According to the symptoms that Cynthia presented in the vignette, there can be deduced that she suffers from Post-Traumatic Stress Disorder (PTSD), which appears after a traumatic experience, determining the individual suffering of this disorder to be highly vigilant, to relive the emotions of the traumatic event, to manifest increased arousal and avoidance behavior, to start numbing or to indicate that his/her function is affected, over a period longer than a month (“Mental Illness among Trauma-Affected Populations”).
At one glance through Cynthia’s general assessment about her concerns related to the symptoms and the changes in her behavior that she experiences after suffering a car accident, there can be easily identified most of the symptoms defining the PSTD. Cynthia has become extremely vigilant when she drives her car, becoming very anxious and even starts to hyperventilate when she hears the wheels of a large truck next to her, which was the type of automobile with which she entered in the collision in her car accident. Likewise, she manifests avoidance behavior, because she never drives on the freeway and often, in the comfort of her own home even, she relieves the traumatic event, hearing again the screeching of the breaks, feeling as if she was right in the middle of that event. All these symptoms are indicating that this traumatic event is still very vivid in Cynthia’s mind and she feels threatened that a similar event can occur, when she drives, and she feels caught in the moment of the accident, as she vividly recalls it even when she is in a safe place.
Nevertheless, the first indication that Cynthia provided that she “goes blank” and feels “unreel”, detached from her environment and disconnected from her body seem to be enrooted in a different kind of problem. Although there can be argued that the woman feels detached of her body and from her environment because her mind takes her to the place of the event, it seems to be something more to this self-evaluation of her symptoms.
The dissociation from the body and the estate of “going blank” seems to be related to substance use and abuse. Meisler (1996) indicates that there is a high correlation between the PTSD and alcohol or drug abuse, because individuals are seeking to heal their post-traumatic stress disorder by appealing and abusing alcohol or drugs, pointing out that women who experienced PTSD are 28% likely to also abuse alcohol or drugs, leading to dependence.
Actually, in the treatment of PTSD, there are usually prescribed drugs for conducting the healing problems and this assessment also considers the possibility that Cynthia might have received a drug prescription prior to her traumatic experience, to help her get out of the shock and to ease her of the traumatic effects that she expressed, but the patient abused them and she might have even combined the prescribed drugs with alcohol, which could have represented for her a remedy, preventing her from going back to the place of the accident, but causing, however, as a secondary effect, the impression that she became dissociated of her body and the sensation that she goes blank.
More recent research, conducted by Papastavrou, Farmakas, Karayinnis and Kotrotsiuou (2011) also relate to the strong connection between the psychopathological estates and the development of dependence, indicating a strong positive correlation between PTSD and the severity of drug problems, showing that the higher the level of dependence the more serious the PTSD symptoms severity index. Similarly, Kofoed, Friedman & Peck (1993) reveal that individuals who manifest the symptoms for PTSD are likely to also show DSM-III-R symptoms for alcoholism and drug abuse. This would indicate a dual diagnosis for Cynthia, including PTSD and substance use disorder SUD (Kosten, Rounsavillem Babor et al., 1987).
For justifying substance use disorder diagnosis, there are relevant information that Cynthia offered in the vignette, as she states that she feels detached of her body and that she feels “unreal” during the day, which represent signs of depersonalization, which has been identified to be connected to alcohol or drug abuse (Lambert et al., 2001).
Another significant aspect that Cynthia presents is the fact that she has these sensations for about two weeks, which follow the traumatic car incident that has caused her PTSD. Observing that alcohol or drug abuse can represent a method of self-medication for individuals who suffered PTSD events, Meiser (1996) states that PTSD and alcohol and drug use symptoms can have the same evolution or a separate development, yet following a parallel course in time. In Cynthia’s case, there can be observed that she had started manifesting the symptoms of depersonalization two weeks after the car accident, which sustains Meiser’s (1996) observation that PTSD symptoms can be influenced by alcohol or drug abuse symptoms and that the symptoms of the two pathological estates can evolve separately, but having a parallel course over time. As such, as the level of alcohol and drug dependency increases, the symptoms o PTSD become more severe, as proof, in Cynthia’s case, her anxiety and panic related to her traumatic event (feeling that she relives the whole event, even in safe environments or sensing that she begins to sweat and when she sees large trucks approaching). Therefore, the manifestation of her anxiety and panic sensations (specific to the post-traumatic disorder stress), which started in the same time with the sensation of feeling unreal, dissociated from her body, or having a blank mind (specific to depersonalization, probably determined by substance used disorder) indicate and explain the double diagnosis, PTSD and substance use disorder, the latest being the differential diagnosis, rejected for lack of evidences.
