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Patient Management Exercise
Ronald C. Albucher, M.D.; B. Harrison Levine, M.D., M.P.H.
FOCUS 2004;2:360-365.
View Author and Article Information

CME Financial Disclosure
Ronald C. Albucher, M.D., Clinical Assistant Professor of Psychiatry, University of Michigan Medical School, and Assistant Chief, Psychiatry Service, Ann Arbor VA Health System.

No affiliations with commercial supporters.

B. Harrison Levine, M.D., M.P.H., VA Ann Arbor Healthcare System.

No affiliations with commercial supporters.

Disclosure of Unapproved or Investigational Use of a ProductAPA policy requires disclosure by CME authors of unapproved or investigational use of products discussed in CME programs. Off-label use of medications by individual physicians is permitted and common. Decisions about off-label use can be guided by the scientific literature and clinical experience.

Copyright 2004 American Psychiatric Association

Abstract

This patient management exercise is designed to test your comprehension of material presented in this issue of Focus as well as your ability to evaluate, diagnose, and manage clinical problems. Answer the questions below, to the best of your ability, on the basis of the information provided, making your decisions as you would with a real-life patient.Questions are presented at "decision points" that follow a paragraph that gives information about the case. One or more choices may be correct for each question; select your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections.You are given points on a graded scale for the best possible answer(s), and points are taken away for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. On questions that focus on differential diagnoses, bonus points are awarded if you select the most likely diagnosis as your first choice. At the end of the exercise you will add up your points to obtain a total score.

Abstract Teaser
Figures in this Article

Ms. P, a 24-year-old divorced law student, reluctantly goes to the local mental health clinic because she doesn’t want to go to her school’s mental health services for fear that she will see someone she knows. You have only 20 minutes before your next scheduled appointment. She is anxious and insists on seeing you even though you do not have time for a full evaluation, and she cannot come back today because of her class schedule. You agree to see her.

She complains of feeling "on edge" but not to the extent that she is in danger of failing out of law school. She reports that she has been having difficulty sleeping, especially over the past year, maybe two; she gets about 4—5 hours of broken sleep per night. She has tried in the past to have a couple of alcoholic drinks before bed but reports, "I don’t like the feeling." A friend suggested she try smoking marijuana, which she said "calmed my nerves," but she says she no longer smokes pot because she heard that it affects short-term memory, which she cannot afford to lose given the demands of law school. Her parents both drink Scotch and sodas every evening "to unwind," so the patient does not think that using alcohol or pot is "a big deal."

Ms. P was married immediately after high school for 1 year to her high school sweetheart, who was captain of the football team, but she complained that he was too jealous and did not want her to study with friends and often called her on her cell phone eight to ten times a day to check on her. She moved home after they separated, both to save money and because her parents "want me to be safe." She reports that her father works long hours and is away a lot. She describes her mother as "needy" and says, "She likes it when I’m around to help her with shopping or to have a lunch companion." She mentions that she was given Valium by one of her friends; it helped her sleep and relax, and she would like to know if it would be possible to get a prescription for it.

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Decision Point A

Given this history, which of the following would you do? (Select as many as appropriate. Points are taken away for incorrect answers.)

  • A1. ____ Tell the patient that you understand she is under a great deal of stress but that 20 minutes is much too short a time to make an adequate assessment. Invite her to return to see you within 1 week for a full evaluation.

  • A2.____ Tell the patient that you understand what she’s going through since you were once a medical student and you know that law school is similarly stressful. Ask her how much Valium she took, prescribe a month’s supply to help her when she’s “on edge,” and ask her to return to see you within a month for a full evaluation.

  • A3.____ Ask her about her drinking and drug history. If she reports that she is drinking or using substances regularly, suggest an independent substance use evaluation.

  • A4.____ Arrange an emergency psychiatric hospitalization.

