Case Example: Trauma and Stress‑Related Disorder and Sleep Disorder (Follow‑Up) NRNP 6635 – Week Assignment
Case Example: Trauma and Stress-Related Disorder and Sleep Disorder (Follow-Up)
A 40-year-old Hispanic female with Post-Traumatic Stress Disorder (PTSD) and Insomnia returned for follow-up. She reports frequent nightmares and difficulty falling asleep due to hypervigilance and intrusive memories related to a past traumatic event. She describes feeling constantly on edge, with racing thoughts and an inability to relax, which worsens her sleep difficulties and increases daytime fatigue.
Preceptor Plans include continuing trauma-focused cognitive-behavioral therapy (CBT) to address PTSD symptoms, introducing cognitive-behavioral therapy for insomnia (CBT-I), and practicing mindfulness and relaxation techniques before bed. Follow-up is scheduled in three weeks to assess progress and adjust the treatment plan as needed.
1. Introduction
Patient: 40‑year‑old Hispanic female.
Diagnoses: Post‑Traumatic Stress Disorder (PTSD) and Insomnia.
Clinical Context: Follow‑up visit after initial treatment planning.
Presenting Concerns:
Frequent nightmares.
Difficulty falling asleep due to hypervigilance and intrusive memories.
Constantly on edge, racing thoughts, inability to relax.
Daytime fatigue due to poor sleep quality.
Preceptor Plan:
Continue trauma‑focused CBT for PTSD.
Introduce CBT‑I for insomnia.
Practice mindfulness and relaxation techniques before bed.
Follow‑up in three weeks to monitor progress.
2. Post‑Traumatic Stress Disorder (PTSD)
Definition
A psychiatric disorder that may occur after experiencing or witnessing traumatic events such as assault, accidents, disasters, or combat.
Characterized by intrusive memories, avoidance, negative mood/cognition, and hyperarousal.
DSM‑5 Criteria
Exposure to trauma.
Intrusive symptoms (memories, nightmares, flashbacks).
Avoidance of trauma reminders.
Negative alterations in cognition/mood.
Hyperarousal (sleep disturbance, irritability, hypervigilance).
Duration >1 month.
Functional impairment.
Clinical Features in Case
Nightmares and intrusive memories.
Hypervigilance preventing sleep.
Racing thoughts, constant tension.
Daytime fatigue and impaired functioning.
Risk Factors
Female gender.
Prior trauma history.
Lack of social support.
Co‑occurring psychiatric disorders (depression, anxiety).
Genetic vulnerability.
Assessment Tools
PCL‑5 (PTSD Checklist).
CAPS‑5 (Clinician‑Administered PTSD Scale).
C‑SSRS (suicide risk assessment).
Treatment
Pharmacological: SSRIs (sertraline, paroxetine), SNRIs, prazosin for nightmares.
Psychotherapy: Trauma‑focused CBT, EMDR, prolonged exposure therapy.
Supportive: Family involvement, peer support groups.
3. Insomnia Disorder
Definition
Difficulty initiating or maintaining sleep, or waking too early, with associated daytime impairment.
Chronic insomnia persists ≥3 nights per week for ≥3 months.
Clinical Features in Case
Difficulty falling asleep due to hypervigilance.
Frequent nightmares disrupting sleep.
Racing thoughts preventing relaxation.
Daytime fatigue, impaired concentration.
Risk Factors
PTSD and other psychiatric disorders.
Stressful life events.
Female gender.
Poor sleep hygiene.
Medical comorbidities.
Assessment Tools
Insomnia Severity Index (ISI).
Sleep diaries.
Polysomnography (if needed).
Treatment
CBT‑I (Cognitive Behavioral Therapy for Insomnia):
Sleep restriction therapy.
Stimulus control (bed only for sleep).
Cognitive restructuring (challenge maladaptive sleep beliefs).
Relaxation training.
Pharmacological (short‑term): Non‑benzodiazepine hypnotics, melatonin.
Lifestyle: Sleep hygiene, mindfulness, relaxation techniques.
4. Comorbidity: PTSD and Insomnia
Interaction:
PTSD symptoms (hypervigilance, nightmares) exacerbate insomnia.
Insomnia worsens PTSD by reducing resilience and increasing irritability.
Clinical Implications:
Must treat both disorders concurrently.
Integrated approach essential.
Challenges:
Nightmares resistant to treatment.
Hyperarousal interfering with sleep.
