NUR 7632 Module 4 PTSD Case: PCL-5 Scoring, Cognitive Processing Therapy and the Prazosin Question Example

Five Months After the Knife: PCL-5 Scoring, Cognitive Processing Therapy and a Careful Answer on Prazosin for a 36-Year-Old Bus Operator

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7632: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Adult Population, Part A

Mentor Name

Month Day, Year

Five Months After the Knife: PCL-5 Scoring, Cognitive Processing Therapy and a Careful Answer on Prazosin for a 36-Year-Old Bus Operator

The Number 39 Route

Tanisha, an invented patient, is 36 and has driven a city bus in Newark for nine years. Five months ago a passenger pulled a knife at a late stop, held it to her neck and took the fare box while she waited for him to leave. She was not cut. Since then she has nightmares of the knife three or four nights a week, wakes soaked and shaking, startles when anyone stands behind her and checks her mirrors so often that she has missed turns. She has taken a different route, then sick leave, and she avoids the corner store near the stop where it happened.

She blames herself for opening the doors at that stop after dark and says she is "not the same person." She has become short with her two children and has stopped going to church because crowds feel unsafe. She drinks one or two beers most nights to fall asleep. She has no history of psychiatric treatment, no prior trauma she wishes to discuss at this visit and no thoughts of suicide. Her union's assistance program referred her after a supervisor noticed she had used most of her sick time.

Measuring the Symptoms

Blevins et al. (2015) built the PCL-5, twenty self-rated items on how much each symptom troubled the respondent over the last month, scored 0 to 4. In two samples of trauma-exposed college students, 278 in the first study and 558 in the second, the scores showed strong internal consistency, with an alpha of .94 in the first study, along with good test-retest reliability and convergent validity. The items fit the four symptom clusters of the DSM-5 criteria, and models with six or seven factors fit even better.

Tanisha scores 54. Her highest items are the nightmares, the physical reactions to reminders, avoidance of the stop and the store, the self-blame and feeling on guard. The paper notes that the checklist was validated in students, not bus drivers, and that the score supports rather than replaces the interview, which confirms intrusive memories, avoidance, darker beliefs and moods and heightened arousal, all present beyond a month, with clear harm to her work and family life.

The Wider Picture

Depression often sits beside PTSD, and her PHQ-9 is 13, moderate, with no suicidal thoughts. Her AUDIT-C is 4, showing drinking that has grown since the robbery and is used to fall asleep, a habit that feeds avoidance and fragments her early-morning sleep. Her blood pressure is mildly raised at 142 over 90. Head injury and a medical cause for her symptoms are unlikely given the history, and her sleep is disturbed by nightmares rather than by snoring or breathing pauses, which her partner confirms.

Choosing a Trauma-Focused Therapy

Resick et al. (2002) randomly assigned 171 women with chronic PTSD after rape to cognitive processing therapy, prolonged exposure or a minimal attention waiting condition, with 121 completing treatment. Both therapies reduced PTSD and depression far more than the waiting condition, the gains held at follow-up nine months later, and the two active therapies did about equally well, although cognitive processing therapy improved two of the four guilt subscales more. The trial was in women after sexual assault, and the paper says so, while noting that the same two therapies are now used across many kinds of trauma.

Cognitive processing therapy is chosen for Tanisha because her self-blame is so strong. Over twelve weekly sessions she writes an account of the robbery, then works with the therapist on the "stuck points" in her thinking, such as the belief that opening the doors made her responsible and that no stop is safe. Practice sheets between sessions help her test those beliefs. Prolonged exposure, which would take her back to the stop step by step, remains a strong alternative if she prefers it or if the first course stalls.

The Medicine Plan

Sertraline, one of two medicines approved by the U.S. Food and Drug Administration for PTSD, is started at a low dose and raised over several weeks, which also addresses her depressive symptoms. She is told that early nausea and jitteriness usually pass and that benefit builds over six to twelve weeks. Her drinking is discussed plainly, and she agrees to stop drinking on weeknights while treatment begins, with a plan to recheck the AUDIT-C at each visit.

The Prazosin Question

Tanisha asks about a pill for the nightmares, which a coworker took. Raskind et al. (2018) randomized 304 veterans at 13 VA medical centers, all with long-standing PTSD and recurring nightmares, to prazosin or a placebo for half a year, with the dose raised over five weeks. At ten weeks there was no meaningful difference between the groups in nightmare scores, sleep quality or overall change, and none at 26 weeks either. Earlier, smaller trials had been positive, and the authors suggested the patients in the large trial may have been more stable.

For Tanisha, the paper takes a middle position. Prazosin is not started now, because trauma-focused therapy often reduces nightmares and because her raised blood pressure would need watching on a drug that lowers it. If her nightmares remain frequent after therapy and sertraline, a trial of prazosin with careful blood pressure checks, or nightmare-focused imagery rehearsal, can be discussed again.

Returning to Work

Her union assistance program and employer are involved only with her consent. A graded return is planned, starting on a daytime route that does not pass the stop and moving later to evening runs once her checklist score has fallen. The transit agency's assault protocol, including the driver shield on newer buses, is reviewed with her so that her sense of danger is matched against real changes to her workplace.

Conclusion

Tanisha has PTSD after a robbery at knifepoint, with a PCL-5 score of 54, moderate depressive symptoms and drinking used to sleep. Cognitive processing therapy, chosen for her self-blame from a trial in which it matched prolonged exposure, is paired with sertraline. Prazosin is set aside for now after a large negative trial, with a clear point at which it will be reconsidered. The PCL-5, PHQ-9 and AUDIT-C will be repeated every four weeks, with a fall of ten to twenty points on the checklist taken as meaningful change, and her return to driving will move in steps that she agrees to.

References

Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K., & Domino, J. L. (2015). The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and initial psychometric evaluation. Journal of Traumatic Stress, 28(6), 489-498. https://doi.org/10.1002/jts.22059

Raskind, M. A., Peskind, E. R., Chow, B., Harris, C., Davis-Karim, A., Holmes, H. A., Hart, K. L., McFall, M., Mellman, T. A., Reist, C., Romesser, J., Rosenheck, R., Shih, M.-C., Stein, M. B., Swift, R., Gleason, T., Lu, Y., & Huang, G. D. (2018). Trial of prazosin for post-traumatic stress disorder in military veterans. New England Journal of Medicine, 378(6), 507-517. https://doi.org/10.1056/NEJMoa1507598

Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., & Feuer, C. A. (2002). A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. Journal of Consulting and Clinical Psychology, 70(4), 867-879. https://doi.org/10.1037/0022-006X.70.4.867