# Clinical Cases: Trauma and Stressor-Related Disorders ## 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 --- ## Case 2: Acute Stress Disorder ### Patient Demographics - **Age:** 28 years old - **Sex:** Female - **Occupation:** Bank teller ### Chief Complaint "I was held at gunpoint during a robbery 2 weeks ago. I can't stop shaking. I can't go back to work." ### History of Present Illness The patient presents to the emergency department 2 weeks after experiencing a bank robbery at her workplace. A masked gunman entered the bank, pointed a weapon at her face, and demanded she fill a bag with cash. She was held at gunpoint for approximately 5 minutes, during which she believed she would be killed. Since the event, she has been unable to return to work. She experiences frequent intrusive images of the gun pointed at her face and the robber's eyes. She has had nightmares about the robbery every night. She describes episodes where she feels like the robbery is happening again (flashbacks), during which she feels disconnected from her body. She has been avoiding the news, driving past banks, and any crime shows on TV. She is unable to feel happiness and feels emotionally numb, as if "everything is muted." She is jumpy and startles at minor sounds. She has difficulty falling asleep and concentrating. She has not left her apartment in a week and has been calling in sick to work. She is worried she will lose her job but cannot imagine returning to the bank. ### Mental Status Examination **Appearance:** Young woman, appears frightened, tearful, tremulous **Behavior:** Hypervigilant, startles when phone rings in office, requests door remain open **Speech:** Soft, trembling voice **Mood:** "Terrified" and "numb" **Affect:** Anxious, fearful, blunted, tearful **Thought Process:** Linear but occasionally loses track due to intrusive thoughts **Thought Content:** - Intrusive images of robbery - Fear of returning to work - No suicidal or homicidal ideation - No delusions **Perceptions:** Flashbacks (dissociative), no hallucinations **Cognition:** Alert, oriented, concentration impaired **Insight:** Good **Judgment:** Fair - seeking help ### Psychiatric Workup **Screening Tools:** - Acute Stress Disorder Scale (ASDS): 74 (clinical range >56) - PCL-5: 54 (high, though PTSD diagnosis requires >1 month duration) - PHQ-9: 12 (moderate) **Timeline:** - Trauma occurred 2 weeks ago - Symptoms began within days of event - Duration: 2 weeks (within 3 days to 1 month window for ASD) ### Diagnosis **Acute Stress Disorder (F43.0)** **DSM-5 Criteria:** - Exposure to actual/threatened death (gunpoint) - present - 9+ symptoms from five categories present after trauma: **Intrusion symptoms:** - Intrusive memories - present - Distressing dreams - present - Flashbacks - present - Distress at reminders - present **Negative mood:** - Inability to experience positive emotions - present **Dissociative symptoms:** - Altered sense of reality (derealization) - present - Inability to remember aspect of trauma - not reported **Avoidance symptoms:** - Avoidance of memories/thoughts - present - Avoidance of external reminders - present **Arousal symptoms:** - Sleep disturbance - present - Hypervigilance - present - Exaggerated startle - present - Concentration problems - present - Duration 3 days to 1 month: Present (2 weeks) - Causes significant distress/impairment: Present (cannot work) ### Treatment Plan **Immediate Support:** - Normalize acute stress reactions (common response to trauma) - Psychoeducation about expected symptom course - Provide information about ASD and potential for PTSD **Pharmacotherapy:** - Consider short-term sleep aid: trazodone 50-100 mg QHS - Avoid benzodiazepines (may increase PTSD risk) - SSRI not typically started immediately but consider if symptoms persist **Trauma-Focused CBT (First-line for ASD):** - Brief intervention (4-5 sessions) shown to prevent PTSD development - Components: - Psychoeducation about trauma responses - Anxiety management/relaxation training - Imaginal exposure to trauma memory - In-vivo exposure to avoided situations - Cognitive restructuring **Practical Support:** - Letter for employer requesting medical leave - Discuss workplace accommodations when ready to return - Different position (not teller window) - Gradual return schedule - Victim services/crime victim compensation information **Safety Planning:** - No current suicidal ideation - Provide crisis resources (988) - Social support activation (family, friends) **Prognosis:** - With early intervention, many ASD patients do not develop PTSD - Early trauma-focused CBT reduces PTSD development by ~50% - Without treatment, ~50% of ASD patients develop PTSD **Follow-up:** - Twice weekly trauma-focused CBT for 2-3 weeks - Re-evaluate at 1 month; if symptoms persist, diagnose PTSD and adjust treatment --- ## Case 3: Adjustment Disorder with Mixed Anxiety and Depressed Mood ### Patient Demographics - **Age:** 45 years old - **Sex:** Male - **Occupation:** Sales manager ### Chief Complaint "Since I got laid off 