High-Yield Psychiatry for USMLE Step 1

Psychiatry! Finally a topic with information that might be condensed into a single high-yield treatise!

But don’t tell that to the psychiatrists. The information needed to get through Step 1 is much less than what’s necessary to be a psychiatrist. No matter what your chosen field, you will definitely need a basic understanding of depression, suicidality, personality disorders, and psychiatric medications. You will definitely need to know all of these to rock Step 1!

Psychiatry is full of subtle distinctions—and the exam questions love to test your ability to tell them apart. The difference between brief psychotic disorder and schizophreniform disorder? Just a few weeks. Bipolar I vs. bipolar II? It hinges on whether there’s ever been a mania—not just hypomania.

That means mastering psychiatry isn’t just about recognizing symptoms, but also paying close attention to the terminology and the timing. We’ll break these down, focus on buzzwords and timelines, and give you quick ways to tell confusing diagnoses apart—even when they try to trick you.

1. Ego defenses (7)

There are 15+ ways that our egos try to make us feel better about the state of affairs. While a lot of this feels like a vocabulary test, this guide breaks it down for you with examples to help you retain the information. Do your best to learn all of these, but if forced to triage, internalize splitting, rationalization, dissociation, denial, repression, and projection.

Ego defenses are buzzwords galore—you just need to match the behavior to the defense.

Must-Know Defenses:

Splitting

Seeing people or situations as all good or all bad—no gray area.

“My doctor is amazing. That nurse is a monster.” → Associated with borderline personality disorder.

Projection

Attributing your own unacceptable thoughts or feelings to someone else.

A person who is angry at their coworker accuses the coworker of being hostile.

Denial

Refusing to accept a painful reality or fact.

“I don’t have a drinking problem,” says the man with daily forgetfulness and missing work from being drunk.

Rationalization

Creating logical explanations to justify unacceptable feelings or behaviors.

A student says they didn’t match because “the program wasn’t that good anyway,” when in reality they’re deeply disappointed.

Repression

Unconsciously blocking unwanted thoughts or memories. Unlike suppression, repression is not deliberate.

A man cannot recall any details of a traumatic car accident he survived years ago.

Dissociation

Temporarily disconnecting from reality to avoid emotional distress; a disruption in memory, identity, or perception.

A person who experienced trauma reports feeling like they were “watching themselves from outside their body” during the event.

Pearl: Test writers often pair these with personality disorders or substance abuse to add confusion.

2. Childhood disorders (6.5)

Attention-Deficit/Hyperactivity Disorder (ADHD)

Children are not immune from psychiatric diagnoses. Attention-Deficit/Hyperactivity Disorder (ADHD) is quite common, self-explanatory, and is treated with stimulants like methylphenidate.

ADHD is a neurodevelopmental disorder with symptoms that begin in childhood and affect functioning in at least two settings (e.g., home and school).

There are three core symptom domains:

Inattention
Hyperactivity
Impulsivity

Duration: Symptoms must be present for ≥6 months and have functional impairment.

Pearl: Look for a kid who interrupts constantly, can’t sit still, and is underperforming in school. The question stem may use phrases such as: easily distracted, forgetful, disorganized, or often loses things.

Often associated with learning difficulties (especially reading and math), conduct disorder, anxiety and sleep disturbances.

Austism Spectrum Disorder (ASD)

Autism spectrum disorder is hallmarked by repetitive behaviors and poor social interactions. Children in question stems might be fixated on car wheels instead of the car as a whole.

ASD is a neurodevelopmental disorder characterized by deficits in social communication and interaction, and restricted, repetitive patterns of behavior, interests, or activities.

Symptoms are present in the early developmental period, typically recognized before age 2–3 years old and ASD can be associated with language delay.

Early signs include:

No babbling or pointing by 12 months
No single words by 16 months
No two-word phrases by 24 months

Language regression (loss of speech or social skills) around 18–24 months is a red flag and ASD is more common in boys (about 4:1). There’s a strong genetic component—more likely in siblings and behavioral and speech therapy is beneficial.

Applied Behavior Analysis (ABA) – most evidence-based

Oppositional Defiant Disorder

Oppositional defiant disorder is also a common testable one, which presents earlier and is characterized by a pattern of angry or irritable mood, argumentative or defiant behavior toward authority figures.

