Case 2: Volume 2, Case #11: The Figment Of A Man Who Looked Upon The Lady

Post a response to the following: Case 2: Volume 2, Case #11: The figment of a man who looked upon the lady

• Review this week’s Learning Resources and reflect on the insights they provide.
• Go to the Stahl Online website and examine the case study you were assigned.
• Take the pretest for the case study.

• Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.
• Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).
• Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.
• Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.
• Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.
• Review the posttest for the case study.

• Provide the case number in the subject line of the Discussion.
• List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.
• Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.

  Case 2: Volume 2, Case #11: The Figment Of A Man Who Looked Upon The Lady

• Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
• List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
• List two pharmacologic agents and their dosing that would be appropriate for the patient’s sleep/wake therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
• If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
• Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentationsCase 2: Volume 2, Case #11: The Figment Of A Man Who Looked Upon The Lady

  PATIENT FILE

  The Case: The figment of a man who looked upon the lady

  The Question: Are atypical antipsychotics anti-manic, antidepressant, anxiolytic, and hypnotic as well?

  The Psychopharmacological Dilemma: How to improve insomnia that is caused by depression, anxiety, mood swings, and hallucinations

  Pretest self-assessment question (answer at the end of the case)

  Which of the following properties of certain atypical antipsychotics lend to their ability to promote and maintain sleep?

  A. Histamine-1 receptor antagonism B. Serotonin-2A receptor antagonism C. Serotonin-7 receptor antagonism D. A and B E. All of the above

  Patient evaluation on intake

  • 42-year-old woman with a chief complaint of depression and interpersonal stress

  Psychiatric history

  • The patient states she was horribly abused as a child and had been addicted to alcohol and other substances for many years. Now has been sober for 10 years and attends AA and Narcotics Anonymous (NA) routinely with good results

  • Admits moderate levels of PTSD symptoms with nightmares, flashbacks, and panic attacks

  • Routinely experiences dysthymia (persistent depressive disorder) with intermittent full MDEs

  • Psychiatric review of symptoms suggests symptoms of marked mood lability, affective dyscontrol, empty depression, dissociative events consistent with mild borderline personality disorder (BPDO)

  • There is no history of inpatient psychiatric admissions, and rarely any suicidal gestures or self-injurious behaviors

  • Denies hallucinations and delusions, but states she is paranoid that people might mean her harm and always needs to “be aware of her environment”

  • She has been in legal trouble for reacting to social situations by striking out – This occurs usually when narcissistic injury occurs or if emotions

  are triggered by reminders of past abuse

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  Case 2: Volume 2, Case #11: The Figment Of A Man Who Looked Upon The Lady

   

  PATIENT FILE

  • The patient has been tried on – One SSRI, paroxetine (Paxil) 40 mg/d – One TCA, nortriptyline (Pamelor) 75 mg/d

  • Both monotherapies allowed for moderate improvements in her symptoms at best

  • Has attended supportive psychotherapy weekly for many years • Attends AA or NA daily and has a sponsor who is supportive

  Social and personal history

  • Single, never married, and has no children • Has a General Education Diploma and attends college classes

  sporadically now • Past alcohol and SUD, but has been in remission for 10 years • No current legal issues but has some financial hardships

  Medical History

  • Patient is overweight • Has CAD, DM2, chronic obstructive pulmonary disease (COPD),

  hyperlipidemia, GERD, HTN, glaucoma • Compliant with her primary care clinician who collaborates well with her

  psychiatrist

  Family History • MDD in mother and aunts • SUD throughout her extended family • GAD in her mother • Possible ADHD in siblings

  Current psychiatric medications

  • Paroxetine (Paxil) 40 mg/d (SSRI)

  Current medical medications

  • Exenatide (Byetta) • Metformin (Glucophage) • Glipizide (Glucotrol) • Ramipril (Altace) • Albuterol (Ventolin inhaler) • Fluticasone/salmeterol (Advair Diskus) • Latanoprost (Xalatan) • Ezetimibe (Zetia) • Pravastatin (Pravachol) • Protonix (Pantoprazole)

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  Case 2: Volume 2, Case #11: The Figment Of A Man Who Looked Upon The Lady

   

  PATIENT FILE

  Question

  Based on this patient’s history and the available evidence, what might you do next, given that she still has moderate, residual depression and PTSD symptoms?

  • Try another SSRI • Switch to an SNRI • Augment with a mood stabilizer • Augment with an NDRI, like bupropion-XL (Wellbutrin-XL) • Augment with a 5-HT1A receptor partial agonist, like buspirone (BuSpar) • Augment with an atypical antipsychotic

  Attending physician’s mental notes: initial evaluation

  • Patient has worked hard on sobriety and even to control her personality disorder symptoms

  • She is clearly depressed and agitated with PTSD • At the time, the only other approved agent for PTSDwas sertraline (Zoloft),

  an SSR • Buspirone (BuSpar) and bupropion-XL (Wellbutrin-XL) are widely used,

  off-label depression augmentation options, which might help her • Perhaps it is best to see what symptoms the patient deems most

  important to treat first, PTSD or depression • As she is overweight with metabolic comorbidities, it may be worth

  choosing medications that limit risk of weight gain

  Further investigation Is there anything else you would especially like to know about this patient? • What symptoms does the patient consider critical?

  – Insomnia – she does not sleep well in general and this may be caused either by depression, PTSD, or her current SSRI

  – Nightmares and flashbacks – these are very problematic as they trigger in the patient other symptoms such as mood lability and potential for violence and drug use

  – Depression– for her, this is secondary. Her depression is usually caused by PTSD flare-ups, their aftermath, and her interpersonal stressors

  – She feels that controlling her PTSD and sobriety will mitigate her depression

  Question

  Based on what you know about this patient’s history, current symptoms, and medication, what would you do now?

  • Try another SSRI • Switch to an SNRI

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