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Stem
A 29-year-old woman presents to her general practitioner 8 weeks after being raped at knifepoint by an unknown assailant. She describes recurrent intrusive flashbacks in which she feels the assault is happening again, with sweating, palpitations and a choking sensation; nightmares several times a week in which she wakes screaming; intense distress and avoidance when walking alone after dark or seeing men who resemble the assailant; a pervasive belief that she is 'permanently damaged' and that the world is entirely dangerous; irritability with her partner; difficulty concentrating at work; and insomnia with hypervigilant scanning of her house at night. She has started drinking four glasses of wine each evening 'to take the edge off'. She mentions in passing that she has been having fleeting thoughts that 'everyone would be better off without me'. She has no prior psychiatric history.
Questions
a) State the most likely diagnosis and the DSM-5 criteria it satisfies. (2 marks)
Diagnosis: Post-Traumatic Stress Disorder (PTSD). The patient meets all eight DSM-5 criteria:
- Criterion A (exposure): direct experience of actual/threatened sexual violence (rape).
- Criterion B (intrusion, at least 1 — she has 3): flashbacks; nightmares; intense psychological and physiological distress at reminders.
- Criterion C (avoidance, at least 1 — she has 1): avoidance of walking after dark and of men resembling the assailant.
- Criterion D (negative cognition/mood, at least 2 — she has 2): pervasive negative belief ('I am permanently damaged', 'the world is entirely dangerous').
- Criterion E (arousal/reactivity, at least 3 — she has 4): irritability; concentration problems; hypervigilance; sleep disturbance.
- Criterion F: duration more than 1 month (8 weeks).
- Criterion G: clinically significant distress and impairment (work, relationship).
- Criterion H: not attributable to substance or medical condition.
b) What immediate risk assessment must be performed, and what features in this patient raise concern? (2 marks)
FORMAL SUICIDE RISK ASSESSMENT is mandatory at every visit (use the Columbia Suicide Severity Rating Scale, C-SSRS). Concerning features here: she has FLEETING SUICIDAL IDEATION ('everyone would be better off without me'); COMORBID ALCOHOL USE ( disinhibition, hopelessness); INSOMNIA; PERCEIVED BURDENSOMENESS (she thinks she is damaging her partner); and SOCIAL WITHDRAWAL. Assess specifically: ideation frequency/intensity; intent; plan; access to means (medications, weapons); recent attempt; hopelessness; protective factors (partner, work, treatment engagement). Do not leave her alone if acute risk; remove access to means; safety plan; urgent psychiatric review if intent or plan present.
c) Outline the stepwise management of this patient, citing drug doses where relevant. (4 marks)
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TRAUMA-INFORMED CARE AND ENGAGEMENT: explain the diagnosis, the neurobiology of trauma reactions, and the rationale for treatment; ask permission, give choice; same-sex chaperone for any examination; ensure her immediate safety and offer specialist sexual-assault support (e.g. SARC in the UK).
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TREAT COMORBID ALCOHOL USE AND SUICIDALITY FIRST if acute (brief intervention, alcohol service referral, safety plan). AVOID benzodiazepines — no efficacy, impair fear extinction, dependence.
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FIRST-LINE: TRAUMA-FOCUSED PSYCHOLOGICAL THERAPY — 8 to 12 weekly sessions of trauma-focused CBT or EMDR. Do NOT offer single-session debriefing (harmful per Roberts 2019 Cochrane).
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ADD SSRI PHARMACOTHERAPY given severity and comorbidity — start sertraline 25 to 50 mg PO once daily in the morning, titrate every 1 to 2 weeks to 50 to 200 mg/day (typical effective 100 to 150 mg/day). Allow 4 to 8 weeks for full effect. Paroxetine is the other FDA-approved SSRI but is avoided in women of child-bearing age (teratogenic).
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PRAZOSIN 1 mg at night titrated to 6 to 10 mg at night for trauma-related NIGHTMARES if they persist despite the above; warn of first-dose syncope.
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FOLLOW-UP, MONITORING AND SAFETY NET: review at 2 to 4 weeks then monthly; reassess suicide risk every visit; booked GP follow-up; written safety plan; engage partner/family with consent.
d) Name two pharmacological treatments that are specifically discouraged in PTSD and briefly state why. (2 marks)
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BENZODIAZEPINES (e.g. diazepam, temazepam): NO efficacy for PTSD; IMPAIR fear-extinction learning (the central mechanism by which PTSD resolves); carry DEPENDENCE risk; worsen PTSD outcomes; risk of falls, respiratory depression with opioids; discouraged by NICE, APA and VA/DoD.
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SINGLE-SESSION PSYCHOLOGICAL DEBRIEFING (mandatory single-session recounting of trauma in the immediate aftermath): COCHRANE 2019 evidence shows it is INEFFECTIVE for preventing PTSD and may WORSEN outcome (perhaps by disrupting natural recovery and forcing re-exposure without therapeutic processing); contraindicated by every current guideline.