Post Traumatic Stress Disorder (PTSD)

Artwork (c)2006, www.psychotherapy.net


It was a warm Sunday at Thong Sia. I had a hearty meal with family at Sushi Tei, Paragon before class. One of the air-cons was down but I was strategically seated where the working air-con faithfully blew at me. How blessed! Soon papers and hands were swaying to keep one awake… The ‘traumatized’ ones kept nodding as Prof Bates continued.

Wow, Swinburne University was rated top Victorian university for The Educational Experience (Source: The Good Universities Guide, 2007.) We have been informed previously that the university was ranked 4th out of 39 universities in Australia for Learning and Teaching Quality (Source: Department of Science, Education and Training (DEST), 2005) I have made the right choice and now proud indeed to be associated with the University! < LET’S GET ON WITH IT. >

I was all ears throughout Prof Bates’ lecture because I am currently seeing a client diagnosed and medicated for PTSD. I have seen her once todate and have provided her (Applied) education about trauma and PTSD. It was indeed timely to be further equipped by Prof Bates!

My client (K) suffered sleepless nights for 3 weeks before she sought psychiatrist help. A new colleague (M) she was closed to for 3 months had jumped to her death after sms-ing her the night before. K is an only child. She became very agitated to loud noises and fearful in darkness. She wept whenever she thought of M.

There seemed to be a psychological trauma K is suffering. It is an injury to her mind and inherent processes and functions (including identity and sense of self). Her assumptions about the world have been shattered and must be rebuilt.

In DSM-IV-TR the range of event that became a stressor for K was neither Directly Exposured to the tragedy nor Witnessed the Event. It was an Event Learnt About of the sudden loss of a close colleague. As a stress syndrome PTSD is defined as a psycho-biologically driven organismic function of adaptation to abnormal excessive or extreme stressor events that tax individual coping resources.

K consistently re-experienced ruminations of the tragic news. She kept thinking of the days before the fatal plunge. Whenever she read of news pertaining to suicide, she would bring it up to the parents. Her parents were upset by her ruminations. K had recurrent and distressing dreams aligned with death. Her symptoms of hyper-arousal include: Difficulty falling or staying asleep, irritability with noise, hyper-vigilance (have to sleep with the lights on).

K’s sense of self, others and the world have undergone a drastic shift. She needs strategies for developing self-awareness to restore herself to the previous functioning:

1. Recounting the specific episodes (the ABC model)
2. Exploring shifts in affect 3. Free association 4. Using Imagery
5. Role-plays 6. Symptom induction 7. Discussion of the worst case scenario
8. Look for thoughts that might explain feelings 9. Dysfunctional Thought Records 10. Homework

K is now being medicated (I am a believer in pharmacotherapies) and she will be offered Phased Treatment of PTSD. There will be symptom management of low tolerance level of noise using relaxation techniques. Trauma focused work (imaginal exposure in K’s case) as well as cognitive restructuring (grief and guilt, etc) will be followed up. We will also collaborate and work on Relapse prevention and maintenance of treatment.

A snapshot of treatment strategies for K as proposed by Prof Bates

1. Writing Therapy (Pennebacker) to develop a trauma narrative.

K will be asked to describe the traumatic event in an open ended manner. I will enquire about the details of the event to ensure inclusion of:

- physiological and emotional reactions at the time.
- choice points and actions taken before, during and after
- meanings attached to the event, own reactions or behaviours
- responses of others during and after
- cues that trigger memories
- specific symptoms of re-experiencing, avoidance, arousal
- difficulties in relationships, academic or work since the event

Confronting the traumatic memories has to be done gradually and safely. Research shows too few practitioners offer effective interventions esp exposure.

2. Imaginal Exposure (IE)

IE is graded, prolonged, repeated, pace, collaborative and functional. K needs to know emotional processing helps to organize the memory and process the trauma and that thinking about it is not dangerous. She needs to be repeatedly exposed to the trauma and in the long run it will lower her anxiety and disconfirm beliefs. Exposure enhances her sense of self-control and personal competence.

Before I conduct IE on K, I need to be aware if she has a history of impulsivity or psychosis. There are 3 primary targets for exposure:

1. The memory of the trauma
2. Other internal and external cues that trigger anxiety and re-experiencing
3. Situations that are avoided (The workplace)

Conducting IE:

1st step:

1. Client initially relaxes and `book ends’ are established.
2. Client then tells the story of the trauma (which is tape recorded)
3. The therapist acts as guide asking questions to a) focus on details (e.g. sights, sounds, smells and other sensory experiences) b) ensure all significant details of the story are included and nothing is avoided.
4. Periodically rate client’s distress (0 to 10)

2nd step:

1. Client listens to tape recording of the story again and again closing eyes and attempting to relive it
2. Exposure should continue until anxiety ratings drop at least 50%
3. If trauma is complex, story needs to be broken into segments and tell across several sessions.
4. Exposure must proceed until anxiety drops because a) terminating when distressed strengthens the distress b) decreasing anxiety for the first time is a powerful experience that contradicts fears of being overwhelmed by anxiety and provides motivation for future work.

3rd step:

1. Once client has habituated to the tape of the trauma story at the clinic, client listens to the tape as homework.
2. At least 45 mins per day is recommended to supplement writing the trauma narrative.
3. Anxiety specific cues can be included (loud noises, car horns)

3. Cognitive Restructuring

K was feeling guilty about not being able to detect depression in M. She wished she had spent more time with her. In PTSD, cognitive restructuring targets the client’s distorted thoughts, assumptions and beliefs associated with the trauma.

K said, ‘What happened was my fault.’

Techniques:
• Examine knowledge and choices available to K at the time.
• Double standard technique – would she blame a friend in a similar situation?
• Construct pie chart assigning responsibility to all relevant parties
• Practice self-forgiveness


K thinks ‘The world is unpredictable.’

Techniques:
 List advantages/disadvantages of the belief.
 List areas of K’s life where she has some control and rate degree of control
 Cost/benefits of specific attempts at control
 Record behaviours producing predicted outcomes
 Engage in behaviours with predictable outcomes
 Accept that some events are unpredictable

K feels that she is incompetent and that’s why M did not trust her enough to share her problems before she jumped to her death.

Techniques:
 Examine evidence of competence in K’s daily life
 Examine unreasonable expectations of competence in extreme and unusual circumstances
 Keep a log of competent coping
 Graded task assignment

K is also experiencing defensiveness when she is relating to people. ‘Other people cannot be trusted. M said one thing but did another.’

Techniques:
σ List known people who are trustworthy
σ Rate people on a continuum of trustworthiness
σ Carry out behavioural experiments that involve trusting people
σ Keep a daily log of people who honour commitment

K’s sense of life, ‘Life is meaningless.’

Techniques:
List activities that formerly were rewarding
Schedule pleasurable/rewarding activities
Recognize that feelings of loss confirm meaning
Examine which goals or activities no longer seem meaningful and which now appear more important
Work toward an acceptance of death
Find meaning in each day