A 38 year old single mother of a six year old biological son was referred by her PCP as an emergency to a Psychiatric NP. Upon entering the waiting room the woman looked exhausted and disheveled. Her straight short blond hair looked uncombed and she was dressed in a worn sweat suit. She was accompanied to the session by her best friend who drove her to the session. Although the woman’s mood seemed tired but controlled while filling out the admission papers, upon telling her story the woman immediately began to sob.
The woman described that at 8:30PM on the previous evening her house was entered by a man whom she did not recognize. She was bound, gagged and intermittently raped over the next 2 and ½ hours. Prior to his entry the woman had been in her study working on documents which she had brought home from work. Upon walking out of her study the woman confronted the man standing in her kitchen. At this point she realized that the she had left the door open as it was a warm night and, “everyone in the neighborhood” trusts each other.
After 2 ½ hours of the man alternating between pacing her house and raping her he left her after he unbound her. She remembers feeling too scared to scream, feared that he would kill her,yet also feeling grateful that her son was not at home but staying overnight with his relatives.
After the man left her house the woman called her best friend who begged her to call the police but she refused. She was afraid that the incident would be put in the newspaper if she called the police. She describes showering for 1 hour, scrubbing herself over and over. She then lay awake the entire night until her PCP saw her in the morning who referred her to the local Emergency Room for Rape Crisis Care and to the local therapist who saw her that day.
Upon admission she described feeling numb and anxious. She stated that on her way to the therapist office she continually scanned her environment to see if the rapist was watching her or following her. She stated that she had always considered herself to be in control and independent but now was feeling totally helpless to know what to do and also felt somewhat unreal and fearful. She stated that she felt nauseated and could vomit.
The woman seemed to be a fairly reliable historian, as she was able to give very specific details of the entire event. Although she repeated herself several times on many of the specifics her history was coherent and consistent.
At the time of the admission she denied any intrusive, distressing thoughts or images, flashbacks, nightmares. She simple stated, “I’m numb” and stated that she just could not imagine how she will work at her job as it was locatedin a very public environment.
Past History
When asked if she had ever had any other incidences of trauma she initially stated, “No”. She then qualified the response by stated that her ex-husband was emotionally abusive which escalated after the birth of their only child. At that point she divorced him.
She described that she was adopted when she was 3 days old.She stated that she was an only child raised by two alcoholic parents and that she felt that she had to walk on eggshells most of her life trying to placate and please her “critical” mother and perfectionistic father. She stated that she was a very shy child and remembered vomiting on the school bus frequently in her first year of school.She describes having sleep problems and could only go to sleep with the light on. Since she was a bed-wetter until the age of 10 years old she refused to go to any “sleep-overs” with friends.She described school as very difficult and states that she has never lived out her dream to become a lawyer because she knows she could not “make the grade”. Although she has a well paying job in a marketing firm she prefers to work alone as people just “get on my nerves”.
She states that she has been in a fairly consistent relationship with a gentleman whom she calls her “best friend”. However, because she prefers her own home environment nor enjoys traveling the relationship consists of watching Monday night football at her house or occasional dinners out. She states that her male friend surprised her with a cruise for her birthday the year before. The woman stated that as time got closer to leaving for the cruise she began to develop palpitations, chest pain, nausea, numbness and tingling of her hands and eventually refused to take the trip with her friend. She says she “lives for her son” and gives him her undivided attention until his bedtime each night
Medical History
Her medical history consists of chronic back problems having sustained significant injuries in an AA 2 years prior. She sees a chiropractor on a regular basis. She complains of chronic muscle tension and is frequently fatigued and exhausted at the end of a day’s work.
Include:
- Any differential diagnoses
- Your diagnosis and reasoning
- Any additional questions you would have asked
- Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.
- Any labs and why they may be indicated
- Screener scales or diagnostic tools that may be beneficial
- Additional resources to give (Therapy modalities, support groups, activities, etc.)
Expert Solution Preview
Introduction:
A woman in her late thirties was referred by her primary care physician to a psychiatric nurse practitioner for emergency evaluation. She had been raped in her home the previous evening by an unknown man and was struggling with feelings of anxiety, numbness, and helplessness. This case study will explore the woman’s history, symptoms, and potential treatment options.
1. Any differential diagnoses:
Possible differential diagnoses for this patient may include post-traumatic stress disorder (PTSD), acute stress disorder (ASD), or major depressive disorder (MDD). These disorders share many symptoms, such as intrusive thoughts, avoidance behaviors, and feelings of anxiety or depression.
2. Your diagnosis and reasoning:
Based on the woman’s symptoms and history, the most likely diagnosis is acute stress disorder (ASD). ASD is a short-term condition that can develop after experiencing a traumatic event and is characterized by symptoms such as dissociation, anxiety, and numbing. It is a precursor to PTSD and can develop within days to weeks after a traumatic event.
3. Any additional questions you would have asked:
Additional questions that may be helpful include exploring the woman’s support system, any previous experiences with therapy or mental health treatment, and any family history of mental health conditions.
4. Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent:
Medication recommendations may include selective serotonin reuptake inhibitors (SSRIs) such as sertraline or paroxetine, which have been shown to be effective in treating symptoms of PTSD and ASD. Possible side effects may include gastrointestinal distress, insomnia, or sexual dysfunction. It is important to discuss potential side effects with the patient and address any concerns they may have about taking medication.
5. Any labs and why they may be indicated:
There may not be specific labs indicated for a diagnosis of ASD, but a general medical exam may be warranted to rule out any physical injuries or illnesses that may have resulted from the assault.
6. Screener scales or diagnostic tools that may be beneficial:
Screening scales or diagnostic tools that may be beneficial for this patient include the PTSD Checklist for DSM-5 (PCL-5) and the Acute Stress Disorder Scale (ASDS). These tools can help to assess the severity of symptoms and track progress in treatment.
7. Additional resources to give (Therapy modalities, support groups, activities, etc.):
Additional resources that may be beneficial for this patient include trauma-focused cognitive behavioral therapy (TF-CBT), support groups for survivors of sexual assault, and self-care activities such as exercise, meditation, or journaling. It may also be helpful to provide resources for legal advocacy or other services to support the patient in seeking justice for the assault.
