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.These indi-viduals can be extremely compliant.They need to know the details of theircondition in scientific language.¤' Patients with OCD have prominent obsessions and compulsions that alter-nately create anxiety and reduce it (through the compulsive behavior).¤' Patients with obsessive-compulsive personality disorder have pervasivepatterns of behavior that include rigidity and perfectionism but not trueobsessions and compulsions.¤' Patients with obsessive-compulsive personality traits often resemblepatients with the personality disorder.The difference is one of degree andimpairment of function.Individuals who are significantly impaired canexhibit symptoms that meet the requirements for the personality disorder.¤' Defense mechanisms include rationalization, intellectualization, undoing,isolation of affect, and displacement.REFERENCESEbert M, Loosen P, Nurcombe B, eds.Current Diagnosis and Treatment in Psychiatry.New York, NY: McGraw-Hill; 2008:482-484.Sadock BJ, Sadock VA.Kaplan & Sadock's Synopsis of Psychiatry.10th ed.Baltimore,MD: Lippincott Williams & Wilkins; 2007:805-806. This page intentionally left blank Case 21A 34-year-old woman comes to a psychiatrist with a chief complaint ofa depressed mood.She states that she was raped 1 year previously by anunknown assailant in the parking lot of a grocery store, and since thattime, things just have not been the same. She describes becomingirritable and angry with her spouse for no apparent reason and feelsdisconnected from him emotionally.Her sleep is restless, and she is havingtrouble concentrating on her work as a laboratory technician.She hasnightmares about the rape in which the event is replayed.The patientstates that she has told very few people about the rape and tries not tothink about it as much as possible.She avoids going anywhere near thelocation where the event occurred.On mental status examination, her appearance, behavior, and speechare all unremarkable.Her mood is described as depressed, and her affectis congruent and restricted.Her thought process is linear and logical.She denies any psychotic symptoms or suicidal or homicidal ideation,although she says that she wishes her attacker would die a horribledeath. Her cognition is grossly intact.Her judgment and impulse controlare not impaired.¤' What is the most likely diagnosis?¤' Should this patient be hospitalized? 200 CASE FILES: PsychiatryANSWERS TO CASE 21:Posttraumatic Stress DisorderSummary: A 34-year-old woman suffered a traumatic event 1 year ago.Sincethat time, she has been depressed, irritable, angry, and disconnected emo-tionally.She has trouble sleeping and concentrating.She has nightmaresabout the rape, tries not to think about it, and avoids going near the placewhere it occurred.On mental status examination she shows a depressed moodthat is congruent with her affect, which is also restricted.She has violent fan-tasies toward her attacker but no overt homicidal or suicidal ideation.¤' Most likely diagnosis: Posttraumatic stress disorder (PTSD).¤' Should this patient be hospitalized: No.Although she has passive homicidalideation (which is fairly typical in this kind of circumstance), she has nospecific intent or plan to cause something terrible to happen and does notknow her attacker or his location.This patient is not committable.Admission to the hospital should not be offered on a voluntary basis either,as she would probably do well on an outpatient basis.ANALYSISObjectives1.Recognize PTSD in a patient.2.Be aware of the need to hospitalize such a patient (or not).ConsiderationsThis patient shows many of the characteristic signs and symptoms of PTSD.After a significant traumatic event, she finds herself responding emotionally(depression, anger, and irritability) and withdrawing from those she caresabout.She is reexperiencing the event through nightmares and recurrentintrusive thoughts about the event.She tries not to think about it (by pushingit out of her mind) and avoids the location where she was raped.She hastrouble sleeping and concentrating, which is interfering with her ability towork.The results of her mental status examination are consonant with thispicture as well. CLINICAL CASES 201APPROACH TOPosttraumatic Stress DisorderDEFINITIONPOSTTRAUMATIC STRESS DISORDER: A syndrome that develops after aperson witnesses, experiences, or is confronted with a traumatic event; theperson reacts with feelings of helplessness, fear, and horror.CLINICAL APPROACHThe identification of PTSD in a patient involves understanding the traumaticevent and the patient characteristics.The trauma itself can be a single eventor multiple events occurring over several weeks, months, or even years (suchas in cases of domestic