Making a Differential Diagnosis

"CASE 4

Posttraumatic Stress Disorder

Table 4-1

Dx

Checklist

Posttraumatic Stress Disorder

1.Person is exposed to a traumatic event—death or threatened death, severe injury, or sexual violation.

2.Person experiences at least 1 of the following intrusive symptoms: • Repeated, uncontrolled, and distressing memories • Repeated and upsetting trauma-linked dreams • Dissociative experiences such as flashbacks • Significant upset when exposed to trauma-linked cues • Pronounced physical reactions when reminded of the event(s).

3.Person continually avoids trauma-linked stimuli.

4.Person experiences negative changes in trauma-linked cognitions and moods, such as being unable to remember key features of the event(s) or experiencing repeated negative emotions.

5.Person displays conspicuous changes in arousal and reactivity, such as excessive alertness, extreme startle responses, or sleep disturbances.

6.Person experiences significant distress or impairment, with symptoms lasting more than a month.

(Based on APA, 2013.)

At age 65, Elaine, a retired professor of social work, was living a full and active life. Although retired, she had never been one to sit back and let life pass her by. She had always been an energetic and outgoing woman, something of a social butterfly who enjoyed good friends and good food. She was a regular subway rider, traveling all over the city to go to her favorite shops, restaurants, museums, and lectures and to visit her numerous friends from the university community.

Interest in stress disorders intensified during the Vietnam War, when clinicians observed that increasing numbers of returning veterans were having flashbacks

(intense recollections of combat traumas) and were generally alienated from everyday life.

Elaine A Woman of Energy and Optimism

In fact, Elaine’s energetic and optimistic life in retirement was consistent with the robust and challenging state of mind with which she had always approached life. Indeed, she had never had any psychological difficulties to speak of, or even a significant physical illness. On the other hand, she certainly had her share of trauma earlier in her life. She spent her childhood living in Alabama during the civil rights movement. Her father, an African-American man who became an outspoken local leader for civil rights, was a frequent target of hate mail and community protests. Throughout her early childhood into her teenage years, Elaine witnessed marches and nonviolent protests that were often met with threats and violence. At age 14, she was one of the first African-American students to attend a desegregated high school in her hometown. At best, her white classmates ignored her; at worst, they mocked and bullied her. Elaine got used to eating lunch alone and staring stone-faced into the distance as the white high school students taunted and mocked her. Even in her own community, some people expressed hatred for her and her family. Every night as she and her parents watched the nightly news, she saw the stories of the many people who had been hurt or killed during the civil rights movement. She became skilled at walking through the hallways of her school and the streets of her town with her head held high, ignoring the frequent taunts and occasional shoves. She became skilled at avoiding situations that seemed ready to erupt, and her ability to overcome taunting and isolation, as well as cope with danger, had instilled in her a fierce pride in her self-sufficiency, mental acuity, and physical resilience. She likened herself in those times to a cat: someone who quickly sized up a situation and made the right move almost instinctively, always landing on her feet.

Following high school, Elaine went to a Northeastern university to study for a bachelor’s degree in social work. She eventually earned a doctorate and obtained a faculty appointment at a major university in the Northeast, where she remained for 30 years.

At the university, she threw herself wholeheartedly into her career, devoting her life to teaching, research, and writing. Her intense involvement in her work was legendary, and anecdotes circulated in her department of how she had occasionally

been found asleep at her desk when colleagues arrived in the morning; apparently, she had become so absorbed in her work that she had ended up staying the night.

With her devotion to her career, there was no doubt in Elaine’s mind that her personal life had suffered. As she remained unmarried, her colleagues and students became her family. (Both of her parents had since passed away, and her siblings remained in the South.) Sensing her devotion, students flocked to receive the benefits of her wisdom and experience, which she generously bestowed. She, in turn, took great personal interest in her students’ progress, maintaining contact with them and following their careers, sometimes for decades, after they had graduated.

And so it was, both prior to and during retirement. Elaine was a picture of emotional and physical strength—a woman of incredible poise, self-confidence, and direction. Then, in one brief moment, everything seemed to change. She was struck by a catastrophe that took her life and state of mind in a direction that she could never have anticipated or imagined.

Stress disorders can occur at any age, including childhood.

