Psychiatry · Year 3 · from Psychiatry

Case 1: Post-Traumatic Stress Disorder

Patient Demographics

  • Age: 34 years old
  • Sex: Male
  • Occupation: Iraq War veteran, currently unemployed

Chief Complaint

"I can't get the images out of my head. Every loud noise makes me think I'm back there."

History of Present Illness

The patient is a combat veteran who served two tours in Iraq from 2007-2010. He presents to the VA mental health clinic at his wife's urging. He describes persistent symptoms since returning from deployment, which have worsened over the past year. He experiences intrusive memories of combat, particularly a roadside IED explosion that killed two members of his unit. He has recurrent nightmares about the event 3-4 times per week, waking in a cold sweat with his heart racing. He avoids news about the Middle East, war movies, and conversations about his service. He no longer attends July 4th celebrations or any events with fireworks due to the sounds triggering intense anxiety and flashbacks. He reports feeling emotionally numb and disconnected from his wife and children, stating "I love them but I can't feel it anymore." He is hypervigilant, constantly scanning for threats, and positions himself with his back to the wall in restaurants. He has an exaggerated startle response to sudden noises. He sleeps only 3-4 hours nightly, checks door locks multiple times, and keeps a loaded weapon by his bed. He has become increasingly isolated, quit his job 6 months ago after an argument with a coworker, and spends most days alone. He drinks 6-8 beers nightly "to shut my brain off." He denies suicidal ideation but admits to passive thoughts that his family "would be better off without me."

Mental Status Examination

Appearance: Muscular man in fatigues, sitting with back to wall, scanning room frequently

Behavior: Hypervigilant, tense, startles when door opens, maintains physical distance from examiner

Speech: Clipped, measured, low volume

Mood: "On edge"

Affect: Restricted, tense, constricted range, occasionally flat when discussing trauma

Thought Process: Linear, goal-directed

Thought Content:

  • Intrusive trauma memories
  • Hypervigilant threat assessment
  • Negative beliefs about self ("I should have saved them")
  • Passive suicidal ideation (no plan or intent)
  • No homicidal ideation
  • No paranoid delusions (hypervigilance is trauma-related, not psychotic)

Perceptions: Flashbacks (dissociative re-experiencing), no frank hallucinations

Cognition: Alert, oriented, concentration impaired by hypervigilance

Insight: Fair - recognizes he needs help

Judgment: Impaired by avoidance and substance use

Psychiatric Workup

Screening Tools:

  • PCL-5 (PTSD Checklist): 62 (severe; clinical cutoff is 31-33)
  • PHQ-9: 18 (moderate-severe depression)
  • AUDIT: 24 (alcohol use disorder range)
  • Columbia Suicide Severity Rating Scale: Passive ideation present

Trauma Inventory:

  • Index trauma: IED explosion with unit member deaths
  • Additional exposures: Firefights, seeing casualties, killing in combat

Diagnosis

1. Post-Traumatic Stress Disorder (F43.10)

DSM-5 Criteria:

Criterion A - Traumatic Exposure:

  • Direct exposure to death/threatened death - present (combat, IED)

Criterion B - Intrusion Symptoms (1+ required):

  • Intrusive memories - present
  • Nightmares - present
  • Flashbacks (dissociative reactions) - present
  • Psychological distress to trauma reminders - present
  • Physiological reactions to trauma reminders - present

Criterion C - Avoidance (1+ required):

  • Avoidance of trauma-related thoughts/feelings - present
  • Avoidance of external reminders - present (news, fireworks, movies)

Criterion D - Negative Alterations in Cognition/Mood (2+ required):

  • Negative beliefs about self - present ("I should have saved them")
  • Distorted blame - present (survivor guilt)
  • Persistent negative emotional state - present
  • Diminished interest - present
  • Detachment/estrangement - present
  • Inability to experience positive emotions - present

Criterion E - Alterations in Arousal (2+ required):

  • Irritable behavior - present
  • Hypervigilance - present
  • Exaggerated startle - present
  • Concentration problems - present
  • Sleep disturbance - present
  • Duration >1 month: Yes (since 2010)
  • Functional impairment: Yes (unemployment, relationship difficulties)

2. Alcohol Use Disorder, Moderate (F10.20)

Treatment Plan

Pharmacotherapy:

  • Start sertraline 50 mg daily (first-line for PTSD)
  • Titrate to 100-200 mg over 4-6 weeks
  • Add prazosin 1 mg QHS for nightmares, titrate to 6-15 mg as tolerated
  • Avoid benzodiazepines (can worsen PTSD, risk with alcohol use)

Evidence-Based Psychotherapy (First-line):

  • Prolonged Exposure (PE) Therapy
  • Imaginal exposure: Repeated recounting of trauma memory
  • In-vivo exposure: Gradual approach to avoided situations
  • Processing of trauma-related cognitions
  • OR Cognitive Processing Therapy (CPT)
  • Focus on maladaptive beliefs ("It's my fault")
  • Written trauma account
  • Cognitive restructuring

Address Alcohol Use:

  • Psychoeducation about alcohol worsening PTSD symptoms
  • Consider medication-assisted treatment (naltrexone) if motivated
  • Integrated PTSD/substance use treatment

Safety:

  • Discuss safe firearm storage (firearms and PTSD increase suicide risk)
  • Encourage storing weapon with friend/family or using gun lock
  • Safety plan developed
  • Veterans Crisis Line: 988, Press 1

Additional Interventions:

  • Couple therapy if wife willing (address emotional numbing, communication)
  • Peer support through VA Vet Centers
  • Sleep hygiene education
  • Limit caffeine (worsens hyperarousal)

Follow-up:

  • Weekly PE or CPT sessions (typically 8-15 sessions)
  • Medication check in 2 weeks
  • PCL-5 monitoring

All cases for this lecture as Markdown