PTSD Grand Rounds Case Study: Diagnosis and Treatment

Patient Presentation and History

Chief Complaint: "I am just too distressed and anxious and can no longer function well at my workplace."

History of Present Illness: The patient is a 34-year-old father of one who presents with anxiety and severe distress. In this particular session, he was accompanied by his wife of seven years. His wife reports that he often keeps to himself and has been generally withdrawn over the last couple of months. She also notes that he no longer interacts with his closest friends on a regular basis as he once did. After much probing, the client gave an account of an event that occurred approximately one year ago — a topic first raised by the client's wife, as the client had initially refused to discuss it.

One year ago, the client was involved in an arson attack in which unknown persons set ablaze the family home while the family was sleeping inside. Although no person was physically injured, the family lost their dog, which was sleeping in a separate room, and all of their household possessions. The client reports that he was woken by loud screams from his wife, only to find the bedroom engulfed in flames and smoke. He managed to save his wife and two-year-old son by using a pre-installed window feature that converted the bedroom window into an emergency exit by unlocking the entire frame from the inside. The family was left badly shaken by the ordeal.

Over the past several months, the client has been experiencing nightmares themed around the event. For instance, he reports that just the night before this session, he had a nightmare about being captured by cannibals who roasted him alive. He consistently finds it difficult to fall asleep and often stays up all night thinking about, in his words, "nothing in particular." He reports that the sight of flames or smoke — even from a gas burner — makes him shiver and feel disillusioned. The client notes that he is on the verge of losing his job due to erratic performance. He was recently demoted to the position of junior manager and had his salary halved. He attributes his workplace difficulties to absentmindedness and an inability to focus on crucial tasks. When asked about leisure activities, the client reports that he used to be an avid skater but has not been to the rink in months.

Substance Use: No history of substance use.

Review of Systems and Objective Findings

It was necessary to ensure that the anxiety and depressive symptoms the client presented with were not the consequence of an infection or anemia. For this reason, a complete blood count was ordered. The blood test was also ordered to rule out other physical disorders that could be triggering the presenting symptoms — specifically thyroid disease. As Hage and Azar (2012) point out, thyroid disease has been known to negatively affect mood and can trigger depression and/or anxiety. Additionally, an MRI was ordered to rule out other physical causes of the presenting symptoms, including multiple sclerosis, which has been associated in past studies with "significant anxiety, distress, anger, and frustration from the moment of its very first symptoms" (Zoellner et al., 2011, p. 304). The results of all tests were within normal limits.

Mental Status Examination

The client appeared well groomed and was appropriately dressed for the occasion. He appeared his stated age. Although he did not seem agitated, he was largely restless throughout the session. His attitude could be described as guarded. When asked to describe his present mood, the client chose the word "anxious." When asked whether there was a reason for this anxiety, he responded with a firm "no." His affect could be described as blunted, and his speech pattern was sparse and slow. Although his train of thought was largely linear, his thought content was primarily focused on the loss of his dog and household possessions in the fire. There was no indication that the client posed any risk of aggression toward others. The client denied suicidal ideation or thoughts of self-harm. No perceptual disturbances were noted at the time of the examination, though they were reported to occur primarily at night. The client's judgment was largely adequate.

Diagnostic Impression and Differential Diagnoses

Based on the objective and subjective information obtained, three differential diagnoses were considered.

The primary diagnosis, based on the client's presenting symptoms, is post-traumatic stress disorder (PTSD). According to the DSM-5 criteria for PTSD, a person must have experienced or been exposed to an event that resulted in — or threatened — serious harm or death. The arson attack that destroyed the client's home qualifies as such a traumatic event, as the client and his family were inside the house at the time and faced a real risk of serious burns or death.

Second, the DSM-5 criteria require the presence of intrusion symptoms. The client displays two clear intrusion symptoms: nightmares themed around the events of that night, and marked distress upon exposure to flames and smoke — even from a gas burner — which serve as external cues reminiscent of the arson event.

Third, in line with the DSM-5 criteria, the client consistently avoided any discussion of the traumatic event. During the session, he largely refused to mention it until his wife raised the subject, and even then he appeared reluctant to engage further. This represents a deliberate effort to avoid memories associated with a distressing experience.

Fourth, the client demonstrates negative alterations in cognition and mood linked to the traumatic event, consistent with DSM-5 requirements. These include loss of interest in skating — an activity he previously participated in regularly — and emotional detachment from close friends.

Fifth, as per the DSM-5 criteria, the client must demonstrate "marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred" (Goldstein and DeVries, 2017, p. 105). The client reports difficulty falling asleep and chronic inability to concentrate on critical tasks at work — both consistent with this criterion.

The presenting symptoms have persisted for several months and have significantly impaired the client's occupational functioning; he is on the verge of losing his job. Finally, as the diagnostic tests confirm, the symptoms cannot be attributed to a medical condition or to substance use, of which the client has no history.

According to the DSM-5 criteria for MDD, five of nine specified symptoms must be present for a diagnosis to be made. In the present case, the client meets only two potential MDD criteria: sleep disturbance and loss of interest in a previously enjoyed activity (skating). Because the required symptom threshold is not met, MDD was ruled out as a primary diagnosis.

The client presents with several symptoms consistent with generalized anxiety disorder (GAD) under the DSM-5, including excessive anxiety that he is unable to control, sleep disturbances, and difficulty concentrating. These symptoms are also interfering with his daily functioning and workplace performance. However, a key distinguishing feature of GAD is that the anxiety is not attributable to a specific cause. In the present case, the client's anxiety can be directly linked to the traumatic arson event he experienced approximately one year ago. Because the anxiety is trauma-specific rather than pervasive and free-floating, GAD was ruled out as a primary diagnosis.