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Difficulty: HardAnxiety, OCD, and Trauma-Related Disorders

A physician at a community health clinic evaluates a 34-year-old man who reports feeling "constantly tense and detached" for the past half-year. Seven months ago, the patient survived a severe factory explosion in which two of his colleagues died. Since the incident, he experiences recurrent, vivid nightmares about the explosion and becomes visibly diaphoretic and tachycardic whenever he hears loud metallic noises. He has completely stopped driving near the industrial park where he used to work and mentions that he feels entirely disconnected from his wife and children. His medical history is significant for treatment-resistant major depressive disorder, for which his psychiatrist prescribed tranylcypromine three weeks ago after multiple other medication trials failed. His blood pressure is 128/82 mm Hg, and his pulse is 76/min. The patient expresses a strong desire for immediate relief from his hyperarousal and intrusive memories. Which of the following is the most appropriate next step in the management of this patient?

  1. Initiate trauma-focused cognitive behavioral therapyAnswer
  2. B
    Add sertraline to the current medication regimen
  3. C
    Discontinue tranylcypromine and initiate venlafaxine following a 5-day washout period
  4. D
    Disclose the patient's ongoing psychological impairment to his current employer
  5. E
    Reassure the patient that his symptoms of acute stress disorder will likely resolve spontaneously

Answer

Initiate trauma-focused cognitive behavioral therapy
The patient's presentation of intrusive nightmares, severe physiological reactivity to triggers, avoidance behavior, and emotional detachment lasting for 7 months following a life-threatening event is diagnostic of post-traumatic stress disorder (PTSD). First-line treatments for PTSD include trauma-focused cognitive behavioral therapy (TF-CBT) and serotonergic antidepressants (SSRIs or SNRIs). Because this patient is currently taking tranylcypromine, a monoamine oxidase inhibitor (MAOI), the addition of an SSRI or SNRI is absolutely contraindicated due to the high risk of developing life-threatening serotonin syndrome. Therefore, initiating a non-pharmacologic first-line treatment such as TF-CBT is the safest and most appropriate next step in management.

Step-by-Step Solution

1
Establish the correct psychiatric diagnosis based on symptom duration and clinical presentation.
The patient meets the criteria for Post-Traumatic Stress Disorder (PTSD) because his symptoms of intrusion, avoidance, and hyperarousal have persisted for 7 months.
Acute stress disorder resolves or transitions to PTSD after 1 month. The prolonged timeline confirms PTSD.
2
Identify the standard first-line treatment options for PTSD.
First-line therapies include trauma-focused cognitive behavioral therapy (TF-CBT) and pharmacotherapy with SSRIs or SNRIs.
Both psychological and pharmacological approaches have strong, evidence-based efficacy in reducing the core symptoms of PTSD.
3
Evaluate the patient's current medication regimen for potential life-threatening drug interactions.
The patient is taking tranylcypromine, an MAOI. Concomitant use of MAOIs and serotonergic antidepressants (SSRIs/SNRIs) is strictly contraindicated.
Combining these medications can cause fatal serotonin syndrome. Furthermore, safely switching from an MAOI to a serotonergic agent requires a 14-day washout period.
4
Select the most appropriate, safe, and immediate next step in management.
Initiate trauma-focused cognitive behavioral therapy.
TF-CBT provides first-line efficacy for PTSD without risking dangerous drug interactions with the patient's active MAOI regimen.

Key Concept

Management of Post-Traumatic Stress Disorder (PTSD) in the setting of concurrent MAOI therapy
Estimated Time:1m 30s
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Topics

Anxiety, OCD, and Trauma-Related Disorders

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