2 months ago, I can't sleep, I can't think straight, and I'm snapping at my family." ### History of Present Illness The patient presents with depressed mood, anxiety, and irritability that began approximately 8 weeks ago following unexpected job loss. After 18 years with the same company, he was informed his position was eliminated due to restructuring. He describes feeling "blindsided" and "lost." He reports persistent low mood with tearfulness, particularly when thinking about his career. He worries constantly about finances, finding a new job, and what others think of him. He has applied to dozens of positions but feels hopeless about his prospects, stating "I'm too old, no one will hire me." He has difficulty falling asleep and wakes frequently, ruminating about his situation. His appetite is decreased, and he has lost 8 pounds. He has become irritable with his wife and teenage children, leading to frequent arguments. He has withdrawn from friends, not wanting to discuss his unemployment. He has stopped exercising, a previously regular habit, and spends most days at home browsing job listings or watching TV. He denies suicidal ideation but admits to feeling like "less of a man" and questions his worth to his family. Notably, his symptoms are focused specifically on his job loss; he is able to enjoy time with his children when not thinking about work. ### Mental Status Examination **Appearance:** Middle-aged man, appropriate dress but appearing tired, slumped posture **Behavior:** Cooperative, occasionally tearful when discussing job loss **Speech:** Normal rate and volume, sighing frequently **Mood:** "Down" and "worried" **Affect:** Dysphoric, anxious, tearful at times, reactive to content **Thought Process:** Linear, goal-directed, somewhat ruminative about job loss **Thought Content:** - Preoccupied with unemployment - Worry about finances and future - Feelings of worthlessness related to job loss - No suicidal ideation - No homicidal ideation **Perceptions:** No hallucinations **Cognition:** Alert, oriented x4, concentration mildly impaired **Insight:** Good - recognizes symptoms are related to job loss **Judgment:** Fair - seeking help ### Psychiatric Workup **Screening Tools:** - PHQ-9: 14 (moderate depression) - GAD-7: 13 (moderate anxiety) - Work and Social Adjustment Scale (WSAS): 22 (moderate impairment) **Diagnostic Considerations:** - Major Depressive Disorder: Does not meet full criteria (still experiences some pleasure, duration 8 weeks but closely tied to stressor) - Generalized Anxiety Disorder: Worry is focused on specific stressor, not generalized ### Diagnosis **Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23)** **DSM-5 Criteria:** - Emotional or behavioral symptoms in response to identifiable stressor - present (job loss) - Symptoms develop within 3 months of stressor onset - present - Symptoms are clinically significant: - Distress out of proportion to severity/intensity of stressor - present - Significant impairment in functioning - present (family relationships, daily activities) - Symptoms do not meet criteria for another mental disorder - present - Symptoms do not represent normal bereavement - Once stressor is resolved, symptoms would not persist >6 months (theoretical) **Specifier:** With mixed anxiety and depressed mood (symptoms of both) ### Treatment Plan **Psychotherapy (First-line):** - Supportive psychotherapy - Normalize emotional response to significant loss - Process feelings about job loss (grief for lost career identity) - Enhance coping skills - Problem-solving therapy - Structured approach to job search challenges - Practical coping strategies - Cognitive Behavioral Therapy (brief) - Address cognitive distortions ("I'm too old," "I'm worthless") - Behavioral activation (resume exercise, social activities) **Pharmacotherapy:** - Not first-line for adjustment disorder - Consider if symptoms persist or worsen: - Start SSRI (sertraline 50 mg) if progresses toward MDD - Short-term sleep aid if insomnia is impairing function: - Trazodone 50 mg QHS or melatonin 3-5 mg **Practical Interventions:** - Career counseling referral - Review finances with financial counselor if needed - Maintain structure: daily schedule, regular activities - Continue/resume exercise (proven benefit for mood and anxiety) **Family Support:** - Brief family meeting to discuss impact on family - Strategies for communication during stressful period **Lifestyle Recommendations:** - Regular sleep schedule - Daily physical activity - Limit alcohol (can worsen mood/sleep) - Stay socially connected (avoid isolation) - Set realistic job search goals (quality over quantity of applications) **Prognosis:** - Adjustment disorder typically resolves within 6 months of stressor resolution or adaptation - If patient finds employment, symptoms likely to improve significantly - Monitor for progression to MDD if symptoms persist or worsen **Follow-up:** - Every 2-4 weeks - PHQ-9 and GAD-7 monitoring - Re-evaluate diagnosis if symptoms meet MDD/GAD criteria or persist >6 months