Elaine Disaster Strikes

Elaine was taking the subway home from a shopping trip when it struck a stationary train on the track ahead. Although her train was not traveling at high speed—perhaps 20 miles an hour at most—the impact was forceful enough to hurl the passengers from their seats and partially crush the metal cars. Elaine herself had been standing at the moment of impact. As she was thrown forward, her left leg struck a seat jutting out in front of her, wrenching her knee, and her head struck a metal pole, knocking her out. When Elaine regained consciousness, she was lying in a pile of other passengers who had been thrown together in the same corner of the car. As far as she could make out in the dim light, most were unconscious and bleeding. Elaine put her hand to her own forehead and it came back wet with blood. She was horrified. What if she was bleeding to death and no one could reach her to stop the flow? She tried to get up but could not overcome the weight of the other passengers. She spent the next half hour lying there, paralyzed with fear, wondering if she would be able to survive until help arrived.

Generally, the more severe the trauma and the more direct one’s exposure to it, the greater the likelihood of developing a stress disorder.

When the rescue squad finally did arrive on the scene, the injured passengers were taken out of the train on stretchers. Only 4 were judged to require hospitalization— Elaine among them—and they were taken to separate emergency rooms in the vicinity of the train wreck.

The initial examination in the emergency room determined that Elaine did not have a critical loss of blood. Now, as she lay on a gurney awaiting further tests, the terrified woman stared wide-eyed at the gruesome scenes paraded before her: people being brought in as a result of stabbings, shootings, drug overdoses, and the like. A tough-looking stabbing victim with only superficial wounds seated himself next to Elaine and winked at her; Elaine was aghast. She turned her head away from the derelict, hoping to escape his further notice, but she felt she might be set upon at any moment.

Elaine spent 3 hours in this highly anxious state, restrained by the straps on the gurney, until she was finally taken to the radiology department for tests. At first she was relieved to be removed from the throng, but then, as she was wheeled down a dark corridor, she began to wonder if her relief was premature. Overcome by her fears, she even wondered whether she was being taken away to be raped or killed by the hospital orderly, of all people.

Once her X rays and a computed tomography (CT) scan were done, Elaine was returned to the waiting area, where her fears further intensified. Now she began to focus on the risk of contagion. Numerous patients were coughing persistently, and Elaine became afraid that she was being exposed to tuberculosis, which had been making a well-publicized comeback in city hospitals. She glanced at the disreputable-looking man hacking away next to her. He seemed extremely haggard and sickly, practically spitting on the floor, and she became convinced she was about to contract a drug-resistant strain of tuberculosis.

After another 2 hours, the doctor finally arrived and informed Elaine that the X rays and CT scan had revealed no fracture or brain hemorrhage. He then helped her up from the gurney and tested her gait, physical mobility, and neurological signs. Everything seemed normal. The doctor told Elaine she was free to go home as soon as the nurse dressed her head wound. To play things safe, however, he also advised Elaine to see a doctor for follow-up.

Elaine was relieved to be released finally. However, she glanced at the clock and saw that it was now 1:00 A.M., 6 hours from when she had originally been brought to the hospital. The idea of venturing out into the night at this hour, in this

condition, in this neighborhood, was, like everything else, terrifying. She was in a tremendous conflict. This horrifying emergency room was the last place on earth that she wanted to be in. But the alternative, leaving the emergency room to be discharged into the unknown, seemed even worse right now. She soon positioned herself in the same waiting area that moments before she had so fervently been hoping to flee. The frightened woman sat there amid the other patients’ coughing, shaking, vomiting, and bleeding. In fact, she waited there until the first glimmer of dawn, and then hobbled out to a taxi waiting at curbside.

The taxi carried her through the awakening city. It was a strangely quiet, dreamy ride, completing the journey Elaine had begun on the subway some 12 hours before. She arrived at her apartment house in 20 minutes and dragged herself out of the cab and into her building, where she took the elevator up to her floor. Once inside her apartment, she collapsed on her bed, happy to be home at long last. What had begun as a simple trip home from a downtown shopping expedition had turned into a nightmare. Elaine slept for almost a full 24 hours.

