Case Study: Patient Being Confused
The case: You have been asked to evaluate a 44-year-old woman with a chief complaint of “being confused.” Many clinicians have issued several diagnoses and the patient states she has been depressed and anxious “as long as she can remember.”
Psychiatric history
- Chronic and relapsing MDEs throughout her life
- At the initial visit, she reports minor to moderate amounts of depressive symptoms
She reports:
- Poor sleep, mood, interest, energy concentration and appetite
- She has increased guilt and worthlessness at times
- She denies any active suicidal ideation; no history of self-harm behaviors
- There is no evidence of psychosis; however, she does seem to have dissociative spells during times of stress
- She may have had one episode of hypomania, but this was poorly defined, and she was smoking marijuana and drinking alcohol at the time (she has been sober for 3 years)
- The patient does not meet full diagnostic criteria for GAD, but does worry excessively when depressed
- She has occasional panic attacks, but does not meet criteria for panic disorder as these are often induced by interpersonal stressors
- Admits to suffering from Anorexia Nervosa in her teens and early adulthood but has had no weight-related symptomatology in last two decades
- Denies current body image concerns and current body mass index is 22
Medical history
This patient has multiple medical providers and suffers from:
- Temporomandibular joint arthritis
- Hypothyroidism
- GERD
- Osteoporosis
- Migraine Headaches
- Myofacial dystonia
- Pelvic floor dysfunction
Family history
- Bipolar disorder in one aunt
- MDD throughout her family
- GAD in one aunt
Medication history
- Patient reports that she has tried, with minimal sustained improvements:
- Three SSRI’s: Sertraline (200mg/day), Citalopram (40 mg/day), Escitalopram (20 mg/day)
- An NDRI: Bupropion-XL 450 mg /day
- Has never had a trial of MAOs, TCAs, SARIS, Lithium, stimulants, or atypical antipsychotic
- Current Medications
- Venlafaxine 75 mg/d
- Alprazolam 6 mg/day
- Hydroxyzine 125 mg/day
- Fentanyl transdermal (Duragesic) 12 mcg/hour
- Levothyroxine 125 mcg/day
- Omeprazole 40 mg /day
- Ibandronate 150 mg/month
- Ondansetron 8 mg twice per day as needed for migraines
- Eletripan 40 mg/day as needed for migraines
- Naproxen sodium 500 mg twice per day
- Onaboutulinumtoxin-A injection 300 units as needed for muscle spasm
To participate in this discussion, please answer the following question. Be sure to provide a rationale and references to support your responses.
Which of the following would you recommend? (Must provide a rationale for the option you choose as well as for those you do not choose).
a. Increase the venlafaxine to the full FDA dose of 225 mg
b. Increase the alprazolam to a higher, more effective dose for anxiolysis
c. Augment the current medications with another agent that has mood stabilizing properties
d. Augment the current medications with another agent that has antipsychotic features
e. Augment the current medications with another agent that has pain dampening properties
f. Change nothing and refer for psychotherapy