Posttraumatic Stress Disorder (PTSD)

Case History of Psychopathology

History and Referral

The patient was a 29-year-old woman who at the time of referral had been in traditional insight-oriented therapy for approximately five years. The frequency of those sessions varied somewhat during that time, and the goal was alleviating anxiety, particularly manifest in starting and maintaining relationships with men. Initially in therapy the patient had presented as severely anxious, unable to sustain eye contact, and subject to long periods of silence while occasionally regressing to approximate fetal position posture.

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Later in therapy the patient voiced awareness that "something [was] still not right," describing this as gnawing at her, producing diffuse anxiety, vaguely preoccupying, and generally experienced as an abiding dysphoria. Concurrently she focused more pointedly on the problem of relationships and "pushing men away." When the patient was in her mid-twenties a friend of a friend had broken a sexual boundary with her at an overnight gathering. Fully aware of it, she kept it private until late in the work. Discussing it with her therapist ushered in more intense anxiety. Nightmares ensued, and it aggravated her experience of "frozenness" in therapy. Eventually, after considering hypnosis for 9 months, she decided she would pursue it. Her therapist was supportive but did not advocate for hypnosis, electing to follow the patient's lead. At that, it took another half year before she scheduled the first appointment.

She and her therapist considered hypnosis as a way to process those feelings hypothesized as unavailable for resolution in the verbal therapy modality, and her motivation was high. The goal from the outset, then, was not to uncover or probe memory but rather to use hypnosis as a vehicle suited to settling or reorganizing unconscious2 material putatively implicated in her discomfort. Thus hypnosis was seen as palliative and potentially helping to resolve the deeper non-specific discomfort.

Treatment Sessions

Because of the patient's anxiety as described and because her work with her regular therapist would continue, the patient's referring therapist was present initially for support and to have a context for the hypnosis work. That therapist and I had a good working relationship and had collaborated on cases before. The patient reported that her therapist's presence was calming and reassuring, and in their meeting afterwards decided that the therapist's remaining in the hypnosis sessions was useful. Consequently her therapist was present for all but one of the 25 sessions of hypnosis, missing that one session because of a scheduling conflict. These were spread over a year, and the individual therapy apart from hypnosis continued, though more sporadically. Sessions occurred every other week, a spacing preferred by the patient to prevent her other therapy from crowding into the same week and, importantly, to give her what she described as "time to absorb it all."

In the first session we established the context and expectations for the presence of her therapist, elaborated on the information she had read and discussed with her therapist about hypnosis, and conducted the initial induction. The goals of hypnosis were specified again together as improving autonomie regulation within anxiety management, and allowing the unconscious mind-body system to explore and relieve whatever deeper conflicts might be relevant to the problem. No formal hypnotizability or susceptibility measure was used because the patient was eager to "get right to it" to allay nervousness. It was quickly evident that her absorption capacity was high, thereby establishing a credible baseline engagement. This is consonant with Smith's (1996) capitalizing on such apparent involvement without formal assessment, and Telegen and Atkinson's ( 1974) emphasizing absorption capacity as a valid marker of hypnotizability. Sessions averaged 35 minutes of hypnosis, followed by 15 minutes of debriefing, support, deriving meanings discerned by the patient, and ratification of safety and her control.

During the initial eye fixation (Crasilneck ; Hall, 1985) transition into trance there was pronounced facial and some full-body twitching and energetic squinting, lasting only briefly, and this was the case for every hypnosis session. The first session taught controlled relaxation, hand warming to ratify the mind-body connection, techniques for safe place and emergency exit from trance (Dolan, 1991 ), and ideomotor signaling (Weitzenhoffer, 2002). The signaling was enthusiastic and at times fingers seemed to lift her arm off the chair. When this occurred the patient typically was able to smile and verbally acknowledge awareness of this new intriguing energy but did not judge how her body and unconscious were responding. It is interesting, therefore, that hypnosis afforded a relaxed posture regarding her experiences, as opposed to the rigidity described in the other modality. She remained an intrigued, involved follower and observer of what her mind and body appeared to be doing "on their own" during the course of treatment. Thus her presentation was strikingly redolent of van der Kolk's assertion, "...when a traumatic memory is activated, the brain is 'having' its experience, rather than recollecting it'" (2003, p. 26).

