A 33-year-old woman comes to the office due to poor sleep for the past 2 months. The patient says, "Most nights, I wake up around 2 AM in a state of panic-my heart is racing and it's hard to fall back asleep. I can barely stay awake at work, and it takes me twice as long to finish assignments because I need to reread everything." The patient lives alone and works as a computer programmer. She filed for divorce 3 months ago due to her husband's substance use and violent behavior toward her. The patient drinks a glass of wine at bedtime to help her fall asleep and does not use illicit drugs. Vital signs are within normal limits. Physical examination and laboratory evaluation are unremarkable. On mental status examination, she appears tired and her mood is depressed and anxious. The patient jumps when a nearby door slams closed. At one point, she appears to stare into space and does not respond to her name for a few moments. Which of the following is the most likely diagnosis in this patient?

Question

A 33-year-old woman comes to the office due to poor sleep for the past 2 months.  The patient says, "Most nights, I wake up around 2 AM in a state of panic-my heart is racing and it's hard to fall back asleep.  I can barely stay awake at work, and it takes me twice as long to finish assignments because I need to reread everything."  The patient lives alone and works as a computer programmer.  She filed for divorce 3 months ago due to her husband's substance use and violent behavior toward her.  The patient drinks a glass of wine at bedtime to help her fall asleep and does not use illicit drugs.  Vital signs are within normal limits.  Physical examination and laboratory evaluation are unremarkable.  On mental status examination, she appears tired and her mood is depressed and anxious.  The patient jumps when a nearby door slams closed.  At one point, she appears to stare into space and does not respond to her name for a few moments.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d7eb_e2c8_bc81_f7e5e2272ab4_MD0003_00 This patient with a history of exposure to intimate partner violence has several features suggestive of posttraumatic stress disorder (PTSD), including sleep disturbance (poor sleep, panicked awakening), dissociation (eg, momentarily staring and unresponsive), negative mood, and hypervigilance/increased startle response (eg, when nearby door slams). Other characteristic features of PTSD include flashbacks, intrusive memories, and avoidance of reminders of the traumatic event. Patients with PTSD commonly experience depressed mood, irritability, and anxiety and frequently have classic mood symptoms such as insomnia, fatigue, and impaired concentration. Patients may be reluctant to disclose trauma, so physicians must remain alert to signs and symptoms of PTSD and provide further assessment and treatment. Trauma-focused cognitive-behavioral therapy and antidepressants are first-line treatments. (Choice A) Adjustment disorder develops within 3 months of an identifiable stressor and causes significant distress. However, it is not diagnosed when the stressor is of a traumatic nature (rather than a common occurrence) and when the patient has a constellation of symptoms (eg, dissociation, hypervigilance) suggestive of a more specific disorder (eg, PTSD). (Choice B) Depersonalization/derealization (ie, feeling detached from one's body, experiencing surroundings as unreal) is considered part of PTSD and is not diagnosed as a separate disorder when PTSD is present. The specifier, "with dissociative symptoms," can be added to the PTSD diagnosis when such symptoms are persistent. (Choice C) Although generalized anxiety disorder (GAD) is also characterized by anxiety, sleep disturbance, and impaired concentration, these patients worry about a multitude of everyday events. In addition, a duration of 6 months is required for diagnosis of GAD. (Choice D) Major depressive disorder would not explain this patient's panicked awakening, heightened startle response, or dissociation. Negative mood states, decreased interest in activities, and emotional detachment are common features of PTSD. (Choice E) Patients with panic disorder experience unprovoked panic attacks at any time during the day or night. This patient's nighttime panic symptoms are more likely due to nightmares related to PTSD. Educational objective: Patients with posttraumatic stress disorder (PTSD) commonly have symptoms of sleep disturbance, impaired concentration, and negative mood. A history of trauma, dissociative symptoms, and increased startle response are clues for PTSD. References: Post-traumatic stress disorder: theory and treatment update. (http://www.ncbi.nlm.nih.gov/pubmed/25084856) The dissociative subtype of post-traumatic stress disorder: research update on clinical and neurobiological features. (http://www.ncbi.nlm.nih.gov/pubmed/29063485) New developments in intimate partner violence and management of its mental health sequelae. (http://www.ncbi.nlm.nih.gov/pubmed/26711508)

A 33-Year-Old Woman Comes to the Office Due to Poor