Complex Trauma and Grief Case Review
Sabrina Mesiemore (45F)
Assessment: Reasonable Course with Enhancements
1 / 10
Diagnostic Formulation: 5+1 Diagnoses
| Diagnosis | Code | Status |
|---|
| PTSD, Chronic Severe | F43.10 | ✅ Appropriate |
| Prolonged Grief Disorder | F43.81 | ✅ Appropriate |
| Bipolar Disorder, Depressed | F31.4 | ✅ Appropriate |
| Panic Disorder | F41.0 | ⚠️ Modify — In remission |
| Other Specified Anxiety | F41.8 | ✅ Appropriate |
Additional: Nightmare Disorder (F51.5) — specify separately for targeted treatment
2 / 10
Medication Regimen Review
| Medication | Assessment | Action |
|---|
| Fluvoxamine | Reasonable | Continue |
| Vraylar (cariprazine) | Reasonable | Continue; monitor metabolic |
| Lamictal (taper) | ⚠️ Requires modification | Suspend taper |
| Nightmare treatment | Gap identified | Initiate trial |
Critical: Lamictal taper during EMDR = mood destabilization risk in bipolar patient
3 / 10
Critical Issue #1: Suspend Lamictal Taper
Current Plan: Taper lamotrigine
Recommendation: Suspend until EMDR complete
Rationale:
- EMDR activates trauma processing → emotional dysregulation
- Lamotrigine taper → reduced mood stabilization
- Combined effect = high manic/hypomanic switch risk
- Bipolar patients require mood stability during trauma therapy
Timeline: Resume taper 8+ weeks post-EMDR completion with mood stability confirmed
4 / 10
Critical Issue #2: Metabolic Monitoring
BMI 33.94 on Cariprazine
Metabolic syndrome risk requires active monitoring
Required Monitoring:
- Fasting glucose
- HbA1c
- Lipid panel (fasting)
- Weight/BMI tracking
Frequency: Baseline, 12 weeks, then annually (or quarterly if metabolic risk)
5 / 10
Critical Issue #3: Sleep Stabilization Before EMDR
EMDR Prerequisites:
- Sleep study reviewed and addressed
- Nightmare pharmacology trial initiated
- 8+ weeks mood stability confirmed
- EMDR provider bipolar experience verified
Nightmare Treatment Options:
- Prazosin rechallenge 1mg
- Gabapentin 300-600mg at bedtime
- Topiramate 25-50mg (mood stabilizing benefit)
6 / 10
Psychotherapy Integration
| Modality | Status | Notes |
|---|
| Supportive/humanistic | ✅ Continue | Strong therapeutic alliance |
| EMDR | ⏳ Conditional | Pending sleep/mood stability |
| CGT | 💡 Consider | 16-session protocol for prolonged grief |
| CBT-I | 💡 Consider | If insomnia persists |
Self-Compassion Homework: Excellent — well-constructed letter targeting core shame
7 / 10
Integrated Care Coordination
Additional Care Needs:
- Chronic pain: CBT-CP referral; trauma-informed physical therapy
- Caregiver burden: Respite resources, Area Agency on Aging
- Nutrition: Referral given BMI 33.94 + family history
- Safety: C-SSRS during trauma treatment phase
Behavioral Activation Success: Spontaneous pool visit — leverage this positive momentum
8 / 10
Follow-up Timeline
| When | Action | Who |
|---|
| 2 weeks | Review sleep study; start nightmare meds | APRN/PCP |
| 4 weeks | Mood stability check; metabolic labs | APRN/MD |
| 6 weeks | Reassess sleep/nightmares | APRN |
| 8 weeks | EMDR initiation if cleared | EMDR provider |
| Ongoing | Weekly therapy; biweekly psych checks | APRN/MD |
9 / 10
Summary: Reasonable Course, Specific Enhancements
Current Course: APPROVED
Priority: Suspend Lamictal taper, stabilize sleep, then EMDR
Next Steps:
- Suspend lamotrigine taper immediately
- Obtain and address sleep study
- Initiate nightmare pharmacology trial
- Confirm 8-week mood stability before EMDR
- Verify EMDR provider bipolar experience
From: Psychiatric MD Collaborator | To: Stacy Pascarella, APRN
March 19, 2026
10 / 10