Case Analysis Evaluation In PTSD.

Posted: December 3rd, 2022

Case Analysis Evaluation In PTSD.


Chief complaint: “My wife wants me to get help” HPI: Andrew is a 59 Years old male who presents to outpatient mental health clinic with complaint of depressed mood most of the time with high level of irritability, anger outbursts and gets aggravated easily. He says he’s seeking help because his wife has threatened divorce if he does not seek treatment. He reports frequent episodes of intrusive thoughts about past combat experience in Vietnam. The symptoms increased when the war in Iraq started. He tries to avoid watching the news and other things that remind him of his military service in Vietnam when possible. He denies panic attacks and vegetative symptoms of depression, denies hallucinations, and paranoia. He reports frequent feelings of being closed in and need to get fresh air from outdoors to obtain relief. He reports lack of trust in others and does keep distance from others. He reports that he feels uncomfortable and guarded in crowds. Case Analysis Evaluation In PTSD.


says does not sleep well due to frequent nightmares. A recurring dream theme of being captured as a soldier and executed. Denies sudden weight loss, excessive sweats, hair loss, and chronic fatigue. Psychiatric History: Andrew first sought psychiatric treatment 8 years ago. He was prescribed sertraline which helped some but unable to tolerate dose higher than 100mg dose. He took the medication for about two years and stopped because he felt it was not helping any more. He was referred to therapy but did not show up to appointment. Past Medical History: GERD, HTN Surgical History: None Family Medical History: Mother- Anxiety, HTN; died at age 70. Father- Alcoholism; died at age 65-years. Brother- COPD, tobacco smoker. Sister has anxiety Social History: Lives with wife of 30 years and two dogs. Has two adult daughter who live out of state. He was raised as a Baptist faith, but does not attend church regularly. He feels like God hates him and says he’s angry at God. Case Analysis Evaluation In PTSD. alcohol 2-3 beer on weekends. Denies illicit drug use. Denies history of tobacco use. Denies legal history. Educational/Occupational History: He graduated high school at age 17 and went to live with older brother. He worked in construction for about a year and then later drafted into Military. He was in the Military for five years. His longest employment was nine years of construction work. He has held about 15 jobs in his life time. He considers himself a carpenter. He is currently unemployed and supported financially by wife who works as a school teacher. Developmental/Family History- Andrew is the second of three children. He was born and raised on a farm and his parents had little money. He described childhood as happy and fun. He denies developmental problems. He had good relationship with siblings and they all worked on the family farm together after school. He described his parents as hardworking. Although father struggled with alcoholism, he was still able to work and provide for the family. Review of Systems: 10-system ROS negative except symptoms noted in HPI. Medications: Sertraline (SSRI) Allergies: NKDA Vital Signs: BP 110/60 HR 65bpm, T 98.9F, RR 18/min Weight 160lbs without significant recent changes. CAE 1 Instructions Review the above case study and complete the CAE Sections below. Students should be able to apply knowledge of evidence-based psychotherapies and psychotherapeutic treatment for the management of the psychiatric mental health disorders. The use of at least five references is required in APA format, which may include the course textbook. Case Analysis Evaluation A. Health History/History of Present Illness. Identify history questions to be obtained to discriminate critical characteristics of the presenting chief complaint (symptom). B. Differential Diagnosis: Delineate 4 differential diagnosis that could support the chief complaint and HPI. Include DSM-5 diagnostic code for each of the differential diagnosis. Select Post-traumatic stress disorder (PTSD), Generalized Anxiety disorder plus 2 more differential diagnosis C. Mental Status Examination: Delineate mental status exam findings that would be associated with each listed differential diagnosis. D. Etiology: Delineate the etiology of each of the 4 differential diagnosis. Include psychosocial factors and past experiences that may be contributing to current symptoms. E. Diagnostic Screening Tools: Delineate what diagnostic screening tools would be appropriate for each of the 4 differential diagnosis. F. Analysis: Delineate your final assessment along with rationale. (Focus on PTSD) G. Treatment Plan: (Focus on PTSD) Delineate appropriate treatment plan which should include Pharmacological, psychological therapeutic modalities and the focus, social interventions (support or self- help groups, mobilization of family resources, vocational rehabilitation, financial planning) and identification of strengths

Case Analysis Evaluation (CAE) in a 59 Year-Old Male Patient with Post-Traumatic Stress Disorder (PTSD)

  1. Health History/ History of Present Illness

The history questions that would help discriminate critical characteristics of the presenting complaint for Andrew include the following:

  1. Do you sometimes get flashbacks to your days in the military and see as if the events at that time are recurring again?
  2. Do you at times get nightmares related to your time serving in the military in Vietnam?
  • Do the memories of you time in the military fighting in Vietnam intrude into your thinking and distress you considerably?
  1. Do you get psychologically distressed when you see events that are similar to what you underwent in Vietnam, such as when you watch war stories on television?
  2. Does your body sometimes react by you getting physically sick when you are reminded of the past events of the war you fought in Vietnam?
  3. Differential Diagnosis

The differential diagnosis profile for Andrew would be as follows, according to the diagnostic criteria of the fifth edition (latest) of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5. The diagnostic codes for each one of them are included (APA, 2013):

  1. Post-traumatic stress disorder or PTSD – 309.81 (F43.10)
  2. Generalized anxiety disorder – 300.02 (F41.1)
  3. Paranoid personality disorder – 301.0 (F60.0)
  4. Adjustment disorder with depressed mood – 309.0 (F43.21)

In all these differential diagnoses, depressive mood is a common criterion that cuts across almost all of them. In the case of Andrew, this together with irritability was the most prominent characteristic in his history of present illness.