For supporting the substance use disorder diagnosis, however, the vignette should have included information regarding Cynthia’s history related to the alcohol or drug use or abuse, if any, indicating how often and in what quantities she used the indicated substances. Also related to the substance use disorder differential diagnosis, the patient should have mentioned in the interview if she started consuming alcohol or drugs prior or before her car accident, as well as if she had ever experienced similar sensations of depersonalization prior to the car accident.
Equally significant for this evaluation, would have been information regarding the psychiatric history of her family, for identifying if members of her family abused alcohol or drugs, developing substance addiction, as the role of genetics has been found highly relevant in establishing one’s vulnerability to addiction (Garnick, Horgan, Acevedo et al., 2012).
Although Cynthia has defined the history of the presenting issue, research show that under-reported symptoms or new information provided by the patient at a later time can change the evaluation/assessment of the patient’s condition, influencing both the diagnosis set and the prescribed treatment (Lambert, Carl, Fewtrell et al., 2001). For the relevance of the differentiating diagnosis, the vignette should have included information regarding what were the woman’s symptoms in the first days and first weeks from the event and whether the woman used or was administered certain medication for potential symptoms of the traumatic event or for exiting the shock, if she expressed such condition after the accident.
In addition, information related to Cynthia’s personal history (other potential trauma in childhood, adolescence or any other time, loss, abuse, education, occupation, socialization, etc.) would represent data significant for the evaluation of the diagnoses.
All these additional information, related to personal history, presenting issue history, alcohol and drug history or family psychiatric history would be relevant not only from evaluating the consistency of the information provided but also from evaluating the way these data are communicated, determining the psychopathology professional to assess signs of trauma, distress, anxiety, nervousness, unbalanced or inappropriate behavior etc. that might have been correlated for sustaining the substance use disorder diagnosis.
References
Garnick, D., W., Horgan, C., M., Acevedo, A., McCorry, F. & Weisner, C. (2012) “Performance measures for substance use disorders-what research is needed?” Addiction Science & Clinical Practice. Vol. 7, no. 18, pp. 1-11.
Kofoed, L., Friedman, M., J. & Peck, R. (1993) “Alcoholism and drug abuse in patients with PTSD” Psychiatric Quarterly. Vol. 64, no. 2.
Kosten, T., R., Rounsaville, B., J., Babor, T., F., Spitzer, R.,L. & Williams, J., B. (1987) “Substance-use disorders in DSM-III-R. Evidence for the dependence syndrome across different psychoactive substances”. Br J Psychiatry. Vol. 151, pp. 834-843.
Lambert, M., V., Carl, S., Fewtrell, D., Phillips, M., L., David, Anthony, S. (2001) “Preliminary communication. Primary and secondary depersonalization disorder: a psychometric study”. Journal of Affective Disorders. Vol. 62, pp. 249-256.
Meisler, A., W. (1996) “Trauma, PTSD and substance abuse” PTSD Research Quarterly. Vol. 7, no. 4., pp. 151-171.
Mental Illness among trauma-affected populations (n.d.) Boston, Boston University, Johns Hopkins Bloomberg School of Public Health.
Papastavrou, E., Farmakas, A., Karayiannis, G. & Kotrotsiou, E. (2011) “Co morbidity of post-traumatic stress disorders and substance use disorder” Health Science Journal. Vol. 2, no. 2, pp. 107-117.