Elaine Aftermath of the Trauma

The next day, Elaine called some close friends to tell them what had happened. In the light of day, she now realized that one of the most disturbing elements of the whole experience had been coming face-to-face with the prospect of physical disability. As someone who lived alone and had no close living relatives, she realized that even a temporary inability to care for herself could be disastrous. Fortunately, she had a close-knit network of friends and colleagues from the university where she had taught until a few years ago. With her calls this morning, she hoped to reassure herself that her friends would indeed step in if the need arose.

Women are at least twice as likely as men are to develop a stress disorder. About 20 percent of women who are exposed to a severe trauma develop such a disorder, compared to 8 percent of men.

Her friends were sympathetic and asked her if she needed anything. But oddly, Elaine felt disoriented and found it difficult to answer their questions. The previous day’s experience was now jumbled in her mind, and explaining it required considerable effort. It was tiring just to talk for a few minutes. By the time she had made the third call, her voice was so weak that her friend felt great concern and suggested she see a doctor sooner rather than later.

Elaine set up an appointment with a neurologist for 3 days later. In leaving her apartment—for the first time since the accident—she was alarmed at how noisy and confusing it was just to be outside. The city traffic seemed unbearably loud, and Elaine wondered if she would even be able to cross the street. Her body still ached from the accident, but more important, she became concerned that history might repeat itself. She had never been in an accident before and had never been concerned about crossing the street. Now, however, she found herself jumping back and running from cars as they zoomed past, even though she was still on the sidewalk.

Eventually, Elaine reached the doctor’s office exhausted and out of breath. She was panting noticeably, as much from running as from her anxiety about the traffic. She didn’t even speak to the receptionist when she first arrived. Instead, she collapsed on the nearest seat, closed her eyes and gulped for air, as though having just escaped some grave danger. After a few minutes, the receptionist noticed her sitting there and walked up to greet her. At the sound of the receptionist’s voice, Elaine practically jumped out of her seat, she was so startled to find someone suddenly upon her.

The neurologist gave her a thorough examination and reviewed the X rays and CT scan taken in the hospital emergency room. He said that all results seemed normal, but that judging from the cuts and bruises on her head and her complaints about fatigue, noise sensitivity, and disorientation, she might well have sustained a concussion. He told her it was mild, but the symptoms could take several days or even weeks to go away. In the meantime, she should take it easy and get all the rest she needed.

Studies indicate that survivors of severe stress, especially those who develop stress disorders, experience abnormal activity of the neurotransmitter norepinephrine and the hormone cortisol.

Noticing that Elaine’s knee seemed quite swollen, the neurologist also referred her to an orthopedist. Two days later, the latter physician determined that Elaine must have torn the cartilage in her knee as a result of the accident, and now it was becoming inflamed. He said that for the time being, he would treat the knee with an anti-inflammatory drug; but if the inflammation did not improve or if it worsened, arthroscopic surgery to remove the inflamed tissue would be necessary.

Elaine returned home from her appointment with the orthopedist with a vague sense of unease that gradually built to a feeling of impending doom. She had not

expected to hear surgery mentioned, and the idea was unusually threatening to her. She shuddered at the thought of going back to a hospital. She recalled her emergency room experience and practically shook with fear as she considered the terrifying scene.

As time passed. Elaine’s postconcussion symptoms—her fatigue, noise sensitivity, and disorientation—subsided. Physically, she started to feel more her old self, but she couldn’t seem to shake her fearfulness. Each trip outdoors was extraordinarily stressful. Crossing the street was consistently anxiety provoking, as she couldn’t get over her preoccupation with being in another accident, this time as a pedestrian. Taking the bus or subway was simply out of the question. The very thought of getting on a train made her shudder. Accordingly, her travels were confined to small local trips in her neighborhood, just to do the necessities: buy food and go to doctor appointments.

It seemed that Elaine’s accident and emergency room experience had transformed her entire outlook on life. Somehow, having spent several hours in a highly charged emotional state, focusing almost exclusively on the prospect of dying or being raped or murdered, her mind had started to see everything through this lens. And there was no escaping the memories. When home, in what she considered a safe environment, her memories of the subway car or the emergency room would constantly intrude. As she watched television, her eyes would glaze over as some particularly harrowing element of her experience forced itself into her consciousness: the pile of bodies in the subway car, the grim ride down the hall to the X ray room, or one of the bleeding or coughing “thugs” sitting just a few seats away. Then she would try to shake the memory loose, forcing it out of her mind and trying to focus on something more pleasant, only to find it returning in bits and pieces throughout the evening.