  1. Mental Status Examination (MSE)

The mental status examination findings that would be in line with each of the above differential diagnoses would be as presented below:

  1. Post-traumatic stress disorder or PTSD – 309.81 (F43.10)

The mental status examination in the case of PTSD would most likely show that Andrew is hypervigilant and has an increased startle response. He would also be unable to properly interact with the clinician examining him. Furthermore, he would demonstrate significant emotional distress when questions are asked of is traumatic experiences in Vietnam. All these are behavioral considerations that the MSE would have assessed. His mood would be anxious while his affect would be dysphoric (Sadock et al., 2015; Stahl, 2013). Andrew would also show forgetfulness for the traumatic events he witnessed in Vietnam, as well as have difficulties concentrating during the examination. He would have thoughts that are distorted as well as less positive emotions (Sadock et al., 2015; Stahl, 2013).

  1. Generalized anxiety disorder – 300.02 (F41.1)

The MSE in generalized anxiety disorder would generally reveal a patient whose facial appearance is strained, and whose posture is tense. His thought process would be preoccupied with fear of a repeat of the traumatic event. His insight would be intact, his perception devoid of hallucinations and illusions, but he would experience depersonalization and derealisation as he detaches himself from his own self (body). His cognition would be unaffected (Sadock et al., 2015; Stahl, 2013).

  1. Paranoid personality disorder – 301.0 (F60.0)

The MSE findings on this differential diagnosis would indicate a disorganized thought process and content that is full of paranoia. He would also show agitation and aggression (Sadock et al., 2015; Stahl, 2013).

  1. Adjustment disorder with depressed mood – 309.0 (F43.21)

Lastly, for this differential diagnosis the MSE would reveal dysphoria, lack of concentration, and social impairment manifested by difficulty in establishing interpersonal relationships (Sadock et al., 2015; Stahl, 2013).

  1. Etiology

Post-traumatic stress disorder or PTSD

The etiology of PTSD is found in past occurrences that were sufficiently traumatic to the patient to continue frightening him long after the event. These could be natural disasters, war, major accidents, and so on. Loneliness and lack of social support are psychosocial factors that may also contribute to symptom manifestation (APA, 2013; Sadock et al., 2015; Stahl, 2013).

Generalized anxiety disorder (GAD)

The etiology of GAD is from genetic composition and the interaction between this and specific environmental factors. Developmental and personality problems also have a part to play in the etiology of GAD. Difficulties with interpersonal relationships may lead to divorce and loneliness (APA, 2013; Sadock et al., 2015; Stahl, 2013).

Paranoid personality disorder (PPD)

The etiology of PPD is not well known. However, genetic and psychological factors such as early childhood experiences (trauma of emotional or physical nature) are thought to play an important part. It leads to the psychosocial state of loneliness as the paranoia leads to social withdrawal (APA, 2013; Sadock et al., 2015; Stahl, 2013).

Adjustment disorder with depressed mood

Personality, genetic composition, and unpleasant life experiences are at the centre of the etiology of this psychiatric disorder. Marital problems as a psychosocial factor may result from its manifestation (APA, 2013; Sadock et al., 2015; Stahl, 2013).

  1. Diagnostic Screening Tools

The screening tools for PTSD are the primary care PTSD screen (PC-PTSD), the PTSD Brief Screen, the Short Screening Scale (SSS), and the PTSD Checklist (NAS, 2012). For generalized anxiety disorder it is the GAD 7-item scale (GAD-7); for paranoid personality disorder it is the Structured Assessment of Personality Abbreviated Scale (SAPAS); while for adjustment disorder with depressed mood the screening tool is the Schedules for Clinical Assessment in Neuropsychiatry or SCAN (Sadock et al., 2015; Stahl, 2013; Hesse & Moran, 2010).Case Analysis Evaluation In PTSD.

  1. Analysis

Andrew most likely has PTSD as he meets the diagnostic criteria for the condition in the DSM-5. Most significantly, he is a Vietnam war veteran who experienced traumatic war scenes and also personally suffered during the experience (APA, 2013). He currently has nightmares and flashbacks of these experiences, a fact that is making his marital life difficult. This is a psychosocial consequence expected in PTSD (APA, 2013; Sadock et al., 2015; Stahl, 2013). According to the DSM-5, he meets criterion A for having experienced threatened death and serious injury during the Vietnam war. He also meets criterion B (1) for having distressing memories of the war that are repeated. Criterion B (2), B (3), and B (4) also apply to him in that he is getting repeated nightmares and is also afraid of watching television because news about violence reminds him of his past war experiences. He is also having flashbacks of the events.

  1. Treatment Plan

Treatment of this patient will comprise of both psychopharmacologic and psychotherapeutic approaches. On the psychopharmacologic front, selective serotonin reuptake inhibitors (SSRIs) are the most preferred. Another class of drugs used apart from these is serotonin-norepinephrine reuptake inhibitors or SNRIs (Stahl, 2017; Katzung, 2018). These drugs are effective in managing the hypervigilance and anxiety of PTSD. SSRIs include sertraline or Zoloft (on which he had been put before but he failed to comply) and fluoxetine (Prozac). An example of SNRIs that Andrew can be given is desvenlafaxine or Pristiq (Stahl, 2017; Katzung, 2018).Case Analysis Evaluation In PTSD.

Psychotherapeutic treatments that Andrew could benefit from on the other hand include stress-inoculation training (SIT) and dialectical behavior therapy or DBT (Corey, 2013). Apart from these, Andrew may also require to join a support group of persons suffering from PTSD. In such a group, he will understand that he is not alone in suffering from this condition. They will be sharing personal experiences and their journeys through therapy this in itself will prove to be greatly therapeutic.Case Analysis Evaluation In PTSD.

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