  • A5.____ Prescribe a week’s supply of a selective serotonin reuptake inhibitor (SSRI) at a starting dose and tell her that it will help with her anxiety. Prescribe a minimal dose of a long-acting benzodiazepine to bridge the time before the SSRI reaches therapeutic efficacy. Tell her that she should come back to see you in 1 week so you can monitor her improvement.

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Decision Point B

With what you have learned so far, what is your differential diagnosis? (Rank as many as appropriate, in order of their likelihood. Points are taken away for incorrect answers.)

  • B1. ____ It is too early to make any diagnoses

  • B2. ____ Substance-induced anxiety disorder

  • B3. ____ Major depressive episode

  • B4. ____ Bipolar II disorder

  • B5. ____ Social phobia

  • B6. ____ Panic disorder

  • B7. ____ Generalized anxiety disorder

  • B8. ____ Somatization disorder

Ms. P comes back to your clinic 2 weeks later for a scheduled appointment. She is particularly worried about her classes and concerned that she is not reading enough. She says that she sometimes becomes "paralyzed with fear" that she’ll be called on in a class and not know the answer to a question, when her "rational side" knows she typically does know the answer. A couple of the members of her study group complained to her that she has become irritable lately and is sometimes difficult to work with. She noticed that when she is in her group her mind will go blank and she will not know what the conversation is about and require reminding. She has been experiencing this all year but says that it is getting worse. She and her classmates are applying for externships, and she is worried that she will not get "the one I deserve." She insists that she cannot work in any area of law but corporate law, because "that’s what my father does" and she is not interested in any other area. She also knows that this is one of the most competitive areas.

On further investigation of her medical history, she self-effacingly complains that she has had diarrhea nearly constantly for 3 years, for which she has had at least two hospital admissions and has been seen by several gastrointestinal specialists, who have not been able to give her a definitive diagnosis despite a battery of invasive tests. She reports frequent headaches and has been evaluated by several neurologists, who have told her that she does not have a brain tumor or migraines. One of her cousins died of an astrocytoma, and two of her aunts have migraines.

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Decision Point C

Does the new information change your differential diagnosis? (Rank as many as appropriate, in order of their likelihood. Points are taken away for incorrect answers.)

  • C1. ____ It is too early to make any diagnoses

  • C2. ____ Substance-induced anxiety disorder

  • C3. ____ Major depressive episode

  • C4. ____ Bipolar II disorder

  • C5. ____ Social phobia

  • C6. ____ Panic disorder

  • C7. ____ Generalized anxiety disorder

  • C8. ____ Somatization disorder

Ms. P says that in high school she was "popular," with lots of friends and several boyfriends, and she continues to have no difficulty making friends. She has a brand-new car that she says is a "lemon" because she has had it in the shop three times in 3 months for "odd sounds it should definitely not be making, and they can’t find a thing wrong with it." Her father, a wealthy attorney, has mentioned that he had similar problems with some of his cars in the past, so he is not surprised, and he helps her by lending her a car when hers is in the shop. Her mother worries that Ms. P is overreacting to "the little things" and keeps asking her if she’s using illegal drugs, which she denies. She has been single since her divorce because, she complains, "I don’t have the energy to put up with somebody else’s worries when I have enough of my own for two or three people."

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Decision Point D

On the basis of this information, which of the following would you inquire about to make a diagnosis of generalized anxiety disorder? (Select as many as appropriate. Points are taken away for incorrect answers.)

  • D1. ____ Does she experience periods of restlessness? Does she feel “keyed up” or “on edge”?

  • D2. ____ Is she easily fatigued?

  • D3. ____ Has she been irritable?

  • D4. ____ Does she have racing thoughts?

  • D5. ____ Has she experienced chest pain or a feeling of “impending doom”?

  • D6. ____ Has she had a weight loss of more than 20 pounds in the past 3 months?

  • D7. ____ Does she have a family history of alcohol abuse or dependence?

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Decision Point E

Which of the following would be appropriate interventions at this time? (Select as many as appropriate. Points are taken away for incorrect answers.)

