A 22-year-old graduate student comes to the clinic at his mother's urging due to being very tearful, sad, and irritable. Three weeks earlier, he was in a motor vehicle collision in which the other driver lost control of the vehicle and collided with the patient's car, killing his father and sister. The patient was unable to extricate either family member from the vehicle, and they both died before emergency personnel arrived. He remains unable to recall most of the event. Since then, he has felt guilty about his failure to save them and has experienced recurrent nightmares about the collision. The patient says, "I feel like I'm in a daze and everything seems unreal. Last week, while leaving a gas station, I was panicked that my car was spinning out of control and heard screams and sirens although no one was around. Since then, I have stopped driving." The patient insists that his mother avoid the highway where the collision took place. He has been unable to concentrate on his studies and has stopped attending class. His medical history is significant for patellofemoral syndrome and acne vulgaris; family history is significant for depression in a paternal uncle. The patient takes no medications and has no allergies. He does not use alcohol, tobacco, or illicit drugs. Physical examination is unremarkable. Which of the following is the most likely diagnosis?

Question

A 22-year-old graduate student comes to the clinic at his mother's urging due to being very tearful, sad, and  irritable.  Three weeks earlier, he was in a motor vehicle collision in which the other driver lost control of the vehicle and collided with the patient's car, killing his father and sister.  The patient was unable to extricate either family member from the vehicle, and they both died before emergency personnel arrived.  He remains unable to recall most of the event.  Since then, he has felt guilty about his failure to save them and has experienced recurrent nightmares about the collision.  The patient says, "I feel like I'm in a daze and everything seems unreal.  Last week, while leaving a gas station, I was panicked that my car was spinning out of control and heard screams and sirens although no one was around.  Since then, I have stopped driving."  The patient insists that his mother avoid the highway where the collision took place.  He has been unable to concentrate on his studies and has stopped attending class.  His medical history is significant for patellofemoral syndrome and acne vulgaris; family history is significant for depression in a paternal uncle.  The patient takes no medications and has no allergies.  He does not use alcohol, tobacco, or illicit drugs.  Physical examination is unremarkable.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1ae_2ac2_8f63_cb36ff79b0c5_MD0005_00 This patient's recent history of life-threatening trauma, followed by the development of amnesia, nightmares, flashbacks, avoidance of reminders, negative emotions (sadness, guilt), and arousal in response to the triggering event, is consistent with acute stress disorder (ASD). Symptoms must last for >3 days and <1 month following exposure to the traumatic event. Patients typically have some form of intrusive re-experience (eg, distressing memories, nightmares, flashbacks) and are preoccupied with negative thoughts about their role in the traumatic event. Early recognition and intervention are important as patients with ASD are at higher risk for subsequent post-traumatic stress disorder (PTSD). Symptoms may remit within a month or progress after this time. If the symptoms persist for >1 month and meet criteria for PTSD, the diagnosis is changed from ASD to PTSD (Choice E). (Choice B) In adjustment disorder, the stressor can be of any severity and results in symptoms of anxiety and depression that do not meet criteria for another psychiatric disorder. Intrusive recollections and avoidance behavior characteristic of ASD are not present. (Choices C and D) Patients with ASD commonly experience dissociative symptoms, including amnesia for the event, derealization (subjective sense of unreality), and depersonalization (feeling of detachment from one's self). However, dissociative amnesia and derealization/depersonalization disorder are not diagnosed as separate disorders when full ASD criteria are met, as in this patient. Educational objective: Acute stress disorder lasts from 3 days to a month and involves symptoms of intrusion (eg, flashbacks, nightmares), negative mood, dissociation (eg, amnesia, derealization), avoidance of reminders, and arousal in response to a life-threatening, traumatic event. Post-traumatic stress disorder should be considered when symptoms persist for more than a month. References: The physician's role in managing acute stress disorder. (http://www.ncbi.nlm.nih.gov/pubmed/23062092)

A 22-Year-Old Graduate Student Comes to the Clinic at His