As therapy proceeded a sequence of physical gestures emerged that were consistent and cumulative from session to session. In each meeting the patient went into trance quickly and intensely as usual, and then her body briefly replayed, in summary fashion, the sequence up to and then through the most recent installments. For example, an early movement was her right hand's ascending above and behind her head. Next, she appeared to struggle against the force or pressure exerted on the hand and arm. Finally, it became clear that the arm was either held or bound at the wrist into that elevated position. In the ensuing sessions, this sequence was rapidly replayed until she arrived at the next threshold of movements. By the tenth session it appeared that her body was reenacting a scene of oral rape. It was not necessary for her to texture and detail the events. Rather, she reported that while her physical experience was succinct she only needed it to be suggestive enough to validate that experience and provide a sensible scenario for what was happening. Typically in the middle of a scene in which her body was approaching more textured and graphic contact with the experience she would say: "I know what is happening and I will not go any further right now." Then she would return to her safe place briefly and exit trance without incident. My suggestions collaborated with this approach, emphasizing, "your body will experience and communicate only what is useful for your understanding and your health now and in the future." Each repetition of this protocol physically/emotionally engaging an enacted fragment, attending to reactions and meaning, deciding about the degree of texture and specificity to experience, choosing to reconstitute in safe place, and exit trance-deepened and validated her ability to manage not only the physical story but the physiological and emotional discomforts associated with it.

Central throughout this work were reinforcing and utilizing the patient's power to choose. For example, when a nuance or new piece of experience was becoming evident, there always was the inquiry: "It appears there is new energy now (in a hand, arm...). Would it be all right to pay attention to that? Would it be all right to do that now?" As always, the language is key to the art of hypnosis. "Pay attention" was preferred over "process," "deal with," or some other variant implying a verbal, semantically controlled sequence. Her ideomotor signaling was energetic and always clear in response. Interestingly, assertiveness and strength were available in this hypnotically abetted physical-unconscious domain, another stark contrast to her demeanor in the other more conventional therapy as described.

In that conventional ongoing therapy the ideomotor signaling continued in sessions, but it was not sought. In those conversations her fingers would often jump and signal. When that happened she and the therapist noted the energy but did not make it a focus Since her therapist was also present for the hypnosis work, he could read the different response intensities in her fingers, as they "with a mind of their own" were active during that therapy as well. Further, as we two therapists processed the hypnosis work in peer consultation it was clear that the original therapist benefited from having seen every step in the hypnosis interventions. The patient also reported that her fingers were busy during private ruminations, as when driving her car for example. From the start, however, she was taught how to manage her signals and experiences so that they did not suggest or evoke the out-of-control states associated with trauma. Thus throughout this hypnosis work she was able to exercise modulation skills important in her improving integration and understanding of emotional life outside the office. She found this surprising and encouraging, at times reporting that not only was she feeling more "balanced" socially and on the job but also others were giving her feedback indicative of such.

It appeared that the sexual abuse suggested by her body's "memory" and "choreography" was powerfully encrypted in her physico-emotional experience. She reported that it was clear to her what all this suggested, often stating: "I am not sure what happened, or at least I can't see what happened. But I know something happened. And, I am feeling stronger." This strength was apparent also to her therapist; she was increasingly verbal and forthright in those sessions.

There was another benefit. In all of this sequence there was intense observable physical resistance as the attacker relentlessly forced compliance. It was like watching a fight with only one of the combatants visible. So often in trauma work the victim doubts in retrospect her/his will or effort to resist or escape. In this case she believed she had compelling evidence that her struggle was severe and maximal. More importantly, this is how she felt. That she experienced putting up such a fight as part of the physical story apparently was saliently relieving to her.

Eventually the patient felt she had completed what she needed to know and experience. This, as noted, was matched by her reports of increased strength and assertiveness in both relationships and professional and social life in general. She was better able to monitor her emotional and physical responses and demeanor. She felt more comfortable. Finally, there also were others' remarks on changes in her, "looking better," and "happier." Hypnosis ended after the twenty-fifth session, and her other therapy shifted gradually to fewer appointments, terminating after three months post hypnosis.

