Experiencing substance-induced hypomania

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.

Reference no: EM133675907

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