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CASE STUDY Victor (post-traumatic stress disorder)

Case study details.

Victor is a 27-year-old man who comes to you for help at the urging of his fiancée. He was an infantryman with a local Marine Reserve unit who was honorably discharged in 2014 after serving two tours of duty in Iraq. His fiancé has told him he has “not been the same” since his second tour of duty and it is impacting their relationship. Although he offers few details, upon questioning he reports that he has significant difficulty sleeping, that he “sleeps with one eye open” and, on the occasions when he falls into a deeper sleep, he has nightmares. He endorses experiencing several traumatic events during his second tour, but is unwilling to provide specific details – he tells you he has never spoken with anyone about them and he is not sure he ever will. He spends much of his time alone because he feels irritable and doesn’t want to snap at people. He reports to you that he finds it difficult to perform his duties as a security guard because it is boring and gives him too much time to think. At the same time, he is easily startled by noise and motion and spends excessive time searching for threats that are never confirmed both when on duty and at home. He describes having intrusive memories about his traumatic experiences on a daily basis but he declines to share any details. He also avoids seeing friends from his Reserve unit because seeing them reminds him of experiences that he does not want to remember.

• Hypervigilance
• Intrusive Thoughts
• Irritability
• Loss of Interest
• Sleep Difficulties

Diagnoses and Related Treatments

1. posttraumatic stress disorder.

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Post Traumatic Stress Disorder (PTSD)

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• Case Report
• Open access
• Published: 25 November 2008

A case of PTSD presenting with psychotic symptomatology: a case report

• Georgios D Floros 1 ,
• Ioanna Charatsidou 1 &
• Grigorios Lavrentiadis 1  

Cases Journal volume  1 , Article number:  352 ( 2008 ) Cite this article

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A male patient aged 43 presented with psychotic symptomatology after a traumatic event involving accidental mutilation of the fingers. Initial presentation was uncommon although the patient responded well to pharmacotherapy. The theoretical framework, management plan and details of the treatment are presented.

Recent studies have shown that psychotic symptoms can be a hallmark of post-traumatic stress disorder [ 1 , 2 ]. The vast majority of the cases reported concerned war veterans although there were sporadic incidents involving non-combat related trauma (somatic or psychic). There is a biological theoretical framework for the disease [ 3 ] as well as several psychological theories attempting to explain cognitive aspects [ 4 ].

Case presentation

A male patient, aged 43, presented for treatment with complaints tracing back a year ago to a traumatic work-related event involving mutilation of the distal phalanges of his right-hand fingers. Main complaints included mixed hallucinations, irritability, inability to perform everyday tasks and depressive mood. No psychic symptomatology was evident before the event to him or his social milieu.

Mental state examination

The patient was a well-groomed male of short stature, sturdy build and average weight. He was restless but not agitated, with a guarded attitude towards the interviewer. His speech pattern was slow and sparse, his voice low. He described his current mood as 'anxious' without being able to provide with a reason. Patient appeared dysphoric and with blunted affect. He was able to maintain a linear train of thought with no apparent disorganization or irrational connections when expressing himself. Thought content centred on his amputated fingers with a semi-compulsive tendency to gaze to his (gloved) hand. The patient was typically lost in ruminations about his accident with a focus on the precise moment which he experienced as intrusive and affectively charged in a negative and painful way. He could remember wishing for his fingers to re-attach to his hand almost as the accident took place. A trigger in his intrusive thoughts was the painful sensation of neuropathic pain from his half-mutilated fingers, an artefact of surgery.

He denied and thoughts of harming himself and demonstrated no signs of aggression towards others. Hallucinations had a predominantly depressive and ego-dystonic character. He denied any perceptual disturbances at the time of the examination. Their appearance was typically during nighttime especially in the twilight. Initially they were visual only, involving shapes and rocks tumbling down towards the patient, gradually becoming more complex and laden with significance. A mixed visual and tactile hallucination of burning rain came afterwards while in the time of examination a tall stranger clad in black and raiding a tall steed would threaten and ridicule the patient. He scored 21 on a MMSE with trouble in the attention, calculation and recall categories. The patient appeared reliable and candid to the extent of his self-disclosure, gradually opening up to the interviewer but displayed a marked difficulty on describing his emotions and memories of the accident, apparently independent of his conscious will. His judgement was adequate and he had some limited Insight into his difficulties, hesitantly attributing them to his accident.