People who generally view life’s negative events as beyond their control seem more prone to develop a stress disorder when confronted with a traumatic event (Regehr et al., 1999). Nevertheless, even people like Elaine, who have hardy attitudes and personalities, may develop a stress disorder.

Previously a sound sleeper; she now found herself waking frequently from dreams that contained images of her subway or emergency room experience. They were not exactly nightmares; rather, they were mostly accurate renditions of her all-too- real experience. She couldn’t escape the images, even in sleep.

Elaine Drifts Away A Friend’s Perspective

During the weeks immediately following the accident, Elaine talked on the phone to friends regularly, endlessly sharing her experience. At first, her friends were deeply interested and supportive. It pained them to consider what this grand elderly lady had gone through. But after a while, as Elaine turned every conversation back to her “horrible experience,” her friends began to lose patience.

Even Fiona, perhaps Elaine’s closest friend, came to dread her daily phone calls from Elaine. In a later conversation with her sister, Fiona tried to explain such a reaction and to describe the course that her relationship with Elaine had traveled in the months following the accident.

At first I hung on every word, trying to grasp the horror that had befallen her. I worried about her terribly, wanted to help her through this, wanted to be there for her. But after a few weeks a sameness began to set in in our conversations. No matter what we talked about, Elaine found a way of turning the discussion back to her accident or her fears. If I told her about a film I’d seen, she would ask, “Did you take the subway?” and then she’d tell me for the fiftieth time how dangerous the subway is, how many crimes are committed in movie theaters, or some other tale of peril. Eventually I felt unimportant to her, just an excuse to describe the danger she now saw everywhere. Sometimes, it didn’t even seem as if she was even talking to me—just reciting her terrible litany out loud. It didn’t matter that I was her best friend—anyone would have done fine. Once I realized what was happening, I would try to divert her attention from these topics. I would offer gossip about someone at the university, bring up items from the news, or recall a funny or interesting event from past times. Nothing. Elaine showed no interest in anything except her newfound fears.

I would try to make plans to see her in person, rather than just talk on the phone. Elaine would not consider going out to a restaurant or movie; however, she would “let” me come over to visit her. Of course, during these visits we would just wind up talking about her fears again. Over time, the visits became shorter and shorter. Finally, I began to feel like a delivery person. Elaine would “allow” me to take groceries to her or to pick up some laundry from the cleaners. Our whole relationship became empty and superficial. I tried letting her talk about her fears; I tried not letting her talk about her fears. But nothing seemed to help. In time, it became a moot point, because Elaine pushed me out of her life.

By 3 months after the accident, she had stopped calling me and would only occasionally answer my calls. Our communications were brief and very superficial,

as if Elaine couldn’t wait for them to end. She seemed very fearful over what had happened to her and, worse, over what might happen to her in the future. Loving her, I truly felt for her. But, she also seemed to become increasingly angry, nasty, and cynical, not at all the friendly and warm woman I have known for so many years. She acted as if she blamed me—I’m not sure for what—perhaps for not having gone through the same ordeal or maybe for not seeming to care enough or to do enough now. All I know is that after a while conversations or interactions with me seemed to further agitate Elaine. If I suggested that she see her doctor again or gave her advice regarding her bad knee, she would act like I was bothering her and sticking my nose where it didn’t belong. So I pretty much stopped. I stopped making suggestions or trying to coax her back into the world. It seemed easier for Elaine that way; it was certainly easier for me.

One-third of victims of serious traffic accidents may develop a stress disorder within a year of the accident (Stallard et al., 1998).

You know, in an odd way, I feel like I was a victim of that train accident. For the most part, I have lost my dearest friend. I have been forced to stand by and watch her drift away. This warm, energetic, and worldly woman who added so much richness and love to my life has been replaced by a stranger—an obsessive, self- centered, angry woman—who seems to resent me and wants little to do with me. I am just so frustrated and sad and a little angry as well, I guess. For now, Elaine and I have an implicit understanding to keep some distance between us.

