A 21-year-old woman comes to the office at her mother's urging due to irritability and low mood. Two months ago, the patient was sexually assaulted in the parking lot of her workplace. Since then, she has felt that "the world is not a safe place" and is reluctant to go back to work, preferring to stay home. In the middle of the day she will "space out" and hear the voice of her assailant, "as if I am right there in the parking lot." At other times, she feels a sense of unreality as if she is outside her body and cannot recall the exact details about what happened, and says that, "I feel like I am going crazy." The patient has become withdrawn and either avoids her friends or becomes "snappy" when they visit her. She has lost interest in her hobbies of writing poetry and exercising. There is a family history of major depression in the patient's mother and schizoaffective disorder in her maternal grandmother. Which of the following is the most likely diagnosis?

Question

A 21-year-old woman comes to the office at her mother's urging due to irritability and low mood.  Two months ago, the patient was sexually assaulted in the parking lot of her workplace.  Since then, she has felt that "the world is not a safe place" and is reluctant to go back to work, preferring to stay home.  In the middle of the day she will "space out" and hear the voice of her assailant, "as if I am right there in the parking lot."  At other times, she feels a sense of unreality as if she is outside her body and cannot recall the exact details about what happened, and says that, "I feel like I am going crazy."  The patient has become withdrawn and either avoids her friends or becomes "snappy" when they visit her.  She has lost interest in her hobbies of writing poetry and exercising.  There is a family history of major depression in the patient's mother and schizoaffective disorder in her maternal grandmother.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_363c_103f_9249_b39bfa7b903a_MD0001_00 This patient's 2-month history of intrusive flashbacks, avoidance, dissociative symptoms (amnesia, depersonalization), and emotional detachment following a traumatic incident are suggestive of post-traumatic stress disorder (PTSD). Patients suffering from PTSD repeatedly relive a traumatic, life-threatening event in the form of nightmares and/or flashbacks (in which the patient feels as if the traumatic event is actually recurring). Individuals will often avoid people, places, and activities that remind them of the traumatic event and experience sleep disturbance, hypervigilance, low mood, and irritability. PTSD requires persistent symptoms for ≥1 month. (Choice A) Acute stress disorder involves symptoms similar to those observed in PTSD, which last 3 days to 1 month after trauma exposure. Symptoms may remit or progress to PTSD after this time. This patient has symptoms lasting 2 months and so meets the criteria for PTSD. (Choice B) In agoraphobia, the patient avoids situations where escape may not be possible or help is not available if panic or other embarrassing symptoms occur. If the avoidance is secondary to a traumatic event and the criteria for PTSD are met, PTSD is the accurate diagnosis. (Choice C) This patient's experience of hearing her assailant's voice is characteristic of an intrusive flashback that occurs in PTSD. Brief psychotic disorder is characterized by acute onset of psychotic symptoms (delusions, hallucinations) lasting ≥1 day and ≤1 month. (Choices D and E) Patients with PTSD often experience a range of dissociative symptoms, such as derealization (detachment from surroundings), depersonalization (detachment from self), or a lapse of autobiographical memory regarding the traumatic event (dissociative amnesia). If the dissociation is part of a cluster of symptoms that meets the criteria for PTSD, PTSD is the overarching and correct diagnosis. (Choice F) Individuals with PTSD commonly experience negative mood states, including decreased interest in activities and feelings of detachment from others. However, this patient does not meet the full criteria for major depression, and her social withdrawal and loss of interest are better explained by PTSD. Educational objective: Post-traumatic stress disorder is characterized by intrusive thoughts, nightmares, flashbacks, avoidance of trauma reminders, hypervigilance, and sleep disturbance lasting ≥1 month. __________ References: Post-traumatic stress disorder. (http://www.ncbi.nlm.nih.gov/pubmed/23022845) PTSD, emotion dysregulation, and dissociative symptoms in a highly traumatized sample. (http://www.ncbi.nlm.nih.gov/pubmed/25573648)

A 21-Year-Old Woman Comes to the Office at Her Mother's