Module 10
1-Read Chapter 7: Trauma & Stress-Related Disorders” from the DSM-5-TR Clinical Cases book.
2- Read the article, Ahmed, S., Khan,R., Pursglove, D., O’Donoghue, J., & Chakraborty, N. (2015). Discharges from an early intervention in psychosis service: Where do patients stand after 3 years? Early Intervention in Psychiatry, 9, 48–52. doi:
10.1111/eip.12148.
3-Review the DSM-5-TR as needed.
Discussion Question
In near or about 250 words, explain the most important idea from the article, “Discharges from an early intervention in psychosis service:
where do patients stand after 3 years?”

There are 2 treatment plans and one discussion (discussion uploaded
separately)
Module 9
Treatment Plan # 5

Instructions
This assignment is based on the facts provided in Case 6.2 Germs from
the DSM-5-TR Clinical Cases book.
Write a treatment plan based on the information provided in Case 6.2.
The treatment plan should include at least two treatment objectives.
Refer to “The Case Study for Larry J.” from the previous reading in
Module 1 as an example. Use the following template:
I. History & Demographic Factors:
II. Presenting Concern:
III. Perceived Strengths:
IV. Treatment Provider:
V. Treatment Goal:
VI. Treatment Objectives:
VII. Treatment Interventions:
IIX. Treatment Frequency & Modality:
IX: References Used

Outside research is required.

Case 6.2 Germs
Dan J. Stein, M.D., Ph.D.Helen Blair Simpson, M.D., Ph.D.Katharine A.
Phillips, M.D.
Trevor Lewis, a 32-year-old single man living with his parents, was brought
to his psychiatric consultation by his mother. She noted that since
adolescence, her son had been concerned with germs, which led to long-
standing hand-washing and showering rituals. During the prior 6 months,
his symptoms had markedly worsened. He had become preoccupied with

being infected by COVID-19 and spent the day cleaning not only his body
but all of his clothing and linen. He had begun to insist that the family also
wash their clothing and linen regularly, and that they keep the windows
shut all the time. He allowed no visitors to their home. When the parents
were occasionally exposed to other people by going outside, he insisted
that they wear their masks in his presence for the ensuing 48 hours. The
resulting conflicts had led to the current consultation.
Mr. Lewis had in the past received a selective serotonin reuptake inhibitor
and cognitive-behavioral therapy for his symptoms. These had had some
positive effects, and he had been able to complete high school successfully.
Nevertheless, his symptoms had prevented him from completing college
or working outside the home; he had long felt that his home was relatively
germ-free in comparison to the outside world. However, over the past 6
months, he had increasingly indicated that home, too, was contaminated,
including with COVID-19.
At the time of presentation, Mr. Lewis had no other obsessive-compulsive
and related disorder symptoms such as sexual, religious, or other
obsessions; appearance or acquisition preoccupations; or body-focused
repetitive behaviors. However, in the past he had also experienced
obsessions relating to fears of harming himself or others, together with
associated checking compulsions (e.g., checking that the stove was
switched off). He had a childhood history of motor tics. During high school,
he found that marijuana reduced his anxiety. He denied having had access
to marijuana and other psychoactive substances since leaving school.
Mr. Lewis was interviewed over video using a telehealth system. He
appeared disheveled and unkempt. He was completely convinced that
COVID-19 had contaminated his home and that his washing and cleaning
were necessary to stay uninfected. When challenged with information
about COVID-19’s mode of spread, he answered that COVID-19 might
come into the home through an open window or the sweat of visitors, and
his masked parents could certainly get infected by going to the grocery
store. He added that his parents had tried to convince him that he was
excessively worried, but he did not believe them. In fact, his worries kept
returning even when he tried to think of something else.

