Psychiatry USMLE Practice Questions
Mental health disorders and psychopharmacology.
5 free psychiatry practice questions
Pick an answer and check it. After each question you get the same explanation StepGenie students see: the stem decoded clue by clue, the reasoning chain with its infographic, why every wrong option is wrong, and the trap the question was built around. Step 1 questions test mechanism; Step 2 CK questions ask for the next step.
A 31-year-old woman is brought to the emergency department with a 3-hour history of severe throbbing headache, nausea, photophobia, occipital pain, and chest tightness. Earlier in the evening, she attended a networking event where she drank red wine and ate salami and dried fruits. She has a history of recurrent migraine headaches and depression for which she takes daily medication. On examination, she is mildly distressed, diaphoretic, and flushed. Temperature is 37.0°C (98.6°F), pulse is 90/min, respirations are 20/min, and blood pressure is 195/130 mm Hg. She is alert and oriented, and deep tendon reflexes are 2+ bilaterally. This patient's symptoms are most likely caused by a side effect of which of the following medications?
Correct answer · E
Phenelzine
Decoding the stem
Step-by-step reasoning
Step 1 of 6
Patient with depression on daily medication + recent ingestion of red wine, salami, dried fruits → think tyramine exposure.
Step 2 of 6
Tyramine is normally metabolized by monoamine oxidase (MAO) in the GI tract and liver, preventing systemic catecholamine surge.
Step 3 of 6
If a patient is taking an MAOI antidepressant (e.g., phenelzine), tyramine is not broken down and enters the circulation.
Step 4 of 6
Systemic tyramine displaces catecholamines (NE) from presynaptic vesicles → massive norepinephrine release.
Step 5 of 6
Excess NE causes hypertensive crisis: severe throbbing headache, very high BP (195/130), autonomic signs (diaphoresis, flushing, chest tightness).
Step 6 of 6
Normal reflexes and no clonus or hyperthermia argue against serotonin syndrome, supporting tyramine–MAOI hypertensive crisis from phenelzine.
Why not the others?
A. Amitriptyline
This option implies a tricyclic antidepressant, which can cause anticholinergic effects, cardiotoxicity, and orthostatic hypotension, BUT it is not classically associated with tyramine-induced hypertensive crisis after wine and cured meats.
B. Ibuprofen
This option implies an NSAID, which may cause GI irritation or renal effects, BUT it does not interact with tyramine-containing foods to cause sudden severe hypertension and autonomic symptoms.
C. Verapamil
This option implies a calcium channel blocker, which can cause hypotension, bradycardia, or constipation, BUT it would be more likely to lower blood pressure rather than cause a sudden hypertensive crisis after a meal.
D. Sumatriptan
This option implies a 5-HT1B/1D agonist used acutely for migraine. It can cause chest tightness and vasoconstriction, BUT it is taken as-needed, not daily for depression, and it does not explain the tyramine-food trigger and extreme BP elevation.
F. Topiramate
This option implies an antiepileptic used for migraine prophylaxis, which can cause weight loss, kidney stones, and cognitive slowing, BUT it does not cause tyramine-sensitive hypertensive crises with wine and salami.
G. Valproic acid
This option implies a broad-spectrum antiepileptic/mood stabilizer that can cause hepatotoxicity, pancreatitis, and neural tube defects, BUT it has no classic food interaction leading to acute hypertensive crisis.
H. Sertraline
This option implies an SSRI, which can cause sexual dysfunction and, when combined with other serotonergic agents, serotonin syndrome, BUT SSRIs do not cause tyramine-induced hypertensive crises with red wine and aged meats.
Exam trap
Students may see “migraine history” and “chest tightness” and jump to sumatriptan, or see “depression” and pick an SSRI. The key is recognizing the tyramine-rich foods plus severe hypertension, which specifically points to an MAOI (phenelzine)–tyramine hypertensive crisis, not typical migraine therapy side effects.
The bottom line
Hypertensive crisis from MAOI (phenelzine) + tyramine-containing foods (wine, salami, dried fruits) causing acute severe headache, hypertension, autonomic symptoms.
