Introduction
The patient, Tegan, a retired college professor of social studies, used to be an active and outgoing old lady before developing severe mental health issues after being involved in a train accident. This inciting event, like any crisis, happened unexpectedly and caused significant physical and emotional trauma to this woman. Before the incident, Tegan could describe herself as a person with a wide social circle and who enjoyed life. However, the problem arose suddenly when the subway she was on struck a stationary train, resulting in multiple passengers being injured. The patient herself was seriously injured since she had a ligamental tear in her left knee as well as a concussion. After spending six hours in the Emergency Department while undergoing a radiologic examination, she observed various cases of people suffering, which initially caused acute anxious symptoms that transformed into post-traumatic stress disorder (PTSD). Research and clinical practice show that exposure to cognitive-behavior therapy (CBT) is effective in treating PTSD (Bryant et al., 2018). Tegan underwent exposure therapy for her psychiatric condition, leading to the successful subsidence of her symptoms and returning her to normal life.
Clinical Expression
PTSD is a debilitating mental health state that develops after a person experiences a traumatic event. Clinically, PTSD diagnosis is established based on two major criteria. Firstly, a patient must experience or witness a sexual assault, the death of a loved one, grave danger to one’s life, or severe physical injury (Bryant, 2019). Secondly, there should be symptoms from all four clusters listed in the diagnostic manual (Bryant, 2019). The first cluster comprises distressing memories, flashbacks, nightmares, and prolonged psychological disturbance (Bryant, 2019). The second cluster is characterized by active avoidance of triggers that induce trauma (Bryant, 2019). Thirdly, an individual should either have constant negative thoughts or an inability to remember some elements of the traumatic event (Bryant, 2019). Lastly, a person should present with angry and reckless behavior or excessive irritability (Bryant, 2019). If left untreated, PTSD has multiple adverse consequences for a person’s life, causing marital discord, physical illness, absenteeism, and unemployment (Difede et al., 2022). Therefore, adequate and timely intervention is vital not only for the benefit of an individual but also for preventing substantial economic losses to the country due to damage to the workforce.
Symptomology, Precipitating, and Perpetuating Factors
The clinical presentation and symptomatology of PTSD vary depending on the circumstances to which a patient was exposed. In the case of Tegan, her symptoms included flashbacks and memories about the train accident and the time spent in the Emergency Room, avoidance of trips and medical procedures, fearfulness, sleeping problems, and nightmares. Additionally, she became anxious, isolated, disoriented, and terrified to return to her usual mode of living for the past five months; hence, she was diagnosed with PTSD. The primary determinants of PTSD development for an individual are death in the family, physical injury, destruction of property, female gender, older age, lack of social support, and low educational level (Baral & Bhagavati, 2019). The patient seems to have a good education and a strong support circle, but she possesses some of the other listed risk factors. The precipitating event was that she received a physical injury during the accident and spent a prolonged time in an emotionally intense place. The major perpetuating factor is her bruised knee, which requires surgical intervention. Since being in a hospital trigger negative memory, Tegan refuses to receive medical assistance for this problem.
A critical aspect that is often underestimated in PTSD is the role of an individual’s physiology in the development of this disorder. Specifically, it is essential to discuss and explore the role of inflammation and metabolic factors. The reason why these components of the human organism are believed to play an important role in PTSD is that not all people exposed to severe accidents develop this condition. Indeed, “in about 60% of individuals, traumatic symptoms resolve over time without any intervention” (Khan et al., 2018, p. 2). It appears that people with an increased serum concentration of pro-inflammatory cytokines like tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) are at greater risk for developing PTSD (Kim et al., 2020). Research shows that people with more severe post-traumatic symptoms had higher levels of IL-6 and TNF-alpha (Kim et al., 2020). Moreover, it was found that elevated cortisol concentration may make a person more vulnerable to PTSD development (Speer et al., 2019). Although not mentioned in this patient’s case, it might be worth implementing anti-inflammatory treatment for Tegan since the level of pro-inflammatory markers and oxidative stress rises at an older age.
Therapeutic Model Appraisal
The treatment proposed to the patient is exposure CBT, which can be classified into two categories: imaginal and in vivo. The cognitive part of the therapy should help the patient start perceiving her situation more neutrally. The behavioral therapy incorporating the abovementioned imaginal and in vivo approaches will change Tegan’s neurocircuitry by continuous re-exposure to the old narrative but under safe circumstances (Cox et al., 2020). The method of prolonged exposure was developed based on the emotional processing theory. It states that any robust traumatic event that leads to PTSD alters brain structures, making a person hyper-aware of all triggering factors and causing avoidance, fear, and anger (Gramlich et al., 2021). The principles of reimagining one’s negative emotions and traumatizing situations cause desensitization and inhibit fearful mechanisms in the brain (Gramlich et al., 2021). However, the main problem of this treatment modality is the risk of dropout due to the patient’s inability to tolerate the exposure to traumatic memories (Lewis, Roberts, Gibson, et al., 2020). Thus, the therapist’s goal is to acknowledge the patients’ feelings and constantly reassure them that the symptoms will subside in case of treatment adherence.
