NU 665: Sleep Disturbances and Medical Comorbidities

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Chosen video: Title 6  

Mental Status Examination

The patient is a middle-aged female with sleep disturbance, anxiety, and emotional distress following a traumatic motor vehicle accident. She presents inappropriate dress and grooming. Her behavior is cooperative but distressed, as witnessed by frequent crying and physical distress throughout the interview. Her speech is coherent but, at times, interrupted by emotional distress. The mood is anxiolytic and fearful, with affect congruent with supposedly endured trauma. The patient’s thinking process is logical but severely narrowed because of the trauma. This is evident in repeated threatening cognitions, avoidance, and environmental hyperarousal. Delusions and hallucinations are not present. Insight into her situation is partial, with judgment reportedly intact but undermined by anxiety and avoidance behaviour. Suicidal or homicidal ideations are not highlighted by the patient.

Case Formulation/Biopsychosocial Assessment

The patient’s symptoms are compatible with post-traumatic stress disorder (PTSD) with prominent sleep disturbance. The biopsychosocial formulation considers several factors:

1. Biological Factors

The patient complains of pain in the body due to trauma, particularly neck pain, and bruising, which may contribute to sleep disturbance and pain. Hyperarousal and overresponsive startle response are indicators of autonomic nervous system dysregulation, according to Pace-Schott et al. (2023). Sleep disturbance due to PTSD can also be a consequence of cortisol dysregulation and hyperactive noradrenergic activity that can also sustain sleep (Pace-Schott et al., 2023).

1. Psychological Factors

The patient’s avoidance, hyperarousal, and reexperiencing of the initial trauma in flashbacks are characteristic of PTSD. The sleep disturbance is best accounted for by nightmares and hypervigilance. Perpetuation of the symptoms is possible through classical conditioning processes through the association of stimuli (lights, tunes, smells, etc.) with trauma (Zaretsky et al., 2024). Destructive cognitions regarding the accident and self-blame enduring are likely also explanations for distress and serve to perpetuate maladaptive coping.

• Social Factors

Her emotional withdrawal and avoidance behaviors also influence her relationship with her husband. She is having a difficult time returning to normal activities, such as driving and socializing, which is impacting her support system and quality of life (van der Vlegel et al., 2021). Social withdrawal and perceived support deficiency can even persist to enhance PTSD symptoms and contribute to a more complex recovery.

Individualized Treatment Plan

Pharmacologic Treatment:

1. Selective Serotonin Reuptake Inhibitor (SSRI): Sertraline or paroxetine are FDA-approved treatments for PTSD and may enhance anxiety, intrusive symptoms, and sleep disturbance
2. Prazosin: Prazosin, an alpha-1 adrenergic antagonist, has been shown to be effective against sleep and nightmares (Saguin et al., 2021).
3. Melatonin Supplementation: Research shows that melatonin supplementation regulates sleep among PTSD patients by modulating the circadian rhythm (Maguire et al., 2020).

Non-Pharmacologic Therapy:

1. Trauma-focused Cognitive Behavioral Therapy (CBT-PTSD): Trauma-focused CBT, including prolonged exposure, may help the patient process and desensitize trauma reminders (Brownlow et al., 2021).
2. Eye Movement Desensitization and Reprocessing (EMDR): EMDR can facilitate the processing of distressing memories and reduce their subjective intensity
3. Relaxation Skills and Sleep Hygiene: Establishment of a bedtime routine, reduction of nighttime reminders of trauma, and utilization of mindfulness-based relaxation skills can improve sleep quality (Brownlow et al., 2021).
4. Supportive Therapy and Psychoeducation: Psychoeducation of the husband and patient about PTSD symptoms and recovery can improve interpersonal relationships and coping capacity (Brownlow et al., 2021).

Multimodal treatment, combined with the integration of pharmacologic and psychologic therapies, can significantly improve the patient’s symptoms, thereby enhancing her overall functioning and quality of life.

References

Brownlow, J. A., Miller, K. E., & Gehrman, P. R. (2020). Treatment of sleep comorbidities in posttraumatic stress disorder. Current Treatment Options in Psychiatry, 7, 301-316.

Pace-Schott, Edward F., Jeehye Seo, and Ryan Bottary. “The influence of sleep on fear extinction in trauma-related disorders.” Neurobiology of stress 22 (2023): 100500. https://doi.org/10.1016/j.ynstr.2022.100500

Saguin, E., Gomez-Merino, D., Sauvet, F., Leger, D., & Chennaoui, M. (2021). Sleep and PTSD in the military forces: a reciprocal relationship and a psychiatric approach. Brain sciences, 11(10), 1310. https://doi.org/10.3390/brainsci11101310

van der Vlegel, M., Polinder, S., Mikolic, A., Kaplan, R., von Steinbuechel, N., Plass, A. M., … & Center-Tbi Participants And Investigators. (2021). The association of post-concussion and post-traumatic stress disorder symptoms with health-related quality of life, health care use and return-to-work after mild traumatic brain injury. Journal of clinical medicine, 10(11), 2473. https://doi.org/10.3390/jcm10112473

Zaretsky, T. G., Jagodnik, K. M., Barsic, R., Antonio, J. H., Bonanno, P. A., MacLeod, C., … & Yehuda, R. (2024). The psychedelic future of post-traumatic stress disorder treatment. Current neuropharmacology, 22(4), 636-735. https://doi.org/10.2174/1570159X22666231027111147

NU 665: Sleep Disturbances and Medical Comorbidities

Instructions

Log in to Symptom Media using the following credentials:

Username: RegisNursing
Password: Regis0908

After logging in, view the Insomnia Due to a Medical Condition video (10:00 minutes).

Answer the following prompts in a one- to two-page paper:

• Write a mental status examination on this patient.
• Write a case formulation/biopsychosocial assessment for the patient.
• Create an individualized treatment plan for the patient, including pharmacologic and non-pharmacologic treatment options.

All papers must conform to the most recent APA standards.

Please refer to the Grading Rubric for details on how this activity will be graded.