A 29-year-old woman presents to the psychiatric clinic for evaluation of severe, pervasive… — USMLE Step 2 CK

A 29-year-old woman presents to the psychiatric clinic for evaluation of severe, pervasive anxiety, muscle tension, and sleep disturbance that have been present for the past 8 months. She constantly worries about her finances, her family's health, and her job security, which has severely impaired her daily functioning. Her past psychiatric history is significant for a depressive episode at age 22. At that time, she was prescribed fluoxetine, but within two weeks of starting the medication, she developed a markedly elevated mood, decreased need for sleep, and grandiosity, leading to hospitalization. Her symptoms resolved shortly after fluoxetine was discontinued. She is currently taking phenelzine for her anxiety, but she reports it is ineffective and she struggles with the dietary restrictions.

Recent laboratory tests, ordered by her primary care physician to investigate her fatigue, reveal the following:

Test	Result	Reference Range
Thyroid-stimulating hormone (TSH)	$0.1 \text{ mU/L}$	$0.5 - 5.0 \text{ mU/L}$
Free thyroxine (T4)	$0.4 \text{ ng/dL}$	$0.9 - 1.7 \text{ ng/dL}$

She requests a new medication for her anxiety and asks what her laboratory results mean.

Which of the following are appropriate next steps in the management of this patient? (Select all that apply)

Initiate cognitive-behavioral therapy focused on worry exposure and relaxation techniquesCevap
Refer the patient for a pituitary MRI and comprehensive endocrinologic evaluationCevap
C
Initiate citalopram monotherapy to manage her generalized anxiety symptoms
D
Discontinue phenelzine and immediately start sertraline to avoid a gap in anxiety treatment
E
Diagnose primary hypothyroidism based on the low free T4 and recommend initiating levothyroxine

Cevap

The correct steps are to initiate cognitive-behavioral therapy and to refer the patient for a pituitary MRI and endocrinologic evaluation.

The patient's presentation of excessive worry, muscle tension, and sleep disturbance over 8 months is consistent with Generalized Anxiety Disorder (GAD). Because she has a history of antidepressant-induced mania, she is on the bipolar spectrum. Cognitive-behavioral therapy (CBT) is an excellent, safe, first-line treatment for GAD that does not carry the risk of inducing a manic episode. Additionally, her laboratory results (low TSH and low free T4) indicate central (secondary) hypothyroidism. The appropriate next step for this endocrine abnormality is further evaluation of the pituitary-hypothalamic axis, typically including a pituitary MRI and checking other anterior pituitary hormones, before initiating levothyroxine. Initiating levothyroxine blindly in central hypothyroidism can precipitate an adrenal crisis if concurrent secondary adrenal insufficiency is present.

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Analyze the psychiatric presentation and history.

The patient has symptoms of Generalized Anxiety Disorder (GAD). However, her history of fluoxetine-induced mania indicates underlying Bipolar I disorder.

Identifying the bipolar diathesis is critical to avoid prescribing antidepressant monotherapy, which can trigger mania.

Evaluate the current psychiatric medications and potential interactions.

The patient is taking phenelzine, an MAOI. Any switch to a serotonergic medication (like an SSRI) requires a strict 14-day washout period.

Concurrent use or insufficient washout between MAOIs and SSRIs can precipitate severe, potentially fatal serotonin syndrome.

Interpret the laboratory findings.

The patient has both a low TSH and a low free T4.

This pattern indicates central (secondary) hypothyroidism, implying a pituitary or hypothalamic issue, rather than primary hypothyroidism (which would have elevated TSH).

Select the appropriate management steps based on the findings.

CBT is a safe and effective first-line treatment for GAD in bipolar disorder. An endocrinologic evaluation and pituitary MRI are required to investigate the central hypothyroidism.

These steps address both her psychiatric and medical needs safely without risking mania or dangerous drug interactions.

Anahtar Kavram

Management of Generalized Anxiety Disorder in patients with bipolar disorder, MAOI pharmacological safety, and interpretation of central hypothyroidism labs.

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