MEDizzy - A 22-year-old man presents to his family physician with

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Psychiatry-USMLE Set 1

A 22-year-old man presents to his family physician with complaints of insomnia. He was recently honorably discharged from the army after finishing an 18-month tour of duty in Iraq. He states that the insomnia began about seven months ago after a fierce night-time battle. He reports having nightmares and flashbacks of the battle and is easily startled by loud noises. Which of the following pharmacologic agents, along with psychotherapy, would be most appropriate to treat this patient’s condition?

ExplanationThe correct answer is C. This patient meets the criteria for diagnosis of posttraumatic stress disorder (PTSD). He has experienced an event that involved actual death of or threatened death to self or others; the traumatic event is persistently re-experienced through nightmares and flashbacks; he suffers from insomnia; and he has an exaggerated startle response. Other symptoms of PTSD include difficulty concentrating, hypervigilance, and dissociative symptoms. In PTSD, symptoms are present for longer than one month, whereas in acute stress disorder, symptoms last between two days and one month. Selective serotonin reuptake inhibitors such as fluoxetine are first-line medications for the treatment of PTSD. Side effects include nausea, headache, anxiety, agitation, insomnia, and sexual dysfunction. Answer A is incorrect. Buspirone is a partial agonist at the 5-HT1S receptor that is commonly used as an alternative to benzodiazepines in the treatment of generalized anxiety disorder. Although its onset of action is slower than that of benzodiazepines, it does not potentiate the CNS depression of alcohol, and has little potential for abuse and addiction. Answer B is incorrect. Carbamazepine is an anticonvulsant medication that also can be used as a mood stabilizer in bipolar mood disorder. Answer D is incorrect. Propranolol is a non-specific b-blocker. It is useful in the treatment of panic disorder and simple phobia.