A 38-year-old woman comes to the office due to anxiety and poor sleep. A week ago, the patient went on a family hiking trip, which ended when her brother slipped and fell 30 ft down the mountainside. Although his condition is now stable and improving, the patient worries about his recovery and awakens multiple times a night in a profuse sweat. She is unable to take naps because she feels "too wound up." The patient tearfully says, "I keep reliving the moment he fell, and I can't block it out." Medical history is noncontributory. She has started drinking 3 glasses of wine at bedtime to "calm down" but does not use recreational drugs. Vital signs and physical examination are within normal limits. On mental status examination, the patient appears tense and nervously taps her foot; she describes her mood as "numb." Which of the following is the most appropriate management of this patient?

Question

A 38-year-old woman comes to the office due to anxiety and poor sleep.  A week ago, the patient went on a family hiking trip, which ended when her brother slipped and fell 30 ft down the mountainside.  Although his condition is now stable and improving, the patient worries about his recovery and awakens multiple times a night in a profuse sweat.  She is unable to take naps because she feels "too wound up."  The patient tearfully says, "I keep reliving the moment he fell, and I can't block it out."  Medical history is noncontributory.  She has started drinking 3 glasses of wine at bedtime to "calm down" but does not use recreational drugs.  Vital signs and physical examination are within normal limits.  On mental status examination, the patient appears tense and nervously taps her foot; she describes her mood as "numb."  Which of the following is the most appropriate management of this patient?

Quizplus · Accepted Answer

11ec25c8_d7ed_907b_bc81_2b46e91579c9_MD0003_00 This patient's acute onset of anxiety, insomnia, and intrusive flashbacks following exposure to a traumatic event is consistent with acute stress disorder (ASD). Her numb mood, hyperarousal, and tearfulness are also characteristic. Other ASD symptoms include nightmares, dissociation, and avoidance of reminders of the event. ASD is diagnosed when symptoms last for ≥3 days but ≤1 month following trauma exposure. Because patients with ASD are at risk for subsequent posttraumatic stress disorder (diagnosed when symptoms persist for >1 month), early intervention is recommended. First-line treatment consists of trauma-focused cognitive-behavioral therapy (CBT) rather than medication. Components of CBT include education (ie, explaining and normalizing the stress response), exposure (ie, confronting traumatic memories in a safe environment), and cognitive restructuring (ie, adjusting maladaptive thoughts about the trauma). CBT is effective in decreasing ASD symptoms and preventing progression to PTSD. (Choice A) Although a benzodiazepine (eg, alprazolam) may be used as an adjunctive, short-term treatment to target severe anxiety and insomnia immediately following a traumatic event, it would not be preferred in this patient who is misusing alcohol to relax. Prescribing alprazolam would put this patient at risk of abuse/dependence and expose her to cumulative adverse effects of multiple sedative hypnotics. (Choice B) Buspirone is an antianxiety medication that has a role in the treatment of generalized anxiety disorder. It does not have efficacy in ASD. (Choice D) There is a lack of evidence for the use of selective serotonin reuptake inhibitors (eg, escitalopram) in ASD. They are a treatment for PTSD when CBT is unavailable or if the patient prefers medication. (Choice E) Reassurance alone would be inadequate to treat this patient, whose symptoms are severe and impairing. Educational objective: Early intervention for acute stress disorder is indicated to reduce the severity of symptoms and prevent progression to posttraumatic stress disorder. Trauma-focused cognitive-behavioral therapy is recommended as first-line treatment. References: Cognitive behavioral therapy for anxiety and related disorders: a meta-analysis of randomized placebo-controlled trials. (http://www.ncbi.nlm.nih.gov/pubmed/29451967) Acute stress disorder. (http://www.ncbi.nlm.nih.gov/pubmed/28813311)

A 38-Year-Old Woman Comes to the Office Due to Anxiety