Patient Management Exercise for Sleep, Sex , And Eating Disorders

This 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 section that gives information about the case. One or more choices may be correct for each question; make 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 deducted 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.

Vignette part I

You are a general adult psychiatrist in a private group practice in a small city, and your first appointment of the day is a new patient, Mrs. S. You received a summary from her most recent visit to the psychiatric emergency department at the local tertiary care hospital, with the patient’s signed consent, that describes Mrs. S as “drug-seeking, most likely bipolar disorder II with psychotic features versus schizoaffective disorder.”

Mrs. S arrives on time. On her intake form she wrote that her chief complaint at the moment is an inability to have sexual relations with her husband, whom she says wants a divorce because she is “frigid.” She is somewhat conservatively dressed, her hair is pulled back into a bun, and she wears red horn-rimmed glasses with small clear crystals at the tips. She is obese and has apparent acne vulgaris on her cheeks, and she has good hygiene and is well groomed. You introduce yourself and offer your hand, but she seems not to have noticed and moves to sit in the chair opposite you; she immediately takes a tissue from the box on the coffee table. She is tearful and looking downward.

You take your seat on the other side of the coffee table and wait for her to gather her composure. A few minutes pass without her saying anything. Then she says, “I don’t know why I’m here. It all seems so useless. I’ve been trying everything, and now John wants to leave me. It feels like I can’t do anything right. He hates me.” She begins to sob. She still has not looked up from the floor. You wait, but she does not offer any further information about what is so upsetting. Then she says, as if reluctantly, “I suppose you need a history, right?”

Mrs. S is a 35-year-old married woman with two adopted children, a 16-year-old son and a 15-year-old daughter, from her first relationship, which was not a marriage and which ended “amicably.” She is still close to her previous partner, she says, and although he would like to see his children, her current husband does not like him and will not allow him to come to the house. She was seen twice over 1 month in the local university’s adult general psychiatry residents’ clinic 2 years ago for a major depressive episode after a serious suicide attempt by overdose on acetaminophen. She recovered from the overdose without medical complications but remained depressed and anhedonic, with poor sleep, poor concentration, ruminating thoughts, and occasional impulsive behavior but no further suicide attempts. She had mild psychotic symptoms in the form of a non-command-type denigrating voice. She fired the treating resident at that time and did not return until recently, when she came to the hospital’s psychiatric emergency room complaining of panic symptoms and suicidal ideation without intention or plan. She was not hospitalized, and she was referred to your clinic because she refuses to see another “inexperienced wannabe psychiatrist.” She fired previous residents because she felt they were not responsive enough to her need for higher doses of benzodiazepines. Additionally, she admits to several visits over the past 6 months to three different medical emergency rooms with complaints of anxiety and panic.

She reports allergic reactions to lithium, fluoxetine, sulfa drugs, olanzapine, penicillin, and codeine. Her current medications include 60 mg of duloxetine daily, 20 mg of aripiprazole daily, and 0.5 mg of clonazepam twice a day. Previous medication trials included olanzapine, risperidone, lithium, fluoxetine, paroxetine, bupropion, buspirone, and alprazolam.

She completed all four modules of dialectical behavioral therapy in a group setting approximately 2 years ago and has had eight sessions with a master’s-level therapist who used cognitive behavior therapy and supportive psychotherapy.

The patient has a history of opiate dependence after several surgeries, which included a cholecystectomy and several other operations that she adamantly refuses to discuss.

Her mother had major depression and anxiety and had made one suicide attempt; her older sister had major depression and had made two suicide attempts; her paternal grandfather had alcoholism and died 10 years ago of liver failure; and her father has alcoholism.

She currently lives with her husband of 2 years and the two children from her first relationship in a house just outside of town. She is a homemaker. Her husband works as a firefighter and is often not home for extended periods. They are financially stable.

Mrs. S makes herself comfortable in the chair opposite you and is no longer tearful. She says, “I don’t know where to begin.” She is looking at the framed medical credentials on your wall. “I’ve never had sex with my current husband.” She again becomes tearful. You notice she grips the sleeves of her blouse with her fingertips. “He wants to. All the time, really. But I . . . can’t. Or won’t. No, I won’t. I don’t want to. I can’t.”

You wait.

“We never actually had sex in two years. I know that seems crazy. He understood for a while. We’ve been somewhat intimate, but I’ve never let him enter me. Now he wants a divorce, which I suppose is okay. I know I would want one if I were him. Look at me.”

You ask if she was able to have sex in the past with her partner in her first relationship, and she replies that they did have sex, but it was “different.” Then she looks directly at you and says, “Since you have a medical diploma from the university I’m going to trust you. I never told any of the other doctors any of this. Especially the residents, because they could not possibly understand. But I don’t know what to do anymore. I don’t want to lose my family, but I’m carrying a huge secret.”

Before she will tell you, however, her tears resume, and she asks for a prescription for alprazolam, 1 mg t.i.d.

Decision Point A

Given the above information and presentation, what should you do? (Multiple answers are possible; points are taken away for incorrect answers.)

Decision Point B

What are the four stages of the human sexual response cycle?

Vignette part II

Mrs. S becomes angry. “Are you going to be like all the other doctors? I came here for help. Are you going to tell me how to feel? Are you going to tell me everything is going to go away? Because it’s NOT. You have NO idea.” She continues to sob. “Xanax helps me. I know lots of doctors do not like to prescribe it to someone like me, but it HELPS.”

You ask her how it helps.