He was married and a father of three (two boys and a girl aged 7–12) He had no prior medical history for mental or somatic problems and received no medication. He admitted to occasional alcohol consumption although his relatives confirmed that he did not present addiction symptoms. He had some trouble making ends meet for the past five years. Due to rampant unemployment in his hometown, he was periodically employed in various jobs, mostly in the construction sector. One of his children has a congenital deformity, underwent several surgical procedures with mixed results and, before the time of the patient's accident, it was likely that more surgery would be forthcoming. The patient's father was a proud man who worked hard but reportedly was victimized by his brothers, they reaping the benefits of his work in the fields by manipulating his own father. He suffered a nervous breakdown attributed to his low economic status after a failed economic endeavour ending in him being robbed of the profits, seven years before the accident. There was no other relevant family history.

Before the accident the patient was a lively man, heavily involved as a participant and organizer in important local social events from a young age. He was respected by his fellow villagers and felt his involvement as a unique source of pride in an otherwise average existence. Prior to his accident, the patient was repeatedly promised a permanent job as a labourer and fate would have it that his appointment was supposedly approved immediately after the accident only to be subsequently revoked. He viewed himself as an exploited man in his previous jobs, much the same way his father was, while he harboured an extreme bitterness over the unavailability of support for his long-standing problems. His financial status was poor, being in sick-leave from his previous job for the last four months following the accident and hoping to receive some compensation. Although his injuries were considered insufficient for disability pension he could not work to his full capacity since the hand affected was his primary one and he was a manual labourer.

Given that the patient clearly suffered a high level of distress as a result of his hallucinatory experiences he was voluntary admitted to the 2nd Psychiatric Department of the Aristotle University of Thessaloniki for further assessment, observation and treatment. A routine blood workup was ordered with no abnormalities. A Rorschach Inkblot Test was administered in order to gain some insight into patient's dynamics, interpersonal relations and underlying personality characteristics while ruling out any malingering or factitious components in the presentation as suggested in Wilson and Keane [ 5 ]. Results pointed to inadequate reality testing with slight disturbances in perception and a difficulty in separating reality from fantasy, leading to mistaken impressions and a tendency to act without forethought in the face of stress. Uncertainty in particular was unbearable and adjustment to a novel environment hard. Cognitive functions (concentration, attention, information processing, executive functions) were impaired possibly due to cognitive inability or neurological disease. Emotion was controlled with a tendency for impulsive behaviour; however there was difficulty in processing and expressing emotions in an adaptive manner. There were distinct patterns of aggression and anger towards others but expressing those patterns was avoided, switching to passivity and denial rather than succumbing to destructive urges or mature competitiveness. Self-esteem was low with feelings of inferiority and inefficiency.

A neurological examination revealed a left VI cranial nerve paresis, reportedly congenital, resulting in diplopia while gazing to the extreme left, which did not significantly affect the patient. The patient had a chronic complaint of occasional vertigo, to which he partly attributed his accident, although the symptoms were not of a persisting nature.

Initial diagnosis at this stage was 'Psychotic disorder NOS' and pharmacological treatment was initiated. An MRI scan of the brain with gadolinium contrast was ordered to rule out any focal neurological lesions. It was performed fifteen days later and revealed no abnormalities.

