A 28-year-old medical student comes to the office due to anxiety and trouble concentrating. He has worked part-time as a volunteer firefighter and reports that he has been struggling to concentrate in class ever since witnessing a child who had been badly burnt pulled out of a house fire 3 weeks ago. On two occasions the patient began to sweat, shake, and have trouble breathing: "I felt like my head was spinning and had to run out of the classroom to catch my breath." He also reports having trouble sleeping, being irritable with friends and family, and occasionally feeling like he is in a dream. The patient says, "Sometimes I'll be sitting in class, and I suddenly feel like I am back in the burning house. I can smell the fire and see the child." He has missed almost half of his classes to avoid being in crowded classrooms and has recently quit his volunteer job. Which of the following is the most likely diagnosis?

Question

A 28-year-old medical student comes to the office due to anxiety and trouble concentrating.  He has worked part-time as a volunteer firefighter and reports that he has been struggling to concentrate in class ever since witnessing a child who had been badly burnt pulled out of a house fire 3 weeks ago.  On two occasions the patient began to sweat, shake, and have trouble breathing: "I felt like my head was spinning and had to run out of the classroom to catch my breath."  He also reports having trouble sleeping, being irritable with friends and family, and occasionally feeling like he is in a dream.  The patient says, "Sometimes I'll be sitting in class, and I suddenly feel like I am back in the burning house.  I can smell the fire and see the child."  He has missed almost half of his classes to avoid being in crowded classrooms and has recently quit his volunteer job.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_363d_6fd1_9249_297ff3b7dead_MD0001_00 This patient's intrusive flashbacks, arousal (ie, panic-like symptoms, sleep disturbance, irritability), avoidance of returning to his volunteer work, and derealization (feeling detached from his surroundings) lasting for 3 weeks after experiencing a life-threatening event are suggestive of acute stress disorder (ASD). Nightmares of the event, depressed mood, difficulty concentrating, decreased interest in activities, and hypervigilance are also common. Reminders of the event, such as being in an enclosed or crowded space, can result in anxiety or panic and lead to avoidance. This often results in significant functional impairment. In ASD, symptoms usually develop directly following the trauma and last from 3 days to 1 month, after which they can resolve or develop into more chronic symptoms. When symptoms persist for more than 1 month, the diagnosis is changed to post-traumatic stress disorder (Choice F). (Choice B) The precipitating incidents in adjustment disorders are typically common stressors rather than life-threatening traumas. Adjustment disorders are also not diagnosed when symptoms meet the criteria for another, more specific disorder, such as ASD. (Choice C) In agoraphobia, patients avoid situations where escape may not be possible or help may not be available if panic or other embarrassing symptoms occur. This patient's avoidance is secondary to a traumatic event, and his symptoms better meet criteria for ASD. (Choice D) Dissociative symptoms such as depersonalization (detachment from self) or derealization (detachment from surroundings) commonly occur as part of the symptom cluster in ASD. Depersonalization/derealization disorder is not diagnosed separately if the patient meets criteria for ASD. (Choice E) Panic disorder is associated with recurrent panic attacks that occur without a clear precipitant. This patient's panic symptoms are related to his recent trauma. Educational objective: Acute stress disorder is characterized by intrusive experiences (flashbacks, nightmares), arousal (poor concentration, restless sleep), dissociative symptoms, and avoidance of traumatic reminders, as well as mood disturbances in response to a life-threatening trauma. Symptoms last between 3 days and 1 month. __________ References: Acute stress and subsequent health outcomes: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/30097129)

A 28-Year-Old Medical Student Comes to the Office Due to Anxiety