General Data:
J.T., 12 years old, female, Filipino, Roman Catholic, residing
at Jaro, Leyte, Grade 6 pupil admitted for the 2nd time at EVRMC
with a chief complaint of “Magpapatambal ako kay masakit an
akon tiyan”.
History of Present Illness:
• August 4, 2017 - rape incident
• September, 2018
• Stopped doing her usual household chores
• Stayed outside their house late
• Had 3 episodes of nightmares
• Stares blankly to space for long periods of time
• Persistently irritable
History of Present Illness:
• September 20, 2017 - stabbed a classmate with a ballpen and
was suspended
Medical Conditions:
Admitted at Calubian Distric Hospital due to seizure.
Discharged improved with unrecalled home medications
allegedly for seizure.
March 2017: admitted at EVRMC due to seizure. Discharged
after 1 week improved with Phenobarbital as maintenance. She
was advised to follow-up monthly.
Family History:
Patient was born last April 13, 2005. She is the 4th child in a
brood of 5.
Mother, 43 years old., apparently well
Siblings:
1st: 21 years old female, married and apparently well
2nd: 20 years old female, married and apparently well
3rd: 18 years old male, working and apparently well
5th: 8 years old, female, student and apparently well
Prenatal History:
31 y/o G4P4 (4-0-0-4)
Non-alcoholic beverage drinker
Non-smoker
Had prenatal visits at the BHS
No vitamins taken
Received TT5
relevant data:
Birth:
Term, Cephalic presentation, NSVD
At Home in Jaro, Leyte, attended by Midwife
Pinkish and vigorous, with a loud cry immediately at birth
Sucking was noted to be good
No newborn screening done
relevant data:
Neonatal:
No jaundice, cyanosis, dyspnea and congenital defects noted.
Meconium stools and urine were passed out within the first 24
hours of life.
Umbilical stump was cleaned daily with alcohol and water
It sloughed off 7 days after birth.
relevant data:
HEADSS:
Home:
The patient is living with her family in a one bedroom house
made from light materials. The parents were separated since
the child was 3 years old. She is currently living with her
mother and her younger sister. Her 2 older sisters were already
married and her older brother works in a poultry house in
Ormoc City.
Education:
The patient is an average grade 6 pupil. She is diligent in
writing notes and always earns check marks on her notebook.
She is participative in class and playful at school. She has a lot
of friends at school. She dreams to become a policewoman
someday.
relevant data:
HEADSS:
Activities:
She enjoys doing household chores like cooking, washing the
dishes, doing the laundry and fetching water. She is described
as an obedient child before the incident happened.
Drugs:
She is not taking any illicit drugs or any alcoholic beverages.
She does not smoke.
relevant data:
HEADSS:
Sexuality:
She is not involved in a romantic relationship but she gets
along well with her classmates and friends of both sexes.
Suicide:
No suicidal ideation.
There were no attempts to hurt herself.
Physical Examination:
• Ectomorphic; skin is moist and warm
• Wears clean clothes but had unkempt hair
• Her hair has equal distribution with lice
• Pulse rate was 92 beats per minute
• Respiratory rate was 25 breaths per minute
• She is left handed
• No other significant findings upon brief examination.
mental status examination:
General Description
• The patient is talkative and hyperactive. Her speech is rapid with
some incoherent words.
• She is non-combative during the interview and was conversant.
However, she was restless and has short attention span.
• She easily gets distracted by other people talking or crying.
mental status examination:
Mood and Affect
• The patient looks happy and playful.
• She smiles to everyone and laughs to almost everything.
• When asked about what happened to her, she states it vividly
without any emotion evident.
mental status examination:
Thinking
• There are flight of ideas and some loose associations with her
statements. There was no disturbance in the thought content
such as delusions, preoccupation about her illness, or any
compulsion and/or obsession.
mental status examination:
Perception
• There was no hallucinations or illusions during the time of
examination.
mental status examination:
Sensorium and Cognition
• The patient is alert and oriented to place and person. She has
intact remote and recent memory. She remembers well the rape
incident. She recalls all her teachers from Grade 1 to present.
She recalls her meal the past night. She repeats after the
examiner a series of numbers up to 7 digits. She spells some
words correctly like “butterfly” and “bag”.
mental status examination:
Judgment and Insight
• The patient does not understand her condition, she only keeps
on telling that she was admitted because of her abdominal pain.
• She remembered being restrained on bed and she hated it. She
said she hates those people who restrained her. When asked
about it, she said that she was restrained because she was
naughty (“Gingapus ako kay nagpipinasaway man ako”).
Salient Features:
• 12 years old
• Female
• Rape victim 5 months PTA
• Had 3 episodes of nightmares related to the incident
• Changes in behavior noted after the incident:
• Loss of interest in school activities
• Irritability
• Violent behavior
Differential Diagnosis:
Acute Stress Disorder
Is a mental disorder that can occur in the first month following
a trauma.
The symptoms that define ASD overlap with those for PTSD.
One difference, though, is that a PTSD diagnosis cannot be
given until symptoms have lasted for one month.
Also, compared to PTSD, ASD is more likely to involve feelings
such as not knowing where you are, or feeling as if you are
outside of your body.
Panic or Generalized Anxiety
Disorder
May develop in response to traumatic event.
Associated with prominent anxiety and autonomic arousal.