violence).The context of the trauma is also important:The experience of an auto accident is quite different from that of torture orrape.If the trauma occurs when the individual is very young or very old, theeffects can be much more severe.For individuals exposed to a trauma, risk factorsfor developing PTSD include female gender, previous psychiatric illness,lower educational level, and lower socioeconomic status.Resilience in theface of trauma is increased by the presence of strong social support and a pre-vious successful mastery of traumatic events.DIFFERENTIAL DIAGNOSISPosttraumatic stress disorder is usually accompanied by a comorbid condition,such as major depression, another anxiety disorder, or substance dependence;this must be kept in mind when reviewing the differential diagnosis(Table 21 1).Patients can suffer injuries during traumatic events, and symptomsand sequelae of head injuries, particularly partial complex seizures can mimicsymptoms of PTSD.If the patient is not questioned about the occurrence ofa trauma or about intrusive memories, other symptoms of PTSD can resemblethose of generalized anxiety or panic disorder.The social withdrawal andnumbing exhibited by some individuals with PTSD can be confused withdepressive symptoms.Patients with borderline personality disorder can alsohave a history of trauma, especially trauma related to events occurring in earlychildhood, and they may exhibit posttraumatic symptoms such as intrusivememories and hyperarousal.Many patients with dissociative disorders alsohave a history of trauma and can experience posttraumatic symptoms.However, these patients describe and/or exhibit prominent dissociative 202 CASE FILES: PsychiatryTable 21 1 DIAGNOSTIC CRITERIA FOR POSTTRAUMATICSTRESS DISORDERThe individual has been exposed to a situation in which he or she witnessed, experienced,or was confronted with event(s) that involved actual or threatened death or seriousinjury or a similar threat to others.The individual persistently reexperiences the event in the form of distressing and repeatedmemories, which can be in the form of images, thoughts, perceptions, dreams, and/ornightmares or flashbacks.The individual can experience intense distress when exposedto cues or reminders of the original trauma, and these reactions can take the form ofstrong physiologic responses [ Pobierz caÅ‚ość w formacie PDF ]
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.These indi-viduals can be extremely compliant.They need to know the details of theircondition in scientific language.¤' Patients with OCD have prominent obsessions and compulsions that alter-nately create anxiety and reduce it (through the compulsive behavior).¤' Patients with obsessive-compulsive personality disorder have pervasivepatterns of behavior that include rigidity and perfectionism but not trueobsessions and compulsions.¤' Patients with obsessive-compulsive personality traits often resemblepatients with the personality disorder.The difference is one of degree andimpairment of function.Individuals who are significantly impaired canexhibit symptoms that meet the requirements for the personality disorder.¤' Defense mechanisms include rationalization, intellectualization, undoing,isolation of affect, and displacement.REFERENCESEbert M, Loosen P, Nurcombe B, eds.Current Diagnosis and Treatment in Psychiatry.New York, NY: McGraw-Hill; 2008:482-484.Sadock BJ, Sadock VA.Kaplan & Sadock's Synopsis of Psychiatry.10th ed.Baltimore,MD: Lippincott Williams & Wilkins; 2007:805-806. This page intentionally left blank Case 21A 34-year-old woman comes to a psychiatrist with a chief complaint ofa depressed mood.She states that she was raped 1 year previously by anunknown assailant in the parking lot of a grocery store, and since thattime, things just have not been the same. She describes becomingirritable and angry with her spouse for no apparent reason and feelsdisconnected from him emotionally.Her sleep is restless, and she is havingtrouble concentrating on her work as a laboratory technician.She hasnightmares about the rape in which the event is replayed.The patientstates that she has told very few people about the rape and tries not tothink about it as much as possible.She avoids going anywhere near thelocation where the event occurred.On mental status examination, her appearance, behavior, and speechare all unremarkable.Her mood is described as depressed, and her affectis congruent and restricted.Her thought process is linear and logical.She denies any psychotic symptoms or suicidal or homicidal ideation,although she says that she wishes her attacker would die a horribledeath. Her cognition is grossly intact.Her judgment and impulse controlare not impaired.¤' What is the most likely diagnosis?