A 19-year-old female college student is evaluated at the student health center due to sign… — USMLE Step 2 CK

A 19-year-old female college student is evaluated at the student health center due to significant weight loss and academic decline. For the past eight months, she has experienced overwhelming anxiety when eating in the campus dining hall, constantly fearing that other students are intensely watching and negatively judging her table manners. To avoid this distress, she has been skipping meals, resulting in a 5-kg (11-lb) weight loss. She denies any fear of gaining weight or distorted body image. She also strictly avoids raising her hand or speaking in seminars. Her medical history is significant for a recent methicillin-resistant *Staphylococcus aureus* (MRSA) skin abscess, for which she was started on oral linezolid three days ago. Her psychiatric history includes an episode at age 17 characterized by severe depression, which was followed by a distinct two-week period of euphoric mood, decreased need for sleep, and hypersexuality.

Laboratory studies reveal:

Test	Result	Reference Range
Thyroid-stimulating hormone (TSH)	0.2 µU/mL	0.5 - 5.0 µU/mL
Free thyroxine (T4)	0.5 ng/dL	0.9 - 1.7 ng/dL

Which of the following is the most appropriate next step in the management of this patient?

Refer the patient for cognitive-behavioral therapy focusing on social exposureAnswer
B
Initiate citalopram immediately to treat her acute anxiety symptoms
C
Initiate paroxetine monotherapy after she completes her antibiotic course
D
Diagnose primary hyperthyroidism as the cause of her anxiety and initiate methimazole
E
Diagnose brief psychotic disorder based on her paranoid ideation and initiate risperidone

Answer

Refer the patient for cognitive-behavioral therapy focusing on social exposure

The patient exhibits core features of Social Anxiety Disorder (SAD), characterized by an excessive fear of scrutiny and negative evaluation in social or performance situations (e.g., eating in the dining hall, speaking in class). Her symptoms have led to severe avoidance behavior and functional impairment (significant weight loss, academic decline). She lacks the body image distortion required for an anorexia nervosa diagnosis. While selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy (CBT) are both first-line treatments for SAD, this patient's complex history makes pharmacotherapy hazardous. CBT with exposure techniques is the safest and most appropriate immediate intervention, effectively bypassing the risks of drug-drug interactions and mood destabilization.

Step-by-Step Solution

Analyze the psychiatric presentation and establish the primary diagnosis.

The patient has marked fear of scrutiny in social situations (eating in public, speaking in class) causing functional impairment (weight loss, academic decline) lasting over 6 months, without body image distortion. This confirms Social Anxiety Disorder (SAD).

Accurate diagnosis is required before selecting an intervention, distinguishing SAD from eating disorders or psychotic disorders.

Evaluate the patient's medical and psychiatric comorbidities for contraindications to standard pharmacotherapy.

The patient is taking linezolid (a reversible MAOI) and has a clear history of a manic/hypomanic episode (euphoria, decreased sleep, hypersexuality), indicating Bipolar Disorder.

Standard first-line pharmacotherapy for SAD includes SSRIs, but these comorbidities make SSRI use highly dangerous.

Select the safest first-line treatment option.

Cognitive-behavioral therapy (CBT) is chosen.

CBT is a first-line treatment for SAD that avoids the risk of serotonin syndrome (from linezolid) and manic switching (from bipolar disorder).

Key Concept

First-line management of Social Anxiety Disorder in medically and psychiatrically complex patients involves Cognitive-Behavioral Therapy to avoid dangerous pharmacologic interactions and mood destabilization.

Estimated Time:1m 30s

Question

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Topics

More questions from this topic