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Question

Difficulty: HardAnxiety, OCD, and Trauma-Related Disorders

A 32-year-old woman presents to the outpatient clinic 3 weeks after surviving a traumatic emergency plane landing as a passenger. She describes having severe, recurrent nightmares about the event, hypervigilance, and feeling detached from her loved ones. She has refused to fly since the incident and has taken a leave of absence from her job as a corporate executive. She also reports feeling persistently 'down' and fatigued. Her past psychiatric history is significant for bipolar I disorder, but she discontinued her prescribed mood stabilizer 6 months ago. For the past month, she has been taking daily over-the-counter St. John's wort to manage her low mood. She is highly distressed and asks the physician not to disclose her visit to her company's human resources department, which requires medical clearance for her leave. The physician determines she meets the criteria for acute stress disorder. Which of the following are the most appropriate actions in the management of this patient? (Select 2)

  1. Begin trauma-focused cognitive-behavioral therapy as the primary interventionAnswer
  2. Maintain patient confidentiality by declining to contact her employer without written authorizationAnswer
  3. C
    Start sertraline monotherapy to concurrently target her trauma-related and depressive symptoms
  4. D
    Prescribe paroxetine while advising her to continue taking St. John's wort for synergistic benefits
  5. E
    Contact the human resources department directly to coordinate and justify her medical leave of absence

Answer

The correct approaches are to begin trauma-focused cognitive-behavioral therapy (CBT) and to maintain patient confidentiality by not contacting her employer.
Trauma-focused cognitive-behavioral therapy is the safest and most effective first-line treatment for acute stress disorder. Furthermore, physicians must strictly adhere to HIPAA regulations and core medical ethics; medical information cannot be released to a corporate employer without the patient's explicit, written consent.

Step-by-Step Solution

1
Identify the primary psychiatric diagnosis and determine the appropriate first-line treatment.
The patient has acute stress disorder (ASD). Trauma-focused CBT is the indicated first-line treatment for ASD.
CBT addresses the trauma symptoms effectively without the pharmacological risks associated with her bipolar history.
2
Evaluate the risks of initiating pharmacotherapy.
The patient is unmedicated for bipolar I disorder and currently takes St. John's wort.
SSRI monotherapy could precipitate a manic episode, and combining an SSRI with St. John's wort risks severe serotonin syndrome.
3
Apply medical ethics regarding patient confidentiality.
The patient explicitly requested privacy regarding her human resources department.
A physician cannot disclose protected health information to an employer without explicit patient authorization, as this situation poses no imminent public threat.

Key Concept

Management of Acute Stress Disorder in the context of bipolar disorder, dangerous serotonergic drug interactions, and strict medical confidentiality.
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Topics

Anxiety, OCD, and Trauma-Related Disorders

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