Referral for Diagnostic Assessment: 44-Year-Old Female with Complex Trauma and Psychiatric Comorbidities
This patient requires comprehensive psychiatric evaluation with specific focus on trauma-related disorders (PTSD, adjustment disorder) and their relationship to her existing MDD/GAD diagnoses, given her significant trauma history including violent assault and sexual harassment. 1
Essential Components for Referral Documentation
Trauma History Assessment
- Document specific trauma exposures: knife attack (physical trauma with potential head injury), sexual harassment, and ongoing psychosocial stressors related to single parenting 1
- The American Psychiatric Association mandates review of trauma history and exposure to violence or aggressive behavior as core components of initial psychiatric evaluation 1
- Include timeline of traumatic events and their temporal relationship to psychiatric symptom onset 1
Current Psychiatric Symptomatology
Request differential diagnosis between:
- Post-traumatic stress disorder (PTSD) - characterized by reexperiencing, avoidance, hypervigilance, and dysphoria 2, 3
- Adjustment disorder - develops in response to identifiable stressors without meeting full PTSD criteria 3
- Major depressive disorder (MDD) - distinguished by somatic and affective symptom clusters 4
- Generalized anxiety disorder (GAD) - characterized by excessive, uncontrollable worry about multiple life domains 5
These disorders are highly comorbid following trauma, with overlapping negative affective symptoms that require careful differentiation 4, 2
The dysphoria cluster may not be unique to PTSD and can overlap significantly with MDD and GAD 2
Safety Assessment Requirements
Immediate evaluation needed for: 1
- Current suicidal ideation, plans, or attempts (including passive death wishes)
- Self-harm behaviors or self-mutilation
- Access to lethal means
- Reasons for living (particularly responsibility to children as single parent)
- Quality of therapeutic alliance and support systems
Trauma survivors, particularly those with sexual assault history, have elevated suicide risk and require specific screening 1
Up to 80% of rape victims develop post-traumatic stress disorder 1
Medical Differential Diagnosis
Rule out medical conditions mimicking or exacerbating anxiety/depression: 1, 6
- Thyroid function (hyperthyroidism)
- Glucose levels (hypoglycemia)
- Cardiac arrhythmias or valvular disease
- Chronic pain syndromes
- Neurological sequelae from head trauma during knife attack
Laboratory testing should be completed if signs/symptoms suggest medical etiology 1, 6
Psychosocial Stressor Documentation
Current stressors requiring assessment: 1
- Financial strain related to single parenting
- Housing stability
- Occupational functioning
- Social support network adequacy
- Legal consequences or ongoing proceedings related to assault
Single parenting represents significant ongoing stressor that may perpetuate adjustment difficulties 1
Comorbidity Screening
Screen for additional psychiatric conditions: 1
Use standardized screening tools such as GAD-7 (scores ≥10 indicate moderate-severe symptoms requiring specialist referral) 7, 5
Level 1 Cross-Cutting Symptom Measures can efficiently screen for comorbidities 1, 6
Functional Impairment Assessment
- Document specific impairments in: 6
- Parenting capacity and child care responsibilities
- Occupational functioning
- Social relationships
- Activities of daily living
- Sleep, appetite, concentration
Treatment History
- Include: 1, 7
- Previous psychiatric medications and response
- Prior psychotherapy modalities and outcomes
- Medication side effects or allergies
- Current medications (prescribed and over-the-counter)
- Family psychiatric history, particularly anxiety disorders in first-degree relatives 7
Recommended Evaluation Approach
Structured Diagnostic Interview
- Request use of structured interview guides to enhance diagnostic reliability over unstructured clinical interviews 1
- Interview should be conducted in patient's preferred language with interpreter services if needed 1
- May require multiple sessions given complexity of trauma history and multiple diagnoses 1
Trauma-Informed Assessment
- Evaluation should employ trauma-informed approach acknowledging that trust may be compromised by past victimization 1
- Patient may experience guilt, self-blame, or confusion about whether traumatic events were her fault 1
- Sexual harassment history may compound trauma responses and affect therapeutic relationship 1
Treatment Planning Priorities
For moderate-severe symptoms (GAD-7 ≥10): 7
- Referral to licensed mental health professional for individual psychological interventions
- Combined cognitive behavioral therapy (CBT) and pharmacotherapy (SSRIs such as sertraline or fluoxetine)
- CBT with exposure therapy components has strongest evidence for chronic PTSD 1
Specific trauma-focused interventions: 1
- Exposure therapy for PTSD symptoms
- Cognitive therapy for trauma-related distorted cognitions
- Anxiety management techniques
- Eye movement desensitization and reprocessing (EMDR) as alternative
SSRIs represent first-line pharmacotherapy for trauma-related disorders with demonstrated efficacy 1, 6
Continue pharmacotherapy for 12 months after remission before considering taper 6
Immediate Referral Indicators
- Refer emergently if: 6
- Suicidal ideation or self-harm present
- Psychosis or severe agitation
- Severe functional impairment affecting child safety
- Symptoms not responding to current treatment