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Difficulty: MediumAnxiety, OCD, and Trauma-Related Disorders

A 34-year-old male architect is accompanied to the primary care physician by his spouse. The patient survived a severe structural collapse at a building site exactly twenty-four days ago. Since the event, he has experienced recurrent, intrusive nightmares about the collapse and profound distress when exposed to loud noises. He actively avoids visiting any construction zones. The spouse notes that the patient has been highly irritable, jumpy, and disconnected from his family. During the psychiatric review of systems, the physician discovers that six years ago, the patient had a discrete four-week episode characterized by a severely decreased need for sleep, pressured speech, and grandiose delusions that required inpatient psychiatric hospitalization. Current laboratory studies reveal a serum thyroid-stimulating hormone level of 1.8 µU/mL (normal: 0.4-4.5 µU/mL) and a free thyroxine level of 1.2 ng/dL (normal: 0.8-1.8 ng/dL). Which of the following is the most appropriate next step in the management of this patient's condition?

  1. Provision of trauma-focused behavioral psychotherapyAnswer
  2. B
    Commence citalopram monotherapy
  3. C
    Initiate prazosin therapy for post-traumatic stress disorder
  4. D
    Begin methimazole administration
  5. E
    Disclose the patient's occupational restrictions to his employer

Answer

Provision of trauma-focused behavioral psychotherapy
The patient is presenting with symptoms characteristic of a trauma-related disorder (intrusions, avoidance, negative mood, arousal) following a life-threatening event. Because the timeline is exactly 24 days (less than one month), the appropriate diagnosis is Acute Stress Disorder (ASD). The first-line recommended treatment for ASD is trauma-focused behavioral psychotherapy (such as trauma-focused cognitive behavioral therapy). This approach is highly effective in reducing current symptoms and preventing the progression to Post-Traumatic Stress Disorder (PTSD). Additionally, psychotherapy is exceptionally safe in this specific patient, who has a clear history of Bipolar I Disorder (evidenced by his prior manic episode with hospitalization) and is currently not taking a mood stabilizer.

Step-by-Step Solution

1
Evaluate the timeline of the patient's trauma-related symptoms to establish a diagnosis.
The trauma occurred twenty-four days ago. Symptoms of intrusion, avoidance, and hyperarousal lasting less than one month denote Acute Stress Disorder (ASD), not Post-Traumatic Stress Disorder (PTSD).
Accurate psychiatric diagnosis relies heavily on strict timeline criteria defined by the DSM-5.
2
Analyze the patient's psychiatric history for comorbidities.
The history of a four-week episode of decreased sleep, pressured speech, and grandiosity requiring hospitalization indicates a definitive history of Bipolar I Disorder.
Previous psychiatric history directly dictates the safety and selection of current pharmacologic interventions.
3
Determine the most appropriate management based on the diagnosis and psychiatric history.
Trauma-focused cognitive behavioral therapy is the first-line treatment for Acute Stress Disorder. Furthermore, avoiding SSRIs like citalopram is crucial to prevent inducing a manic switch in a bipolar patient.
Psychotherapy is both the gold standard for ASD and completely safe for patients with bipolar disorder who are not currently on mood stabilizers.

Key Concept

Diagnosis and management of Acute Stress Disorder (ASD) in the context of Bipolar Disorder
Estimated Time:1m 15s
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Topics

Anxiety, OCD, and Trauma-Related Disorders

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