Elaine in Treatment The Journey Back to Normalcy

Over the next few months, Elaine’s life became more isolated. Her fearfulness did not improve, and her outdoor activities remained restricted to what she considered safe situations, although nothing felt completely safe. At the same time, her injured knee became more and more painful. When the orthopedist, during a subsequent visit, talked more certainly about the need for surgery, she burst into tears and cried out, “I cannot face going back into that horrible place. My life has already been ruined by this accident. If I go back into the hospital once more, I know I will never survive.” Soon realizing that his patient was in need of more than physical help, the physician suggested that Elaine make an appointment with Dr. Martin Fehrman, a psychologist, just to discuss her situation and see if the psychologist had any helpful suggestions about her lingering fears and upsets. The next morning, after yet another fitful night’s sleep, she decided to call Dr. Fehrman.

At the psychologist’s office, Elaine recounted her “nightmare” and how her life had unraveled overnight. As a former professor of social work, she was rather sophisticated about psychological matters and had spent some time pondering her predicament. She told Dr. Fehrman that on the one hand, she felt that her current state was an understandable result for anyone undergoing such a horrifying experience. But on the other hand, given her previous level of functioning, she would not have expected to be so completely undone by what she knew objectively to be just an accident. Her whole identity had been consumed by this accident and its aftermath. She felt like a different person.

After listening to Elaine’s story, Dr. Fehrman concluded that her condition met the DSM-5 criteria for posttraumatic stress disorder. First, she had been exposed to a traumatic event that posed a threat of death or serious injury; moreover, her response to the event entailed intense fear. Second, the traumatic event was followed by months of intrusive symptoms—in Elaine’s case, in the form of intrusive recollections and intense psychological distress in response to cues that resembled the original trauma (subways, buses, traffic, and strangers on the street). Third, Elaine persistently avoided stimuli associated with the trauma and experienced numbing (in the form of diminished interest or participation in activities and the sense of a foreshortened future). Fourth, she exhibited persistent negative emotions and a significant change in her own thoughts about herself and the dangers of the world. Finally, Elaine also exhibited increased arousal, including sleep difficulties, hypervigilance, and exaggerated startle response. This had been going on for 5 months now, and her functioning had been greatly impaired as a result. Dr. Fehrman believed that Elaine had developed an acute stress disorder in the immediate aftermath of the train crash but that as her early symptoms continued and even intensified after the first month, she now had posttraumatic stress disorder.

A specialist in stress disorders, Dr. Fehrman knew that both behavioral and cognitive approaches have often proved helpful in cases of posttraumatic stress disorder. The behavioral approach involves exposing the person—with either in vivo or imaginal exposure—to anxiety-provoking stimuli. The cognitive approach, called cognitive restructuring, guides the individual to think differently about the trauma itself and about possible current dangers. Dr. Fehrman typically used a combination of the approaches when treating clients.

If the stress symptoms begin within 4 weeks of the traumatic event and last for less than a month, the person has acute stress disorder. If the symptoms continue longer than a month, a diagnosis of posttraumatic stress disorder is appropriate.

In vivo exposure is used to help clients react less fearfully to stimuli and events around them. The in vivo exposure procedure for the posttraumatic stress disorder client is similar to that used with other anxiety disorders, such as phobias. A hierarchy of anxiety-provoking situations, ranging from the least to most threatening, is constructed by the client and therapist. The individual is then given assignments to enter these situations and to remain there for a time, usually until he or she has a significant drop in anxiety. The therapist generally has the individual repeat the exposures on several occasions until only minimal anxiety manifests during the exposure. Such exposure assignments proceed up the hierarchy until the most threatening item is mastered.

Many cases of acute stress disorder develop into posttraumatic stress disorder.

Imaginal exposure is used to help clients with posttraumatic stress disorder react less fearfully when recalling the original trauma. The individual repeatedly visualizes the entire sequence of events involved in the trauma for a long period, on a repeated basis. In visualization exercises, the client usually listens to a lengthy recorded description that he or she has provided. The purpose of the exposure is to desensitize the client to the memory of the trauma in the same manner that someone would be desensitized to any phobic object through repeated exposure. In essence, the meaning of the traumatic memory as a danger signal is changed by the exposure, and it eventually stops producing a sense of threat. Ultimately, the traumatic memory can be readily put aside like any other long-term memory.