PTSD is associated with reexperiencing and avoidance of a
trauma, features typically not present in panic or generalized
anxiety disorder
impression:
Trauma characteristics
— The risk of PTSD varies substantially across different
types of traumatic events:
Events that involve a high degree of life threat are most likely to trigger
PTSD in children
Epidemiology:
Children who experience events involving interpersonal violence,
including rape, sexual assault, and physical abuse by caregivers or
romantic partners, have the highest risk of PTSD onset.
Exposure to war and armed conflict are associated with a high
conditional risk of PTSD in children.
High rates of PTSD have been reported in children who are displaced
and living as refugees.
Epidemiology:
Child characteristics:
Girls are two to three times as likely to develop PTSD as
compared with boys.
Although females are more likely to experience certain types of
traumatic events that strongly predict the onset of PTSD, such
as rape and sexual assault, females remain more likely than
males to develop PTSD, even after accounting for these types
of differences in traumatic event exposure.
Epidemiology:
Family characteristics:
Family characteristics influence risk for PTSD:
Meta-analysis indicates that poor family functioning is a risk
factor for PTSD in children exposed to trauma.
Parent reactions to trauma are associated with PTSD in their
children. In some cases, parents develop PTSD symptoms,
depression, anxiety, or other mental disorders following a child’s
exposure to a traumatic event.
Epidemiology:
Responses to the traumatic event:
Cognitive and emotional responses to a traumatic event have been
associated with risk for PTSD in children:
Higher levels of anger about the traumatic event.
Higher levels of rumination (ie, passive and repetitive thinking about
the causes and consequences of one’s distress) and catastrophizing
(ie, overestimating the negative consequences of an event).
More negative appraisals about the traumatic event.
Elevated levels of avoidance and suppression of trauma-related
thoughts.
Dissociation during and after the traumatic event
Comorbidity:
Child PTSD frequently presents with psychiatric comorbidity,
Including:
Anxiety disorders
Depression
Externalizing behavior problems
Substance use disorders among adolescents
PATHOGENESIS
The precise pathophysiology of posttraumatic stress disorder
(PTSD) is unknown.
A predominant learning model of PTSD argues that the
disorder reflects a failure to inhibit fear. Traumatic events can
result in fear conditioning, such that sights, sounds, smells,
people, and other stimuli present during the experience become
associated with the intense fear and arousal experienced during
the event.
PTSD is specifically associated with heightened amygdala
activation, reduced activity in the vmPFC and rostral ACC in
response t emotional or threatening cues, and elevated activity
in the dorsal ACC during fear conditioning, extinction learning
recall, and response selection
Reduced hippocampal volume has been consistently observed
among individuals with PTSD.
Atypical medial prefrontal cortex function has been identified
as a potential familial risk factor for PTSD.
Reduced hippocampal volume has been observed among
veterans with PTSD and their monozygotic twins discordant for
trauma exposure, indicating that some of these neural
differences might increase vulnerability to PTSD.
Assessment:
It is critical to determine whether symptoms are the sequelae of
a traumatic event as opposed to another mental disorder.
To determine whether the presentation is most consistent with
PTSD, assessment should focus on intrusion symptoms:
intrusive thoughts
strong reactivity to trauma cues
Nightmares
repetitive play
avoidance of trauma reminders
hypervigilance
Diagnosis:
The posttraumatic stress disorder (PTSD) diagnosis includes four core
clusters of symptoms:
Intrusion
Avoidance
Negative alterations in cognition and mood
Hyperarousal
Criterion G (required)
Symptoms create distress of functional impairment (e.g., social and
occupational)
Criterion H (required)
Symptoms are not due to medication, substance abuse, or other
illnesses
DSM-5 Criteria: PTSD
Two specifications:
Dissociative Specification. In addition to meeting criteria for
diagnosis, an individual experiences high levels of either of the
following in reaction to trauma-related stimuli:
Depersonalization: Experience of being an outside observer or
detached from oneself (e.g. feeling as if “this is not happening to me”
or one were in a dream)
Derealization: experience of unreality, distance or distortion (e.g.,
“things are not real”)
Delayed Specification. Full diagnostic criteria are not met until
atleast 6 months after the trauma (s), though onse of symptoms
may occur immediately.
Clinical Manifestation:
Intrusion symptoms reflect persistent and uncontrollable
thoughts, dreams, and emotional reactions about a traumatic
event
These symptoms are the hallmark of posttraumatic stress disorder
(PTSD) and distinguish it from other anxiety and mood disorders.
Intrusive thoughts are frequently triggered by trauma cues:
sights, sounds, smells, people, and places that remind the child
of the traumatic event.
Upsetting dreams and nightmares are common in children with
PTSD.
Severe distress and physiologic reactivity in response to cues
associated with the traumatic event.
Avoidance symptoms often develop in response to distressing
and uncontrollable re-experiencing symptoms. Avoidance of
trauma reminders can manifest in two ways:
TRAUMA-FOCUSED PSYCHOTHERAPIES
PTSD is conceptualized as a disorder of fear conditioning that is
both overgeneralized and fails to extinguish normally.
ANTIADRENERGIC MEDICATIONS
• Clonidine and guanfacine
• Prazosin
• Propranolol
SECOND-GENERATION ANTIPSYCHOTICS:
• Risperidone
ANTICONVULSANT MEDICATIONS:
• Carbamazepine
References:
Kaplan and Sadock's Synopsis of Psychiatry 10th ed.
U.S. Department of Veterans Affairs:
PTSD: National Center for PTSD
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