Two years later the patient called for an appointment for hypnosis work on what turned out to be an emerging re-experience/memory of a date rape. In session she immediately used previous skills (absorption, ideomotor signaling, deepening regulation, and safe place) with the same level of proficiency. This experience was processed in two sessions, focusing on ego strengthening and ratifying previous gains. She also reported the two ensuing years after the initial hypnosis had been good and devoid of significant or unmanageable symptoms and discomforts.

One year after those two sessions, three years after the first hypnosis, she came in for one session to process a trigger event: a man accidentally had barged into her changing room in a clothing store. She did not freeze but rather reprimanded the man, though she was shaken, and exited the store quickly. She used the hypnosis session again for strengthening and affirming her previous work and the action she took in the store. In both these follow-up events we used the familiar protocol of eye fixation induction, affirming her sense of control over her own bodily and emotional responses, affirming her read of the triggers and situations, and visiting of safe place coupled with future projections of successful management of self and situations.

Finally, in our last meeting a few months after that session, the patient sought a nonhypnosis consultation for a new surprising event: she had "met a man." While she felt some apprehension and could acknowledge information and developmental gaps in pursuing a relationship, the flavor of terror was absent, replaced by what appeared to be both predictable nervousness and excitement at this new dimension of life for her. In the few, spread-out sessions subsequent to the initial hypnosis work the patient met solely with me since she had successfully terminated her other therapy, and she reported feeling strong enough to proceed on her own.

Theoretical Support and Propositions

This case may be understood within at least three theoretical domains involving brain and affective science studies for trauma and its register, thus presenting both a foundation and map for future research. First, that the right hemisphere is central-specifically the right parieto-temporal associative area-in altering consciousness as in hypnosis (Tassi ; Muzet, 2001, p.186) and in accommodating trauma as noted above, suggests an affinity between these phenomena by virtue of their locus in brain (see Rainville, et al., 1999 for a comprehensive view). Beyond such speculation, however, some research has elaborated the collaboration between higher right brain regions and more fundamental ones. Hariri, Bookheimer, and Mazziotta (2000), for example, suggest a neural network exists for this collaboration, and while modulating mechanisms may be impaired in emotional disorders they also "may provide the basis for therapies to these same disorders" (p. 48).

Second, research has supported the right hemisphere's role in accommodating and recording stark events like trauma and its connection with the limbic system in this regard (Joseph, 1982; Nadel & Moscovitch, 1997; Tranel & Hyman, 1990). Specifically, certain perceptual memories such as those incurred during trauma leave long-term residues or traces (Christianson, S. A., 1992; James, 1890; Janet, 1904; Pillemer, 1998; Terr, 1990; van der Hart & Horst, 1989; van der Kolk & van der Hart, 1991). Further, Damasio (1994) alleges that "dispositional representations" form during powerful events like trauma (p. 102) and, in state-dependent fashion, may be activated later by triggers or cues to the trauma. While Damasio (1994, 1999) nowhere expounds specifically about abuse trauma, the relevance of his findings appears clear.

Finally, the case has been made for two memory systems (Bornstein, 1995; Hellawell & Brewin, 2002) in which "ordinary" memories of trauma fall within the common cognitive psychology formulations of memory as constructions and not literal video libraries. PTSD memories, and particularly flashback type, however, are quite literal in their right brain registers (Hellawell & Brewin, 2002, and cited in Brewin, 2003, p. 101). In particular Damasio notes that "knowledge which exists in memory under dispositional representation form ... can be made accessible to consciousness in non-language versions" (p. 166; emphasis added), and that these representations "can fire others if linked strongly by circuit design (in the brain) or they can generate a movement by activating motor cortex" (p. 105; emphasis added).

Symptomatology

            Traumatic events may participate acute physical responses in affected persons that are considered an acceptable adaptation to the stress of the traumatic event (American Psychiatric, 2000; Pittman & Fowler, 1998). A chronic stress response from a precipitating traumatic event is diagnosed when a personal reaction endures for more than 4 weeks and the responses are viewed by mental health professionals as maladaptive (American Psychiatric Association, 2000). Characteristics features of PTSD include anger, recurrent distressing thoughts, depression, guilt, shame, fear, anxiety, hyperarousal, dissociation, and intrusive recollections of the precipitating event (American Psychiatric Association, 2000). AS reported in Bisson and Shepherd’s (1995) work, Symonds discussed a four-stage reaction to a traumatic event: initial shock and denial, which are typically followed by fight fear, then apathy and anger, develop, and then a sense of guilt and depression. This is followed by cognitive and affective resolution of the trauma, or use of the defense mechanism of repression (Bisson & Shepherd, 1995).

