Post Traumatic Stress Disorder

Question 1

A 35 year old woman presents with anxiety, irritability and difficulty concentrating which have been present for the past 6 months since her involvement in a motor vehicle accident. What additional features would need to be present for a diagnosis of PTSD? What are the essential components of treatment?

Answer 1

Impression
This is likely a presentation of PTSD given the injurious event temporally related to the onset of her symptoms, would need to screen for further features of intrusive thoughts, evasion, dreams/nightmares, etc.

PTSD is a narrowly defined disorder with specific signs and symptoms.

Ddx to consider

• complex PTSD
• somatoform disorder
• dissociative disorders

Would like to undertake complete psych assessment including history, MSE and investigations before making a diagnosis and initiating appropriate treatment

Question 2

PTSD - History

Answer 2

History
- sx: Had trauma? Has it impacted your life? Then dig deeper:
T - Trauma: exposure to traumatic event
R - Re-experiences: flashbacks, sensory and auditory
A - Arousal: increased awareness, anxiety, hypervigilance
U - Unable to function
M - Month: sx present for at least 1 month
A - Avoidance: avoid things associated with the trauma
C - Cognitive changes??
- screen for: depression, suicidality/self-harm, mania, SUD - maladaptive coping mechanism, other co-morbid psychiatric conditions
- PMHx
- rest of psych history
- Risk assessment

Question 3

PTSD - Examination

Answer 3

Examination
- conduct full MSE
A: dishevelled = poor self care
B: agitation, = anxiousness, hypervigilant
M/A: blunted affect, may have low mood
C: flashbacks, avoidance, other anxiety features
F: normal
P: normal
I/J: impaired

Question 4

PTSD - Investigations

Answer 4

Investigations
No real investigations for PTSD could use validated screening tool to assist in diagnosis:
- PTSD checklist (PCL-5)

Question 5

PTSD - Management

Answer 5

Management
- want to consider safety, risk assessment in deciding the location of treatment

Psychological
Most effective treatment modalities are psychotherapy
- trauma-based CBT: gets patient to re-wire traumatic experience, de-arousal strategies
- eye-movement desensitisation and reprocessing

Biological

• SSRIs, can augment with atypical AP
• Prazosin: can help with blocking nightmares and improving sleep
• Benzo’s are to be avoided, as in long term can worsen the outcomes.

Also consider the treatment of co-morbid conditions, particular SUD which occurs at a higher rate in PTSD patients than for other psychiatric conditions

Social

• counselling
• other community supports