PMH/504 Week 5: Anxiety, Trauma and Stressor-Related Disorders, sample paper

A Paramedic Who Cannot Drive Past the Overpass: Treating PTSD in a 38-Year-Old With Trauma-Focused Therapy First, Sertraline Alongside and Without the Prazosin She Read About

[Student Name]

University of Phoenix

PMH/504: Psychiatric Management Of Adult And Geriatric Patients

Week 5 Assignment

[Instructor Name]

[Date]

The patient is a composite written for a model paper.

Ms. D., a 38-year-old paramedic, responded eight months ago to a highway crash in which a child died under an overpass. Since then she has intrusive images, nightmares three or four nights a week, avoids the route past the overpass, feels detached from her family, startles easily and snaps at coworkers. She has taken leave. Her PCL-5 score is 56. She asks whether prazosin, which a colleague took, would stop the nightmares. What follows sets out how her diagnosis was confirmed, how the options were ranked and what she agreed to try.

Confirming the Diagnosis

Under DSM-5, the qualifying event may be witnessed directly or, for first responders, met through repeated or extreme contact with the aftermath of trauma on the job. Four symptom groups must then persist beyond one month and impair functioning: intrusive memories, avoidance of reminders, negative shifts in thinking and mood, and heightened arousal and reactivity. Ms. D. meets each criterion. Screening for co-occurring conditions finds moderate depressive symptoms (PHQ-9 of 14), alcohol use that has crept up to three glasses of wine each night and no current suicidal thoughts.

Ruling Out Other Explanations

Acute stress disorder is excluded because more than a month has passed. Adjustment disorder does not account for the intrusive re-experiencing or the hyperarousal. She had no head injury at the scene, so postconcussive symptoms are not a factor. Her thyroid function and a basic metabolic panel from her primary care visit last month were normal. Her sleep problems predate the increase in alcohol use, which suggests the drinking is a response to symptoms rather than their cause, though it now makes them worse.

Her Own Account of the Problem

Ms. D. describes feeling that she failed the child, even though the child was beyond help when her crew arrived. This sense of guilt and self-blame is a trauma-related belief that therapy can address directly. She also reports that she now scans every roadway for hazards and cannot relax in a car even as a passenger. Her husband has taken over driving the children to school. She misses her crew and feels guilty about being on leave, which adds to her distress and her wish to return before she is ready.

What Works

Watts et al. (2013) meta-analyzed treatments for PTSD and found that effective psychotherapies included cognitive therapy, exposure therapy and eye movement desensitization and reprocessing, with large effect sizes, and effective medications included paroxetine, sertraline, fluoxetine, venlafaxine, risperidone and topiramate, with smaller effect sizes. They noted that study differences make it hard to name a single best treatment and that not all treatments were effective.

Prolonged Exposure

Schnurr et al. (2007) randomly assigned 284 female veterans and active-duty personnel with PTSD to prolonged exposure or present-centered therapy. Prolonged exposure produced greater symptom reduction, and more women no longer met PTSD criteria, 41.0% compared with 27.8%. The authors concluded that prolonged exposure was effective and feasible across clinical settings.

Avoidance keeps PTSD alive; the treatment with the strongest evidence asks her, carefully, to stop avoiding.

Why Exposure Helps

Avoidance brings short-term relief but prevents the brain from learning that the memory and the reminders are not dangerous in themselves. Prolonged exposure asks the patient to recount the memory repeatedly in session and to approach avoided places in a planned order, so that fear decreases through repeated, safe contact. For Ms. D., the hierarchy starts with looking at a map of the route, then riding as a passenger past the exit, then driving the route at a quiet hour with her husband, and finally driving it alone.

Preparing Her for Therapy

Exposure can feel worse before it feels better. I explain this in advance so that an early rise in distress is not taken as failure. Sessions are recorded so she can listen to her imaginal exposure at home between visits, and her therapist assigns in vivo practice each week. We agree that she will not drink on the evenings of sessions or practice, since alcohol blunts the learning that exposure depends on.

