Essay: Differential diagnoses

Essay: Differential diagnoses

Essay: Differential diagnoses

The Case: The woman who liked late-night TV The Question: What to do when comorbid depression and sleep disorders are resistant to treatment The Dilemma: Continuous positive airway pressure (CPAP) may not be a reasonable option for treating apnea; polypharmacy is needed but complicated by adverse effects.

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Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.

· Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).

· Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.

· Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.

· Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.

· Review the posttest for the case study.

Learning Resources
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

Review the following medications:

For insomnia

· alprazolam

· amitriptyline

· amoxapine

· clomipramine

· clonazepam

· desipramine

· diazepam

· doxepin

· flunitrazepam

· flurazepam

· hydroxyzine

· imipramine

· lorazepam

· nortriptyline

· ramelteon

· temazepam

· trazodone

· triazolam

· trimipramine

· zaleplon

· zolpidem

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Davidson, J. (2016). Pharmacotherapy of post-traumatic stress disorder: Going beyond the guidelines. British Journal of Psychiatry, 2(6), e16-e18. doi:10.1192/bjpo.bp.116.003707. Retrieved from Essay: Differential diagnoses

The case Study


The Case: The woman who liked late-night TV

The Question: What to do when comorbid depression and sleep disorders

are resistant to treatment

The Dilemma: Continuous positive airway pressure (CPAP) may not be a

reasonable option for treating apnea; polypharmacy is needed but

complicated by adverse effects

Pretest self-assessment question (answer at the end of the case)

Which of the following hypnotic agents is less likely to be addictive, impair

psychomotor function, or cause respiratory suppression?

A. Ramelteon (Rozerem)

B. Zolpidem (Ambien)

C. Doxepin (Silenor)

D. Temazepam (Restoril)

E. A and C

F. B and D

G. None of the above

Patient evaluation on intake

• 70-year-old female with a chief complaint of “being sad”

• Feels she had been doing well until her hearing began to diminish in

both ears

– Candidate for cochlear implants in the future, but this is a long way off

– Despite the promise of improved hearing, she often has crying spells

for no clear reason

Psychiatric history

• The patient has been without psychiatric disorder throughout her life

• Has felt increasingly sad over the last year and these feelings were not

triggered by an acute stressor

• Lives alone with the help of a home aide

– Her spouse died many years ago due to CAD

– Despite her aide and her son who visits often, she is having a

harder time coping with both instrumental and basic activities of

daily living

• She admits to full MDD symptoms Essay: Differential diagnoses

– She is sad, has lost interest in things she used to enjoy, and is

fatigued with poor focus and concentration

– Denies feelings of guilt, worthlessness, or any suicidal thoughts

– Appears mildly psychomotor slowed

– Additionally states that sleep is “awful”

◦ Does not fall asleep easily as her legs “ache and jump”

◦ Takes frequent naps during the day as a result

◦ She admits to snoring frequently

• There is no evidence of cognitive decline or memory problems

• She has a supportive son who accompanies her to all appointments and

helps provide her care

Social and personal history

• Graduated high school, was married, and raised her children

• Denied any academic issues, learning disability, or ADHD symptoms

growing up

• Having and maintaining friendships has been easy and successful over

the years

• At times, she is lonely at home

• Her mobility has declined somewhat, which limits her going out

• Participates in activities at a local elders’ center

• No history of drug or alcohol problems

Medical history


• Hypothyroidism


• Anemia

• Environmental allergies

• Obesity

Family history

• Reports AUD throughout her extended family

• MDD reportedly suffered by her mother

Medication history

• Never taken psychotropic medications

Psychotherapy history

• Recently, has gone to a few sessions of outpatient supportive

psychotherapy, but her hearing loss makes this modality almost


– Hearing aids have failed to help

– May be a candidate for cochlear implants

• She has a fax machine at home and states that she and her therapist

often fax notes back and forth, which she finds helpful as receiving them

brightens her mood

– Perhaps this is “supportive facsimile therapy” Essay: Differential diagnoses


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