¤' Should this patient be hospitalized? 200 CASE FILES: PsychiatryANSWERS TO CASE 21:Posttraumatic Stress DisorderSummary: A 34-year-old woman suffered a traumatic event 1 year ago.Sincethat time, she has been depressed, irritable, angry, and disconnected emo-tionally.She has trouble sleeping and concentrating.She has nightmaresabout the rape, tries not to think about it, and avoids going near the placewhere it occurred.On mental status examination she shows a depressed moodthat is congruent with her affect, which is also restricted.She has violent fan-tasies toward her attacker but no overt homicidal or suicidal ideation.¤' Most likely diagnosis: Posttraumatic stress disorder (PTSD).¤' Should this patient be hospitalized: No.Although she has passive homicidalideation (which is fairly typical in this kind of circumstance), she has nospecific intent or plan to cause something terrible to happen and does notknow her attacker or his location.This patient is not committable.Admission to the hospital should not be offered on a voluntary basis either,as she would probably do well on an outpatient basis.ANALYSISObjectives1.Recognize PTSD in a patient.2.Be aware of the need to hospitalize such a patient (or not).ConsiderationsThis patient shows many of the characteristic signs and symptoms of PTSD.After a significant traumatic event, she finds herself responding emotionally(depression, anger, and irritability) and withdrawing from those she caresabout.She is reexperiencing the event through nightmares and recurrentintrusive thoughts about the event.She tries not to think about it (by pushingit out of her mind) and avoids the location where she was raped.She hastrouble sleeping and concentrating, which is interfering with her ability towork.The results of her mental status examination are consonant with thispicture as well. CLINICAL CASES 201APPROACH TOPosttraumatic Stress DisorderDEFINITIONPOSTTRAUMATIC STRESS DISORDER: A syndrome that develops after aperson witnesses, experiences, or is confronted with a traumatic event; theperson reacts with feelings of helplessness, fear, and horror.CLINICAL APPROACHThe identification of PTSD in a patient involves understanding the traumaticevent and the patient characteristics.The trauma itself can be a single eventor multiple events occurring over several weeks, months, or even years (suchas in cases of domestic violence).The context of the trauma is also important:The experience of an auto accident is quite different from that of torture orrape.If the trauma occurs when the individual is very young or very old, theeffects can be much more severe.For individuals exposed to a trauma, risk factorsfor developing PTSD include female gender, previous psychiatric illness,lower educational level, and lower socioeconomic status.Resilience in theface of trauma is increased by the presence of strong social support and a pre-vious successful mastery of traumatic events.DIFFERENTIAL DIAGNOSISPosttraumatic stress disorder is usually accompanied by a comorbid condition,such as major depression, another anxiety disorder, or substance dependence;this must be kept in mind when reviewing the differential diagnosis(Table 21 1).Patients can suffer injuries during traumatic events, and symptomsand sequelae of head injuries, particularly partial complex seizures can mimicsymptoms of PTSD.If the patient is not questioned about the occurrence ofa trauma or about intrusive memories, other symptoms of PTSD can resemblethose of generalized anxiety or panic disorder.The social withdrawal andnumbing exhibited by some individuals with PTSD can be confused withdepressive symptoms.Patients with borderline personality disorder can alsohave a history of trauma, especially trauma related to events occurring in earlychildhood, and they may exhibit posttraumatic symptoms such as intrusivememories and hyperarousal.Many patients with dissociative disorders alsohave a history of trauma and can experience posttraumatic symptoms.However, these patients describe and/or exhibit prominent dissociative 202 CASE FILES: PsychiatryTable 21 1 DIAGNOSTIC CRITERIA FOR POSTTRAUMATICSTRESS DISORDERThe individual has been exposed to a situation in which he or she witnessed, experienced,or was confronted with event(s) that involved actual or threatened death or seriousinjury or a similar threat to others.The individual persistently reexperiences the event in the form of distressing and repeatedmemories, which can be in the form of images, thoughts, perceptions, dreams, and/ornightmares or flashbacks.The individual can experience intense distress when exposedto cues or reminders of the original trauma, and these reactions can take the form ofstrong physiologic responses [ Pobierz caÅ‚ość w formacie PDF ]