Cognitive therapy, which more directly challenges the accuracy of the individual’s negative cognitions, can further bring about changes in the fearful reactions of persons with posttraumatic stress disorder. In one cognitive strategy, a client might be guided to write down or practice less catastrophic, less self-damaging interpretations of the trauma, often in connection with exposure exercises. Thus, Dr. Fehrman, like a number of professionals, included this approach in his treatment program. Under his care, Elaine embarked on a treatment program that extended over 19 sessions.

Session 1 In the first session, Elaine described the anxiety she had been feeling for the past 5 months. She also described the accident and its aftermath in the emergency room. She explained that the feelings resulting from that experience—

mainly the fear of injury or attack—seemed to have colored her entire approach to life. “I just can’t seem to get past this horrible experience. This is not me. It’s like I’ve become somebody else. I’ve got to get my old self back.”

About 3.5 percent of people in the United States have acute or posttraumatic stress disorder in any given year; 7 percent to 9 percent have one of these disorders within their lifetime (Peterlin et al., 2011; Taylor, 2010; Kessler et al., 2009, 2005).

Dr. Fehrman said he was optimistic that Elaine would be able to get back to her former self. He explained that she had posttraumatic stress disorder, the anxiety syndrome that arises following an intensely frightening experience. He also explained that after such an event most people go through a stressful period in which they feel especially vulnerable.

The psychologist then outlined the basic treatment strategy. He said one component of the treatment would be to survey all of the different ways in which Elaine’s life had been changed by her current fears and anxieties, paying particular attention to curtailed activities. Then the two of them would arrange the activities along a scale ranging from the least to the most threatening. Together, they would construct weekly exercises in which Elaine would enter—expose herself to—the situations she was avoiding, according to carefully specified procedures. Dr. Fehrman explained that Elaine’s anxiety should ultimately improve after she repeatedly entered situations for specified durations and frequencies each week.

The second component of treatment, the psychologist explained, also involved exposure, but in this case, exposure to the traumatic memory itself. He noted that the memory of the trauma was provoking a strong emotional reaction in Elaine, and as long as this was the case, it would intrude on both her waking and her sleeping life. He indicated that the emotional reaction provoked by the traumatic memory could be reduced by prolonged exposure to the memory itself.

In many cases of stress disorder, antianxiety drugs are also used to help control the client’s tension and exaggerated startle responses; antidepressants may help reduce the occurrence of nightmares, panic attacks, flashbacks, unwanted recollections, and feelings of depression (Friedman, 1999).

Elaine was puzzled by the logic of this approach. She remarked that she already was repeatedly exposed to the traumatic memory; indeed, it seemed to intrude numerous times each day, but her emotional reaction remained as strong as ever. Dr. Fehrman noted that with these naturally occurring intrusions, the exposure

often lasts only a few minutes; in addition, people are inclined to block out some of the more disturbing elements of the intrusion. The psychologist explained that in general, improvement occurred only with prolonged exposure, perhaps 45 to 60 minutes at a time, and only when all the elements, including the most disturbing ones, were faced.

For the coming week, he asked Elaine to start monitoring her feelings and behavior. She was to note particularly any instances of fear and anxiety, including the circumstances that provoked the anxious reaction and any associated thoughts. In addition, the psychologist asked Elaine to start taking note of the various activities she was avoiding, so that he and she could begin constructing a series of in vivo behavioral exposure exercises.

Session 2 Elaine began the next session by reporting that she had not kept any of the requested records. She explained that at her most recent visit to the orthopedist, he had once again voiced his skepticism that her knee would improve without surgery, although he could not rule it out. Elaine said that since this consultation, she had been completely consumed with deciding whether or not to have the surgery. The decision laid before her by the orthopedist had sent her into a state of anxiety and conflict that was overshadowing everything else.

Dr. Fehrman suggested that inasmuch as the orthopedist had told Elaine that there was no immediate need to make a decision, the client might consider removing that pressure entirely for a defined period. Specifically, the psychologist suggested that Elaine shelve the whole question of surgery for a month. Elaine expressed tremendous relief at this idea. Suddenly the future seemed brighter to her. She said she now felt prepared to throw herself wholeheartedly into the treatment.