Patient was placed on ziprasidone 40 mg bid and lorazepam 1 mg bid. He reported an immediate improvement but when the attending physician enquired as to the nature of the improvement the patient replied that in his hallucinations he told the tall raider that he now had a tall doctor who would help him and the raider promptly left (sic). Apparently, the random assignment of a strikingly tall physician had an unexpected positive effect. Ziprasidone gradually increased to 80 mg bid within three days with no notable effect to the perceptual disturbances but with the development of akathisia for which biperiden was added, 1 mg tid. Duloxetine was added, 60 mg once-daily, in a hope that it could have a positive effect to his mood but also to this neuropathic pain which was frequent and demoralising. The patient had a tough time accommodating to the hospital milieu, although the grounds were extended and there was plenty of opportunity for walks and other activities. He preferred to stay in bed sometimes in obvious agony and with marked insomnia. He presented a strong fear for the welfare of his children, which he could not reason for. Due to the apparent inability of ziprasidone to make a dent in the psychotic symptomatology, medication was switched to amisulpride 400 mg bid and the patient was given a leave for the weekend to visit his home. On his return an improvement in his symptoms was reported by him and close relatives, although he still had excessive anxiety in the hospital setting. It was decided that his leave was to be extended and the patient would return for evaluation every third day. After three appointments he had a marked improvement, denied any psychotic symptoms while his sleep pattern improved. A good working relationship was established with his physician and the patient was with a schedule of follow-up appointments initially every fifteen days and following two months, every thirty days. His exit diagnosis was "Psychotic disorder Not Otherwise Specified – PTSD". He remained asymptomatic for five months and started making in-roads in a cognitively-oriented psychotherapeutic approach but unfortunately further trouble befell him, his wife losing a baby and his claim to an injury compensation rejected. He experienced a mood loss and duloxetine was increased to 120 mg per day to some positive effect. His status remains tenuous but he retains a strong will to make his appointments and work with his physician. A case conceptualization following a cognitive framework [ 6 ] is presented in Figure 1 .

Case formulation – (Persistent PTSD, adapted from Ehlers and Clark [ 6 ] ) . Case formulation following the persistent PTSD model of Ehlers and Clark [ 6 ]. It is suggested that the patient is processing the traumatic information in a way which a sense of immediate threat is perpetuated through negative appraisals of trauma or its consequences and through the nature of the traumatic experience itself. Peri-traumatic influences that operate at encoding, affect the nature of the trauma memory. The memory of the event is poorly elaborated, not given a complete context in time and place, and inadequately integrated into the general database of autobiographical knowledge. Triggers and ruminations serve to re-enact the traumatic information while symptoms and maladaptive coping strategies form a vicious circle. Memories are encoded in the SAM rather than the VAM system, thus preventing cognitive re-appraisal and eventual overcoming of traumatic experience [ 4 ].

The value of a specialized formulation is made clear in complex cases as this one. There is a relationship between the pre-existing cognitive schemas of the individual, thought patterns emerging after the traumatic event and biological triggers. This relationship, best described as a maladaptive cognitive processing style, culminates into feelings of shame, guilt and worthlessness which are unrelated to similar feelings, which emerge during trauma recollection, but nonetheless acts in a positive feedback loop to enhance symptom severity and keep the subject in a constant state of psychotic turmoil. Its central role is addressed in our case formulation under the heading "ruminations" which best describes its ongoing and unrelenting character. The "what if" character of those ruminations may serve as an escape through fantasy from an unbearably stressful cognition. Past experience is relived as current threat and the maladaptive coping strategies serve as negative re-enforcers, perpetuating the emotional suffering.

The psychosocial element in this case report, the patient's involvement with a highly symbolic activity, demonstrates the importance of individualising the case formulation. Apparently the patient had a chronic difficulty in expressing his emotions and integrating into his social surroundings, a difficulty counter-balanced somewhat with his involvement in the local social events which gave him not only a creative way out from any emotional impasse but also status and recognition. His perceived inability to continue with his symbolic activities was not only an indicator of the severity of his troubles but also a stressor in its own right.

Complex cases of PTSD presenting with hallucinatory experiences can be effectively treated with pharmacotherapy and supportive psychotherapy provided a good doctor-patient relationship is established and adverse medication effects rapidly dealt with. A cognitive framework and a Rorschach test can be valuable in deepening the understanding of individuals and obtaining a personalized view of their functioning and character dynamics. A biopsychosocial approach is essential in integrating all aspects of the patients' history in a meaningful way in order to provide adequate help.

