Examkin

Soru

Zorluk: OrtaAnxiety, OCD, and Trauma-Related Disorders

A 31-year-old man comes to the outpatient psychiatry clinic reporting a 2-month history of sudden, terrifying episodes of "feeling like I am going to die." During these episodes, which peak within 10 minutes, he experiences intense palpitations, diaphoresis, shortness of breath, and chest tightness. He has had six of these episodes in the past month. Recently, he has stopped taking the subway to work because he fears being unable to escape if an episode occurs. The patient has no significant past medical history and his physical examination, including an electrocardiogram, is normal. Upon further psychiatric history, the patient describes a 3-week period in his mid-twenties when he felt "invincible," slept only 2 hours a night, spoke incessantly, and aggressively invested his life savings into a fraudulent scheme. He was hospitalized during that time but currently takes no medications. Which of the following is the most appropriate next step in management for this patient?

  1. Initiate cognitive-behavioral therapyCevap
  2. B
    Prescribe fluoxetine monotherapy
  3. C
    Prescribe paroxetine and selegiline
  4. D
    Diagnose brief psychotic disorder and begin haloperidol
  5. E
    Notify the department of motor vehicles to suspend his driver's license

Cevap

The most appropriate next step is to initiate cognitive-behavioral therapy.
The correct answer is to initiate cognitive-behavioral therapy. This patient is currently experiencing Panic Disorder with Agoraphobia, characterized by recurrent unexpected panic attacks and a fear of situations where escape might be difficult. Standard first-line treatments for Panic Disorder include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and cognitive-behavioral therapy (CBT). However, this patient's history of a 3-week episode of grandiosity, decreased sleep, and impulsive behavior requiring hospitalization is classic for a manic episode, establishing an underlying diagnosis of Bipolar I Disorder. In patients with bipolar disorder, antidepressant monotherapy is strictly avoided because it can trigger a manic switch. CBT is highly effective for Panic Disorder and carries no risk of mood destabilization, making it the safest and most appropriate intervention.

Adım Adım Çözüm

1
Diagnose the current acute presentation based on the clinical symptoms and timeframe.
The patient has recurrent unexpected panic attacks with subsequent avoidance behavior (avoiding the subway), confirming a diagnosis of Panic Disorder with Agoraphobia.
Establishing the primary diagnosis is required to select an evidence-based first-line treatment.
2
Analyze the patient's past psychiatric history for comorbid conditions that affect management.
The patient describes a distinct 3-week period of elevated mood, grandiosity, decreased need for sleep, and severe impairment (hospitalization/financial ruin), meeting full criteria for a past Manic Episode and establishing a diagnosis of Bipolar I Disorder.
Comorbid psychiatric conditions often introduce strict contraindications to standard pharmacotherapy.
3
Evaluate treatment options for Panic Disorder while considering the Bipolar I comorbidity.
While SSRIs are typically first-line for Panic Disorder, antidepressant monotherapy is strictly contraindicated in Bipolar I due to the high risk of inducing a manic switch.
To ensure patient safety, non-pharmacologic first-line treatments or mood-stabilizing combinations must be selected instead.
4
Select the safest, most effective management step.
Cognitive-behavioral therapy (CBT) is highly effective for Panic Disorder and carries zero risk of mood destabilization, making it the optimal choice.
CBT provides definitive, evidence-based treatment for the primary complaint without risking a psychiatric emergency.

Anahtar Kavram

In patients presenting with an anxiety disorder (e.g., Panic Disorder) who have a history of Bipolar Disorder, antidepressant monotherapy (SSRIs/SNRIs) must be avoided to prevent a manic switch; psychotherapy (such as CBT) is the preferred, safe first-line intervention.
Bu soruyu puanla

Konular

Anxiety, OCD, and Trauma-Related Disorders

Bu konudan daha fazla soru