At the same time, Elaine expressed concern that her physical limitations might prevent her from proceeding at a reasonable pace with in vivo exercises (that is, doing things she had been avoiding). It was decided, therefore, that for the time being, greater emphasis should be given to the imaginal exposure and that the next session would be devoted to discussing the subway and emergency room experiences in more detail. Still, Elaine would try a couple of brief shopping trips in the coming week if she felt physically capable.

Session 3 Dr. Fehrman asked Elaine to relate the details of her traumatic episode, including the accident and its aftermath in the emergency room. Dr. Fehrman recorded Elaine as she began describing the episode matter-of-factly. She soon closed her eyes in a trancelike fashion, as if trying to focus her efforts on an

intensely painful task. She then described the whole episode in a detailed monologue lasting approximately 45 minutes. She included the bodies in the darkened subway car, the blood on her forehead, her helpless posture on the gurney, the threatening characters in the emergency room, and so on.

When she had finished, Elaine appeared drained. Dr. Fehrman praised her for her tremendous effort in recounting those experiences. He then asked her to estimate her level of anxiety at its peak during the monologue and at the end of it, using a 0- to-10 scale. Elaine assigned ratings of 8 and 5, respectively, indicating that some reduction of anxiety had occurred by the end of the monologue.

In one form of exposure therapy, eye movement desensitization and reprocessing, clients move their eyes in a saccadic or rhythmic manner from side to side while recalling or imaging traumatic and phobic objects and situations. Some people with stress disorders have been helped by this approach (Cahill et al., 1999).

Session 4 Elaine and the psychologist listened to the recording together. While listening, Elaine closed her eyes and, as instructed, tried to imagine the events as vividly as possible. This time, she said she seemed to have had some new insights. First she said she now realized that one of the most troubling elements of the whole experience was the sense of loss of control—in this case, being at the mercy of various ambulance and hospital workers and not being able to fend for herself. She drew a direct connection to her childhood experience during the civil rights movement, when physical and mental quickness were her most prized possessions, which she equated with life itself. She now realized that her accident and emergency room experience had dealt a severe blow to this most precious aspect of her self-image.

Dr. Fehrman tried to offer Elaine a means of viewing the experience in a less negative fashion, suggesting that occasional episodes of loss of control are a normal part of life and that people are not necessarily diminished or demeaned by their occurrence. On hearing this, Elaine seemed tentatively prepared to accept the idea. She herself noted that yes, even during her adolescence, when she felt so independent and vital, she had once been in the hands of the police while jailed for a day for civil disobedience along with both of her parents. Nevertheless, she had later been able to view that episode as a transient interlude in an otherwise independent existence. When freed, she had felt prepared to pursue her independence even more vigorously than before. She said she could now see how it might be possible to view the recent accident in a similar light.

Some people with a stress disorder also benefit from group therapy, where they can discuss with other trauma victims their lingering fears and other symptoms, their feelings of guilt or anger, and the impact that the trauma has had on their personal and social life.

According to one survey, posttraumatic stress symptoms last an average of 3 years with treatment but 5.5 years without treatment (Lessler & Zhao, 1999).

Sessions 5 to 8 During the next 4 weeks, Elaine was instructed to listen to the recording almost every day. She recorded her peak anxiety level for about half of these imaginal exposures. Elaine’s anxiety level declined progressively, and by the end of the fourth week, her anxiety reaction to the recording was virtually extinguished. Decided shifts in Elaine’s thinking accompanied these reductions in anxiety. After about 2 weeks, when her peak anxiety had lessened considerably, Elaine told Dr. Fehrman that listening to the recording was making her feel that many of her fears had been overblown. By the third week, when Elaine’s anxiety had decreased still further, she said that the reduction in anxiety seemed to be carrying over to other parts of her life. She had resumed taking short bus and subway trips, at first with friends and then alone; moreover, she said she felt much closer with her friends, who had remarked on and rejoiced over the improvement in her spirits. Elaine also observed that repeated listening to the recording had made her feel that the episode was “now part of my experience.” The memory was no longer constantly “in the back of my mind”; nor did she feel compelled any longer to shut it out when she did think of it. In other words, its intrusive properties had been eliminated. By the eighth therapy session, Elaine reported that she had actually fallen asleep during a couple of listenings, so relaxing had the recording become.

During these same 4 weeks, Elaine also spontaneously began to take trips downtown, both by subway and bus, to places that she hadn’t visited since the accident (again, first with friends and later on her own). At about the same time, her fear of youths on the street also declined.

