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Zorluk: OrtaAnxiety, OCD, and Trauma-Related Disorders

A 26-year-old woman comes to the outpatient psychiatric clinic reporting severe anxiety, insomnia, and nightmares. Exactly three weeks ago, she was sexually assaulted by an acquaintance at a party. She has not disclosed the assault to anyone else and explicitly asks the physician not to notify law enforcement, stating she is not ready for an investigation. Since the incident, she has avoided social gatherings, feels constantly 'on edge,' and experiences distressing flashbacks. Her past medical history is significant for bipolar I disorder. Her current medications include lithium and tranylcypromine, the latter having been added two months ago for depressive symptoms. She asks if a medication like sertraline could be prescribed, as she has heard it is effective for trauma. Vital signs are within normal limits. Which of the following is the most appropriate next step in management?

  1. Recommend trauma-focused cognitive-behavioral therapy and maintain patient confidentialityCevap
  2. B
    Report the assault to local law enforcement because violent crimes require mandatory reporting
  3. C
    Add sertraline to her current medication regimen to alleviate her acute anxiety and flashbacks
  4. D
    Discontinue her current medications and initiate fluoxetine monotherapy to treat her mood and trauma symptoms
  5. E
    Diagnose post-traumatic stress disorder and begin eye movement desensitization and reprocessing therapy

Cevap

Recommend trauma-focused cognitive-behavioral therapy and maintain patient confidentiality.
The correct answer provides the appropriate first-line treatment for Acute Stress Disorder (ASD) while adhering to ethical guidelines. The patient's symptoms (intrusive memories, avoidance, hyperarousal, and negative mood) occurring exactly 3 weeks after a traumatic event meet the criteria for ASD, not Post-Traumatic Stress Disorder (which requires symptoms lasting longer than 1 month). Trauma-focused cognitive-behavioral therapy is the primary treatment for ASD. Furthermore, as a competent adult, the patient's autonomy must be respected; sexual assault does not mandate reporting to law enforcement unless the patient consents or specific state exemptions apply (e.g., vulnerable populations).

Adım Adım Çözüm

1
Analyze the symptom timeline relative to the traumatic event.
The trauma occurred exactly 3 weeks ago, and symptoms have persisted since then.
Establishing the timeline is necessary to differentiate between Acute Stress Disorder (< 1 month) and Post-Traumatic Stress Disorder (≥ 1 month).
2
Evaluate the ethical obligations regarding the patient's request for confidentiality.
The patient is a competent adult who explicitly requested that law enforcement not be notified.
To determine if mandatory reporting laws apply. Mandatory reporting for sexual assault typically applies only to minors, the elderly, or vulnerable adults, not competent adults.
3
Assess the safety of the patient's pharmacological request.
The patient requested sertraline (an SSRI) but is currently taking tranylcypromine (an MAOI) and lithium (for bipolar I disorder).
To prevent fatal drug interactions (Serotonin Syndrome from MAOI + SSRI) and avoid destabilizing her bipolar disorder (manic switch from SSRI monotherapy).
4
Determine the most appropriate management based on the correct diagnosis and ethical constraints.
Trauma-focused CBT is recommended as the first-line treatment for Acute Stress Disorder, while strict confidentiality must be maintained.
This provides evidence-based care while adhering to ethical standards and avoiding pharmacological harm.

Anahtar Kavram

Management of Acute Stress Disorder requires recognizing the <1 month diagnostic timeline, providing trauma-focused CBT, and respecting the confidentiality of competent adult sexual assault survivors while carefully monitoring for psychiatric drug interactions.
Tahmini Süre:1m 30s
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Anxiety, OCD, and Trauma-Related Disorders

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