Risk of depression and suicidality if untreated.
5. Trauma‑Focused CBT
Definition
Structured psychotherapy targeting trauma‑related thoughts and behaviors.
Evidence‑based for PTSD.
Components
Psychoeducation about trauma and PTSD.
Cognitive restructuring to challenge maladaptive beliefs.
Exposure to trauma memories in safe context.
Skills training for relaxation and coping.
Application in Case
Address intrusive memories and nightmares.
Reduce hypervigilance.
Improve emotional regulation.
Enhance coping strategies.
6. CBT‑I (Cognitive Behavioral Therapy for Insomnia)
Definition
Evidence‑based psychotherapy for insomnia.
Focuses on changing sleep habits and misconceptions.
Components
Sleep restriction therapy.
Stimulus control (bed only for sleep).
Cognitive restructuring (challenge maladaptive sleep beliefs).
Relaxation training.
Sleep hygiene education.
Application in Case
Reduce time to sleep onset.
Minimize nighttime awakenings.
Improve sleep quality.
Reduce daytime fatigue.
7. Mindfulness and Relaxation Techniques
Mindfulness Meditation: Increase awareness, reduce rumination.
Progressive Muscle Relaxation: Release tension.
Deep Breathing Exercises: Reduce physiological arousal.
Guided Imagery: Promote calmness.
Yoga/Stretching: Improve relaxation before bed.
8. Monitoring and Follow‑Up
Three‑week follow‑up: Assess PTSD symptoms, sleep quality, adherence to CBT and relaxation.
Progress Indicators:
Reduced nightmares.
Improved sleep onset and duration.
Decreased hypervigilance.
Reduced daytime fatigue.
Adjustments:
Medication initiation if needed.
Intensify therapy if symptoms persist.
Family involvement if appropriate.
9. Nursing and Clinical Implications
Assessment: Monitor sleep patterns, nightmares, daytime functioning.
Intervention: Support CBT, teach relaxation, encourage adherence.
Education: Explain PTSD‑insomnia link, benefits of therapy.
Support: Encourage social support, family involvement.
Safety: Monitor for suicidality, depression, relapse risk.
10. Ethical and Cultural Considerations
Confidentiality: Respect patient privacy.
Consent: Informed consent for treatment.
Stigma: Address stigma of trauma and sleep disorders.
Cultural Sensitivity: Respect patient’s Hispanic background and beliefs about trauma and healing.
11. Summary
Patient presents with comorbid PTSD and insomnia.
Nightmares, hypervigilance, and intrusive memories impair sleep.
Integrated treatment plan includes trauma‑focused CBT, CBT‑I, mindfulness, and relaxation.
Follow‑up scheduled to monitor progress.
Goal: Reduce PTSD symptoms, improve sleep, enhance functioning and quality of life.
📝 Quiz (15 Questions)
Multiple Choice – Select the best answer.
What are the patient’s diagnoses? a) Depression and OCD b) PTSD and Insomnia c) Bipolar Disorder and ADHD d) Panic Disorder and GAD
What symptom prevents the patient from falling asleep? a) Hunger b) Hypervigilance and intrusive memories c) Pain d) Noise
What therapy is planned to address PTSD? a) Psychoanalysis b) Trauma‑focused CBT c) ECT d) Dialysis
What therapy is planned to address insomnia? a) CBT‑I b) EMDR c) DBT d) Hypnosis
What relaxation technique involves tensing and releasing muscles? a) Guided imagery b) Progressive muscle relaxation c) Yoga d) Deep breathing
What is the patient’s age? a) 35 b) 40 c) 45 d) 50
Which medication can reduce PTSD‑related nightmares? a) Prazosin b) Clozapine c) Lithium d) Haloperidol
Which tool screens for PTSD symptoms? a) PCL‑5 b) ISI c) GAD‑7 d) PHQ‑9
Which tool assesses insomnia severity? a) ISI b) PCL‑5 c) CAPS‑5 d) Y‑BOCS
Which therapy is gold standard for insomnia? a) CBT‑I b) Psychoanalysis c) EMDR d) DBT
Which lifestyle intervention supports sleep? a) Sleep hygiene b) Smoking c) Alcohol use d) Excess caffeine
Which symptom is common in both PTSD and insomnia? a) Nightmares b) Hallucinations c) Delusions d) Mania
What is scheduled in three weeks? a) Hospitalization b) Follow‑up appointment c) Family therapy d) Court
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