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Difficulty: MediumAnxiety, OCD, and Trauma-Related Disorders

A 28-year-old woman is brought to the clinic by her husband due to severe anxiety, poor sleep, and behavioral changes. Three weeks ago, she was the victim of a violent home invasion. Since the event, she has experienced frequent, distressing flashbacks, severe insomnia, and an exaggerated startle response. She refuses to be left alone in the house, feels detached from her family, and is unable to return to work. Her medical history is notable for bipolar I disorder, which has been well-controlled on lithium for 5 years. She is also taking phenelzine, prescribed by a previous physician for treatment-resistant depression prior to her bipolar diagnosis. She is requesting medication to help alleviate her current distress. Which of the following are appropriate next steps in the management of this patient? (Select exactly 2)

  1. Referral for trauma-focused cognitive behavioral therapyAnswer
  2. Provision of psychoeducation about expected acute stress reactions and coping strategiesAnswer
  3. C
    Formal diagnosis of post-traumatic stress disorder and initiation of prolonged exposure therapy
  4. D
    Addition of sertraline to her current medication regimen to target intrusive symptoms
  5. E
    Discontinuation of lithium and initiation of paroxetine monotherapy

Answer

The appropriate next steps are referral for trauma-focused cognitive behavioral therapy and the provision of psychoeducation about expected acute stress reactions.
Acute stress disorder (ASD) is diagnosed when a patient exhibits prominent trauma-related symptoms (intrusion, negative mood, dissociation, avoidance, arousal) lasting from 3 days to 1 month following the traumatic event. The most effective, evidence-based initial interventions for ASD are trauma-focused cognitive behavioral therapy (TF-CBT) and thorough psychoeducation regarding normal trauma responses. These non-pharmacological approaches provide immediate coping strategies and significantly reduce the likelihood of the condition progressing to post-traumatic stress disorder (PTSD).

Step-by-Step Solution

1
Establish the correct psychiatric diagnosis based on the timeline of symptoms.
The trauma occurred 3 weeks ago, making the diagnosis acute stress disorder (ASD), not post-traumatic stress disorder (PTSD), which requires symptoms lasting greater than 1 month.
Accurate diagnosis based on symptom duration dictates the appropriate evidence-based therapy.
2
Identify first-line management strategies for the established diagnosis.
First-line interventions for ASD include trauma-focused cognitive behavioral therapy (TF-CBT) and psychoeducation.
These psychotherapeutic approaches are proven to alleviate acute distress and prevent the progression of ASD to PTSD.
3
Evaluate the patient's current medication regimen for potential pharmacological interventions and contraindications.
The patient is taking phenelzine (an MAOI) and lithium (for bipolar I disorder). Adding an SSRI is contraindicated due to the risk of serotonin syndrome, and switching to antidepressant monotherapy is contraindicated due to the risk of inducing mania.
Recognizing severe drug-drug interactions and disease-drug contraindications prevents iatrogenic harm when considering medication additions.

Key Concept

The diagnosis of Acute Stress Disorder requires trauma-related symptoms lasting between 3 days and 1 month; first-line management involves trauma-focused cognitive behavioral therapy and psychoeducation, while careful attention must be paid to pharmacological contraindications such as MAOI interactions and bipolar disorder history.
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Topics

Anxiety, OCD, and Trauma-Related Disorders

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