A 17-year-old girl is evaluated for secondary amenorrhea of 4 months. She previously had regular 28-day menstrual cycles lasting 3–4 days. She is a good student and runs competitively on her high school track team. She is sexually active with one male partner and reports consistent condom use. There is no significant family medical history. She appears thin. Physical examination reveals bilateral parotid gland enlargement and fine hair over the trunk. A urine pregnancy test is negative. Labs: - Thyroid-stimulating hormone: 3.7 μU/mL - Prolactin: 16 ng/mL - Estradiol: 23 pg/mL (normal >40 pg/mL) - Follicle-stimulating hormone: 1.6 mIU/mL - Luteinizing hormone: 2.8 mIU/mL Which of the following is the most likely cause of this patient’s findings?
Correct answer · F
Nutritional deficiency
Decoding the stem
Step-by-step reasoning
- 1
Parotid enlargement + thin appearance + fine body hair suggests an eating disorder with chronic undernutrition (often seen in athletes and high-achieving teens).
- 2
Undernutrition and excessive exercise → decreased hypothalamic GnRH pulsatility due to low energy availability and stress hormones (↑ cortisol).
- 3
↓ GnRH → ↓ pituitary FSH and LH (hypogonadotropic hypogonadism), as seen in her low FSH (1.6) and low LH (2.8).
- 4
↓ FSH/LH → reduced ovarian follicular stimulation → ↓ estradiol production (23 pg/mL, low for reproductive age).
- 5
Low estradiol disrupts normal endometrial cycling → secondary amenorrhea after previously regular 28-day cycles.
- 6
Normal TSH and prolactin exclude thyroid disease and hyperprolactinemia, focusing the cause on nutritional deficiency–induced hypothalamic suppression.
- 7
Therefore, the most likely cause of her findings is nutritional deficiency leading to functional hypothalamic amenorrhea.
Why not the others?
A. Exogenous steroid use
This option implies anabolic steroid or glucocorticoid use, which often causes virilization (acne, deep voice, clitoromegaly) or Cushingoid features, BUT this patient has no signs of androgen excess; instead, she is thin with features of an eating disorder and has low, not high, gonadotropins.
B. Defective androgen receptors
This option implies androgen insensitivity syndrome, which causes primary amenorrhea in genetically male (46,XY) patients with scant/absent pubic hair and no uterus, BUT this patient is a 17-year-old with a history of normal menses (secondary amenorrhea), which rules out congenital receptor defects.
C. Gonadal dysgenesis
This option implies conditions like Turner syndrome (45,XO) causing streak ovaries and primary amenorrhea with elevated FSH/LH, BUT this patient had previously regular cycles and currently has low FSH/LH, inconsistent with primary ovarian failure.
D. Abnormal neuronal cell migration
This option suggests Kallmann syndrome (defective migration of GnRH neurons) presenting as primary amenorrhea with absent puberty and anosmia, BUT this patient underwent normal puberty with regular menses before, so her problem is acquired, not due to congenital neuronal migration defects.
E. Hyperandrogenic anovulation
This option refers to PCOS, which presents with obesity, acne, hirsutism, and chronic anovulation with elevated LH and normal/high androgens, BUT this patient is thin, lacks hyperandrogenic signs, and has low gonadotropins with features of an eating disorder instead.
Exam trap
Adolescent girl with amenorrhea may tempt you to pick PCOS or congenital causes. Focusing on subtle eating disorder clues (thin, parotid enlargement, lanugo, athlete) and the low FSH/LH pattern directs you to functional hypothalamic amenorrhea from nutritional deficiency, not primary ovarian or receptor defects.
The bottom line
Functional hypothalamic amenorrhea from nutritional deficiency/excess exercise → ↓ GnRH → ↓ FSH/LH → low estradiol → secondary amenorrhea in thin athletic teen with bulimic signs.