Another equally effective approach for PTSD treatment is called eye movement desensitization and reprocessing (EMDR). The aim of EMDR is to change how traumatic memory is perceived by a person and make it less intense and vivid (Khan et al., 2018). In fact, some researchers claim that EMDR’s effectiveness is significantly higher in terms of reducing symptomatology compared to CBT (Khan et al., 2018; Mavranezouli et al., 2020). Still, both are recommended for combined use, especially in severe cases when the functioning of a patient is tremendously damaged. Technological advancement allowed to implement virtual reality and web-based therapy to enhance exposure therapy and make it more accessible (Kothgassner et al., 2019; McLean et al., 2020; McLean et al., 2021; Reger et al., 2019). Apparently, studies demonstrated the efficacy of all these approaches, but at the same time, every PTSD patient requires an individualized approach and a unique choice of therapy.
Administered Techniques
Tegan received imagined and in vivo exposure therapies for her PTSD that allowed to reduce the severity of her symptoms. The former was conducted for one month and was divided into 12 sessions, accounting for three sessions per week, which is a reasonable and justifiable amount considering the severity of Tegan’s state. The imagined therapy requires a person to record one’s traumatic experience in detail and then listen to the recordings for a certain period of time. This approach allows to alter specific brain structures responsible for fear responses, the amygdala and insula, reducing PTSD symptomatology (Zhu et al., 2018). It is crucial because this psychiatric disorder weakens the connection between the prefrontal cortex and the amygdala, which makes people have unrealistic fears in situations that may not be dangerous (Zhu et al., 2018). Indeed, Zhu et al. (2018) state, “reduced amygdala-hippocampus … connectivity and increased amygdala-insula connectivity in PTSD, which may reflect enhanced attention to threat and biased memory for adverse events” (p. 975). After that, the in vivo exposure part involved the patient restarting her daily activities, visiting public places, and using the subway again.
Effectiveness of Intervention
After intense exposure therapy, Tegan started to return to everyday life, became less anxious and fearful, as well as agreed to her knee surgery that she had been refusing for months and which went well. Indeed, numerous studies have proven the efficacy of prolonged exposure therapy, and it is considered one of the most powerful methods for reducing PTSD symptoms (Peterson et al., 2020; Vermes et al., 2020). It involves psychoeducation about people’s typical reactions to trauma, relaxed breathing practices, imaginal exposure, and real-world or in vivo exposure (Peterson et al., 2020). These techniques are intended to reduce the intensity of traumatic memories and to alleviate somatization symptoms as well as other mental health illnesses that sometimes are present in PTSD cases (Nesterko et al., 2020). Psychotherapists should be mindful of the choice of methodology because what works for one patient may not apply to another person due to their background differences (Lewis, Roberts, Andrew, et al., 2020). Overall, the method of prolonged imagined and in vivo exposure worked for this patient during a relatively short period of time.
The prolonged exposure therapy is likely effective due to the fact that it employs knowledge about classical conditioning. Based on the understanding of the latter, exposing a person to an aversive stimulus in combination with a neutral idea or situation may make the negative experience feel less dangerous (Vermes et al., 2020). In fact, Tegan’s PTSD was successfully resolved because behavioral therapy coupled with cognitive therapy helped her understand that the traumatic event that happened to her is a normal part of life. Furthermore, listening to the recordings about her unpleasant experiences helped her realize that they were not as dramatic as she believed. This approach was efficacious because the woman remained compliant with treatment and was eager to return to everyday life. Additionally, Tegan had supportive friends and was well educated, which are known as protective factors from developing PTSD and can be assumed to be vital elements of her mental recovery.
The treatment would be much more complicated if the patient were a depressed and physically unhealthy woman before the accident. The therapy could take longer or might fail if Tegan had an elevated level of pro-inflammatory cytokines and cortisol. In that case, she would require additional therapy for other mental health issues and treatment for possible chronic illnesses, which could shift the patient’s focus on her fears again. Fortunately, in this case, Tegan had the chance to focus mainly on her primary mental health issue and then seek medical help for her injured knee. Moreover, if the patient could not leave her house, it would require the use of web-based and virtual reality approaches to make exposure therapy as realistic as possible and ensure this patient’s issue is resolved.
Conclusion
Tegan’s PTSD was caused by a train accident in which the patient was unwillingly and unexpectedly involved, which caused quite severe physical and emotional injury to the woman in this case study. It appears that the major problem was induced by the fact that the patient spent six hours in the Emergency Room, where she saw traumatic pictures of human suffering. Furthermore, Tegan got a concussion and tore one of the ligaments in the left knee. Since her symptoms of PTSD worsened to the point that the patient tried to avoid social circumstances that caused her trauma and refused to undergo surgical repair of the knee, a therapist’s help was needed. The psychotherapist, experienced in PTSD, suggested that Tegan undergo prolonged exposure therapy to rewire her brain to view traumatic events as less dramatic and restore her normal functioning. Indeed, the exposure method was proven effective for substantially improving PTSD symptoms since it involved negative learning and desensitization. Overall, the therapy helped the patient eliminate her fears and return to her normal and active life as it was before the inciting incident.
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