Identifying Information
J. M. is a twenty-eight-year-old single Caucasian female presenting to the psychiatric health provider to undergo a psychiatric evaluation. The woman has no history of psychiatric disorders but recently undergone a traumatic experience due to an armed conflict occurring in her country. She was admitted to the facility on 06/01/2022 due to the symptoms of depression, severe anxiety, and suicidal ideation. She lives in a communal housing for refugees and has never been diagnosed with any psychological issues in the past.
Subjective Data
J. M. mentioned that she felt that “every new day is harder than the previous one; I cannot seem to get better and continue relieving the trauma time and time again.
Present Illness History (Based on Subjective Data)
JM has no history of anxiety or depression. She has engaged in occasional alcohol use, but nothing that could be seen as addictive has occurred. She indicated that the recent events in her life, such as having to leave her home country as a refugee and the trauma of being sexually assaulted by a foreign soldier, caused her mental health to deteriorate. She has been having nightmares every time she would go to sleep, which caused her to avoid sleeping and stay awake for up to forty-eight hours, making her feel exhausted and highly anxious. Few times anxiety increased to high level with sweating, nausea, rapid heart rate and thoughts about dying. However, for several weeks there was no cases of panic attack. Based on the DSM-5 (PCL-5) checklist, JM’s score was 33, which indicates a high likelihood of PTSD. For the past several weeks, JM has been feeling particularly down because she felt survivors’ guilt that she was in a safe place. Still, the thoughts of trauma and the general psychological distress caused her to feel helpless and alone because she did not know how to manage them effectively.
When being assessed through SPAN Self-Report Screen, JM states that she feels the need to be constantly on guard and watchful to ensure that there is no one around her that can cause harm. Even though she tries not to think about the traumatic event, she cannot help herself but to keep returning to those thoughts, which makes her mental health deteriorate. JM mentions that she avoids getting into contact with men and prefers staying in women’s company because it makes her feel safer and at ease. The young woman also said that she has only recently begun caring for herself regularly, such as having showers, and brushing her hair and teeth. She said that she felt that neglecting her physical appearance would prevent men from getting interested in her. She has only started taking her of herself physically because others have begun developing wrongful impressions of her.
JM says that she did have suicidal thoughts all the time after the traumatic event, and the thought has never left her mind entirely, and she even tried to commit suicide once. She mentions that ending her life can be something that will alleviate the burden of having to live with traumatic memories that prevent her from having a normal life. She admits trying to increase her alcohol intake just to feel whether the intrusive memories would go away, but they did not and got even more severe with alcohol use. She tried to gain access to some psychotic drugs but could not find any in her social circle because most of the people with whom she speaks are from the same circle of refugees. While JM denies having any seizures and blackouts, she mentions having some hallucinations and warped memory.
Past Psychiatric History
Because JM’s traumatic event occurred pretty recently, she has not undergone any mental health treatment. She has not been prescribed any medication for initial anxiety because the main concerns of healthcare providers were associated with her physical health. Several weeks ago, JM attempted to commit suicide by cutting her wrist but was unsuccessful because her roommate found her very quickly. After the attempt, JM mentioned that she had realized that ending her life was not the answer to her mental health problem and that she did not feel relief when cutting her wrist.
Previous Psychiatric Medications
No psychiatric medications were prescribed.
CURRENT MEDICATIONS
Omega-3 950 mg PO PC daily
50HTP 200 mg PO daily stress and mood improvement
Melatonin 5 mg PRN HS for insomnia
Substance Use/Addictive Behaviors
Alcohol: 1 bottle of red wine every four to five days, has some beer occasionally. The last use was two days before admission. No illicit drug use was reported; JM does not smoke and has never tried. She drinks several cups of coffee a day; most of it is consumed at night to avoid sleeping and the nightmares that come with it.
Family’s Psychiatric History
Father: absent from the family since the patient’s childhood, possible history of mental health issues.
Mother: suffers from anxiety and mood disorders.
Grandparents: all grandparents are deceased, and there is no history of mental health issues among them.
Siblings (older brother): no history of mental health issues.
Surgical and Medical History
JM had her appendix removed three years prior to admission.
Allergies
Allergic to pollen, has taken some antihistamines to relieve the symptoms.
Psychosocial
JM is a 28-year-old single woman born and raised in Kharkiv, Ukraine. She is the youngest of two siblings and was raised in a single-parent household. Her mother has always worked hard to provide for her children, who never felt that they lacked anything. JM and her brother finished school successfully and got into university for their dream specializations. They have never been subjected to any physical or emotional abuse when growing up, and the idea of trauma has been foreign to them. However, with the recent invasion of the country and the targeting of JM’s home region, the young woman got exposed to severe conditions that disrupted her mental health. Before the war, JM worked as a Social Media Marketing Manager and loved her job. She has never been married and has no children. JM says that she is happy that she does not have any children, so they do not have to experience the bombings and devastation that she has seen. She was lucky enough to get some help from volunteers who initially transported JM to Europe and then the UK, where she had undergone some initial assessment. Later, she was contacted by some relatives who helped her get to the USA.