A 46-year-old homeless man is brought to the emergency department after being found wandering aimlessly in a supermarket. He is disoriented and insists that the President has appointed men to kill him because he is revealing state secrets to extraterrestrial beings. Neurologic examination reveals horizontal nystagmus and a broad-based, ataxic gait. What is the most likely cause of this patient’s clinical presentation?
Correct answer · E
Necrosis of mammillary bodies
Decoding the stem
Step-by-step reasoning
Step 1 of 5
Homelessness suggests poor nutrition and likely chronic alcohol use, both major risks for thiamine (B1) deficiency.
Step 2 of 5
Thiamine deficiency primarily damages structures around the third ventricle and aqueduct, especially the mammillary bodies and periaqueductal gray.
Step 3 of 5
Damage to these areas produces Wernicke encephalopathy, classically presenting with the triad: confusion, ophthalmoplegia/nystagmus, and ataxia.
Step 4 of 5
This patient has confusion/disorientation, horizontal nystagmus, and broad-based ataxic gait, fitting the classic Wernicke triad.
Step 5 of 5
Therefore, the most likely cause of his clinical presentation is necrosis of the mammillary bodies due to thiamine deficiency.
Why not the others?
A. Hypothyroidism
This option implies hypometabolic state causing fatigue, weight gain, cold intolerance, depression, and slowed reflexes, BUT it does not cause the acute triad of confusion, horizontal nystagmus, and gait ataxia seen here.
B. Trinucleotide repeat disorder
This option implies diseases like Huntington disease or Fragile X, which cause progressive movement or cognitive disorders, BUT these present with chronic deterioration (e.g., chorea, dementia), not acute confusion with nystagmus and ataxia in a malnourished homeless patient.
C. Neurofibrillary tangles
This option implies Alzheimer disease, which causes progressive memory loss and cognitive decline, BUT Alzheimer’s does not present acutely with nystagmus and gait ataxia, and it is less likely in a 46-year-old with clear nutritional risk factors.
D. Atrophy of globus pallidus
This option suggests disorders like Wilson disease or other basal ganglia pathologies causing movement disorders (dystonia, parkinsonism), BUT the patient’s key features are confusion, nystagmus, and ataxia, not extrapyramidal motor symptoms.
Exam trap
Students may latch onto the bizarre delusions and think primarily of a primary psychotic disorder (e.g., schizophrenia) or Alzheimer pathology, but the high-yield clues are homelessness (malnutrition), acute confusion, horizontal nystagmus, and ataxic gait—classic for Wernicke encephalopathy from mammillary body necrosis.
The bottom line
Wernicke encephalopathy from thiamine deficiency (alcoholism/malnutrition) causes mammillary body necrosis → confusion, ophthalmoplegia/nystagmus, and ataxia.
A 22-year-old man develops agitation and restlessness 1 hour after an uncomplicated laparoscopic appendectomy. He has received 1 L of lactated Ringer solution intraoperatively with an estimated blood loss of 100 mL and a urine output of 100 mL. Postoperative pain has been managed with intravenous morphine. He was admitted 3 days ago and has not eaten for the past 18 hours. He has no significant past medical history. He is a college junior who drinks 3 beers and 2 glasses of whiskey daily during the week and more on weekends with his fraternity. He has experimented with intravenous illicit drugs. His mother has Hashimoto thyroiditis. On examination, he appears anxious and diaphoretic and reports headache, nausea, and dry heaves. Temperature is 37.4°C (99.3°F), pulse is 120/min, respirations are 19/min, and blood pressure is 142/90 mm Hg. He is alert and fully oriented but repeatedly asks if his father, who is not present, can leave the room. Mucous membranes are moist, and the skin is warm. Cardiac examination reveals tachycardia with a regular rhythm, and lung auscultation is clear. The abdomen has three port sites with clean, dry dressings. His hands demonstrate a fine tremor with arms extended and fingers spread. Which of the following is the most appropriate next step in management?
Correct answer · B
Administer intravenous lorazepam
Decoding the stem
Step-by-step reasoning
- 1
Patient has clear history of chronic heavy alcohol use, implying physiological dependence on ethanol.
