A 32-year-old physician comes to the office due to insomnia for the past 6 weeks. He says, "I feel restless at night, and I can't get any sleep. I've tried reading boring books and drinking herbal teas, but nothing seems to help." The patient feels his lack of sleep has made it difficult to focus and started drinking 2 cups of coffee before his shifts "to get through the day." He previously worked in the emergency department but switched to doing shifts at an urgent care clinic a month ago. The patient says, "I was seeing a lot of gunshot wounds at the hospital. Compared to my old job, this one is much calmer, but I still feel anxious a lot of the time." He still thinks about patients he treated and what he could have done differently to save them. The patient says, "The world has just gotten too dangerous, and I feel like medicine can't keep up with it." He drinks 3-4 beers on the weekends and does not use tobacco or illicit drugs. Medical history is noncontributory. Temperature is 37 C (98.6 F), blood pressure is 130/80 mm Hg, pulse is 84/min, and respirations are 16/min. Physical examination is unremarkable. The patient appears tired and speaks in a low volume. Which of the following is the most appropriate next step in management of this patient?

Question

A 32-year-old physician comes to the office due to insomnia for the past 6 weeks.  He says, "I feel restless at night, and I can't get any sleep.  I've tried reading boring books and drinking herbal teas, but nothing seems to help."  The patient feels his lack of sleep has made it difficult to focus and started drinking 2 cups of coffee before his shifts "to get through the day."  He previously worked in the emergency department but switched to doing shifts at an urgent care clinic a month ago.  The patient says, "I was seeing a lot of gunshot wounds at the hospital.  Compared to my old job, this one is much calmer, but I still feel anxious a lot of the time."  He still thinks about patients he treated and what he could have done differently to save them.  The patient says, "The world has just gotten too dangerous, and I feel like medicine can't keep up with it."  He drinks 3-4 beers on the weekends and does not use tobacco or illicit drugs.  Medical history is noncontributory.  Temperature is 37 C (98.6 F), blood pressure is 130/80 mm Hg, pulse is 84/min, and respirations are 16/min.  Physical examination is unremarkable.  The patient appears tired and speaks in a low volume.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d776_3d25_bc81_eb5978037b53_MD0003_00 This patient's sleep disturbance, impaired concentration, and persistent anxiety are most likely due to posttraumatic stress disorder (PTSD) (related to trauma exposure in the emergency department). His avoidance of reminders of trauma (ie, stopped working in the emergency department), self-blame, and negative beliefs about the world are also characteristic of the disorder. Other common PTSD symptoms include nightmares, flashbacks, irritability, dissociation, emotional detachment, exaggerated startle response, and hypervigilance. First-line treatment of PTSD includes trauma-focused cognitive-behavioral psychotherapy and antidepressant medication. Selective serotonin reuptake inhibitors, such as paroxetine, and serotonin-norepinephrine reuptake inhibitors have the best evidence. Although anxiety and severe insomnia are common PTSD symptoms, benzodiazepines such as lorazepam are not effective in PTSD (Choice B). Benzodiazepines particularly should be avoided in patients with a comorbid substance use disorder. (Choice A) Although caffeinated beverages may exacerbate insomnia and anxiety, advising this patient to discontinue caffeine without addressing the underlying cause of his insomnia is insufficient. However, the patient could be advised to gradually taper caffeine use in conjunction with treatment for PTSD. (Choice C) Melatonin has been used in the treatment of insomnia associated with shift work but is not effective for PTSD. The alpha-adrenergic receptor blocker prazosin has been helpful for some patients with PTSD-related nightmares and sleep disturbance. (Choice E) Reassurance with close follow-up may be indicated for some patients with milder cases of acute stress disorder (symptoms present <1 month). However, this patient has had persistent symptoms for at least 6 weeks that are causing significant distress and impairment. Early treatment of PTSD may prevent the development of chronic functional impairment. Educational objective: Trauma-focused cognitive-behavioral psychotherapy and selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors are first-line treatments for posttraumatic stress disorder. References: Pharmacotherapies for posttraumatic stress disorder: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26894318) Evidence-based pharmacotherapy of post-traumatic stress disorder (PTSD). (http://www.ncbi.nlm.nih.gov/pubmed/21798109)

A 32-Year-Old Physician Comes to the Office Due to Insomnia