40-year-old woman with a chief complaint of anxiety and narcoleptic.

40-year-old woman with a chief complaint of anxiety and narcoleptic.

Psychiatric History : The patient had onset of anxiety and depression at about age 15, which she began self-medicating with alcohol • After graduating from high school, she began college and was about to leave for study abroad when she experienced a panic attack for which she was treated in the emergency room • She was then hospitalized and treated for alcohol abuse at age 18, and has remained sober ever since, although she does admit to some possible alprazolam (Xanax) abuse in 1999 as well as one overdose with alprazolam

• Her history also includes multiple hospitalizations for major depression – Age 19 (approximately one year after her release from the hospital for alcohol abuse) because she became suicidal – Age 24 due to recurrence of depression – Age 26 with an overdose following a divorce and recurrence of depression – Age 27 due to recurrence of depression – Age 29 after two miscarriages, with a possible postpartum element and some discontinuation of her medications at that time to try to get pregnant – Age 30 when she received electroconvulsive therapy (ECT): 7 sessions as an inpatient and 23 as an outpatient.

Details of medication history unclear from available information and from patient’s memory, but has received numerous psychotropic drugs including antidepressants, antipsychotics, and mood stabilizers, all with poor results • She was much better for several years following her ECT treatment, but had severe memory impairment • She had a recurrence of her depression one year ago severe enough to become totally disabled, necessitating resignation from a job as an offi ce worker that she had enjoyed • She continues to be disabled from depression and has a great deal of anxiety, subjectively more disturbed by her anxiety than by her depression Social and Personal History: Married since 1996 (second marriage); no children from either marriage • Non smoker • Husband an architect, supportive • Little contact with her family of origin • Few friends or outside interests.

Family History: Grandmother: depression and who has received ECT with good results Current Medications: Bupropion (Wellbutrin XL) 450 mg/day (thinks it is helpful as she worsens if she tries to taper) • Ziprasidone (Geodon, Zeldox) 60 mg in the morning and 180 mg at night (unsure if this is helpful) • Lamotrigine (Lamictal) 200 mg in the morning and 150 mg at night (thinks it is helpful for her mood). Gabapentin (Neurontin) 300 mg in the morning, 600 mg at noon, and 900 mg at night; occasional 100 mg as needed for breakthrough anxiety (experiences intolerable return of anxiety at much lower doses) • Pramipexole (Mirapex) 1 mg/night for restless legs syndrome (unclear whether helpful) • Methylphenidate extended-release (Concerta) 54 mg/day for daytime sleepiness (thinks it is helpful) • Sodium oxybate (Xyrem) 9 mg in one dose at night for narcolepsy and daytime sleepiness (not taken in recommended split dose) • DDAVP (the peptide Desmopressin) 0.4 mg/night for bedwetting


· 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 at least three 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.

· 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. Refer to the DSM-5 for guidance.

· List three 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.

· 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 presentation