- 2
He has been hospitalized for 3 days and has not eaten (and thus not drunk alcohol) for 18 hours, creating abrupt cessation of alcohol intake.
- 3
Abrupt alcohol cessation in a dependent patient leads to alcohol withdrawal, due to loss of CNS depressant effect and unopposed excitatory neurotransmission.
- 4
Withdrawal manifests as tremor, anxiety, diaphoresis, tachycardia, hypertension, nausea, agitation, which are all present here, and he is still oriented (early withdrawal, not delirium tremens).
- 5
First-line treatment for alcohol withdrawal is benzodiazepines to enhance GABA and reduce CNS hyperexcitability.
- 6
In a postoperative hospitalized patient, intravenous lorazepam is preferred because of reliable IV dosing and safer metabolism in potentially stressed liver.
- 7
Therefore, the most appropriate next step in management is to administer intravenous lorazepam to treat alcohol withdrawal.
Why not the others?
A. Administer intravenous propranolol
This option implies treating autonomic symptoms (tachycardia, tremor) alone, BUT it does not address the underlying CNS hyperexcitability of alcohol withdrawal and may mask severity, delaying proper benzodiazepine therapy.
C. Administer intravenous naloxone
This option implies opioid overdose, which causes respiratory depression, miosis, decreased mental status, BUT this patient is tachypneic, alert, hypertensive, and tremulous, which is inconsistent with opioid toxicity.
D. Adminster intravenous dexamethasone
This option implies adrenal or cerebral edema/anti-inflammatory therapy, BUT there is no evidence of airway compromise, adrenal crisis, or increased intracranial pressure; symptoms are classic for withdrawal, not steroid-responsive pathology.
E. Administer 5% dextrose in 1/2 normal saline
This option implies focusing on fluids/nutrition (e.g., hypoglycemia), BUT his mucous membranes are moist, vitals show hyperadrenergic state, and giving dextrose alone does not treat alcohol withdrawal; benzodiazepines are required.
F. Administer intravenous dantrolene
This option implies malignant hyperthermia or neuroleptic malignant syndrome, which present with hyperthermia, muscle rigidity, markedly elevated CK. BUT this patient is afebrile with a fine tremor, not rigidity, and had a routine laparoscopic case with no triggering anesthetic history presented.
Exam trap
Post-op agitation can tempt you toward pain meds (naloxone) or surgical complications. The key is to associate tremor + tachycardia + diaphoresis in a heavy drinker off alcohol with alcohol withdrawal, not opioid toxicity or anxiety, then choose benzodiazepines.
The bottom line
Alcohol withdrawal due to abrupt cessation in a heavy drinker → autonomic hyperactivity, tremor, agitation post-op → treat with benzodiazepine (lorazepam).
A 23-year-old woman presents to the emergency department after a self-inflicted laceration to the distal volar forearm. She reports cutting her wrist because she was convinced that her husband was having sexual thoughts about a woman who works at their local grocery store. The bleeding has been controlled, and she is now medically stable. During the interview, she appears teary, repeatedly apologizes for her behavior, expresses gratitude for your care, and says she regrets her actions. She reports a long-standing pattern of intense but unstable romantic relationships that she “deeply desires” yet “always seem to fall apart.” She has had a similar emergency department visit in the past related to self-harm behavior when she was experiencing distress about online dating. On examination, she appears frightened and is wearing a revealing dress that prominently displays her breasts. When informed that she will need to remain in the psychiatric emergency department overnight, she becomes extremely angry and upset. Which of the following personality disorders is the most likely diagnosis?
Correct answer · B
Borderline
Decoding the stem
Step-by-step reasoning
- 1
She has a long-standing pattern of intense but unstable relationships that repeatedly “fall apart,” suggesting a cluster B personality disorder.
- 2
She engages in recurrent self-harm (cutting, prior ED visit) in the context of relationship distress, a hallmark of borderline personality disorder.
- 3
Her affect is labile: teary and apologetic, grateful and regretful, then suddenly extremely angry when asked to stay—classic affective instability.
- 4
Her intense reaction to staying overnight reflects frantic efforts to avoid perceived abandonment (common trigger for borderline crises).
