CC (chief complaint): “I don’t want to go anywhere. I just stay in my room all day afraid to sleep. It is bad”.
HPI: P.F. is a 27-year-old male combat veteran who served in the Marines and separated from active duty less than a year ago and has come to seek psychiatry help at the insistence of his fiancé. The patient reports that things and events that may appear mundane and ordinary to other people invoke strong memories of his wartime experience and cause strong reactions that are alarming to him and those around him. The patient recalls that certain sights, smells, and sounds make him feel he is “right back in the middle of enemy fire.”
Past Psychiatric History:
Substance Current Use and History: The patient has no history of substance abuse.
Family Psychiatric/Substance Use History: Father has a history of Alcohol abuse, and the paternal Grandfather, a combat veteran, has a history of depression.
The patient is currently a furniture salesman but left active service less than a year ago, after long tours of duty in war zones. He is engaged to be married (no date set) and is currently working as a furniture salesman. The patient denies drug and alcohol use, has a fiancé with whom he lives, and his parents and two siblings live in a different state.
NRNP 6635 Assignment Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD
Physical exam: N/A
Diagnostic results: N/A
Mental Status Examination: Patient is alert and oriented to person, place, time, and situation, speech is clear and coherent, and appropriate response to questions. The patient shows signs of anxiety and appears desperate for answers to his extreme reactions to the triggers of wartime experiences. No suicidal ideations, but the patient finds it difficult to sleep and has nightmares when he manages to sleep.
Post Traumatic Stress Disorder(PTSD)
This patient is a combat veteran, so it is easy to conclude PTSD as a diagnosis, but specific criteria must be met before this diagnosis can be made. This patient has experienced traumatic events that happened to him and others during his career as a combat veteran, and specific triggers make him react and relive these memories.
As explained by Carlat D. (2016), all the classic signs and symptoms experienced by PTSD patients, including flashbacks, nightmares, hyperarousal, and intense distress when exposed to events symbolic of the original event, are evident in this patient.
Generalized Anxiety Disorder
According to DSM-5, a PTSD diagnosis requires that trauma exposure precede the onset or exacerbation of pertinent symptoms. During the interview, this patient displays signs of intense anxiety and is very worried about the intense emotions he is experiencing from these triggers.
According to Sadock, B. et al. (2015), Generalized anxiety disorder (GAD)is excessive anxiety and worry about several events or activities most days for at least six months. This diagnosis would not be the first choice as this patient reacts to specific stressors that remind him only of events he witnessed or experienced as a combat veteran.
Major Depressive disorder
This patient’s paternal Grandfather, a combat veteran, also suffered from depression. So a thorough evaluation must be made to exclude depression or consider it co-existing comorbidity with PTSD.
Major depressive disorder (MDD) is a debilitating disease characterized by depressed mood, diminished interests, impaired cognitive function, and vegetative symptoms, such as disturbed sleep or appetite. (Otte, C. et al., 2016). From the clinical interview, it appears this patient lives a relatively normal life and is looking forward to a life with his fiancé. He is affected solely by the traumatic events he experienced as a combat veteran.
Sayer N. et al., 2021 recommend Rama-focused psychotherapies as the most effective treatment across PTSD Clinical Practice Guidelines. Reliving these traumatic experiences in a clinical, non-judgemental atmosphere is the right step toward treatment. This patient should also be encouraged to engage in leisure activities that he enjoys where there would be minimal stressors to disrupt him. A patient may also benefit from joining a group where fellow veterans who have PTSD like him can be a support system
The patient has already taken the first step, as suggested by his fiancé, to see a psychiatrist and seems willing to do anything to relieve his reactions. As the therapist rightly said, “talking helps your brain to heal.” If insomnia persists and the quality of his sleep continues to be affected due to nightmares, a pharmacological intervention may become necessary and should be considered.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM5.
Carlat, D. (2016). The Psychiatric Interview. Lippincott Williams & Wilkins.
Otte, C., Gold, S., Penninx, B. et al. Major depressive disorder. Nat Rev Dis Primers 2, 16065 (2016). https://doi.org/10.1038/nrdp.2016.65
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.
Sayer, N. A., Bernardy, N. C., Yoder, M., Hamblen, J. L., Rosen, C. S., Ackland, P. E., … & Noorbaloochi, S. (2021). Evaluation of an implementation intervention to increase the reach of evidence-based psychotherapies for PTSD in US Veterans Health Administration PTSD clinics. Administration and Policy in Mental Health and Mental Health Services Research, 48(3), 450-463.
Also Check: NUR 699 GC Week 1 Discussion 1
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