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Difficulty: Very hardAnxiety, OCD, and Trauma-Related Disorders

A 34-year-old woman presents to the clinic accompanied by her sister due to a 4-week history of recurrent, unexpected episodes of intense fear, palpitations, sweating, and chest pain. Each episode peaks within 10 minutes. Because of these attacks, she has stopped going to work and refuses to leave her house, fearing she will be unable to escape if an attack occurs. She has a history of bipolar I disorder, diagnosed after a severe manic episode at age 24, but discontinued her lithium 3 years ago. For the past month, she has also felt profoundly sad, with low energy and hypersomnia. She recently saw another physician who prescribed phenelzine two weeks ago. In the waiting room, the sister pulls the physician aside and asks, 'Is she developing schizophrenia like our mother? I need to know her exact diagnosis.' Vital signs are temperature 37.0°C (98.6°F), blood pressure 128/82 mm Hg, and pulse 108/min. Physical examination is unremarkable. Which of the following are appropriate next steps in this patient's management? (Select all that apply)

  1. Initiate cognitive-behavioral therapyAnswer
  2. Assessment of serum thyroid-stimulating hormoneAnswer
  3. C
    Initiate sertraline monotherapy
  4. D
    Disclose the suspected diagnosis to the patient's sister
  5. E
    Discontinue phenelzine and initiate citalopram therapy in 24 hours

Answer

The most appropriate next steps are to initiate cognitive-behavioral therapy and assess serum thyroid-stimulating hormone.
The patient's presentation of recurrent, unexpected episodes of intense fear accompanied by autonomic symptoms and subsequent avoidance behavior is consistent with panic disorder and agoraphobia. Cognitive-behavioral therapy is a first-line treatment for this condition and is particularly appropriate here given the complexities of her medication history and comorbidities. Additionally, because the patient has new-onset autonomic symptoms (tachycardia) and panic attacks, standard practice dictates ruling out physiological causes such as hyperthyroidism by ordering a serum thyroid-stimulating hormone (TSH) level.

Step-by-Step Solution

1
Identify the primary psychiatric syndrome.
The patient exhibits recurrent, unexpected panic attacks leading to agoraphobia (avoiding leaving the house).
This establishes a working diagnosis of panic disorder with agoraphobia.
2
Evaluate for medical etiologies.
The patient has resting tachycardia (108/min) and new-onset panic symptoms.
Basic laboratory testing, including TSH, is required to rule out hyperthyroidism, which can mimic panic attacks.
3
Determine appropriate psychiatric treatment while considering comorbidities.
Cognitive-behavioral therapy (CBT) is selected as a safe and effective initial treatment.
Pharmacological interventions like SSRIs are complicated by her bipolar I history (risk of manic switch) and current MAOI use (risk of serotonin syndrome).
4
Address the ethical dilemma regarding the sister's request.
The physician must refuse to disclose the diagnosis.
Without the patient's explicit consent, sharing health information violates patient confidentiality.

Key Concept

Management of panic disorder with agoraphobia in complex patients requires medical rule-out (e.g., TSH), evidence-based psychotherapy (CBT), careful navigation of psychiatric comorbidities (avoiding SSRI monotherapy in bipolar disorder), and strict adherence to medical confidentiality.
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Topics

Anxiety, OCD, and Trauma-Related Disorders

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