Patient's perspective

"My life situation can't seem to get any better. I haven't had any support from anyone in all my life. Leaving home to go anywhere nowadays is hard and I can't seem to be able to stay anyplace else for a long time either. Just getting to the hospital [where the follow-up appointments are held] makes me very nervous, especially the minute I walk in. Can't seem to stay in place at all, just keep pacing while waiting for my appointment. I am only able to open up somewhat to my doctor, whom I thank for his support. Staying in hospital was close to impossible; I was very stressed and particularly concerned for my children, not being able to be close to them. I still need to have them near-by. Getting the MRI scan was also a stressful experience, confined in a small space with all that noise for so long. I succeeded only after getting extra medication.

I hope that things will get better. I don't trust anyone for any help any more; they should have helped me earlier."

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Abbreviations

stands for 'Post Traumatic Stress Disorder'

for 'Verbally Accessible Memory'

for 'Situationally Accessible Memory'

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Acknowledgements

The authors wish to acknowledge the valuable support and direction offered by the department's chair, Professor Ioannis Giouzepas who places the utmost importance in creating a suitable therapeutic environment for our patients and a superb learning environment for the SHO's and registrars in his department.

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2nd Department of Psychiatry, Psychiatric Hospital of Thessaloniki, 196 Langada str., 564 29, Thessaloniki, Greece

Georgios D Floros, Ioanna Charatsidou & Grigorios Lavrentiadis

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Correspondence to Georgios D Floros .

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The authors declare that they have no competing interests.

Authors' contributions

GF was the attending SHO and the major contributor in writing the manuscript. IC performed the psychological evaluation and Rorschach testing and interpretation. GL provided valuable guidance in diagnosis and handling of the patient. All authors read and approved the final manuscript.

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Floros, G.D., Charatsidou, I. & Lavrentiadis, G. A case of PTSD presenting with psychotic symptomatology: a case report. Cases Journal 1 , 352 (2008). https://doi.org/10.1186/1757-1626-1-352

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Received : 12 September 2008

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Published : 25 November 2008

DOI : https://doi.org/10.1186/1757-1626-1-352

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• Ziprasidone
• Psychotic Disorder
• Amisulpride
• Hallucinatory Experience

Cases Journal

ISSN: 1757-1626

Case Example: Mike, a 32-year-old Iraq War Veteran

Mike engages in EMDR and through the simultaneous eye movements and exposure to traumatic memory, finds reduction in his distress and changes in his thinking.

About this Example

Mike’s Story

Mike was a 32-year-old flight medic who had completed two tours in Iraq. He had been discharged from the Army due to his posttraumatic stress disorder (PTSD) and was divorced with a 2-year-old son. The Army psychologist referred Mike for treatment of his PTSD with Eye Movement Desensitization and Reprocessing (EMDR) therapy and he traveled to the therapist’s location in Clarksville, TN. He received five successive days of EMDR therapy, twice a day.

EMDR therapy’s theoretical model, the Adaptive Information Processing (AIP) model, views pathology as being the result of maladaptive, unprocessed memories. Such unprocessed disturbing memories continue to carry a high emotional charge that, when triggered, create the symptoms of PTSD and/or other disorders. In contrast, memories that have been adequately processed, even if they were distressing at the time of the occurrence, can be remembered without being relived or emotionally activated. EMDR therapy treats past disturbing memories, present triggers, and prepares the person to effectively manage similar situations in the future. It uses an eight-phase approach: (1) History-taking; (2) Preparation; (3) Assessment; (4) Desensitization; (5) Installation; (6) Body Scan; (7) Closure; and, (8) Reevaluation. When Mike arrived for EMDR therapy, the first session reviewed his history and prepared him for EMDR treatment. The Preparation Phase provided Mike with a technique to use to access a positive state of safety and calm. This helps ensure a sense of confidence and control if needed both during and in-between sessions. He identified 10 distressing target events related to his service as a combat medic. He also described a childhood incident that occurred when his father informed Mike (age 7 years) that he was moving away, separating from his mother, and that Mike would now be the man of the house responsible for his mother. All of these memories were directly addressed in subsequent sessions.

