The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.
A 26-year-old man presents to the emergency department, escorted by his concerned wife. She states that her husband has been experiencing episodes in which he awakens at night and screams, sweats, and becomes agitated, disrupting their ability to sleep restfully. He is an Army Ranger who just returned from active military duty in Afghanistan 3 months prior to presentation.
During the evaluation, the patient reveals that he has been having recurrent nightmares about events that occurred during his deployment. He reports that one of the most common nightmares features the violent death of a fellow soldier and friend, which the patient witnessed directly in front of him. He describes vivid imagery of the event as well as hearing his friend scream at him.
The patient states that he is often unable to push thoughts about this and similar events out of his mind. He tells the evaluating physician: "It's like I'm stuck in an endless movie. I hear the explosions, I see it happening again, I even smell the sand of the desert. I lose track of time. It's like I am back there. I can't escape, I can't breathe, I can't live. I shouldn't have lived. He should have!"
At this point, the patient begins to exhibit significant distress and is unable to continue the interview. With his permission, his wife provides additional information. She notes that specific things (such as helicopters, fireworks, and smells) cause her husband to periodically exhibit a state in which he cannot distinguish his present reality from events that occurred in combat zones abroad. She says, "He hasn't been the same since he returned. Yesterday, we went to a coffee shop, and he started screaming at the barista because she looked like someone he had seen overseas. I have to beg him to leave the house. When he does go out, he insists on always having his back to the wall."
His wife further recounts a marked change in the patient's mood and demeanor upon his return. "He's been morose and somber. Before, he was always an energetic and engaged father of our three young children. Now, even they don't cheer him up the way they used to. He's become numb and negative about everything. He cannot help me with the kids or household chores the way he did before. With him constantly waking both of us several times each night, we are always exhausted. I'm so overwhelmed — this has taken a toll on me and our family. I want my husband back!"
At this point, the patient's wife begins to exhibit significant anxious distress and tearfulness. She reports that she has had great difficulty coping with her husband's return and his apparent illness. She says, "I find myself making mistakes that I never used to, at home and at work. I'm always depressed and anxious. I feel like I'm failing as a parent. It's bad enough that I don't have any help, but even the slightest thing sets him off. I don't know what to do anymore!"
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Cite this: Psychiatry Case Challenge: Alarming Behavior in a 26-Year-Old Soldier and Father of Three - Medscape - Jun 27, 2022.