  • E1. ____ Recommending cognitive behavior therapy once per week

  • E2. ____ Recommending long-term psychodynamic therapy

  • E3. ____ Prescribing clonazepam

  • E4. ____ Prescribing buspirone

  • E5. ____ Prescribing paroxetine

  • E6. ____ Prescribing venlafaxine

  • E7. ____ Referring the patient to a local chapter of Alcoholics Anonymous

  • E8. ____ Prescribing a low dose of divalproex

  • E9. ____ Suggesting that the patient exclude refined sugars from her diet

High positive scores (+3 and above) indicate a decision that would be effective, would be required for diagnosis, and without which management would be negligent. Lower positive scores (+2) indicate a decision that is important but not immediately necessary. The lowest positive score (+1) indicate a decision that is potentially useful for diagnosis and treatment. Neutral scores (0) indicate a decision that is neither clearly helpful nor harmful under the given circumstances. High negative scores (−3) indicate a decision that is inappropriate and potentially harmful or possibly life-threatening. Lower negative scores (−2) indicate a decision that is nonproductive and potentially harmful. The lowest negative score (−1) indicates a decision that is not harmful but is nonproductive, time consuming, and not cost effective.

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Decision Point A

  • A1. +5 The length of this evaluation is too short and the information too incomplete to make an informed diagnosis. Asking her to come back would both allow for a more substantial evaluation and contribute to the creation of a therapeutic relationship.

  • A2. −3 The opening statement may be empathetic and can help normalize and validate the patient’s feelings of anxiety. However, given some of her character traits, she may interpret this as a lack of empathy. Prescribing a controlled substance on such minimal evidence, especially with hints of substance or alcohol abuse, is not advisable.

  • A3. +3 This is necessary given the hints of the patient’s willingness to self-medicate, especially with illegal drugs. The therapist must be careful of how this is phrased, so that the patient-physician relationship is not damaged and a therapeutic alliance can be forged. If the patient’s history offered specific indications of abuse or dependence, substance or alcohol abuse/dependence rehabilitation should be considered.

  • A4. −5 At this point a psychiatric hospitalization is unwarranted. There is no evidence of a psychiatric emergency, such as psychosis, a severe major depressive episode, suicidality, or mania. Trying to force an admission would disrupt the patient-physician relationship.

  • A5. +1 SSRIs are safe but will take a while to be effective. Although it is usually not good practice to prescribe a medication with minimal evidence for diagnosis and no method of monitoring the patient, starting such a relatively safe medication given this scenario could serve as a transitional object and help reinforce the patient’s own need to return for further treatment.

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Decision Point B

  • B1. +3 (Add 2 points if this was your primary response on the differential.) Yes, there is not enough information to make an informed diagnosis. The information is suggestive of many psychiatric diagnoses but also suggestive of normal variants.

  • B2. 0 It is too early to make this diagnosis. You first need to explore substance and alcohol use, since the patient hints that this may have been a problem. Additionally, she may have stopped using alcohol on her own.

  • B3. −1 There is no evidence of a depressive disorder. Decreased sleep over a long period is a nonspecific finding, and there are no other symptoms indicative of this diagnosis.

  • B4. −1 There is no evidence of bipolar II disorder. Decreased sleep over a long period is not evidence of a manic or hypomanic episode.

  • B5. −1 There is no evidence for this diagnosis thus far.

  • B6. 0 Her decision to move back with her parents could be a practical decision given her recent divorce, her demanding educational responsibilities, and other considerations. Currently in the United States it is not uncommon for college graduates to move back home with their families until they are better able to manage on their own, so this is not culturally aberrant. Additionally, there is no evidence of a pathological need on the part of the patient to stay home with her parents, such as agoraphobia, or a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, as in dependent personality disorder.

  • B7. +1 There certainly is some evidence to support this diagnosis, but the differential is too great and the symptoms are still too nonspecific. The only symptoms that point more specifically toward GAD are her complaint that she is “on edge.”

  • B8. 0 The patient has no physical complaints up to this point.