The session described in this case report, his seventh session, addresses Mike's memory of a mass casualty incident. He initially rated his subjective units of disturbance (SUD) score (where 0=no disturbance and 10=worst possible) for this event at a 10. During this incident, Mike and his fellow medic Sid had rescued two soldiers who had been badly injured when their Humvee had struck an improvised explosive device (IED). The session begins with the Assessment phase, in which the therapist guides Mike in identifying and rating the relevant components of the targeted memory (i.e., image, negative belief, emotion, body sensations). Mike becomes agitated and angry as he begins to recall the incident. He has difficulty focusing and tells a disjointed and chaotic account of the event, rather than responding to the questions.

Therapist: As you focus on the last mission, what picture represents the worst part of that memory?

Mike: The doctor in the CaSH (combat support hospital) was saying, "He’s gone." I started to cry. Sid got me by the collar and said, "Come on now" and he pulled me away.… One of the worst days. The whole mission was the f***ing worse image.

Therapist: What words would best describe your negative belief about yourself now?

Mike: Indecisive. “Let me ask you, with utmost respect, where are we going with this? That mission was f***ed up! We were in charge, we took too long.

Therapist: I heard you say something to the effect, "I let the soldiers down." What’s the negative belief about yourself as you think about it now?

Mike: I’m a failure.

Therapist: So if you think about what you’d like to believe about yourself, instead of "I’m a failure," would it be, "I did the best I could"?

Mike: No, I didn’t – I failed them. I’m sorry, I’m completely trying to help you, but I failed them. I failed them.

Mike is resistant to even naming a positive belief, but finally agrees that he would like to believe, “I did the best I could” and gives it a ‘1’ rating on the validity of cognition (VOC) scale of 1 (where 1=completely false and 7= completely true). He says that the emotion he feels is “pain” and gives the memory a SUD score of 10. “I feel I deserve to feel it.” He identifies the location of any negative sensations in his body as in his “heart.”

The therapist then starts the Desensitization Phase, and asks Mike to think of the incident, the negative cognition “I’m a failure”, and the body location and to hold these in mind while following the therapist’s left-right hand movements with his eyes, for about 30 seconds. At the end of the set of eye movements, he instructs the client to take a deep breath and let it all go, and then asks what the client now notices.

Mike: I’m confused.

Therapist:  "Go with that."

<Eye movements and silence.>

"Take a deep breath. Let it all go. What do you get now?"

(The therapist's phrasing may vary slightly and the therapist is silent or minimally encouraging during the eye movements. This sequence is repeated and represented below by ***************)

Mike: It must have been a big bomb, because the Humvee was lying on its side.

Therapist: ***************

Mike: I wanted to help them so bad, I didn’t care about the (unexploded) bomb.… I walked right in front of it. I wanted the solider out of the vehicle. Sid was already giving his patient help while I was still trying to find a way to help the soldier.…

Mike: ...It’s our job to save people’s lives. So you need to do your job, and when you don’t people die. I can’t think of a higher responsibility in the army …

Therapist: Who decides if a person lives or dies?

Mike: God does.

A few sets of eye movements and responses follow, focusing on how it is God’s decision if someone dies, not Mike’s.

Therapist: *************** 

Mike : It sucks. It sucks that we weren’t able to save those soldiers.… It’s a fool’s errand. Every time you go out, the choice isn’t up to you. We pulled a lot of people back from death.

The therapist, a veteran, picks up on a theme Mike has been getting at that is consistent with his military training.

Therapist: We are not judged by how many we save, but whether we do our best. ************

Mike: I was doing my best on the mission.

In the next few sets, he recalls incidents when his role was compromised by decisions made by superiors. “It was not my decision...maybe I don’t need to hold onto it.” A number of sets follow on the issue of responsibility and decisions.

Therapist: What would Sid say to you about the incident?

Mike: ...Your guy was f***ed man. I knew that.