There was no evidence of hallucinations or of a formal thought disorder.
He denied an intention to harm or kill himself or others. He was cognitively
intact.
Discussion
Mr. Lewis is completely convinced that his home is contaminated by
COVID-19. He is unable to suppress these preoccupying, intrusive
thoughts. He feels obliged to perform unreasonable behaviors in response
to his excessive worries. These behaviors consume his day and are socially
and occupationally debilitating. He meets the symptomatic criteria for
DSM-5 obsessive-compulsive disorder (OCD). Contamination and
cleanliness concerns, with subsequent washing and cleaning rituals, are a
common symptom dimension in OCD.
DSM-5 listed two specifiers for OCD. The tic-related OCD specifier is
based on a growing literature indicating that individuals with OCD and
current or past tics have particular distinguishing features, and that the
presence or absence of tics helps guide assessment and intervention. Mr.
Lewis had a history of motor tics in childhood. DSM-5 also recommends an
assessment of insight, particularly specifying whether the individual with
OCD has good or fair insight, poor insight, or absent insight/delusional
beliefs. The “with absent insight/delusional beliefs” specifier is provided
not only for OCD but also for body dysmorphic disorder and hoarding
disorder, and appears to be a valid, clinically useful distinguishing feature.
Obsessive thoughts and compulsive behaviors are found in other
psychiatric disorders. Patients with illness anxiety disorder (IAD) are
preoccupied with having or acquiring a serious illness, and may perform
excessive related behaviors, such as seeking reassurance. Mr. Lewis is
worried about getting COVID-19, which might prompt the consideration
that he has IAD. His cleaning compulsions and checking are more
characteristic of OCD, however, and he lacks the somatic symptoms, other
health-related concerns, and checking of the body for signs of illness that
are commonly found in IAD. Similarly, although patients with generalized
anxiety disorder can have worries about their own or others’ health, they
also have other kinds of worries, and they do not have compulsions.

Patients with delusional disorder do not have the obsessions, compulsions,
preoccupations, or other characteristic symptoms of OCD. Conversely,
patients with OCD with absent insight/delusional beliefs may appear
delusional but do not have other features of psychotic disorders, such as
hallucinations or formal thought disorder. Mr. Lewis does not have a
substance use or medical history that is associated with psychotic
symptoms.
It would be useful to have a more detailed picture of the nature and
severity of Mr. Lewis’s OCD symptoms, including avoidance and functional
impairment. Mr. Lewis was noted to be disheveled and unkempt, for
example, which might seem odd for someone with prominent cleanliness
concerns. His appearance might be explained, however, if his
contamination rituals are so time-consuming that he avoids starting them.
Although Mr. Lewis’s diagnosis appears clear, it can be helpful to make use
of one of the symptom severity scales designed for OCD, such as the Yale-
Brown Obsessive Compulsive Scale, or a scale to measure
insight/delusionality, such as the Brown Assessment of Beliefs Scale.
Diagnosis
 Obsessive-compulsive disorder, tic related, with absent
insight/delusional beliefs
Suggested Readings

du Toit PL, van Kradenburg J, Niehaus D, Stein DJ: Comparison of
obsessive-compulsive disorder patients with and without comorbid
putative obsessive-compulsive spectrum disorders using a
structured clinical interview. Compr Psychiatry 42(4):291–300,
2001
Eisen JL, Phillips KA, Baer L, et al: The Brown Assessment of Beliefs
Scale: reliability and validity. Am J Psychiatry 155(1):102–108,
1998
Goodman WK, Price LH, Rasmussen SA, et al: The Yale-Brown
Obsessive Compulsive Scale, I: development, use, and reliability.
Arch Gen Psychiatry 46(11):1006–1011 1989
Leckman JF, Denys D, Simpson HB, et al: Obsessive-compulsive
disorder: a review of the diagnostic criteria and possible subtypes
and dimensional specifiers for DSM-V. Depress Anxiety
27(6):507–527, 2010
Stein DJ, Costa DLC, Lochner C, et al: Obsessive-compulsive
disorder. Nat Rev Dis Primers 5(1):52, 2019

Module 10
Treatment Plan #6

Instructions
This assignment is based on the facts provided in Case 7.4 Easily
Triggered from the DSM-5-TR Clinical Cases book.
Write a treatment plan based on the information provided in Case 7.4
The treatment plan should include at least two treatment objectives.
Refer to “The Case Study for Larry J.” from the previous reading in
Module 1 as an example. Use the following template:
I. History & Demographic Factors:
II. Presenting Concern:
III. Perceived Strengths:
IV. Treatment Provider:
V. Treatment Goal:
VI. Treatment Objectives:
VII. Treatment Interventions:
IIX. Treatment Frequency & Modality:
IX: References Used

Outside research is required.
Case 7.4 Easily Triggered
Lori L. Davis, M.D.