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Decision Point C

  • C1. 0 There is enough evidence at this point to make a diagnosis, and waiting for more information, while usually helpful, is not necessary to begin treatment.

  • C2. +1 There is enough evidence to suggest that alcohol or other substances are playing a role in the patient’s life that may be a cause for her other psychiatric complaints—not enough to make a primary diagnosis, however. She does not endorse depressed mood but does complain of irritability. You would want to know more details about her alcohol use to clarify this issue.

  • C3. −1 A diagnosis of major depressive episode requires either symptoms of loss of interest or pleasure and/or depressed mood.

  • C4. −1 A diagnosis of bipolar II disorder requires the presence or history of one or more major depressive episodes, the presence or history of at least one hypomanic episode, and no evidence ever of a manic or mixed episode.

  • C5. +1 Social phobia, also known as social anxiety disorder, should be specified as generalized or nongeneralized (specific to one type of situation). A social phobia features a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack. Ms. P has described anxiety symptoms related to school, namely, being called on in class and difficulties encountered in her study group.

  • C6. −1 Panic disorder requires recurrent unexpected panic attacks, and at least one of the attacks must have been followed by 1 month or more of persistent concern about having additional attacks, worry about the implications or consequences of the attack, or a significant change in behavior related to the attack. A panic attack is a discrete period of intense fear or discomfort in which four or more of the following symptoms developed abruptly and reached a peak within 10 minutes: palpitations; pounding heart, or accelerated heart rate; sweating; trembling or shaking; sensations of shortness of breath or smothering; feeling of choking; chest pain or discomfort; nausea or abdominal distress; feeling dizzy, unsteady, lightheaded, or faint; derealization or depersonalization; fear of losing control or going crazy; fear of dying; paresthesias; and chills or hot flushes.

  • C7. +5 (Add 2 points if this was your primary response on the differential.) Ms. P’s worry about school performance occurred consistently for at least 6 months. She indicates that she had difficulty controlling her worries, attempted self-medication, and is now seeking help. She feels “on edge,” has difficulty concentrating, has been irritable, complains that her mind goes blank, and reports a disturbance in her sleep. She does not describe the focus of her anxiety as confined to panic attacks or symptoms of social phobia as described above.

  • C8. +1 While Ms. P does have a history of somatic complaints occurring before age 30 for which she sought treatment and which caused her significant impairment in function, for a diagnosis of somatization disorder she must also have four pain symptoms: two gastrointestinal symptoms, one sexual symptom, and one pseudoneurological symptom. Her complaints were not diagnosed as actual physiological problems by multiple specialists, but she does not give the impression that she is feigning her illnesses, nor is there evidence of secondary gain. Recall that she “self-effacingly” revealed this information only after additional investigation. Further history may reveal that she does have additional complaints, so this diagnosis can remain on the differential. Moreover, a person who has generalized anxiety disorder may also have additional diagnoses, especially other anxiety disorders.

+

Decision Point D

  • D1. +3 Correct

  • D2. +3 Correct

  • D3. +3 Correct

  • D4. −3 This is nonspecific and suggests an affective disorder, not an anxiety disorder.

  • D5. −3 This suggests a panic attack or a myocardial infarction, not generalized anxiety disorder.

  • D6. −3 This is not specific for generalized anxiety disorder.

  • D7. −3 While substance abuse is a common comorbid condition, it is not needed to make the diagnosis of generalized anxiety disorder.

+

Decision Point E

  • E1. +3 Cognitive therapy directly addresses the patient’s cognitive distortions, and behavioral approaches address somatic symptoms and self-defeating behavior directly. There is evidence that the combination is more effective than either part alone. This particular patient would likely benefit from cognitive behavior therapy.

  • E2. +1 If the patient can afford long-term psychodynamic therapy, this could help her explore the unconscious conflicts, whatever they are and whenever they appeared in the course of her development, that may be expressed as anxiety. This could be a good strategy for longer-term treatment, but it is not appropriate in the acute setting.