Asset
She has found stable employment and will soon be able to move out of the refugee accommodation to get an apartment with some roommates. JM is quite determined to provide for herself and get her life back on track; she hopes that she will be able to send some money to her family and wants to return to her home country once the conflict is over.
Stressors
JM wants to restore her previous mental health condition that she used to have prior to the armed conflict.
Mental Status Examination
JM appears tired and sluggish, but she is oriented to time, place, and person. She seems to be clean and dressed in an appropriate manner; however, her face is pale with dark under-eye circles that make her face appear sunken-in and overall tired. She does not maintain eye contact very well and, when asked about traumatic events, appears to shut down. In terms of psychomotor disturbances, JM’s hands appear to tremble from time to time. Her tone of voice is calm while the speaking volume is quiet, especially when she recalls her experiences trying not to cry. Throughout the process, some of her speech gets incoherent despite the fact that she speaks perfect English and does not seem to experience any issues with the language barrier. Speech issues are rather associated with her anxiety about having to explain her feelings and thoughts. She admits to having some auditory and visual hallucinations, paranoid thoughts, and severe anxiety, along with suicidal ideations that are not as strong as they used to be.
Physical Examination
BP 130/70, P 70/min, RR 14/min, T 97.7 F. Height 5’4, Weight 132,2 Lbs, SPO2 100%.
Differential Diagnoses
Acute Stress Disorder (F43.0)
Panic Disorder (F41.0)
Posttraumatic stress disorder (F43.1)
Diagnostic Impression (Including Formulation)
Acute stress disorder (ASD), outlined in the diagnostic and statistical manual for mental disorders (DSM-5), explains acute reactions to stress occurring for no less than three days or no more than four weeks after the traumatic event (Fanai & Khan, 2021). The criteria based on DSM-5 for ASD include exposure to threatened death, severe injury, or sexual violation, the presence of intrusive distressing memories, dissociation, negative mood, avoidance, and social and/or occupational disturbances.
Panic Disorder (PD), as outlined by DSM-5, is characterized by the presence of sudden and spontaneous onset of discomfort or fear. The criteria for PD include experiencing recurrent panic attacks, with one or more attacks followed by at least one month of fear of having another attack, including other maladaptive behaviors associated with the attacks. The criteria based on DSM-5 for PD include the sudden surge of fear accompanied by a pounding heart, an increased heart rate, shaking or trembling, shortness of breath, the feeling of dizziness, derealization, and fear of losing control (SAMHSA, 2016).
Posttraumatic Stress Disorder (PTSD) is included in the DSM-5 on trauma- and stress-related disorders and include the presence of an outside event – a traumatic experience. The DSM-5 criteria (subcategories of symptoms) for PTSD include exposure to trauma, intrusion, avoidance, negative mood and cognition alterations, as well as marked alterations in arousal and reactivity. In the criterion of intrusion, a person may have distressing memories, nightmares, flashbacks, and intense psychological distress accompanied by physiological responses due to re-experiencing (Rothbaum, 2021). In PTSD, an individual is likely to avoid thinking or talking about the traumatic event, any external reminders, and the inability to experience positive emotions. Negative alterations are illustrated by the negative emotional state and the persistent blame of others or self.
Risk Assessment
Possibility of repeated suicidal attempts.
Recommendations and Plan for Treatment With Rationale
Begin pharmacologic treatment for symptoms of PTSD – recommended to start with 100 mg Zoloft daily, which is an FDA-approved selective serotonin reuptake inhibitor that can help the regulation of serotonin in both peripheral and central nervous systems (Jeffreys, 2018). To address the recurring hallucinations linked to PTSD, the patient should be prescribed Olanzapine 10 mg once a day. To make the patient fall asleep and stay asleep, she should take 1 mg of Estazolam at bedtime, with the dose being adjusted as needed. It is essential to begin pharmacologic therapy with lower doses of medication and increase when required to avoid dependency.
To overcome the adverse symptoms of PTSD and ongoing depressive symptoms in the patient, it is recommended for them to engage in trauma-focused therapy. While exposure-based therapy may elicit other negative emotions associated with the trauma, cognitive-behavioral therapy (CBT) will be the best fit. During CBT sessions with the patient, she will be educated on exploring the relationships between her feelings, thoughts, and behaviors and taught how the changes in these domains could improve functioning.
CBT can combine methods drawing from emotional processing theory and social cognitive theory. The patient may get encouraged to rethink her mental and cognitive patterns and assumptions to identify those patterns that hinder good mental functioning (APA, 2017). CBT will delve deeper into the patients’ overgeneralization of bad outcomes, negative thinking, the diminishing of positive thinking, and the continuous expectations of repeated trauma to help reach more balanced and effective patterns of thinking (APA, 2017). JM will be taught how she can reconceptualize the understanding of the traumatic experience, including her understanding of themselves and the ability to cope.
References
APA. (2017). Cognitive behavioral therapy (CBT). Web.
Fanai, M., & Khan, M. (2021). Acute stress disorder. Web.
Jeffreys, M. (2018). Clinician’s guide to medications for PTSD. Web.
Rothbaum, B. (2021). Understanding DSM-5 criteria for PTSD: A disorder of extinction. Web.
SAMHSA. (2016). Impact of the DSM-IV to DSM-5 changes on the national survey on drug use and health. Web.