Eric Reynolds, a 75-year-old retired electrician, sought help at the
Veterans Affairs outpatient mental health care clinic because of his “very
short fuse” and tendency to be “easily triggered.” Mr. Reynolds indicated
that he had had these symptoms for decades, but that he had finally
agreed to get treated because his wife seemed desperate that he get in
better control.
Mr. Reynolds indicated that he always felt on guard, especially while in
public. When unexpectedly startled by sudden noises, he tended to fly into
a rage. That was apparently one reason he had chosen to be a self-
employed electrician: he could work by himself. Similarly, he enjoyed
hunting and gardening, activities that he could enjoy in quiet solitude.
Reluctantly, he described intrusive memories of watching his fellow
soldiers die in the field, which caused him enormous shame, guilt, and
sadness, Several times a week, he awakes in a panicky sweat after a
combat nightmare, although, as he said, “It’s ridiculous. Those guys have
been dead for 50 years.”
Although these symptoms are very distressing, Mr. Reynolds is most
worried about his “hair-trigger” temper. Without cause, he finds himself
antagonizing other drivers who cut him off, confronting strangers who
stand too close to him in checkout lines, and shifting into “attack mode”
when approached from behind by others. He springs into this aggressive
mode automatically, without a thought or consideration of the
circumstances. Although he keeps a handgun in the console of his car for
self-protection, Mr. Reynolds has no intention of harming others. He is
always remorseful after a threatening incident and worries that he might
inadvertently hurt someone. Most recently, while drifting off to sleep on
his physician’s examination table, a nurse touched his foot, and he leapt up
and began cursing in a threatening manner. He felt as if he were back on
guard duty, when he was accidentally dozing, and an incoming mortar
round stunned him into action. His reaction scared both the nurse and
himself.
Mr. Reynolds’s symptoms apparently began soon after he left Vietnam,
where he served as a field radio operator. He never sought help for his
symptoms, apparently because of his independent and self-reliant nature.

After retirement as a self-employed electrician, he spent almost all of his
time at home. During these past few years, his wife and adult children
became more aware of his various symptoms, including how they were
putting a severe strain on his family relationships and overall happiness.
Mr. Reynolds was raised in a loving family that struggled financially as
Midwestern farmers. At age 20, Mr. Reynolds was drafted into the U.S.
Army and deployed to Vietnam. He described himself as having been
upbeat and happy prior to his army induction. He said he enjoyed basic
training and his first few weeks in Vietnam, until one of his comrades got
killed. At that point, all he cared about was getting home alive, even if it
meant killing others. His personality changed from that of a happy-go-
lucky farm boy to a terrified, overprotective soldier. Upon returning to
civilian life, he managed to get a graduate business degree, but he became
a self-employed electrician because of his need to stay isolated in his work.
In his retirement, he hoped to volunteer, garden, and get some “peace and
quiet.” It turned out, however, that his retirement was much like the rest of
his adult life: although he could occasionally settle into one of his hobbies,
most of his days were filled with tension, guilt, and arguments.
Despite having used alcohol and marijuana during his early adulthood, he
had not consumed excessive alcohol for several decades or used marijuana
since the age of 30. He had no legal history.
On examination, Mr. Reynolds was a well-groomed man who appeared
anxious and somewhat guarded. He was coherent and articulate. His
speech was at a normal rate, but the pace accelerated when he discussed
disturbing content. He denied depression but was anxious. His affect was
somewhat constricted but appropriate to content. His thought process
was coherent and linear. He denied all suicidal and homicidal ideation. He
had no psychotic symptoms, delusions, or hallucinations. He had very good
insight. He was well oriented and seemed to have above-average
intelligence.
Discussion
Mr. Reynolds manifests symptoms from all four PTSD symptom
categories: intrusive symptoms, persistent avoidance, negative alterations

