A 38 year old single mother of a six year old biological son was referred by her PCP as an emergency to a Psychiatric NP. Upon entering the waiting room the woman looked exhausted and disheveled. Her straight short blond hair looked uncombed and she was dressed in a worn sweat suit. She was accompanied to the session by her best friend who drove her to the session. Although the womans mood seemed tired but controlled while filling out the admission papers, upon telling her story the woman immediately began to sob.
The woman described that at 8:30PM on the previous evening her house was entered by a man whom she did not recognize. She was bound, gagged and intermittently raped over the next 2 and ½ hours. Prior to his entry the woman had been in her study working on documents which she had brought home from work. Upon walking out of her study the woman confronted the man standing in her kitchen. At this point she realized that the she had left the door open as it was a warm night and, everyone in the neighborhood trusts each other.
After 2 ½ hours of the man alternating between pacing her house and raping her he left her after he unbound her. She remembers feeling too scared to scream, feared that he would kill her,yet also feeling grateful that her son was not at home but staying overnight with his relatives.
After the man left her house the woman called her best friend who begged her to call the police but she refused. She was afraid that the incident would be put in the newspaper if she called the police. She describes showering for 1 hour, scrubbing herself over and over. She then lay awake the entire night until her PCP saw her in the morning who referred her to the local Emergency Room for Rape Crisis Care and to the local therapist who saw her that day.
Upon admission she described feeling numb and anxious. She stated that on her way to the therapist office she continually scanned her environment to see if the rapist was watching her or following her. She stated that she had always considered herself to be in control and independent but now was feeling totally helpless to know what to do and also felt somewhat unreal and fearful. She stated that she felt nauseated and could vomit.
The woman seemed to be a fairly reliable historian, as she was able to give very specific details of the entire event. Although she repeated herself several times on many of the specifics her history was coherent and consistent.
At the time of the admission she denied any intrusive, distressing thoughts or images, flashbacks, nightmares. She simple stated, Im numb and stated that she just could not imagine how she will work at her job as it was locatedin a very public environment.
When asked if she had ever had any other incidences of trauma she initially stated, No. She then qualified the response by stated that her ex-husband was emotionally abusive which escalated after the birth of their only child. At that point she divorced him.
She described that she was adopted when she was 3 days old.She stated that she was an only child raised by two alcoholic parents and that she felt that she had to walk on eggshells most of her life trying to placate and please her critical mother and perfectionistic father. She stated that she was a very shy child and remembered vomiting on the school bus frequently in her first year of school.She describes having sleep problems and could only go to sleep with the light on. Since she was a bed-wetter until the age of 10 years old she refused to go to any sleep-overs with friends.She described school as very difficult and states that she has never lived out her dream to become a lawyer because she knows she could not make the grade. Although she has a well paying job in a marketing firm she prefers to work alone as people just get on my nerves.
She states that she has been in a fairly consistent relationship with a gentleman whom she calls her best friend. However, because she prefers her own home environment nor enjoys traveling the relationship consists of watching Monday night football at her house or occasional dinners out. She states that her male friend surprised her with a cruise for her birthday the year before. The woman stated that as time got closer to leaving for the cruise she began to develop palpitations, chest pain, nausea, numbness and tingling of her hands and eventually refused to take the trip with her friend. She says she lives for her son and gives him her undivided attention until his bedtime each night
Her medical history consists of chronic back problems having sustained significant injuries in an AA 2 years prior. She sees a chiropractor on a regular basis. She complains of chronic muscle tension and is frequently fatigued and exhausted at the end of a days work.
Any differential diagnoses
Your diagnosis and reasoning
Any additional questions you would have asked
Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.
Any labs and why they may be indicated
Screener scales or diagnostic tools that may be beneficial
Additional resources to give (Therapy modalities, support groups, activities, etc.)