“I get panic attacks. I can’t control my anxiety. When I take a Xanax—which I don’t abuse, I only use it when I need to—I feel better. Sometimes after I take it I end up having a panic attack anyway, so it’s not the greatest medication. I can’t sleep. All I do is worry about my husband, what he’s going to think of me. . . .”

You wait.

“I’m a freak show, doctor. A fucking freak show.” She gathers her purse and stands up. “I can’t talk to you anymore about this.”

You ask her why she feels the need to leave.

“If you aren’t going to give me the medication, I’ll have to find another doctor.”

She starts to sob again and says, “I don’t know if it’s him or if it’s me. Either way, I can’t have sex. It’s not that it’s painful, I’m just afraid.”

Decision Point C

Which agents affect the first three stages of human sexual response, positively or negatively? Fill in the appropriate boxes in the chart below using the list of agents provided. (Correct answers receive +2 points, incorrect answers receive −2 points.)

Vignette part III

Mrs. S states that she needs to tell you something that will help you understand her problem. She has not told you until now because she was not sure how you would handle the information, but she decided that you seem like an open-minded doctor and “this is too important,” she says. “I am a postsurgical transsexual. I was able to have sex with my first ‘husband’ because at that time I still had a penis. He did not mind it when I started taking hormones and grew breasts, and he was even supportive when I had breast augmentation surgery. However, when I discovered that I would not be satisfied until I had sexual reassignment surgery, he told me he could not maintain the same relationship with me.” She smiles. “We’re still friends, and he still sees the kids, but he is gay and wants to be with a man.” She takes a deep breath. “I can live with that.”

You ask if her new husband knows about her reassignment surgery. She says, “No. He actually thinks I’m a woman. I can’t bring myself to tell him. My children know, but they’re never around, so he never heard it from them. I don’t know, maybe he did. But he never let on that he knows. Either way, he says he just isn’t going to force me to have sex with him.”

Decision Point D

Given the above information, what is your differential diagnosis for Mrs. S?

Decision Point E

Sexual dysfunction is divided into two primary disorders according to whether they describe a dysfunction of desire or of arousal. Use the following table to classify the listed criteria into one of the three columns.

Answers: Scoring, relative weights, and comments

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) indicates a decision that is potentially useful for diagnosis and treatment. A neutral score (0) indicates a decision that is neither clearly helpful nor harmful under the given circumstances. High negative scores (−5 to −3) indicate a decision that is inappropriate and potentially harmful or possibly life-threatening. Lower negative scores (–2 and above) indicate a decision that is nonproductive and potentially harmful.

Decision Point A

Decision Point B

Decision Point C

Correct answers receive +2 points, incorrect answers receive −2 points.

Decision Point D

Hypoactive sexual desire disorder (–2). Since Mrs. S was able to have sex during her first relationship, the criteria of persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity are not met. She did not describe a lack of desire for sexual activity but a fear that she will be “found out” by her husband, who does not know about how she has transitioned her sexual identity. It is reasonable to expect that if her husband accepted her sexual identity and was truly interested in having sexual relations with his wife, she would likely desire sex.

Sexual aversion disorder (+1). Mrs. S does avoid having sex with her husband out of fear that he will discover her transsexuality. Consequently, she persistently avoids all, or almost all, genital sexual contact with him. This disturbance clearly causes marked distress and interpersonal difficulty, as evidenced by her repeated attempts to find help from professionals and her husband’s allegedly seeking a divorce. This sexual dysfunction might be considered better accounted for by her gender identity disorder if one considers only the interpersonal ramifications of keeping her transsexuality a secret from her husband. It is possible to specify subtypes of sexual aversion disorder to include acquired type, situational type, or due to psychological factors.

Gender identity disorder (+2). DSM-IV-TR criteria for this disorder include:

Rule out benzodiazepine abuse (+1). From the interview so far, you have not been able to establish a more pervasive pattern to suggest substance dependence. The criteria for substance abuse, however, may apply on further evaluation. For this reason, the diagnosis is considered a “rule-out” until evidence is gathered. The criteria for substance abuse include:

Mrs. S has only described a need to obtain more alprazolam despite other physicians’ refusal to prescribe adequate supplies. It is possible that she is using this medication to help with the anxiety caused by her marital discord. The primary maladaptive pattern she has suggested is “doctor shopping” for a clinician willing to prescribe a particular short-acting benzodiazepine known for its abuse potential. She has made this a central issue in her presentation despite the more substantial issues that she began to describe only later. For this reason, exploration of the above criteria is crucial to determine whether she has developed an abusive pattern of using this medication. You will be able to offer her safer methods for handling the stress she is experiencing both pharmacologically and psychotherapeutically once you establish an effective and positive therapeutic alliance. Given what you have learned of the experiences of her previous clinicians, you should be careful not to challenge her drug use early in the relationship, as this will drive her from your care.

History of opiate dependence (+1). From the history; there is no evidence of current use.

Decision Point E

Sexual dysfunction is divided into two primary disorders according to whether they describe a dysfunction of desire or of arousal. Use the following table to classify the listed criteria into one of the two categories, or neither.

Comments on the “Neither” answers

E2 describes a sexual pain disorder known as vaginismus. Dyspareunia, described in E7, is defined as recurrent or persistent genital pain associated with sexual intercourse in either a male or a female. E3 describes an orgasm disorder, of which there are male and female types. The primary difference between these types has to do with the wide variability in the type or intensity of stimulation that triggers orgasm in the female; otherwise they are essentially the same disorder.