PANCE® Question of the Day: Post-traumatic stress disorder (PTSD)

This week, we are sharing another PANCE® style practice question to test your knowledge of medical topics. Today's case focuses on a 30-year-old man with a history of depression presents to his primary care PA with symptoms of negative mood, emotional detachment, and irritability following the death of his partner officer. What's the most likely diagnosis? Can you figure it out?

A 30-year-old man comes to his primary care PA to discuss his “negative mood” for two months. The patient’s sibling tells the PA he is not attending activities he previously enjoyed, like playing golf or hanging out with his friends. They state, “He seems emotionally detached from everyone.” They add that he has been increasingly irritable with spontaneous outbursts of anger several times over the past two months. The patient is a police officer and confides that his symptoms appeared after he witnessed the death of his partner officer three months ago. The patient states, “Every night, I keep seeing my partner getting shot, and I can’t sleep.” He has a past medical history of depression in his youth, treated with sertraline. Which of the following is the most likely diagnosis?

A. Acute stress disorder

B. Adjustment disorder

C. Post-traumatic stress disorder

D. Major depressive disorder

E. Normal stress response


Scroll down to find the answer!                       

The correct answer to today's PANCE® Question is...

C. Post-traumatic stress disorder

Before we get to the Main Explanation, let's look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!

Incorrect answer explanations

The incorrect answers to today's PANCE® Question are...

A. Acute stress disorder

Incorrect: Acute stress disorder is very similar to post-traumatic stress disorder (PTSD); however, symptoms that persist for more than one month meet the criteria for a diagnosis of PTSD.

B. Adjustment disorder

Incorrect: Adjustment disorder is not diagnosed if the patient meets the criteria for another diagnosis, such as PTSD in this patient.

D. Major depressive disorder

Incorrect: Although this patient has symptoms of major depressive disorder (e.g., negative mood, anhedonia, sleep disturbance, irritability), his symptoms are related to an exposure to a threatening event–making the diagnosis of PTSD more appropriate.

E. Normal stress response 

Incorrect: This patient is experiencing symptoms related to a traumatic event. PTSD is associated with increased mortality due to suicide and should not be treated as a normal psychologic response. 

Main Explanation

This patient was exposed to a traumatic event, and since that time, he has had flashbacks, nightmares, irritability, negative mood, and difficulty sleeping for more than one month. This presentation is consistent with a diagnosis of post-traumatic stress disorder (PTSD).

PTSD results from exposure to a traumatic life event, such as sexual assault, a near-death experience, the violent death of a relative or friend, or war conflicts. PTSD is associated with significant impairment of functionality and distress and poses an increased risk of suicidal ideation and attempt. Trauma-focused psychotherapy is the first-line management of patients with PTSD and is efficacious in improving this condition. Selective serotonin reuptake inhibitors are the first-line medical treatment of PTSD. Additional therapeutic options include prazosin for nightmares and trazodone for underlying insomnia. 

The DSM-V criteria for the diagnosis of PTSD include: 

1. Exposure to a severe traumatic event 

2. Presence of one or more of the following intrusive symptoms: nightmares related to the event; flashbacks in which patients may re-experience the traumatic event; recurrent involuntary intrusive thoughts of the event; intense and prolonged psychological distress upon exposure to a reminder of the event; intense physical reactions upon exposure to a reminder of the event (e.g. increased heart rate).

3. Avoidance: Persistent avoidance of the traumatic stimuli must be present and may take the form of either of the following: avoidance or efforts to avoid thoughts about the traumatic event, or avoidance or efforts to avoid any external reminders of the event (e.g., people, places, conversations).

4. Adverse alteration in mood and cognition is evident by the presence of two or more of the following: inability to remember important aspects of the traumatic event; persistent and exaggerated negative beliefs; persistent negative emotions (e.g., fear, anger, sadness); marked decrease in interest in activities that used to be enjoyable; feeling detached from others; inability to experience positive emotions (e.g., happiness, love).

5. Alteration in arousal and reactivity, which is evident by two or more of the following: sleep disturbances, inability to concentrate, exaggerated startle response, irritability, hypervigilance, reckless behavior. 

6. Symptoms last more than one month after the traumatic event. 

PS: If you or someone you know needs this, here's the number for the National Suicide Prevention Lifeline 1-800-273-8255 or text HOME to the Crisis Text Line at 741741. 

Major Takeaway

Post-traumatic stress disorder (PTSD) is a disorder that develops after exposure to a traumatic event. It is characterized by a negative mood, re-experiencing the traumatic event (e.g. flashbacks), avoidance of the traumatic stimuli, hypervigilance, and irritability. Symptoms must be present for greater than one month following the event before a formal diagnosis can be made. 

References

Mann SK, Marwaha R. Posttraumatic Stress Disorder. [Updated 2020 Nov 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559129/ 

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