The Case of William J.
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Introduction
William is a 34 year-old man living comfortably with his wife and two children. He had no health issues, other than cholecystectomy for biliary colic four years ago.
On his way home from work, William was driving under an overpass when a woman jumped to her death in front of him. His car struck her, and he veered into the ditch. He sustained only scratches, though was taken to hospital for shock.
A few weeks later, William comes to you, his family doctor, to discuss his ongoing severe distress. He has been unable to work since the event, he describes being constantly 'keyed-up', his sleep is very poor, and he is drinking 4-6 beers a day to help him relax. He knows something is wrong and would like your help.
Q1: What is the preferred diagnosis? The differential diagnosis?
William is most likely suffering from post-traumatic stress disorder.
It will be important to exclude other possible underlying diagnoses, including:
- adjustment disorder (less than one month)
- generalized anxiety disorder
- panic disorder
- major depressive disorder
- substance abuse
- factitious disorder, malingering
Q2: What are the clinical features of this condition?
PTSD is characterized by at least one month of:
- re-experiencing the event though recurrent thoughts, flashbacks or dreams
- intense psychological distress and physiologic response to reminders of event
- emotional numbness and isolation from others
- signs and symptoms of autonomic arousal, including increased startle, irritability, difficulty sleeping, difficulty concentrating
Acute PTSD lasts for less than three months, while chronic is longer than this.
Q3: What are its treatments?
PTSD may be treated with antidepressants, especially SRIs such as sertraline.
Benzodiazepines
Mood stabilizers and antipsychotics have been used and published in case reports.
Psychotherapy is important, and includes:
- CBT to provide coping strategies and combat negative thoughts (ie this was my fault)
- exposure flooding
- group therapy
- family therapy as necessary
background information
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