Reference no: EM133295587

Case: Eric is a 49-year-old professional cisgender male who has been an established patient in your practice for going on three years. His physical health is exceptional for his age, with no acute or chronic medical conditions, but you notice he's way past due for his annual physical with his primary care physician. His primary family members have a history of prostate cancer, DM1, mitral valve repair, and hypothyroidism. Your working diagnoses for him at this time is:

309.28 (F43.23) Adjustment Disorder with mixed anxiety and depressed mood following his father's stroke and subsequent dysphagia two months ago.

He has a history of Posttraumatic Stress Disorder (PTSD) from his military service and was once misdiagnosed with Bipolar II Disorder due to what he calls "poor care management" after his discharge. None of his past trauma appears to be resurfacing in your current interactions, and the focus of your interventions has been a Cognitive Behavioral Therapy (CBT) approach to processing his emotions surrounding his father's sudden change in health and the strain it places on his mother as the primary caregiver at home. He is generally satisfied with his treatment and has shown significant improvement in his depressed mood and ability to regulate anxious moments.

His current medications are:

OTC Melatonin 3-5mg PO QHS PRN - sleep support

Protein and multivitamin supplements for his gym routine

OTC PRN antihistamines during the Spring for seasonal allergies

"The last two weeks have been a real struggle. I've been doing a lot of what we talked about in here with reframing my thoughts, and I feel like it's helping. Sleep is the real problem. I've been taking the melatonin every night for the last month it seems, and it's not working anymore. I'm tossing and turning in bed for hours on end, often until almost 2 or 3 in the morning. I can't get my mind to stop racing and allow me to sleep. I try to distract myself by playing games on my phone or scrolling through the news to fall asleep, and it sometimes works. But then, once I do fall asleep, I have these horrible dreams that wake me up in a cold sweat. My alarm goes off by the time I fall back asleep, and it's time to start the day, but not before I take something for the all-over body ache I usually wake up with. Work is becoming increasingly difficult to concentrate on because I am constantly tired throughout the day and feel drained by it all. How should I proceed? Can you give me something to help me sleep?"

Question: Write a dynamic formulation for Eric that includes his working and differential diagnoses, recommended treatment for today, and your planned course of treatment if his sleep worsens over the next three months. Support your formulation and recommended interventions with citations from current evidence.