Attending physician’s mental notes: initial evaluation

Patient has marked chronic history of non-comorbid GAD. He has never been symptom free but has had relatively long periods of well-controlled symptoms that are mild in nature

Patient had 10–20 years of effective care with moderate-dose BZ sedatives. Why were these stopped? Addiction? Ataxia? Apnea?

TRD is gaining ground as a clinical entity and approvals exist for TRD (olanzapine–fluoxetine combination [Symbyax], VNS, TMS, quetiapine [Seroquel])

• – Perhaps this patient has TRA as he has clearly failed two SSRIs (paroxetine and now escitalopram), two sedatives, and an NaSSA antidepressant (mirtazapine), supportive psychotherapy, and currently is failing a full dose of an SSRI plus NaSSA combination with low-dose TCA

He appears to have much hypochondriacal thought, which may make prescribing side effect-prone medications tenuous and hurt compliance

Collaboration with primary care and/or hematology is warranted

Geriatric age may make dosing psychotropics proceed slowly and cautiously

Further investigation

Is there anything else you would especially like to know about this patient?

Does he really have no psychiatric comorbidity, and does his medical history contribute to his anxiety?

• – Hypochondriasis (illness anxiety disorder in the DSM-5) is defined as a preoccupation with fears of having, or the idea that one has, serious disease based on the person’s misinterpretation of bodily symptoms This type of anxiety must persist despite appropriate medical evaluation and reassurance. In addition, it cannot be better accounted for by GAD. This patient reports that his anxiety symptoms regarding medical health really began a few years back when he started to have significant medical problems such as cancer. Prior to this, he reports that he was not preoccupied with his medical conditions or symptoms

Primary insomnia occurs when the predominant complaint is difficulty initiating or maintaining sleep, or having non-restorative sleep. The insomnia must cause significant distress or impairment. Previously, it was felt that insomnia must not occur exclusively during the course of another mental disorder such as MDD or GAD

• – However, the DSM-5 allows insomnia to be a stand-alone, comorbid psychiatric entity if it is a focus of clinical attention. It may not need to be declared if insomnia is primary, or secondary to another psychiatric or medical disorder

• – This patient reports classic “clock-watching” fear and phobia at nighttime. He reports these symptoms began after reading a report that patients who sleep less than eight hours are more likely to die of cardiac arrest

Adjustment disorder is the development of an emotional or behavioral set of symptoms in response to an identifiable stressor. These symptoms are clinically significant in that the patient shows marked distress that is in excess of what would be expected from exposure to the stressor or that the patient has significant impairment in functioning. Again, for this DSM-5 diagnosis, the adjustment does not meet criteria for MDD, anxiety disorder, etc. This patient’s GAD symptoms have been ongoing for many years, but they seem to be exacerbated by adjustment-related issues due to his age, more severe medical conditions, threat of mortality. His insomnia and illness anxiety seem to fit under the rubric of generalized anxiety, but chronologically seem to be fueled by real-world stressful issues causing an exacerbation of GAD symptoms

Iron deficiency/iron toxicity: iron deficiency often results in anemia and a clinical picture more consistent with depression or dementia. Iron toxicity, however, is mostly asymptomatic. Nonspecific early symptoms (such as abdominal discomfort and fatigue) may delay diagnosis until severe damage to the heart or liver produces clinically apparent symptoms. Anxiety exacerbation is not typical