Mike: ...That night on the ground,… we stepped up, we handled it like professionals. Those guys were bad off.

Therapist: ************

Mike: I’m trying to ask you, "How did you do that?" That pit in my chest is not there. God, it’s not there. This is all I had do for the last four years?! This is different. I don’t feel heavy. I wish those guys hadn’t died. I feel different about it. I kept thinking EMDR won’t work with this one.… I really didn’t let those guys down. I’m not God. I wish I could have saved them but they were so bad off.… War is so horrible. It’s OK. I was there. It’s conflicting emotions.

Mike: ...I see that I can carry (the memory) with pride. I can carry it for those guys...

Mike then tells the therapist that the incident no longer causes him any emotional disturbance (SUD=0) and treatment moves into the Installation phase. Mike confirms that his preferred positive cognition is still “I did the best I could.” The therapist tells Mike to think of this cognition while thinking of the event, and to rate it on the VOC scale and Mike gives it a VOC score of 7, totally true.

The therapist then asks Mike to scan his body for any disturbance (phase 6). Mike explains to the therapist that he still feels sad that the men died, but that he feels “OK”. The session (phase 7) is closed with the therapist asking Mike about his experience in the session.

Therapist: Is there anything you learned or gained today?

Mike: I didn’t know it could be like this. It’s like I’ve got on a different pair of glasses. Strange. So fresh. I’m so surprised. You helped me see. I feel lighter. (The treatment) doesn’t fix the problem. It makes me different.

Treatment continued with other targeted memories. On Friday of that week the therapist used the Future Template to prepare him to go home. He no longer reported any PTSD symptoms. After returning home, Mike enrolled in vocational rehab and trained to be a medical technician. After 18 months, the therapist lost track of him as he relocated somewhere on the west coast.

In addition to illustrating the desensitization of distress, the session illustrates shifts in cognition. From the perspective of the AIP theoretical model, disturbing memories are stored in an isolated manner, and not connected to more adaptive or contextual information. During EMDR therapy, the client spontaneously accesses related information, and the new material links up with the disturbing memory, transforming it. In this session, Mike recalls details about the incident, putting into perspective the severe injuries of the soldier and what he could realistically do and not do, and his own bravery and determination to save the soldier at all costs. He remembers positive memories of his colleague Sid, and other aspects of his experience in the army and as a medic in Iraq, saving many lives.

Mike also noted how the session had changed him, as though he was “wearing a different pair of glasses.” The treatment addressed Mike’s belief, instilled when his father left during childhood, that his role was to be responsible for the well-being of others. While training to be an Army medic at Ft. Sam Houston, Mike was taught, “If you don’t do your job, people die.” In his mind, he unconsciously reversed that to be, “If people die on you, it means you did not do your job.” By the end of the session, Mike had realized that the soldier’s death was not his fault and that he could let go of the burden of responsibility. He said, “I feel lighter.” The session also changed his feelings about what had occurred. Instead of feeling shame and guilt, he said, “I can carry the memory with pride.”

Case presentation written by Drs. E.C. Hurley, Louise Maxfield, and Roger M. Solomon.

Updated July 31, 2017 

Other Case Examples

• Cognitive Behavioral Therapy Jill, a 32-year-old Afghanistan War Veteran
• Cognitive Therapy Philip, a 60-year-old who was in a traffic accident (PDF, 294KB)
• Narrative Exposure Therapy Eric, a 24-year-old Rwandan refugee living in Uganda (PDF, 28KB)
• Prolonged Exposure Therapy Terry, a 42-year-old earthquake survivor

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A Case of Pediatric Post-Traumatic Stress Disorder Presenting as Attention Deficit Hyperactivity Disorder: A Case Report

Muhammad a tahir.