Conduct Disorder

Meanwhile, conduct disorder (CD) involves more severe behaviors such as aggression toward people or animals, property destruction, deceitfulness or theft, and serious rule violations (e.g., truancy, running away, breaking laws).

CD is considered a precursor to antisocial personality disorder if the behavior persists into adulthood. Both disorders are more common in males and can be associated with environmental factors like family conflict, trauma, or inconsistent discipline. Treatment includes behavioral therapy, family interventions, and sometimes medications for comorbid conditions.

3. Schizophrenia (9)

This is the prototypical psychiatric disease. Look for both positive (delusions, hallucinations) and negative (social withdrawal, lack of self-care) symptoms. You will certainly be tested on teasing out schizophrenia proper from a brief psychotic disorder, which lasts less than one month, and schizophreniform disorder, which lasts 1-6 months. When schizophrenia is combined with a mood disorder like depression or bipolar, you’ve got schizoaffective disorder.

Positive symptoms = hallucinations, delusions
Negative symptoms = flat affect, avolition

Timeline breakdown:

<1 month = Brief Psychotic Disorder
1–6 months = Schizophreniform Disorder
>6 months = Schizophrenia
Schizoaffective = Mood symptoms + psychosis. Psychosis must occur without mood symptoms at times.

Pearl: Auditory hallucinations are most common. Look for bizarre beliefs—e.g., “My brain is controlled by satellites.”

4. Major Depressive Disorder (8.5)

With a prevalence of almost 10% in the US population, depression is certainly a disease you will be tested on.

MDD is a common psychiatric condition characterized by persistent low mood and loss of interest or pleasure in most activities for at least two weeks, along with associated symptoms such as changes in sleep, appetite, energy, concentration, guilt or worthlessness, and thoughts of death or suicide. Diagnosis requires at least five symptoms, with at least one being depressed mood or anhedonia. MDD can significantly impair daily functioning and is often recurrent. It is more common in females and frequently co-occurs with anxiety, substance use, or medical illnesses. Treatment includes psychotherapy (like CBT), antidepressant medications (e.g., SSRIs), or a combination of both. In severe or treatment-resistant cases, electroconvulsive therapy (ECT) may be considered.

Your first-line choice in treatment is an SSRI +/- CBT. Many options exist if SSRIs are ineffective or if their side effects are intolerable.

1st line: SSRIs (e.g., sertraline, fluoxetine) ± CBT
Try 6–8 weeks before switching

Pearl: SSRIs may cause sexual side effects → consider bupropion (no sexual dysfunction, but avoid in seizures).

5. Personality disorders (7)

Whether they are diagnosed by a psychiatrist or not, in all likelihood, you have met somebody out in the real world who is suffering from a personality disorder. Maybe it’s that uncle who keeps to himself, doesn’t really acknowledge the family, and has always taken jobs where he doesn’t have to interact with others. Or your coworker from the grocery store who could hold down a job and was enjoyable to be around but wholeheartedly believed she was married to the ghost of Jim Morrison (true story).

Personality disorders are so hard to address because the afflicted patient is not aware of the problem, cannot recognize anything as being wrong, and has no desire to change. Keep this in mind when choosing between personality disorders, and similar conditions in which the patient does indeed recognize their behavior as not fitting in with social norms.

As an example, a patient with obsessive-compulsive disorder doesn’t want to wash their hands 4 times before setting the table, and realizes this is a bizarre behavior. A patient with obsessive compulsive personality disorder might have similar behaviors, but would not see anything wrong with them.

Grouped into clusters:

Cluster A (weird): Paranoid, schizoid, schizotypal
Cluster B (wild): Antisocial, borderline, histrionic, narcissistic
Cluster C (worried): Avoidant, dependent, obsessive-compulsive

Pearl: Differentiate OCD (ego-dystonic) vs OCPD (ego-syntonic). OCD knows it’s irrational; OCPD thinks their perfectionism is beneficial and necessary.

Example: A man insists his family set the dinner table with perfect symmetry but doesn’t see anything wrong with it → OCPD.

6. Intoxications/Withdrawal Syndromes (9)

Being able to recognize intoxication and withdrawal from drugs of abuse is one of the cornerstones of psychiatry and also has a huge role in the emergency department.

Remember, withdrawing from a GABA-ergic drug like alcohol or benzodiazepines can be lethal. Other withdrawals are more unpleasant than deadly. Always consider cocaine use in a young, “healthy” patient with a cardiac condition like a STEMI.

