PTSD

Question 1

Nurse who was involved in bad covid incident (hospitalisation and infection affecting husband and child). Now experiencing ongoing symptoms - anxiety, chest tightness, sore throat, anhedonia, low mood, still hasnt gone back to work, nightmares. What would you like to know on assessment? What is your ddx and formulation? How would you manage this patient?

Answer 1

Impression
Given nightmares after a significant traumatic event, am concerned about PTSD or Depression-anxiety. Would like to conduct full psychiatric assessment including MSE to further circumscribe the presentation and consider other differentials.

Ddx to consider:

• Depression/ Major depression
• GAD + depression

Question 2

PTSD - History

Answer 2

Assessment
Conduct psych history
- PC: 
- PTSD: real event threatening life (or witnessed), flashbacks, dreams, irritability, intrusive/distressing memories, marked physiological reactions to internal/external cues, avoidance of stimuli associated with the event
- depression screen: worthlessness, low mood, anhedonia, eating/sleep changes, agitation, suicide/self-harm (risk assessment)
- anxiety: cognitions - panic attacks? fear of having one? fear of negative assessment? generalised anxiety? obsessions and compulsions? reliving past trauma?
- screen for mania
- screen for psychosis
- past psych history
- past medical history
- fam history
- substance use history
- developmental history
- social
- forensic/legal
- current background

Question 3

PTSD - Examination

Answer 3

Examination:
Conduct full MSE
- appearance
- behaviour: 
- speech/motor
- affect/mood: blunted/reactive, euthymic vs dysthymic
- thought content: delusions, suicidal
- thought form: disordered
- perceptions: hallucinations, de-personalisation
- cognition
- insight
- judgement

Would also conduct cardiorespiratory examination given history of long covid - assess for any organic pathology.

Question 4

PTSD - Investigations

Answer 4

Investigations
Rule out organic causes
- Bloods: B12/folate, TFTs, UEC, LFT, ANA/ENA
- Imaging: MRI Brain (?long COVID)

Question 5

PTSD - Management

Answer 5

Management
No research supports the use of medication to prevent the onset of PTSD, nor to treat PTSD symptoms in the first 4-8 weeks as the majority will remit spontaneously.

PTSD
Non-pharmacological:
- trauma based CBT
- Eye movement desensitisation and reprocessing
- can offer non-trauma focussed psychotherapy to those not ready to engage with traumatic incident.

Pharmacological
May be used as adjunctive therapy, or in the instance of significant anxiety/depression symptoms warranting diagnoses, or in non-response to psychotherapy
1 - SSRI
2 - +/- atypical antipsychotic
3 - Atypical antidepressant (Mirtazepine)