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Nusrat Jahan

3 Psychiatry, Mount Sinai Chicago

In the past few years, there has been increased recognition that children, who have faced traumatic incidences, can develop post-traumatic stress disorder (PTSD), just like in adults. We present a case of PTSD in a 6-year-old child who endured three surgical procedures because he was suffering from a congenital cranial stenosis (Pfeiffer) syndrome. Because of repetitive painful episodes, resulting from the syndrome, and then post-surgical complications, the child developed behavioral outbursts, hypervigilence, concentration problems, and irritability. In the past, the child was diagnosed with attention deficit hyperactivity disorder (ADHD) in the realm of his behavioral complaints, and he was already on stimulant medications for last one year. But there was no remarkable effect of pharmacotherapy on child’s behavior despite increasing dosages. Ultimately the child’s medical and psychiatric history was reviewed and a diagnosis of pediatric PTSD was made. Stimulant medications were discontinued and management was started on the lines of pediatric PTSD, resulting in a remarkable improvement in child’s psychiatric outcome.

Introduction

The term post-traumatic stress disorder (PTSD) was first coined in Diagnostic and Statistical Manual of Mental Disorders (DSM) 3. The DSM-4 describes three symptom clusters in PTSD: persistent re-experiencing of the trauma (e.g., intrusive memories and flashback experiences, often triggered by exposure to traumatic reminders, and recurring trauma-related nightmares); avoidance of traumatic reminders (including places, people, and conversations) and a general numbing of emotional responsiveness; and chronic physiological hyperarousal, including sleep disturbances, poor concentration, and hypervigilance to threat. In order to meet the PTSD diagnosis, at least one re-experiencing symptom, three avoidance/numbing symptoms, and two hyperarousal symptoms should be present for at least one month, and must cause significant distress or functional impairment [ 1 ]. When symptom duration is less than one month, a diagnosis of acute stress disorder (ASD) is made [ 1 ]. Children who are suffering from chronic syndromes need multiple admissions, medical and surgical interventions, and sometimes on top of that they have to face complications. Multiple cycles of hospital admissions, therapies, and complications pose significant stressors to a child’s psychological health. In this article, we will describe a case report of a pediatric PTSD. Our main aim is to help the pediatricians in early diagnosing and managing the PTSD in pediatric population.

Case presentation

A 6-year-old child with past history of cranial stenosis (Pfeiffer) syndrome and attention deficit hyperactivity disorder (ADHD) was referred to the psychiatric emergency of a tertiary care hospital in Faisalabad, Pakistan. Complaints at the presentation were worsening aggression and behavioral outbursts that had caused the patient to be picking at his sutures leading to dehiscence of the suture sites along with multiple episodes of sleep problems, increased arousal, exaggerated startle, hypervigilance, and behavioral reenactment for the past three years. Patient’s mother reported that there were many times when the child lost control and there had been many spells of worsening of such behavior especially when the child is brought to the hospital for the management of cranial stenosis syndrome. The patient had three surgeries in the past at the ages of 2, 3, and 6 years. The first surgical procedure was fronto-orbital advancements for bilateral coronal synostosis. Wound infection and septicemia developed as part of post-surgical complication and prolonged the hospital stay. The second and third surgical procedures were mainly dental interventions for overcrowding teeth. The patient was diagnosed with ADHD because of the behavioral symptoms and he was started on the Adderall and clonidine one year ago. Parents reported no significant improvement in the psychiatric symptoms. On examination, the child was very aggressive and did not engage well in the mental status and physical examinations. We reviewed the patient’s history of ADHD under the DSM-5 criteria and found that the child is not fulfilling the entire criteria. So we ruled out ADHD and the history of pediatric PTSD was taken in the light of DSM-5 criteria, and the child fulfilled the criteria and so the management was started on the lines of pediatric PTSD. Stimulants and clonidine were gradually discontinued. Trauma-focused psychotherapy was started under the supervision of psychotherapist. Aggression episodes, hypervigilance, and sleep problems declined gradually over a period of three months. The child is no longer picking at his suture sites. Parents reported that whenever the child is brought to the hospital, there are episodes of increased arousal, but overall the behavioral health is much better as compared to earlier.

