Psychiatry · Year 2 · from Psychiatry
Case 1: Post-Traumatic Stress Disorder
Patient Presentation
Demographics: 34-year-old male
Chief Complaint: "I keep having nightmares about the accident. I can't drive anymore."
History of Present Illness: A 34-year-old construction worker presents 4 months after being involved in a serious motor vehicle accident. He was driving home from work when a truck ran a red light and struck his vehicle on the driver's side. He was trapped in the vehicle for 45 minutes before being extracted and was hospitalized for 2 weeks with multiple fractures and a pulmonary contusion. He states, "I was sure I was going to die." Since the accident, he has been plagued by intrusive memories of the crash that occur multiple times daily, often triggered by traffic sounds or seeing similar vehicles. He has nightmares about the accident 3-4 times per week, waking in a panic. He avoids driving entirely and becomes highly distressed when a passenger in a car. He also avoids the route where the accident occurred and has stopped watching news or shows featuring accidents. He reports feeling emotionally numb and disconnected from his wife and children. He is hypervigilant when near traffic, easily startled by loud noises, and has difficulty concentrating. He has become irritable and has had angry outbursts at home. He sleeps only 4-5 hours per night due to fear of nightmares. He admits to increased alcohol use (4-5 beers nightly) to "quiet my mind."
Physical Examination:
- Healed fracture sites with residual stiffness
- Vital signs: BP 138/86, HR 92 (elevated)
Mental Status Examination:
- Appearance: Fatigued, tense, guarded
- Behavior: Hypervigilant, startled by door closing
- Mood: "On edge, can't relax"
- Affect: Constricted, anxious
- Thought content: Intrusive trauma memories, avoidance behaviors, no SI/HI
- Cognition: Concentration impaired
Workup:
- PCL-5 (PTSD Checklist): Score 58 (clinical cutoff is 31-33)
- PHQ-9: Score 14 (moderate depression)
- AUDIT: Score 14 (harmful drinking)
- Life Events Checklist: Confirmed Criterion A trauma
Diagnosis: Post-Traumatic Stress Disorder; Alcohol Use Disorder, mild (likely trauma-related self-medication)
Treatment:
- Psychoeducation about PTSD symptoms as normal responses to abnormal events
- Started sertraline 50 mg daily, titrated to 150 mg (FDA-approved for PTSD)
- Prazosin 1 mg at bedtime for trauma-related nightmares, titrated to 4 mg with significant nightmare reduction
- Referral for Prolonged Exposure (PE) therapy:
- Imaginal exposure to trauma memory with processing
- In vivo exposure hierarchy starting with sitting in parked car, progressing to driving
- Brief intervention for alcohol use; agreed to limit to 1-2 drinks/night during treatment
- At 12-week follow-up: Nightmares reduced to 1/week on prazosin
- Completed PE therapy with significant reduction in avoidance
- Successfully drove short distances with plan to gradually increase
- PCL-5 decreased to 32
Clinical Pearl: PTSD requires exposure to actual or threatened death, serious injury, or sexual violence, followed by symptoms from four clusters: intrusion (nightmares, flashbacks), avoidance (of reminders), negative alterations in cognition/mood, and hyperarousal. Prazosin, an alpha-1 adrenergic blocker, has specific evidence for reducing trauma-related nightmares. Prolonged Exposure and Cognitive Processing Therapy are first-line psychotherapies with strong evidence. Importantly, benzodiazepines should be avoided in PTSD as they may interfere with extinction learning and worsen outcomes.