A 28-year-old female complains of generalized headache, dizziness (characterized as lightheadedness), and generally not feeling well for 3 days. This started at the same time as her menses and coincided with a major examination in a college class she is taking. Her review of symptoms is otherwise negative. Her past medical history includes a recent acute onset of low back pain related to lifting, and a recent depressive episode which responded well to medication. Her current medications include an oral contraceptive which she has taken for 2 years, a corticosteroid nasal spray, and ibuprofen for the past 2 weeks. She was on paroxetine (Paxil), 30 mg/day, for 7 months, but this was stopped 5 days ago because of sexual dysfunction. Because of her symptoms she has not taken any medications for the past 2 days. Since then the headache has eased substantially, but the feeling of lightheadedness has remained. A physical examination is unremarkable.
Which one of the following is the most likely cause of her symptoms?
Correct Answer B:
The timing of the symptoms (starting about 2 days after paroxetine was stopped) and the symptoms (headache, light headedness) are consistent with SSRI discontinuation syndrome. This syndrome is more likely with abrupt withdrawal, after prolonged treatment, at higher doses.
Which one of the following is most likely to induce withdrawal symptoms if discontinued abruptly?
Correct Answer A:
The abrupt discontinuation of venlafaxine, or a reduction in dosage, is associated with withdrawal symptoms much more severe than those seen with other SNRIs such as duloxetine. This is likely due to venlafaxine's relatively short half-life and therefore rapid clearance upon discontinuation. Although more pronounced with higher dosages and prolonged administration, they also occur at lower dosages. These symptoms include agitation, anorexia, confusion, impaired coordination, seizures, sweating, tremor, and vomiting. To avoid this withdrawal symptom, dosage changes should be instituted gradually.
Abrupt discontinuation of mood stabilizers such as divalproex, and atypical antipsychotics such as olanzapine, can result in the return of psychiatric symptoms, but not severe physiologic dysfunction. Similarly, stopping cholinesterase inhibitors such as donepezil will not cause a withdrawal syndrome.
An 18 year old female visits you because she is having difficulty sleeping, cannot concentrate, and is more irritable. She also says that people around her remark on how overly alert and wary she seems to be and how easy it is to startle her. With gentle probing you discover that 6 months ago she was driving a car that was involved in an accident in which a close friend was killed.
Since that time she avoids driving and always tries to avoid the intersection where the accident occurred. In spite of trying to put it out of her mind, she still dreams about the event, and even during the day may relieve the accident. Her mother is concerned because she has begun to withdraw from participation in school and church activities and just broke off a relationship with her long-term boyfriend.
The most probable primary diagnosis in this patient is which one of the following?
Correct Answer E:
This patient’s findings include all four categories of criteria for the diagnosis of post-traumatic stress disorder (PTSD). First, a traumatic event occurred in which the patient witnessed or experienced actual or threatened death or serious injury and responded with intense fear, horror, or helplessness. Second, on exposure to memory cues, the patient has re experiencing symptoms such as intrusive recollections, nightmares, flashbacks, or psychological distress. Third, the patient avoids trauma-related stimuli and feels emotionally numb. Finally, the patient has increased arousal, manifested by hypervigilance, irritability, or difficulty sleeping. The symptoms must also be persistent for at least 1 month and significantly disturb the patients social or occupational functioning, or both.
Acute stress disorder also occurs after exposure to a traumatic event, but symptoms appear within 4 weeks of the trauma and last from 2 days to 4 weeks. Patients with this disorder also have more dissociative symptoms, describing themselves as feeling “in a daze” or having temporary amnesia about the event. PTSD increases the risk of later developing comorbid psychiatric problems. The most common diseases that occur with PTSD are major depression, dysthymia, generalized anxiety disorder, substance abuse, somatization, panic disorder, bipolar disorder and dissociative disorders.
Which one of the following is the most appropriate adjunct medication for treating patients with posttraumatic stress disorder resistant to the first-line medications?
Correct Answer D:
PTSD Pharmacotherapy includes:
There is insufficient evidence of the effectiveness of tricyclic antidepressants, monoamine oxidase inhibitor, serotonin modulators (eg, trazodone), or atypical antidepressants (eg, mirtazapine) for PTSD.
A 28-year-old male presents to your clinic complaining of disturbing dreams he has been having since he returned from Afghanistan where he had been deployed for military service. He returned 7 months ago. While on the battlefield, he witnessed his best friend get killed by an improvised explosive device. Few weeks before that he had witnessed an other member of his platoon lose his right leg to landmines.He reports that often he has flashbacks of these events and they are very distressful. He experiences visual hallucinations that he feels are "driving him insane". Recently a plate fell down on the floor at his house when his wife was cleaning and he felt that it triggered those bad memories and he could barely eat, could not talk with family, or even be able to sleep at night for 3 days. The patient's speech is well organized.
What is the most likely diagnosis?
Many veterans returning from the battlefield develop posttraumatic stress disorder (choice B). It is defined as a pathological anxiety that usually occurs after an individual experiences or witnesses severe trauma that constitutes a threat to the physical integrity or life of the individual or of another person. The diagnosis can be made when a group of symptoms such as disturbing recurring flashbacks, avoidance or numbing of memories of the event, and hyperarousal (high levels of anxiety) continue for more than a month after the traumatic event.
→ Acute stress disorder (choice A) presents in the same way like post-traumatic stress disorder, but lasts less than 4 weeks.
→ Depression (choice C) is characterized by what is "mnemonically" known as SIGE CAPS- sleep changes, increased or decrease; Interest in activities previously enjoyed is lost, guilt and feelings of worthlessness,energy is lacking,concentration is reduced, appetite lost, psychomotor changes such as lethargy, and suicidal ideation.
→ Schizophrenia (choice D) is characterized by positive and negative symptoms.Positive symptoms include psychotic symptoms, such as hallucinations, which are usually auditory; delusions; and disorganized speech and behavior. Negative symptoms include decrease in emotional range, poverty of speech, and loss of interests and drive.
→ Manic episodes (choice E) are characterized by grandiosity,diminished need for sleep,excessive talking or pressured speech racing thoughts or flight of ideas,clear evidence of distractibility,increased level of goal-focused activity at home, at work, or sexually, and excessive pleasurable activities, often with painful consequences.
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