Reference no: EM133675907
Patient Intake: 33-year-old woman with a chief complaint of "extreme anxiety"
Psychiatric History
The patient was well until about age 20 when, as an undergraduate in college, she developed a major depressive episode (perhaps related to seasonal depression)
She responded to paroxetine (Paxil, Seroxat) and continued treatment with it for two years
After stopping medication, she had at least two emergency room visits for panic attacks but received no treatment
Over the next seven years she received no treatment despite experiencing a great deal of generalized anxiety and feeling tense and overwhelmed
Because of relapse of her depression in the last two years she started again on various SSRIs
Restarted paroxetine but unlike the first time she took it, could not tolerate it after 2 weeks and discontinued it - had fatigue and blurred vision
Trial of sertraline (Zoloft) - had worsening anxiety and discontinued it after a week, started CBT
Trial of fluoxetine (Prozac) - first dose caused a panic attack and discontinued it, continued CBT
Trial of venlafaxine (Effexor XR) - vomited on the first dose and discontinued it, continued CBT
Trial of fluvoxamine (Luvox) - made her tired and stopped after 3 days, continued CBT
Trial of duloxetine (Cymbalta) - racing pulse and palpitations after first dose and discontinued it, continued CBT
Trial of escitalopram (Lexapro) - insomnia and agitation and stopped after 3 days
Social and Persona History
Single, no children
Non-smoker
No drug or alcohol abuse
College graduate
Unemployed, supported by wealthy parents
Medical History
Mitral valve prolapse
BP normal
BMI normal
Normal fasting glucose and lipids
Family History
Father: PTSD and depression
Maternal grandparents: alcoholism and anxiety
Paternal grandparents: bipolar disorder; grandmother received ECT
Current Medication: Lorazepam 0.5 mg, up to 1 mg/day
Psychiatric Nurse Practitioner's Notes from Initial Psychiatric Evaluation:
Patient seems very upset and apprehensive
Afraid attending physician is going to prescribe something else
For the past few years she has not been able to function fully independently, to maintain significant relationships, or to maintain steady and fulfilling employment
The patient is well-informed and well-read but seems to irrationally overvalue the side effects of medications
In particular, she anticipates catastrophic consequences such as death in the middle of the night, problems from serotonin syndrome, and some of the other most dire potential consequences of psychotropic drugs
She both readily acknowledges the excessive nature of these fears and yet still has some degree of belief in them and certainly experiences subjective fear about them
However, she always has activating side effects, electric shock sensations, headaches, tremors on the inside but not on the outside, hair on her head standing on end, no matter what medication she takes lately
Does not understand why these problems were not present with these medications in the past nor why she tolerates and, in fact improves on lorazepam (Ativan)
She also recognizes that her chronic anxiety is interfering with her life and keeping her from being employed, having relationships, and again becoming independent
She is therefore highly motivated to find a plan to reduce her symptoms and allow her to resume a normal life with the high level of functioning that she has enjoyed in the past
She displays a broad affect but a somewhat depressed mood, almost becoming tearful at times while discussing her history
She is able to respond to humor and paradox and is not currently suicidal
Questions
1. What is this patient's current level of functioning, and can it be improved by a medication adjustment?
2. Are her side effects exaggerated, legitimate, or both? How would you manage her resistance to taking medication if she believed she really experienced side effects from them?
3. Is she experiencing a substance-induced hypomania?? Explain your thought process for or against.
4. Does CBT or psychotherapy appear to be working for management of her symptoms?
5. Would you want to get any genotyping or drug levels?? If so or if not, why?
6. How would you manage this patient's medications at this point?? Support your answer with evidence.