At presentation, we diagnosed Julie as having chronic posttraumatic stress disorder (PTSD), recurrent major depressive disorder, and eating disorder not otherwise specified. At 5 feet, 7 inches and 190 pounds, her body mass index is 30 kg/m2, indicating clinical obesity. She has been taking duloxetine, 60 mg/d, extended release dextroamphetamine, 20 mg/d, aripiprazole, 20 mg/d, and amitriptyline, 10 mg/d nightly. She also has been taking sumatriptan, 100 mg as needed, for migraines.
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The authors’ observations
After a life-threatening sexual assault, Julie suddenly became irritable and hostile. She could not keep relationships, yet she feared being alone. She impulsively hurt herself, experienced nightmares, and systematically avoided school activities. These behaviors suggest PTSD,1 which is prevalent among sexual assault victims (Box 1). For 3 years, however, psychiatrists kept missing the diagnosis as Julie kept her shame a secret.
Julie tells us that she re-experiences trauma-related dysphoria when exposed to cues, such as the anniversary of the rape. She endorses avoidance symptoms, including feelings of estrangement from her family and friends. She shuns thoughts, feelings, places, and conversations associated with the trauma, which partly explains her refusal to stay in school. She reports arousal symptoms, including difficulty falling and staying asleep and fears of harm if left alone, even during the day. At night she has rituals for checking windows and doors to ensure they are locked.
Julie’s decision to hide her trauma was understandable given her age and developmental phase. For a teenager trying to separate from her parents and fit in at school, the humiliation was overwhelming. She lacked the cognitive tools to process and describe her experience. She was assaulted while on a date, normally a positive rite of passage. Further, as a young Hispanic/Native American, Julie feared disappointing her Caucasian parents by not fitting in at school.
When a previously well-adjusted teenager presents with sudden-onset behavioral problems, ask about past or recent trauma. Watch for contextual, developmental, and sociocultural factors that may prevent the youth from disclosing embarrassing events.
Also question the diagnosis if several adequate medication trials have failed. Check for comorbidities, lack of adherence, or other circumstances that can hamper response to treatment.
What determines progression from trauma to PTSD?
The National Comorbidity Survey estimates lifetime prevalence of PTSD at 7.8%.2 Sexual assault victims face a high risk of PTSD among persons exposed to trauma.3,4
Factors that may influence whether trauma exposure progresses to PTSD:
Natural resiliency
Genetic loading
Type of trauma
Whether the trauma is natural or man-made
Past traumas
Psychiatric comorbidities
When a patient presents immediately after a life-threatening trauma:
Ensure physical and psychological safety
Screen for prior traumas that may increase risk of developing PTSD
Refer for physical examination, particularly for victims of rape or physical violence
PTSD checklists can help confirm the diagnosis (see Related resources)
Factors that may signal ptsd
American Psychiatric Association (APA) practice guidelines for treating PTSD list several factors to consider if you suspect this diagnosis:5
Impulsive and episodic aggression can result from an anticipatory bias that increases readiness for “fight, flight, or freeze.” For Julie, this turned previously comfortable interactions into dissonance and conflict.
Self-injurious and suicidal behaviors often occur when trauma creates stigma, shame, or guilt. Julie felt these emotions while trying to establish herself in a new community and school. Her obesity and ethnic background further set her apart from peers. She also left behind friends who provided emotional support outside the home and helped her differentiate from her mother.
Trauma during early adolescence can impair age-appropriate development, making it difficult to develop a stable self-image, consolidate and integrate the personality, and form relationships. At age 16, poor self-image and maladaptive coping strategies were an enduring pattern in Julie’s life.
Psychiatric comorbidities. Many patients with PTSD develop psychiatric comorbidities that exaggerate symptoms, making the disorder more difficult to detect and treat. Julie’s depression increased her avoidance tendencies and rein-forced her isolation. Difficulty concentrating—misdiagnosed as ADHD—deterred her from engaging in school. Dissociative symptoms related to PTSD impaired her reality testing, diminishing her ability to interact with others.
Treatment: Medication change
We continued extended-release dextroamphetamine, 20 mg/d, as Julie felt the medication helped her focus on her schoolwork. We also:
- weaned her off aripiprazole, which was not helping her symptoms
- stopped amitriptyline and duloxetine because of her history of impulsive overdose and to reduce side-effect risk from polypharmacy
- titrated fluoxetine to 40 mg/d to treat her ongoing chronic depression and added trazodone, 50 mg/d as needed, to help her sleep
- stopped sumatriptan, as the headaches remitted after Julie’s eyes were tested and eyeglasses prescribed.