A 33-year-old woman comes to the physician because of difficulty sleeping. She is afraid of falling asleep and gets up earlier than desired. Six months ago, she was the driver in a car accident that resulted in the death of her unborn child. She has vivid nightmares of the event and reports that she frequently re-experiences the accident.
She blames herself for the death of her child, has stopped working as an accountant, avoids driving in cars, and has withdrawn from her parents and close friends. Which of the following is the most likely diagnosis?
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Correct Answer � B
Explanation
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Post traumatic stress disorder
Major depressive disorder
Major depressive disorder can occur following traumatic events and present with impaired functioning in important areas of life (e.g., work). However, diagnosis of this condition requires at least 5 of 9 A criteria (SIGECAPS), of which this patient only has 2 (sleep disturbances and guilt).
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) can develop in response to experiencing a traumatic event (e.g., a car accident). Symptoms include distressed mood, altered reactivity (e.g., sleep disturbances), avoidance of triggering stimuli (driving in this case), and intrusive symptoms such as flashbacks and nightmares, all of which are present in this patient.
A diagnosis of PTSD is made if these symptoms last > 1 month and impair social and/or occupational functioning as seen in this woman, who has stopped working and withdrawn from her friends and family.
Treatment of PTSD includes cognitive behavioral therapy and pharmacological therapy with SSRIs, SNRIs (first-line), and prazosin (to improve sleep).
Major depressive disorder with peripartum onset
Major depressive disorder with peripartum onset can occur following miscarriage and intrauterine fetal demise and present with impaired functioning in important areas of life (e.g., work). However, diagnosis of this condition requires at least 5 of 9 A criteria (SIGECAPS), of which this patient only has 2 (sleep disturbances and guilt).
Normal grief
Normal grief can manifest with sleep disturbances and feelings of guilt following the loss of a loved one as seen in this patient who has lost her child. However, normal grief does not normally impair daily functioning. This patient’s inability to work, avoidance of driving, and social withdrawal all suggest a pathological condition. Furthermore, flashbacks are not a feature of normal grief.