PTSD in children occurs when the child is exposed to a traumatic event such as injuries, accidents, death, physical and sexual violence, and recurrent painful episodes because of some diseases, its complications, or management. Prevalence is higher for female than male (8.0% vs. 2.3%) and increases with age [ 2 ]. Children with subthreshold criteria for PTSD demonstrate substantial functional impairment and distress [ 3 ]. An undiagnosed case of PTSD in children can have long lasting complications like major depression, aggression, substance abuse and dependence, suicides and physical comorbidities (chronic fatigue, fibromyalgia, irritable bowel syndrome) [ 4 ]. The American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5), lists the following diagnostic criteria for PTSD in adults, adolescents, and children older than 6 years [ 5 ]:

Exposure to actual or threatened death, serious injury, or sexual violence (any undesired sexual activity is sexual violence) Presence of one or more specified intrusion symptoms in association with the traumatic event(s) Persistent avoidance of stimuli associated with the traumatic event(s) Negative alterations in cognitions and mood associated with the traumatic event(s) Marked alterations in arousal and reactivity associated with the traumatic events(s) Duration of the disturbance exceeding one month Clinically significant distress or impairment in important areas of functioning Inability to attribute the disturbance to the physiologic effects of a substance or another medical condition

DSM-5 criteria for PTSD in children aged 6 years or younger are as follows:

Directly experiencing the traumatic event, witnessing the event, or learning it occurred to a parent or caregiver Intrusion symptoms associated with the event (recurrent memories, distressing dreams, dissociative reactions, marked distress, or physiological reaction in response to exposure to traumatic triggers) Avoidance of situations or things that arouse recollections of the trauma OR negative alterations in cognitions (increased negative emotions, decreased interest in significant activities, social withdrawal, decreased positive emotions) Alterations in arousal and reactivity associated with the traumatic events (two of irritability, hypervigilance, exaggerated startle, concentration problems, sleep disturbance ) Duration of the disturbance exceeding one month Clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or in school behavior Inability to attribute the disturbance to the physiologic effects of a substance or another medical condition

There are no specific laboratory tests for PTSD. Several psychometric measures, such as semistructured interviews or self-report measures, are used to evaluate PTSD in children. Child PTSD Symptom Scale (CPSS) is an effective scale with the sensitivity of 84% and specificity of 72% [ 6 ]. Management starts with the safety. The child should be in the safe environment. If there is suspicion of child abuse, child protective services (CPS) should be called. Non-pharmacological therapies in the form of trauma-focused cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) are the preferred initial management strategy for PTSD in children. DBT, helping children and adolescents to deal with painful feelings, may be necessary before CBT can be done [ 7 ]. Currently, no selective serotonin reuptake inhibitors (SSRIs) are food and drug administration (FDA) approved for the treatment of PTSD in the pediatric population. But, in children with persistent symptoms despite psychotherapeutic interventions, pharmacologic treatment may be used. Pharmacologic agents that can be considered in this aspect are SSRIs though not FDA approved, alpha-adrenergic agonists (e.g., guanfacine and clonidine), and beta-blockers (e.g., propranolol).

It is not unusual that the symptoms of pediatric PTSD may mimic like ADHD. It is very important for the physicians to imply the ADHD DSM-5 diagnostic criteria comprehensively. DSM-5 criteria for the diagnosis of ADHD needs to fulfil the following sub-criteria: at least six or more symptoms either of inattention or hyperactivity for the period of six months, symptoms should be present prior to age of 12 years and must be in two different settings, symptoms should reduce the quality of life, and the symptoms are not better explained by other mental disorders. Just using the symptoms to diagnose ADHD and not paying attention to other factors like age, setting, quality of life affected, and excluding other psychiatric diseases may result in over-diagnosis of the ADHD. Stimulants have excellent results for ADHD in adolescents and good results in children. If in a child (like in this case), stimulants are not improving the symptoms of ADHD, then the health-care provider should review the diagnosis of ADHD.

Conclusions

Pediatric population suffering from chronic and congenital anomalies is exposed to multiple painful episodes because of diseases, their complications, and management. Mental health physicians should have a low threshold for pediatric post-traumatic stress order in these circumstances.

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The authors have declared that no competing interests exist.

Human Ethics

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