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Difficulty: HardAnxiety, OCD, and Trauma-Related Disorders

A 22-year-old female college student presents to the university health clinic reporting recurrent, unexpected episodes of intense fear. During these episodes, she experiences palpitations, diaphoresis, shortness of breath, and a profound fear of losing control. The episodes peak within 10 minutes and have occurred four times in the past month. She now actively avoids the campus library, where two of the episodes occurred, fearing she will have another attack and be unable to escape. Her medical history is significant for a hospitalization one year ago for a 3-week period of severely decreased need for sleep, pressured speech, and grandiose delusions involving a belief that she was a prophet chosen to solve world hunger. She was stabilized and discharged but voluntarily discontinued all her psychiatric medications 6 months ago. Vital signs are within normal limits. Physical examination, electrocardiogram, and baseline laboratory studies, including a comprehensive metabolic panel, thyroid-stimulating hormone, and urine toxicology, are unremarkable. Which of the following is the most appropriate next step in management?

  1. Initiate cognitive-behavioral therapyAnswer
  2. B
    Initiate sertraline monotherapy
  3. C
    Initiate citalopram and phenelzine concurrently
  4. D
    Disclose the diagnosis to her roommate to ensure safety during future attacks
  5. E
    Initiate haloperidol for a presumed recurrence of schizophreniform disorder

Answer

Initiate cognitive-behavioral therapy
The correct approach is to initiate cognitive-behavioral therapy (CBT). This patient's current presentation of recurrent, unexpected panic attacks followed by avoidance of specific locations (the library) is classic for Panic Disorder with Agoraphobia. Normally, first-line treatments include CBT, SSRIs, or SNRIs. However, this patient's history of a hospitalization for decreased sleep, pressured speech, and grandiose delusions indicates she has Bipolar I Disorder. In patients with bipolar disorder, the use of antidepressant monotherapy (such as an SSRI or SNRI) is contraindicated due to the high risk of precipitating a manic or hypomanic episode (manic switch). Therefore, the safest and most effective initial intervention for her panic disorder is psychotherapy, specifically CBT. If pharmacotherapy were deemed necessary for her anxiety, it would need to include a mood stabilizer or atypical antipsychotic to protect against a manic switch.

Step-by-Step Solution

1
Identify the current psychiatric diagnosis based on the clinical presentation.
The patient has recurrent, unexpected panic attacks with subsequent avoidance behavior (agoraphobia), leading to a diagnosis of Panic Disorder with Agoraphobia.
Accurate diagnosis is required before selecting a management plan.
2
Review the patient's past medical history for comorbid psychiatric conditions.
The history of a 3-week episode characterized by decreased sleep, pressured speech, and grandiose delusions confirms a past manic episode, diagnostic of Bipolar I Disorder.
Past psychiatric history often dictates the safety profile of current treatment options.
3
Determine the safest and most effective initial treatment for panic disorder in the context of Bipolar I Disorder.
Cognitive-behavioral therapy (CBT) is selected over SSRI monotherapy.
SSRI monotherapy carries a significant risk of inducing a manic switch in patients with bipolar disorder. CBT is highly effective for panic disorder and carries no risk of mood destabilization.

Key Concept

Management of anxiety disorders in patients with comorbid bipolar disorder
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Topics

Anxiety, OCD, and Trauma-Related Disorders

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