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Zorluk: OrtaAnxiety, OCD, and Trauma-Related Disorders

A 31-year-old man presents to the outpatient psychiatric clinic accompanied by his sister. He describes a 3-month history of severe anxiety, hypervigilance, and recurrent nightmares following a violent mugging. He actively avoids the neighborhood where the incident occurred and feels detached from his family. His past psychiatric history is significant for bipolar I disorder; however, he stopped taking his prescribed valproate a year ago. He currently describes his mood as 'very low' and states he has no energy or appetite. During the interview, the patient's sister steps out to take a phone call. Privately, the patient confesses that for the past two weeks, he has been hearing a voice telling him he is worthless. He explicitly requests that his condition and medical records be kept strictly private from his family. Later, when the sister returns, she asks the physician to share the details of the psychiatric evaluation so she can help arrange a medical leave of absence at his workplace.

Which of the following are appropriate actions by the physician? (Select all that apply)

  1. Initiate trauma-focused cognitive-behavioral therapyCevap
  2. Decline the sister's request for the psychiatric evaluation detailsCevap
  3. C
    Initiate paroxetine monotherapy to treat the trauma-related symptoms and depressed mood
  4. D
    Diagnose schizophreniform disorder based on the two-week duration of auditory hallucinations
  5. E
    Disclose the evaluation details to the sister since it will directly benefit the patient's employment status

Cevap

The physician should initiate trauma-focused cognitive-behavioral therapy for the patient's PTSD and decline the sister's request for medical records to maintain patient confidentiality.
The patient's presentation of hypervigilance, nightmares, and avoidance for 3 months following a violent mugging is diagnostic of Post-Traumatic Stress Disorder (PTSD). Trauma-focused cognitive-behavioral therapy (TF-CBT) is a first-line, evidence-based treatment for PTSD that is safe to administer. Furthermore, the physician must uphold strict medical confidentiality. The patient is a competent adult who explicitly requested that his information remain private. Disclosing medical records to the sister, even for the ostensibly beneficial purpose of securing workplace accommodations, is an unethical breach of confidentiality.

Adım Adım Çözüm

1
Identify the primary psychiatric diagnoses based on the clinical presentation.
The patient has Post-Traumatic Stress Disorder (PTSD) due to greater than 1 month of trauma-related symptoms, alongside a current bipolar depressive episode with psychotic features.
Accurate multiaxial diagnosis is required before selecting appropriate therapy.
2
Determine the appropriate first-line treatment for the trauma-related symptoms in the context of his comorbidities.
Trauma-focused CBT is a safe and effective first-line treatment. SSRI monotherapy must be strictly avoided due to his unmedicated bipolar history.
Antidepressant monotherapy in unmedicated bipolar patients carries a severe risk of precipitating mania.
3
Evaluate the ethical implications of the sister's request for medical records.
The request must be declined.
The patient is a competent adult who explicitly requested confidentiality; there is no legal exception justifying a breach of privacy.

Anahtar Kavram

The management of complex PTSD requires trauma-focused psychotherapy and careful avoidance of SSRI monotherapy if a bipolar diathesis exists. Additionally, respecting patient confidentiality is a strict ethical obligation that overrides familial requests for secondary gain.
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Konular

Anxiety, OCD, and Trauma-Related Disorders

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