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Case Presentation: PTSD

Dr. Hadeel Jawad 23rd November 2011

NAME:AR
Age:24 Gender: Male

Country of origin: Iraq

Demographic Details

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Poor sleep Flashbacks Hearing voices of Iraqi terrorist telling him to kill Americans He believes that T.V and newspapers talk about him He thinks that there is a conspiracy to kill him in Ireland. Garda and Iraq terrorist are part of this conspiracy Panic attacks

Presenting complaints

In February 2008 AR witnessed his brother being shot dead in front of him .Since then ,things have never anyway normal for him . He is always tense ,very sensitive to noise ,flashbacks .He is trying to avoid reminders of the event. He is also suffering from low mood.
He has been attending the Millmount OP clinic since May 2011

History of presenting complaints

He admitted having panic attacks since 2003 ,and he was getting treatment from Iraq(sleeping tablets??)
He was treated by a doctor in Iraq for PTSD in 2008. He claimed that he was treated by a psychiatrist in Waterford and Rathmines.

Past psychiatric history

Type 1 DM

His blood sugar is poorly controlled .

Medical history

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In May he was on: Diazepam 5 mg BD, zopiclone 7.5 mg OD, Amisulpride 200mg mane-400 mg nocte. In July Amisulpride was switched to Olanzapine 2.5mg B.D-7.5 mg nocte. He benefited significantly from Olanzapine with a reduction in symptoms. In August :olanzapine 5 mg b.d,10 mg nocte ,zopiclone 7.5 mg nocte,diazepam 5 mg mane and 3 mg evening,citalopram 20 mg o.d

medications



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He is the eldest of 4 boys. One of his brothers shot dead in Iraq in 2008. His parents and 2 siblings are still living in Iraq. He has 1 cousin living in Dublin. His mother is suffering from chronic depression

Family history

He was born in Iraq .Reportedly, his birth and early developmental milestones were normal.
He did a course at a college in Whitehall , but he didn’t finish and dropped out because he couldn’t cope. He believed that his classmates may be out to kill him.

Personal history

He arrived in Ireland 2 months after the attack.
He doesn’t smoke or drink alcohol. Social isolation. He has an Irish girlfriend , they are doing well He receives social welfare benefit.

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Social History

He described himself as fun-loving, outgoing person prior to the incident.

Personality

Appearance and behaviour: He was casually dressed, poor eye contact, reasonable rapport.  Speech: was reduced in rate and amount.  Mood: Objectively he appeared depressed.  I couldn’t complete the assessment as he started to hear voices so he became agitated and hyperventilated.

MSE on /11/11


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FBC , TFT ,B.S ,Coagulation profile.
ECG,ECHO. U+Es, LFT, Creatinine.

investigations


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PTSD.
Acute psychotic episode.

Mood disorder with psychotic symptoms.
Anxiety disorder. Malingering. Enduring personality change after a catastrophic event [duration at least 2 yrs.

Differential Diagnosis

1.Predisposing factors: personality,previous traumatic events.
2.Precipitating factors: He witnessed his brother being shot dead in front of him in 2008 and his family house was burnt down. 3.Maintaining factors: Away from the family, social isolation due to cultural and language barriers.

Formulation

Severe psychological disturbance following a traumatic event
Both ICD-10 and DSM-IV criteria include: 2 or more of the following [not present before exposure to stressor]

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1.Difficulty falling or staying a sleep
2. Irritability or outbursts of anger 3. Difficulty in concentrating 4. Hypervigillance 5.Exaggerated startle response

PTSD

Other ICD-10 criteria :  Persistent remembering or reliving of stressor in intrusive flashbacks , vivid memories.  Actual or preferred avoidance of circumstances resembling or associated with the stressors.  Inability to recall either partially or completely.

Epidemiology: Risk of developing PTSD 8-13% for men,20-30% for women. cultural differences exist.
Aetiology: 1.Psychological/Biological. 2.Neuroimaging. 3.Genetic

PTSD


Risk factors:

Low education , low social class , female gender , low self-esteem, neurotic traits, previous or family history of psychiatric problems , previous traumatic events.

PTSD

Management:

1.Psychological

-CBT
- EMDR -Psychodynamic therapy.

2.Pharmacological. Out-Come:~50% will recover within 1 yr. chronic course. ~30% will run a

PTSD

Thank

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