Question 1

A 45-year-old woman presents for "treatment-resistant depression." She has tried four antidepressants over 5 years with no significant improvement. She reports persistent emotional numbness, inability to enjoy anything, chronic insomnia with nightmares, avoidance of intimacy, and difficulty trusting others. She has never been asked about trauma history. When asked directly, she discloses a history of prolonged childhood sexual abuse. What is the most important diagnostic consideration?

Accepted Answer

When "treatment-resistant depression" includes nightmares, avoidance, emotional numbing, and an undisclosed trauma history, reconsider the diagnosis before escalating antidepressant treatment. Her symptoms map directly onto PTSD clusters, and the failure to respond to antidepressants is a red flag that the primary diagnosis may be wrong. Childhood trauma does not become irrelevant with time - PTSD can persist for decades when untreated.

Question 2

A 30-year-old male paramedic presents 4 months after responding to a call where a child died despite his resuscitation efforts. He reports no nightmares or flashbacks. His primary symptoms are persistent guilt ("If I had been faster, the child would have lived"), pervasive belief that the world is unsafe, emotional detachment from his wife and children, loss of interest in activities, chronic irritability, and difficulty sleeping. Does he meet criteria for PTSD despite the absence of prominent intrusion symptoms?

Accepted Answer

PTSD does not require flashbacks or nightmares to be the dominant symptoms. Cluster B requires at least one intrusion symptom, which could be physiological reactivity to trauma cues rather than overt flashbacks. Cluster D and E-dominant presentations are common and frequently missed because clinicians expect the "classic" intrusion-heavy presentation. This is not adjustment disorder because the event (witnessing a death during professional duties) meets Criterion A, and his symptoms span multiple clusters. Moral injury is a clinical concept, not a formal diagnosis, and can co-occur with PTSD.

Question 3

A 22-year-old college student presents 3 months after being sexually assaulted at a party. She has nightmares twice weekly, avoids the neighborhood where the assault occurred, feels detached from friends, and has an exaggerated startle response. She also reports feeling persistently detached from her own body, as though watching herself from the outside, and describes the world as looking "foggy and unreal." What PTSD subtype should be assessed?

Accepted Answer

The dissociative subtype of PTSD involves persistent depersonalization and/or derealization in addition to full PTSD criteria, and it carries specific treatment considerations. Three months is not delayed expression - the delayed expression specifier requires full criteria not being met until at least 6 months after the event. Depersonalization/derealization disorder would be considered if these symptoms occurred outside the context of PTSD, but here they co-occur with a full PTSD presentation. The dissociative subtype is associated with more severe trauma, higher comorbidity, and may require stabilization before exposure-based treatment.

Post-Traumatic Stress Disorder

Red Flags & Key Clinical Considerations

Undisclosed Trauma History

Treatment-Resistant Depression

Substance Use Mapping to Symptom Clusters

Anger as the Presenting Problem

Premature Diagnosis in the Acute Window

Related Medications

Practice With Related Cases

References & Further Reading