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Zorluk: OrtaAnxiety, OCD, and Trauma-Related Disorders

A 26-year-old woman comes to the clinic due to feeling "constantly on edge" for the past 8 months. During this time, she has experienced excessive, uncontrollable worry about her job performance, finances, and relationships. She reports associated muscle tension, poor concentration, and feeling easily fatigued. She denies any depressed mood, suicidal ideation, or hallucinations. Two years ago, she was hospitalized for a 3-week episode characterized by a severely decreased need for sleep, euphoric mood, pressured speech, and hypersexuality. She was treated with a medication that she stopped taking 6 months ago. Her current medications include a daily multivitamin. Vital signs are within normal limits. Physical examination shows mild trapezius muscle tenderness but is otherwise unremarkable. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 2.1 µU/mL (normal: 0.5-5.0 µU/mL). Which of the following is the most appropriate next step in management for this patient?

  1. A
    Obtain a serum free T4 level
  2. B
    Initiate sertraline
  3. Refer for cognitive behavioral therapyCevap
  4. D
    Initiate citalopram and phenelzine
  5. E
    Contact her employer to recommend a medical leave of absence

Cevap

Refer for cognitive behavioral therapy
This patient's presentation of excessive, uncontrollable worry lasting for at least 6 months, accompanied by fatigue, poor concentration, and muscle tension, is diagnostic of Generalized Anxiety Disorder (GAD). First-line treatments for GAD include antidepressants (SSRIs, SNRIs) and cognitive behavioral therapy (CBT). However, this patient's past psychiatric history is highly significant for a manic episode (euphoria, severely decreased sleep, pressured speech, hypersexuality), meaning her underlying diagnosis includes Bipolar I Disorder. Because she stopped her previous psychiatric medication 6 months ago, she is currently unprotected from mood destabilization. Initiating an SSRI or SNRI monotherapy in this patient is strongly contraindicated due to the high risk of precipitating a manic switch. Therefore, non-pharmacological treatment with CBT is the safest and most appropriate first-line management for her anxiety.

Adım Adım Çözüm

1
Identify the primary current diagnosis based on the clinical presentation.
The patient has Generalized Anxiety Disorder (GAD).
She has experienced greater than 6 months of excessive, uncontrollable worry accompanied by somatic symptoms including muscle tension, fatigue, and poor concentration.
2
Identify any relevant past psychiatric history that would affect medication management.
The patient has a history of Bipolar I Disorder.
Two years ago, she had a 3-week hospitalization for an episode of decreased need for sleep, euphoric mood, pressured speech, and hypersexuality, which is a classic manic episode.
3
Determine the safest and most effective first-line treatment for GAD in this specific patient.
Cognitive behavioral therapy (CBT) is the most appropriate next step.
While SSRIs and SNRIs are typically first-line for GAD, administering them as monotherapy in an unmedicated patient with Bipolar I Disorder carries a high risk of precipitating a manic episode. CBT is highly effective for GAD and completely avoids pharmacological risks.

Anahtar Kavram

First-line management of generalized anxiety disorder in patients with a history of bipolar disorder
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Konular

Anxiety, OCD, and Trauma-Related Disorders

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