- 5
Although she is somewhat sexually provocative (revealing dress), the dominant pattern is instability, self-harm, and abandonment fears—not attention-seeking alone.
- 6
Putting these together—unstable relationships, fear of abandonment, affective lability, and self-injury—the most likely diagnosis is borderline personality disorder.
Why not the others?
A. Histrionic
This option implies histrionic personality disorder, which features excessive emotionality and attention-seeking with sexually provocative behavior, BUT it does not typically involve recurrent self-harm and intense abandonment-driven crises; her core pathology is unstable relationships and self-injury, more consistent with borderline.
C. Avoidant
This option implies avoidant personality disorder, which causes social inhibition, feelings of inadequacy, and avoidance of relationships for fear of rejection, BUT she actively seeks intense relationships and is not socially withdrawn or avoidant.
D. Dependent
This option implies dependent personality disorder, which is marked by submissive, clingy behavior and difficulty making decisions independently, BUT there is no pattern of pervasive submissiveness or reliance on others to make decisions—her presentation centers on emotional instability and self-harm, not passive dependence.
E. Antisocial
This option implies antisocial personality disorder, which involves disregard for others’ rights, deceit, and lack of remorse, often beginning with conduct disorder, BUT she shows remorse, guilt, and distress; her self-harm is directed inward, not toward violating others’ rights.
Exam trap
The revealing dress and sexualized appearance tempt you to pick histrionic by buzzword, but the exam wants you to prioritize the dominant pattern: unstable relationships, self-harm, and abandonment fears → borderline personality disorder.
The bottom line
Borderline personality disorder: unstable relationships, frantic efforts to avoid abandonment, self-harm, intense affective lability, impulsivity, and chronic emptiness/regret.
Source: StepGenie question bank. Questions are written by StepGenie, not taken from NBME or USMLE materials, and are chosen for this page by how students actually performed on them (first-attempt accuracy on StepGenie). Selection last refreshed September 5, 2026.
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Comprehensive psychiatry covering mood disorders, psychotic disorders, anxiety, substance abuse, and psychopharmacology. Learn DSM-5 criteria and evidence-based treatment approaches.
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Psychiatry — Frequently Asked Questions
How do the durations separate the psychotic disorders?
Duration is the discriminator. Brief psychotic disorder lasts less than one month. Schizophreniform disorder lasts one to six months. Schizophrenia requires at least six months of symptoms including at least one month of active-phase symptoms. Schizoaffective disorder additionally requires a period of psychosis without prominent mood symptoms, which separates it from mood disorder with psychotic features.
What antipsychotic side effects are most tested?
Typical antipsychotics carry high extrapyramidal risk, with acute dystonia in hours, akathisia and parkinsonism in days to weeks, and tardive dyskinesia after months. Atypicals carry metabolic risk with weight gain, hyperglycemia and dyslipidemia. Clozapine requires monitoring for agranulocytosis and carries myocarditis and seizure risk. Neuroleptic malignant syndrome can follow any of them.
How do you distinguish delirium from dementia?
Delirium develops acutely over hours to days, fluctuates through the day, impairs attention prominently, and often includes an altered level of consciousness with a reversible medical cause. Dementia develops insidiously over months to years, progresses steadily, and preserves the level of consciousness until late. Any acute mental status change in a hospitalised patient should be treated as delirium until proven otherwise.
What are the highest-yield psychiatry topics on the USMLE?
Mood disorders including bipolar disorder and the criteria that separate its types, psychotic disorders by duration, anxiety disorders, personality disorder clusters, substance intoxication and withdrawal, and psychopharmacology with its side effect profiles. Suicide risk assessment and the situations requiring involuntary hold recur because they test safe clinical judgement.
Are the psychiatry practice questions on this page free?
Yes. The 5 questions above come from StepGenie's question bank and can be answered here without an account, with the full explanation shown after each one. From the link under the set you can try three more Psychiatry questions in the dashboard preview, also without an account; a free account is what lets you choose the system and keep going.