The psychologist felt Elaine no longer needed to listen to the recording at this point, suggesting that the most benefit would come from Elaine’s increasing the range of her behavioral activities through in vivo exposure. The therapist and client designed a plan for Elaine to take at least one local shopping or subway trip per day, plus a couple of downtown shopping trips per week.

Sessions 9 to 13 During these sessions, held over a 4-week period, the emphasis remained on the in vivo behavioral exercises. Elaine continued to become more comfortable using public transportation and now did so without hesitation. At the same time, however, her physical condition was starting to deteriorate. Her knee had grown so tender that she was finding it difficult to walk at all. The orthopedist was again pushing for surgery.

Intellectually, Elaine felt that the surgery was the rational solution to her problem, but she didn’t know whether emotionally she could face going into a hospital. Thus, Dr. Fehrman suggested that perhaps this anxiety could be reduced through some exposure to preliminary aspects of the medical process. He suggested that Elaine begin taking some of the steps that would be involved if the surgery took place, as a type of hypothetical exercise. The first step would be to make an appointment with the orthopedic surgeon to inquire about the surgical procedure, including such matters as the preoperative testing, the duration of the surgery, the length of the hospital stay, and the recovery.

Sessions 14 and 15 Elaine carried out the assignment and reported on the information she received from the orthopedic surgeon. It turned out that surgery would be arthroscopic, a couple of small incisions, through which the inflamed and torn cartilage would be removed. There would be a recovery period of several weeks, but after the first week she shouldn’t be any more debilitated than she was now, and she should steadily improve after that point. Acquiring this information seemed to allow Elaine to consider the idea with some objectivity for the first time.

To further promote Elaine’s psychological preparedness, Dr. Fehrman suggested that she now look into the arrangements that would have to be made for a home recovery—again, hypothetically. At Session 15, Elaine reported that the home recovery arrangements could apparently be made without much difficulty. The psychologist then asked her to call the orthopedist’s office manager and ask how one would go about actually scheduling the surgery, should she decide to do so.

Sessions 16 to 19 Returning for Session 16, Elaine discussed her phone call to the orthopedic surgeon’s office. In fact, she had gone ahead and scheduled the surgery, reminding herself that she could always cancel or reschedule it. By Session 19, the surgery date was only a week away, and she felt only limited hesitation about proceeding.

One study conducted 2 to 3 years following the 9/11 terrorist attacks found that 12.6 percent of people living in lower Manhattan had posttraumatic stress disorder (DiGrande et al., 2008).

Epilogue

Elaine had the surgery and reported to Dr. Fehrman that it had gone “marvelously.” From beginning to end, she was impressed with the professionalism and caring of the medical staff. Her only remaining task was to recover physically, which she expected would take several weeks. From a psychological standpoint, she felt she had now come full circle. It had been just about a year since her accident, and here she was, once again emerging from a hospital, but this time in good spirits and filled with optimism, this time embracing her friends and their offers of help rather than pushing them away

Dr. Fehrman contacted Elaine by phone 3 months later and learned she had made a full recovery from the surgery. She said she now felt fully restored, both physically and mentally. Her traumatic accident had finally come to an end.

Assessment Questions

1. What event precipitated Elaine’s posttraumatic stress disorder?

2. Which neurotransmitter and which hormone often have abnormal activity in survivors of severe stress?

3. Why do friends and relatives eventually distance themselves from a person who has had a traumatic incident?

4. Why did Elaine finally decide to seek treatment?

5. Why did the doctor diagnose Elaine with posttraumatic stress disorder rather than acute stress disorder?

6. What modes of therapy did Dr. Fehrman select to assist Elaine with her disorder? Give an example of each type of therapy.

7. During the first session, Dr. Fehrman gave Elaine 3 components of her therapy. Describe those 3 components.

8. What was the purpose of recording the traumatizing incident?

9. Why did Elaine fail to take notes of her feared activities as part of her treatment plan? How did Dr. Fehrman handle this problem in his session with Elaine?

10. What other incident in Elaine’s early life may have contributed to her posttraumatic stress disorder?

11. According to the text, how long does it typically take for people to recover from posttraumatic stress disorder? What percent of people continue to experience symptoms even after receiving treatment for many years?"