in cognitions and mood associated with the traumatic event, and marked
alterations in arousal and reactivity. Mr. Reynolds’s primary concerns
relate to fear-mediated symptoms, particularly his exaggerated fight-or-
flight responses to unexpected stimulation. As is often seen in PTSD, the
reaction is out of proportion to the circumstances and can be
unpredictable; in other words, the reaction is not premeditated or part of
general impulsivity. In addition to hyperreactivity, Mr. Reynolds
demonstrates hypervigilance, excessive concern for safety, and anxiety or
fear. He has classic reexperiencing symptoms of intrusive memories,
nightmares, flashbacks, and physiological reactivity to triggers that
resemble or remind him of the traumatic events. Although not present in
this patient, suicidality and psychotic symptoms are not uncommon in
PTSD and should be evaluated on a regular basis.
As is often the case with PTSD, Mr. Reynolds exhibits a powerful,
involuntary reaction to particular kinds of external stimuli. These
symptoms of being “easily triggered” are very disturbing for the individual
as well as for family members, friends, and caregivers.
Mr. Reynolds’s efforts to avoid conflict have progressively narrowed his
opportunities in all spheres, including social, family, and hobbies. For
example, his decision to work as an electrician rather than to take
advantage of his business degree seems based largely on his effort to
control his personal space. It would be useful to know more about how Mr.
Reynolds’s PTSD might be affecting his relationship with his wife. His
retirement appears to have worsened his symptoms and propelled him
into finally seeking treatment. One possibility is that his wife is now
spending more time with him and able to see his reactions more frequently
and serves as a force behind his decision to seek treatment. Another
possibility is that his retirement was precipitated by the negative
consequences of untreated PTSD symptoms on his job-related duties and
relationships.
Because people with PTSD have high rates of psychiatric comorbidity, the
practitioner should carefully consider other diagnoses. Mr. Reynolds has
apparently not consumed excessive alcohol or marijuana in many years, so
neither appears related to the exacerbation of his symptoms; however,

because substance use is very common in patients with PTSD, special
attention should be paid to the possibility of underreporting.
Mr. Reynolds’s edgy hyperarousal overlaps somewhat with the dysphoric
irritability that can be seen in bipolar II disorder, but his most intense
symptoms are reactive and sudden; this contrasts with the multiday
periods of manic symptoms such as mood changes, racing thoughts,
elevated energy or drive, or a reduced need for sleep. He denies feeling
depressed, and his reduced pleasure appears more related to his
avoidance of social activities that he previously found enjoyable. He has
maintained interest in woodworking and reading, which are consistent
with his tendency to self-isolate in a safe and quiet environment.
Like many survivors of trauma, Mr. Reynolds prides himself on his
resiliency and independence; such qualities likely served him well in
Vietnam and while running his business. That same independence seems
to have contributed to his avoidance of mental health treatment despite
50 years of uncomfortable symptoms. It would be useful to further explore
his thoughts about stigma, psychotherapy, and PTSD, given that the
development of a trusting alliance will be crucial to his treatment.
Diagnosis
 Posttraumatic stress disorder
Suggested Readings

Bryant RA: Post-traumatic stress disorder: a state-of-the-art
review of evidence and challenges. World Psychiatry
18(3):259–269, 2019
Moore BA, Pujol L, Waltman S, Shearer DS: Management of post-
traumatic stress disorder in veterans and military service members:
a review of pharmacologic and psychotherapeutic interventions
since 2016. Curr Psychiatry Rep 23(2):9, 2021
Schein J, Houle C, Urganus A, et al: Prevalence of post-traumatic
stress disorder in the United States: a systematic literature review.
Curr Med Res Opin 37(12):2151–2161, 2021

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Trauma & Stress-Related Disorders

Trauma & Stress-Related Disorders

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