  • E3. +3 Benzodiazepines have long been considered the drug of choice for generalized anxiety disorder. Additionally, there is the possibility of selecting medications with a shorter half-life and a quicker onset for acute crises or longer-acting formulations to provide more consistent coverage. However, 25%–30% of all patients do not respond to a benzodiazepine trial, and some patients develop tolerance and dependency. The choice of benzodiazepine should be based on potency, half-life, side effects, and the specific symptoms targeted.

  • E4. +1 This is a potentially useful treatment if the patient does not require immediate relief of symptoms, since the drug requires 4–6 weeks to become effective. However, it does have fewer side effects than the benzodiazepines (e.g., drowsiness, psychomotor impairment, and alcohol potentiation), and it has less potential for abuse.

  • E5. +3 SSRIs have been shown to have significant antianxiety effects, but they take 3–4 weeks to become effective and may transiently increase anxiety, especially fluoxetine. This is why paroxetine and sertraline are better choices. They are safe medications in general and are not known for abuse.

  • E6. +3 Venlafaxine extended release has been approved for generalized anxiety disorder. Published studies have reported efficacy both in acute settings (Davidson et al. 1999; Rickels et al. 2000) and in 6-month continuation trials (Gelenberg et al. 2000).

  • E7. −1 Unless there is evidence of alcohol abuse or dependence, this is inappropriate.

  • E8. −1 There is no evidence supporting the use of mood stabilizers to treat generalized anxiety disorder.

  • E9. 0 Some believe that high levels of sugar in the diet may increase anxiety, although the evidence is mostly anecdotal; reducing sugar intake should not be considered as a first-line treatment in the case of Ms. P.

 
Anchor for JumpAnchor for Jump
Davidson JR, DuPont RL, Hedges D, Haskins JT: Efficacy, safety, and tolerability of venlafaxine extended release and buspirone in outpatients with generalized anxiety disorder. J Clin Psychiatry  1999; 60:528—535
 
Gelenberg AJ, Lydiard RB, Rudolph RL, Aguiar L, Haskins JT, Salinas E: Efficacy of venlafaxine extended-release capsules in nondepressed outpatients with generalized anxiety disorder: a 6-month randomized controlled trial. JAMA  2000; 283:3082—3088
 
Rickels K, Pollack MH, Sheehan DV, Haskins JT: Efficacy of extended-release venlafaxine in nondepressed outpatients with generalized anxiety disorder. Am J Psychiatry  2000; 157:968—974
 
Sadock BJ, Sadock VA: Synopsis of Psychiatry, 9th ed. Philadelphia, Lippincott Williams & Wilkins,  2003
 
Schatzberg AF, Nemeroff CB: Essentials of Clinical Psychopharmacology. Washington, DC, American Psychiatric Publishing,  2001
 
Anchor for JumpAnchor for Jump
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References

Davidson JR, DuPont RL, Hedges D, Haskins JT: Efficacy, safety, and tolerability of venlafaxine extended release and buspirone in outpatients with generalized anxiety disorder. J Clin Psychiatry  1999; 60:528—535
 
Gelenberg AJ, Lydiard RB, Rudolph RL, Aguiar L, Haskins JT, Salinas E: Efficacy of venlafaxine extended-release capsules in nondepressed outpatients with generalized anxiety disorder: a 6-month randomized controlled trial. JAMA  2000; 283:3082—3088
 
Rickels K, Pollack MH, Sheehan DV, Haskins JT: Efficacy of extended-release venlafaxine in nondepressed outpatients with generalized anxiety disorder. Am J Psychiatry  2000; 157:968—974
 
Sadock BJ, Sadock VA: Synopsis of Psychiatry, 9th ed. Philadelphia, Lippincott Williams & Wilkins,  2003
 
Schatzberg AF, Nemeroff CB: Essentials of Clinical Psychopharmacology. Washington, DC, American Psychiatric Publishing,  2001
 
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