A 42-year-old woman is evaluated for insomnia, anxiety, and irritability. She is accompanied by her husband to the appointment due to her fear of leaving home unaccompanied. The patient was raped in her neighborhood 3 months ago. Since then, she has become increasingly socially isolated and no longer goes out shopping or to the gym to exercise. The patient has difficulty falling and staying sleep and has frequent nightmares. She has difficulty concentrating when reading or staying focused during long conversations. During the day she feels anxious and exhausted, and she has had several unusual episodes of feeling a sense of unreality and as if she is detached from her physical body. Her husband comments, "She seems to be someplace else when I am talking to her." Her appetite is unchanged and she has continued her hobbies of painting and sewing at home. She has no suicidal thoughts.
Vital signs and physical examination are normal.
Which of the following is the most likely explanation for this patient's symptoms?

Question

A 42-year-old woman is evaluated for insomnia, anxiety, and irritability.  She is accompanied by her husband to the appointment due to her fear of leaving home unaccompanied.  The patient was raped in her neighborhood 3 months ago.  Since then, she has become increasingly socially isolated and no longer goes out shopping or to the gym to exercise.  The patient has difficulty falling and staying sleep and has frequent nightmares.  She has difficulty concentrating when reading or staying focused during long conversations.  During the day she feels anxious and exhausted, and she has had several unusual episodes of feeling a sense of unreality and as if she is detached from her physical body.  Her husband comments, "She seems to be someplace else when I am talking to her."  Her appetite is unchanged and she has continued her hobbies of painting and sewing at home.  She has no suicidal thoughts.
Vital signs and physical examination are normal.
Which of the following is the most likely explanation for this patient's symptoms?

Quizplus · Accepted Answer

11ec193a_98be_0438_853d_7f07427afdf2_MD0002_00 This patient's history of a traumatic experience followed by >1 month of insomnia, nightmares, and avoidance behavior are suggestive of post-traumatic stress disorder (PTSD). Flashbacks and dissociative symptoms such as amnesia and depersonalization/derealization (feelings of unreality or being detached from one's body) are also characteristic of the disorder. Most patients with PTSD have intense anxiety and hyperarousal when experiencing reminders of the trauma and compensate by avoidance (as in this patient's reluctance to leave her home). Irritability, decreased interest in activities, and feelings of emotional detachment from others commonly occur. Treatment consists of trauma-focused cognitive-behavioral therapy and serotonergic antidepressants. (Choice A) Patients experiencing post-traumatic stress and functional impairment for the first 30 days following a traumatic event are diagnosed as having acute stress disorder, which is treated primarily with cognitive-behavioral therapy. Patients who remain symptomatic after 30 days are diagnosed with PTSD and may benefit from the addition of an antidepressant. (Choice B) This patient's avoidance behavior is associated with trauma-specific cues and would be explained by PTSD. An independent diagnosis of agoraphobia is not required. (Choice C) Depersonalization and derealization are dissociative symptoms that can be seen as part of PTSD. Depersonalization/derealization disorder is not diagnosed as a separate disorder when PTSD criteria are met. (Choice D) This patient still enjoys doing activities at home and does not have sufficient depressive symptoms to diagnose major depressive disorder. Patients with PTSD are at increased risk for developing major depression. Educational objective: Post-traumatic stress disorder is characterized by at least 1 month of symptoms in response to a life-threatening event and includes intrusive thoughts, nightmares, or flashbacks about the trauma; avoidance of reminders of the event; hyperarousal; dissociative symptoms; and sleep disturbance. __________ References: Post-traumatic stress disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26611143) Posttraumatic stress disorder in the DSM-5: controversy, change, and conceptual considerations. (http://www.ncbi.nlm.nih.gov/pubmed/28208816)

A 42-Year-Old Woman Is Evaluated for Insomnia, Anxiety, and Irritability