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Soru

Zorluk: OrtaAnxiety, OCD, and Trauma-Related Disorders

A 29-year-old man comes to the clinic reporting severe anxiety, poor sleep, and frequent nightmares for the past 3 weeks. Three weeks ago, he was the driver of a commercial truck that was involved in a fatal collision with a pedestrian. Although he was not physically injured, he witnessed the aftermath. Since the incident, he has experienced intense intrusive memories of the event, refuses to drive or be near large vehicles, feels emotionally numb, and is constantly hypervigilant. His medical history is significant for bipolar I disorder, diagnosed at age 22, and chronic lower back pain. He discontinued his maintenance lithium 6 months ago because he felt well, and he currently takes no psychiatric medications. He takes tramadol as needed for his back pain. He expresses intense distress about his symptoms. Which of the following is the most appropriate next step in management?

  1. Refer for trauma-focused cognitive-behavioral therapyCevap
  2. B
    Diagnose post-traumatic stress disorder and recommend support groups
  3. C
    Initiate sertraline to manage the acute stress symptoms
  4. D
    Initiate phenelzine to acutely reduce autonomic arousal
  5. E
    Contact the patient's employer directly to request temporary administrative leave

Cevap

Refer for trauma-focused cognitive-behavioral therapy
The correct answer is referring the patient for trauma-focused cognitive-behavioral therapy (CBT). This patient presents with symptoms of intrusion, avoidance, negative mood, and hyperarousal following a life-threatening traumatic event. Because his symptoms have been present for exactly 3 weeks (less than 1 month), the correct diagnosis is acute stress disorder (ASD). Trauma-focused CBT is the evidence-based, first-line treatment for ASD and is highly effective at preventing the subsequent development of post-traumatic stress disorder (PTSD). Additionally, psychopharmacologic interventions in this specific patient carry significant risks due to his unmedicated bipolar disorder and concurrent use of tramadol.

Adım Adım Çözüm

1
Identify the clinical syndrome and its timeline.
The patient experienced a life-threatening traumatic event 3 weeks ago and presents with intrusion, avoidance, negative mood, and hyperarousal symptoms.
Establishing the duration of symptoms is necessary to differentiate between acute stress disorder (symptoms for 3 days to 1 month) and post-traumatic stress disorder (symptoms for >1 month).
2
Establish the diagnosis.
Because the symptoms have been present for exactly 3 weeks, the correct diagnosis is acute stress disorder (ASD).
Diagnostic criteria strictness dictates management protocols and prognostic expectations.
3
Evaluate the patient's medical and psychiatric history for treatment contraindications.
The patient has unmedicated bipolar I disorder (making SSRI/SNRI monotherapy dangerous due to manic switch risk) and takes tramadol (making MAOIs contraindicated due to serotonin syndrome risk).
Safe psychopharmacologic prescribing requires ruling out drug-drug interactions and psychiatric contraindications.
4
Select the best treatment option.
Trauma-focused cognitive-behavioral therapy (CBT) is selected as the safest and most effective intervention.
Trauma-focused CBT is the evidence-based, first-line treatment for ASD and avoids all pharmacologic risks present in this patient.

Anahtar Kavram

Diagnosis and management of Acute Stress Disorder (ASD), including recognition of psychopharmacologic contraindications
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Konular

Anxiety, OCD, and Trauma-Related Disorders

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