As a general rule, stimulants will increase sympathetic activity when in use, and leave a person in a low-energy state when withdrawing. Depressants slow things down when being taken, and sympathetic overdrive kicks in during withdrawal.

Depressants (alcohol, benzos):

Withdrawal = life-threatening: tremors, seizures, DTs (delirium tremens)
Tx: Benzos (e.g., lorazepam)

Stimulants (cocaine, amphetamines):

Intoxication: Euphoria, agitation, ↑HR, ↑BP, psychosis
Withdrawal: Crash—fatigue, depression, hypersomnia
Think cocaine in a young adult with chest pain + ST elevations + no risk factors.

7. Antipsychotics (7.5)

You can 100% expect to see antipsychotics on Step 1. There are very many to internalize, so a framework is necessary.

Separate your typical antipsychotics (prototype = haloperidol, a D2 receptor blocker, work mostly on positive symptoms) from your atypicals (risperidone, quetiapine, olanzapine, aripiprazole, etc., which work on both positive and negative symptoms).

While remembering every nuance here is a near-impossibility, try to hang onto one major side effect for each one, as this is what makes them testable.

For instance, think of olanzapine causing weight gain, risperidone causing elevated prolactin, and clozapine causing bone marrow suppression. Understanding the continuum of extrapyramidal symptoms from acute dystonia all the way to tardive dyskinesia is also crucial.

Typical (1st gen):

Haloperidol, fluphenazine
Blocks D2 receptors → treats positive symptoms

Atypical (2nd gen):

Risperidone, olanzapine, quetiapine, aripiprazole, clozapine
Treat positive and negative symptoms

Side Effect Pearls:

Olanzapine → weight gain
Risperidone → ↑ prolactin → galactorrhea, gynecomastia
Clozapine → agranulocytosis (monitoring CBC required), seizures

EPS spectrum:

Acute dystonia (hrs-days) → Tx: benztropine
Akathisia (days-weeks) → Tx: propranolol
Parkinsonism → Tx: benztropine
Tardive dyskinesia (months-years) → irreversible, switch meds

8. Antidepressants (10)

There are numerous drug classes to choose from when treating depression. Start with an SSRI, and remember these versatile drugs have applications to other maladies like panic disorder, PTSD, and OCD. Also, give them time, up to 2 months, to take effect. A classic question stem is a patient coming in at 2 weeks after initiation of an SSRI, not feeling much effect. Exercise patience.

Other classes include serotonin-norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants, both of which have application to chronic pain. As far as atypical choices, bupropion leads the pack for lack of sexual side effects, mirtazapine stimulates appetite, and trazodone makes you sleepy and causes priapism.

Classes:

SSRIs: 1st-line for depression, anxiety, PTSD, OCD
- Pearl: Takes 4–8 weeks. Don’t switch too soon.
SNRIs (e.g., venlafaxine, duloxetine)
- Can be useful for chronic pain
TCAs (e.g., amitriptyline): Dangerous in overdose → arrhythmias, coma
- Anticholinergic SEs = dry mouth, constipation, urinary retention
MAOIs (e.g., phenelzine): Hypertensive crisis with tyramine (aged cheese, wine)

Atypicals:

Bupropion – No sexual SEs—lowers seizure threshold
Mirtazapine – Appetite stimulant (safe to use in elderly)
Trazodone – Sedation + priapism

Bonus Pearls:

Neuroleptic Malignant Syndrome: Fever + rigidity + ↑CK after antipsychotic → Tx = dantrolene or bromocriptine
Serotonin Syndrome: Agitation, hyperreflexia, clonus → Stop meds, give cyproheptadine
Suicidality: Always assess for plan, means, intent. If yes to all → inpatient hospitalization

Are you intimidated by these countless pharmacologic therapies and their laundry list of side-effects? It’s great that patients have options if one drug doesn’t agree with them, but tough on test takers who need to remember 30 drugs instead of 3. As above, hang onto the most common or most particular side effect for these medications, as that’s what really sets them apart and will be tested.

Treat psychiatry like biochem with better stories. It’s high-yield, fast to study, and saves your Step 1 score if you treat it seriously. Mnemonics, question bank repetition, and drug side effect flashcards are your best friends here.

Now go PSYCH yourself up for some studying. You got this!

Now, That’s What I Call High-Yield: Psychiatry