What defense mechanism is exhibited by a 58-year-old woman who is caring for her elderly father, despite feeling resentful and having a complicated past with him?

From the Guidelines

The most appropriate pharmacotherapy for the 32-year-old man experiencing recurrent episodes of chest pain, dizziness, and numbness is sertraline (option E). This patient is presenting with classic symptoms of panic disorder, including sudden episodes of palpitations, shortness of breath, sweating, dizziness, and paresthesias. Selective serotonin reuptake inhibitors (SSRIs) like sertraline are first-line treatments for panic disorder due to their efficacy and favorable side effect profile 1. While benzodiazepines like alprazolam or diazepam can provide rapid symptom relief, they carry risks of dependence and are not ideal for long-term management, especially given this patient's daily alcohol and marijuana use. Buspirone is primarily used for generalized anxiety disorder but is less effective for panic attacks. Propranolol can help with physical symptoms of anxiety but is not a first-line treatment for panic disorder. Sertraline would address the panic attacks while avoiding potential complications with his substance use and would be safe to use alongside his current antihypertensive medication.

Some key points to consider in this case include:

• The patient's symptoms are consistent with panic disorder, which is a common condition that can be effectively treated with SSRIs like sertraline.
• The patient's daily use of alcohol and marijuana increases the risk of dependence on benzodiazepines, making sertraline a safer choice.
• Sertraline has a favorable side effect profile and is generally well-tolerated, making it a good option for long-term management of panic disorder.
• The patient's current antihypertensive medication, enalapril, is not likely to interact with sertraline, making it a safe choice for concomitant use.

In terms of the evidence, a recent study published in The Lancet Healthy Longevity 1 highlights the importance of individualized treatment approaches for patients with complex conditions like dementia and frailty. While this study is not directly related to the patient's condition, it emphasizes the need for careful consideration of treatment options and potential interactions. In this case, sertraline is a well-established treatment for panic disorder and is likely to be effective and safe for this patient.

From the Research

Patient 1: Recurrent Episodes of Chest Pain, Dizziness, and Numbness

• The patient's symptoms, such as sudden episodes of chest pain, dizziness, numbness, and tingling in both arms, suggest a panic disorder.
• According to the studies 2, 3, 4, sertraline is an effective treatment for panic disorder and has a good tolerability profile.
• The patient's history of occasional insomnia and hypertension, as well as his use of marijuana and wine, should be considered when selecting a treatment.
• Based on the evidence, sertraline (option E) is the most appropriate pharmacotherapy for this patient.

Patient 2: Irritability, Hyperactivity, and Risky Behavior

• The patient's symptoms, such as irritability, hyperactivity, and risky behavior, suggest a mood disorder, possibly bipolar disorder.
• The patient's history of similar behavior in the past and his use of marijuana support this diagnosis.
• According to the studies, there is no direct evidence to support a specific treatment for this patient.
• However, based on the patient's symptoms and history, bipolar I disorder (option B) is a possible explanation for his behavior.

Patient 3: Behavioral Disturbances in a Patient with Alzheimer Disease

• The patient's symptoms, such as wandering, agitation, and aggression, are common in patients with Alzheimer disease.
• The use of risperidone has improved the patient's aggression but worsened her restlessness and wandering.
• According to the studies, there is no direct evidence to support a specific treatment for this patient.
• However, discontinuing risperidone (option C) and considering alternative treatments, such as environmental and behavioral interventions, may be the most appropriate next step.

Patient 4: Concerns about Skin Appearance

• The patient's symptoms, such as excessive concern about her skin appearance and repetitive behaviors, suggest a body dysmorphic disorder.
• According to the studies, there is no direct evidence to support a specific treatment for this patient.
• However, a statement acknowledging the patient's concerns and encouraging her to seek help (option E) may be the most appropriate response.

Patient 5: Schizophrenia with Agitation and Suicidal Ideation

• The patient's symptoms, such as agitation, suicidal ideation, and delusions, suggest a severe psychotic episode.
• According to the studies, clozapine is an effective treatment for treatment-resistant schizophrenia 5.
• The patient's history of multiple hospitalizations and lack of response to previous treatments support the use of clozapine.
• Based on the evidence, clozapine (option B) is the most appropriate treatment for this patient.

Patient 6: Caregiver's Behavior towards her Father

• The caregiver's behavior, such as being extremely attentive to her father and asking if he is comfortable, suggests a defense mechanism.
• According to the studies, there is no direct evidence to support a specific defense mechanism for this patient.
• However, reaction formation (option C) is a possible explanation for the caregiver's behavior, as she may be expressing feelings that are opposite to her true feelings towards her father.