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Ron is a 24-year-old male with a recent history of combat deployment, presenting for psychiatric evaluation. He reports a progressive worsening of symptoms over the past six weeks. Initially, he felt depressed, and his family practice provider diagnosed him with depression and started him on bupropion. However, he reports no improvement in mood. Ron describes experiencing nightmares, flashbacks, and intrusive thoughts related to a traumatic explosion during his mission, where he lost several unit members while he was driving. He has also experienced a panic attack while driving and has since avoided driving.
Ron discloses that he sustained two traumatic brain injuries (TBIs) during his deployment over the past year. His symptoms have escalated, and he now feels increasingly irritable and withdrawn. His primary care provider prescribed Ativan for his panic attacks and referred him to psychiatry for further management.
Assessment:
Diagnosis:
Post-Traumatic Stress Disorder (PTSD): Ron exhibits classic PTSD symptoms, including nightmares, flashbacks, intrusive thoughts, avoidance behavior (avoiding driving), and heightened irritability.
Traumatic Brain Injury (TBI): History of TBIs may complicate the clinical picture and contribute to cognitive and emotional dysregulation.
Depression: Initially diagnosed and treated with buPROPion, though with limited efficacy.
Panic Disorder: Acute panic attack while driving, indicating possible comorbidity with panic disorder.
Plan:
Medications:
Discontinue bupropion: Given the lack of improvement and the potential for bupropion to exacerbate anxiety and irritability, discontinuation is recommended.
Initiate Sertraline: Start Sertraline 25 mg daily, titrating up to 50 mg after one week, targeting PTSD and depressive symptoms. Sertraline is an SSRI approved for PTSD and depression, providing a dual benefit.
Continue Ativan (LORazepam) PRN: For acute panic attacks, continue Ativan 0.5-1 mg as needed, but aim for minimal use due to the risk of dependency.
Therapy:
Cognitive Behavioral Therapy (CBT): Refer Ron to a therapist specializing in CBT, focusing on trauma-focused CBT to address PTSD symptoms.
Eye Movement Desensitization and Reprocessing (EMDR): Consider referral for EMDR therapy, which has shown effectiveness in reducing PTSD symptoms by processing traumatic memories.
TBI Management:
Neuropsychological Assessment: Refer Ron for a comprehensive neuropsychological evaluation to assess cognitive impairments related to his TBIs and guide further management.
Rehabilitation Services: Depending on the neuropsychological assessment, consider cognitive rehabilitation to address any deficits identified.
Sleep Hygiene: Educate Ron on maintaining good sleep hygiene practices to help manage nightmares and improve the quality of sleep.
Mindfulness and Relaxation Techniques: Encourage the practice of mindfulness, meditation, and other relaxation techniques to manage stress and anxiety.
Driving Desensitization: Gradual exposure therapy to help Ron overcome his avoidance of driving, with the guidance of his therapist.
Follow-Up:
Schedule follow-up appointments in 2–4 weeks to monitor the efficacy of Sertraline and adjust the dose as necessary.
Regularly assess Ron’s response to therapy and any side effects from medications.
Rationale and Evidence:
The treatment plan incorporates evidence-based approaches for managing PTSD and depression, with particular consideration of Ron’s combat-related experiences and TBIs. Sertraline is a first-line treatment for PTSD and has a favorable profile for depressive symptoms (Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder, 2017). Trauma-focused therapies like CBT and EMDR have robust support for their effectiveness in reducing PTSD symptoms (Shapiro, 2017). Managing TBIs with neuropsychological assessments ensures a comprehensive approach, addressing potential cognitive impairments contributing to Ron’s symptoms.
References
Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder [American Psychiatric Association]. (2017). Retrieved June 10, 2024, from Links to an external site.https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines/ptsdLinks to an external site.
Shapiro, F. (2017). Eye Movement Desensitization and Reprocessing (EMDR) Therapy (3rd ed.). Guilford Press. Links to an external site.https://www.apa.org/ptsd-guideline/treatments/eye-movement-reprocessingLinks to an external site.
Ron is a 24-year-old male veteran who recently returned from a combat mission where he experienced significant trauma, including the loss of several members of his unit during an explosion while he was driving. He presents for psychiatric evaluation following a referral from his primary care provider (PCP). Ron reports that his symptoms have progressively worsened over the past six weeks. Initially, he experienced depressive symptoms, which prompted his PCP to start him on bupropion. However, he reports no improvement with this medication.
Ron describes experiencing nightmares, flashbacks, and intrusive thoughts related to his combat experience and the explosion. He reports a panic attack while driving, which has led him to avoid driving altogether. His PCP prescribed Ativan (lorazepam) for these panic attacks, but Ron reports ongoing distress.
Additionally, during the past year, Ron sustained two traumatic brain injuries (TBIs) during deployment. He reports increasing irritability and withdrawal from social interactions. No previous psychiatric disorders were reported.
Assessment
Post-Traumatic Stress Disorder (PTSD): Ron’s symptoms of nightmares, flashbacks, intrusive thoughts, avoidance of driving, and panic attacks strongly suggest PTSD, likely related to his combat experiences and the traumatic event involving the explosion. PTSD is a psychiatric condition that arises in response to exposure to traumatic events, significantly impacting an individual’s mental well-being (Mann et al., 2024).
Traumatic Brain Injury (TBI): The patient has a history of two TBIs in the past year which can contribute to his cognitive and emotional symptoms, including irritability and withdrawal.
The patient reports depressive symptoms, which have not improved with bupropion. In addition, the patient also reports an episode of panic attacks while driving.
Plan
Medication Management:
Given the lack of improvement and the presence of PTSD symptoms, bupropion will be discontinued as it is not the most appropriate choice for PTSD. Sertraline 50 mg daily will be started. Sertraline is an SSRI with evidence-based efficacy for PTSD and comorbid depression (Mann et al., 2024). Continue lorazepam 0.5 mg BID for 2 weeks for anxiety management.
Psychotherapy:
The patient will be referred for CBT, with a focus on trauma-focused CBT (TF-CBT) to address PTSD symptoms.
The patient will be referred to a neurologist for a comprehensive evaluation of his TBIs and potential cognitive effects. This can help in tailoring his treatment plan to address any neurocognitive deficits.
The patient will be recommended to participate in a veterans’ support group to provide peer support and reduce social withdrawal. In addition, the patient should be introduced to mindfulness-based stress reduction (MBSR) techniques to help manage anxiety and improve overall well-being (Mann et al., 2024). Regular physical activity is encouraged since it can help reduce symptoms of depression and anxiety (Mann et al., 2024).
The patient needs to be seen in two weeks to assess response to sertraline and any side effects. Lorazepam will be tapered off due to the high risk of dependence. The patient needs to be educated about the importance of medication compliance and to report any side effects or adverse effects immediately. The patient needs to go to the nearest emergency room or call 911 in case of suicidal or homicidal thoughts.
The above plan of care has been chosen since it is evidence-based practice. Sertraline was chosen for its efficacy in treating PTSD and comorbid depression, and CBT and Exposure Therapy have proved to be effective for PTSD (Mann et al., 2024).
References
Mann, SK., Marwaha, R. & Torrico, TJ. (2024). Posttraumatic Stress Disorder. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559129/
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