Why Not Prazosin

Raskind et al. (2018) randomly assigned 304 veterans with chronic PTSD to prazosin or placebo for 10 weeks and found no significant differences in distressing dreams, sleep quality or overall clinical status. Earlier smaller trials had been positive, but this larger trial did not confirm benefit. I explain to Ms. D. that prazosin is not the first choice for her nightmares and that nightmares often improve with trauma-focused therapy and with specific treatments for nightmares such as imagery rehearsal therapy.

The Plan

Psychotherapy: prolonged exposure, about 10 to 15 weekly sessions, including imaginal exposure to the memory and in vivo exposure to avoided situations, such as driving the route past the overpass in gradual steps. Medication: sertraline, starting at 25 mg and increasing toward 100 to 150 mg, which may help both PTSD and depressive symptoms (Watts et al., 2013). Alcohol: she agrees to stop drinking during treatment, since alcohol worsens sleep and interferes with exposure learning.

Work and Occupational Factors

First responders face repeated trauma. With her consent, I coordinate with her employer's peer support program and plan a graded return to work once symptoms improve, avoiding the crash-heavy highway shifts at first.

Nightmares Specifically

If nightmares persist after exposure therapy, imagery rehearsal therapy, in which she rewrites the dream and rehearses the new version while awake, is the next step.

Safety

PTSD raises suicide risk, particularly with depression and alcohol. We complete a safety plan, and she agrees to remove extra medications from her home.

Choosing Among Medications

Sertraline and paroxetine carry FDA approval for PTSD, and venlafaxine has trial support (Watts et al., 2013). Sertraline is chosen because of its lower anticholinergic burden, fewer drug interactions and a gentler discontinuation profile than paroxetine. I explain that benefit may take six to eight weeks and that early side effects such as nausea or restlessness usually fade. Benzodiazepines are avoided because they do not treat PTSD, may interfere with exposure learning and add dependence risk, especially with her current drinking.

Her Family

With her permission, her husband joins one session to learn how PTSD works and how to support exposure practice without taking over tasks she is working to reclaim, such as driving the children.

Measuring Progress

The PCL-5 is repeated every two weeks; a reduction of 10 or more points indicates clinically meaningful change. The PHQ-9 and a weekly drinking log are tracked alongside it, and her return-to-work date is set by symptom change rather than by the calendar.

Conclusion

Ms. D. meets criteria for PTSD after occupational trauma. Meta-analytic evidence supports trauma-focused psychotherapy and several medications, and a trial of prolonged exposure in women exposed through military service supports the chosen therapy. A large trial found prazosin ineffective for nightmares in chronic PTSD, so it is not her first choice. Prolonged exposure with sertraline, alcohol cessation and work coordination form her plan.

References

Raskind, M. A., Peskind, E. R., Chow, B., Harris, C., Davis-Karim, A., Holmes, H. A., Hart, K. L., McFall, M., Mellman, T. A., Reist, C., Romesser, J., Rosenheck, R., Shih, M.-C., Stein, M. B., Swift, R., Gleason, T., Lu, Y., & Huang, G. D. (2018). Trial of prazosin for post-traumatic stress disorder in military veterans. New England Journal of Medicine, 378(6), 507-517. https://doi.org/10.1056/NEJMoa1507598

Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea, M. T., Chow, B. K., Resick, P. A., Thurston, V., Orsillo, S. M., Haug, R., Turner, C., & Bernardy, N. (2007). Cognitive behavioral therapy for posttraumatic stress disorder in women: A randomized controlled trial. JAMA, 297(8), 820-830. https://doi.org/10.1001/jama.297.8.820

Watts, B. V., Schnurr, P. P., Mayo, L., Young-Xu, Y., Weeks, W. B., & Friedman, M. J. (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. The Journal of Clinical Psychiatry, 74(6), e541-e550. https://doi.org/10.4088/JCP.12r08225