Narcissism

Post-traumatic stress disorder

This is a case about a 26 year old female that was a victim of a snatch and grab robbery. She had her purse forcefully taken from her left shoulder. She had the purse strap in her hand and the assailant pulled the strap out of her hand and forced the shoulder into guarded flexion. The scapula was also taken forcefully into protraction. The assailant then knocked the victim onto the ground on her right shoulder/upper back. The victim felt pain in her neck and in the shoulder girdle bilaterally. Over the next 24 hours, she developed pain in her entire back, buttocks, legs, and arms. She also had a headache. Exam reveals restriction with pain in the cervical range of motion. Shoulder range of motion was painful and restricted bilaterally. Exquisite tenderness was noted in almost any area of the body. Her affect was flat and noted on the exam form. For our purposes of discussion in this case, we will assume that this incident occurred 3 months ago and there was no fracture to any osseous structure in the body.

To begin, we need to start with the self reported history. Of particular interest to us is the past medical history, current medications (prescribed or not prescribed), past trauma history (including this one), family history, social history, and psychological history. We will focus on the psychological history for this discussion.

With regard to her flat affect while undergoing the physical exam, we need to be cognizant of any residual posttraumatic symptoms that the victim may be enduring. Posttraumatic stress disorder (PTSD) is a pathological anxiety that usually occurs after an individual experiences or witnesses severe trauma that constitutes a threat to the physical integrity or life of the individual or of another person (Gore). The events experienced may be natural disasters, violent personal assaults (as in our case), war, severe automobile accidents, or the diagnosis of a life-threatening condition. PTSD can be acute (symptoms lasting 3 mo), or of delayed onset (6 mo elapses from event to symptom onset).

We want to know how the victim responded initially. Did she respond with intense fear, helplessness, or horror? We also want to know if she is persistently re-experiencing the event, with resultant symptoms of numbness, avoidance, and hyper arousal (Stevens). These symptoms result in clinically significant distress or functional impairment. To meet the full criteria for PTSD, these symptoms should be present for a minimum of 1 month following the initial traumatic event (Gore). We would need to further develop the post-incident history to see how she reacted. We want to know if she is having nightmares, fear of current stimuli that resemble the original event, amnesia of the incident, numbing or decreased interest of others, estrangement, or an inability to feel positive. This victim is feeling the effects of the incident many months after the fact so this would help rule out acute stress disorder which is normal response and passes within a few days. She is also experiencing a generalized pain pattern that may be indicative of a chronic pain syndrome in addition to the pain in the neck, upper back, and headaches. Another important differential to rule out would be a somatization disorder since she did not present initially with a long drawn out, exaggerated history of the incident along with an extensive medical history.

Chronic pain syndrome (CPS) is a common problem that presents a major challenge to healthcare providers because of its complex natural history, unclear etiology, and poor response to therapy. CPS is a poorly defined condition. Most consider ongoing pain lasting longer than 6 months as diagnostic, and others have used 3 months as the minimum criterion. Some authors suggest that any pain that persists longer than the reasonable expected healing time for the involved tissues should be considered chronic pain.

The pathophysiology of CPS is complex and is poorly understood. Some suggest that CPS is learned behavior that begins with a noxious stimulus that causes pain. This pain behavior then is rewarded externally or internally. Internal reinforcers are relief from personal factors associated with many emotions (e.g., guilt, fear of work, sex, responsibilities). External reinforcers include such factors as attention from family members and friends, socialization with the physician, medications, compensation, and time off from work.

We need to know if this patient is under care for other psychological syndromes such as major depression, somatization disorder, or hypochondriasis. Focus the history on a characterization of the patient's pain. Obtaining the characteristics of the pain helps establish appropriate diagnostic and therapeutic plans. We can see how she describes the pain on the Visual Analog Scale attached to the vignette.

The location of pain is an important part of the history. We would ask questions about factors that provoke or intensify pain, any factors that help