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Difficulty: HardAnxiety, OCD, and Trauma-Related Disorders

A 38-year-old woman presents to the outpatient psychiatry clinic seeking help for severe distress. Ten months ago, she was the victim of a violent home invasion. Since then, she experiences recurrent, intrusive nightmares of the event, avoids being alone in her house, and feels constantly "on guard." She states she feels emotionally detached from her husband. Her past psychiatric history includes a hospitalization at age 22 for a week-long period of decreased need for sleep, rapid speech, and grandiose delusions, followed by a severe depressive crash. Three weeks ago, a primary care physician started her on phenelzine for her low mood. She read online that paroxetine is effective for trauma survivors and asks if she can start taking it today to help with her nightmares. Which of the following are the most appropriate actions in the management of this patient's current presentation? (Select 2)

  1. Initiate exposure-based trauma-focused psychotherapyAnswer
  2. Advise the patient that combining paroxetine with her current medication risks life-threatening autonomic instability and neuromuscular hyperactivityAnswer
  3. C
    Prescribe paroxetine immediately to aggressively target her intrusive trauma symptoms
  4. D
    Discontinue phenelzine, complete a 14-day washout period, and then initiate paroxetine monotherapy
  5. E
    Reclassify her diagnosis as schizophreniform disorder based on her history of delusions and current emotional detachment

Answer

The most appropriate actions are to initiate exposure-based trauma-focused psychotherapy and to explicitly warn the patient about the fatal risks of combining her current MAOI (phenelzine) with an SSRI (paroxetine).
The patient presents with classic symptoms of Post-Traumatic Stress Disorder (PTSD) stemming from a traumatic event 10 months ago. Trauma-focused cognitive behavioral therapy, including exposure techniques, is a first-line treatment for PTSD and is highly appropriate. Additionally, her request to start paroxetine (an SSRI) while taking phenelzine (a monoamine oxidase inhibitor) presents a critical safety issue. The physician must advise her that this combination is absolutely contraindicated as it can precipitate Serotonin Syndrome, characterized by autonomic instability, altered mental status, and neuromuscular hyperactivity.

Step-by-Step Solution

1
Establish the primary current diagnosis based on the clinical presentation.
The patient exhibits intrusive symptoms (nightmares), avoidance, negative alterations in cognition/mood (emotional detachment), and hyperarousal (on guard) persisting for >1 month following a life-threatening event. Diagnosis: Post-Traumatic Stress Disorder (PTSD).
Accurate diagnosis is required to guide first-line treatment selection, which for PTSD includes trauma-focused psychotherapy.
2
Evaluate the patient's request to add paroxetine to her current phenelzine regimen.
Phenelzine is an MAOI. Paroxetine is an SSRI. Combining them is absolutely contraindicated due to the risk of Serotonin Syndrome.
Preventing lethal pharmacological interactions is the most urgent safety priority in this clinical scenario.
3
Analyze the patient's past psychiatric history to assess the safety of future pharmacological adjustments.
The patient has a history of a week-long episode of decreased sleep, rapid speech, and grandiose delusions. This represents a manic episode, confirming a diagnosis of Bipolar I Disorder.
Identifying comorbid Bipolar I Disorder is crucial because it rules out the use of antidepressant monotherapy (such as starting an SSRI after a washout period) due to the high risk of inducing a manic switch.

Key Concept

Management of PTSD requires careful screening for comorbid Bipolar Disorder to avoid antidepressant-induced mania, and strict avoidance of MAOI and SSRI co-administration to prevent Serotonin Syndrome.
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Topics

Anxiety, OCD, and Trauma-Related Disorders

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