            Intense impetus threatening stimuli may produce differences in psychological and psychological response (Schwebel & Suls, 1999). emotional hyperactivity, one several symptoms of PTSD, has intrapersonal and interpersonal components (Kandel, 1999; Schwebel & Suls, 1999). The level of stress perceived by survivors may change as they experience interactions that support or refute theier beliefs about the hostility of the environment (Schwebel & Suls, 1999). Exaggerated response to a stressor may be, in part, a premorbid condition within the neuroticism they exhibited to the trauma (Kandel, 1999), or it may result from subjective distress recognition after traumatic event (Schwebel & Suls, 1999). Regardless of the origin of their response mechanism, people’s current hyperreactivity levels could be manifested in the beliefs and controls they demonstrate intrapersonally and socially (Schwebel & Suls, 1999).

            Posttraumatic stress disorder (PTSD) represents a pathological response to a potentially threatening or harmful event that occurred in a person’s life (Cauffman, Feldman, & Waterman, 1998; Classen, Koopman, Hales & Spiegel, 1998; Mueser et. al., 1998). Te extent and duration of the symptomatology exceeds the diagnosis of acute stress disorders (ASD) in terms of chronicity, intensity, etiology not withstanding (Harvey & Byant, 1998). Although research indicates that ASD symptoms involving dissociation tend to correlate with later onset of PTSD, the linkage between ASD and PTSD is still in need of additional study and is beyond the scope of this research (Classen, Koopman, Hales, & Spiegel, 1998). Higher sympathetic nervous system arousal is often associated with a person’s posttrauma response to stimuli that resemble the traumatic event (Orr, Metzger, Lasko, Macklin, Peri, & Pitman, 2000). Hyperrarousal, observed as intrusive recollections of the precipitating event; dissociation and depersonalization; and motor restlessness are possible indicators of PTSD. These symptoms are generally not observed in ASD (Harvey & Bryant, 1998). Improved global functioning may reflect self-awareness of the trauma and the acceptance of assistance, thus possibly reducing the intensity of PSTD symptoms to subclinical levels (Kazak et. al., 1998). Global functioning after the trauma may also be indicative of the resiliency of the individual in terms of hardiness and personal protective factors, and attempts to reestablish control (Hartup & van Lieshout, 1995). Control is perceived by the individual as the ability to influence the posttraumatic symptomalogy and the belief about personal responsibility within the dynamics of the traumatic event (Goenjian et. Al., 1999; Hartup & van Lieshout, 1995; Shepperd & Kashani, 1991).

            Individual differences account for variability when predicting the impact of the traumatic event (Goengian et. al., 1999; Magwaza, 1999). For example, a diagnosis of PSTD may be confounded by the emergence of a medical disorder (Carver & Harris, 2000). The onset of a life-threatining illness may also lead to clinical symptomatology reflective of PTSD (Brewin, Andrews, & Valentine, 2000; Carver & Harris, 2000). The activity of the physical illness may subside before the symptoms of PTSD diminish (Stuber et al., 1997). The diagnosis of PTSD may also be confounded by the existence of cooccuring psychiatric disorders (Mueser et. al., 1998).

            Also part of the difficulty in accounting for PTSD is the tendency to under diagnose it, due in part to symptoms common in other disorders (Goodman,k Rosenberg, Mueser, & Drake, 1997). Underreporting of PTSD is common in women with severe and persistent mental illness (Goodman,k Rosenberg, Mueser, & Drake, 1997). Goodman and colleagues (1997) suggested several other reasons for underreporting. For instance, recollection of events may be confounded by delusional thinking, hallucinations,  intoxication, language barriers between the historian and the data collector, amnesia cognitive deficits, and memory impairments (Goodman,k Rosenberg, Mueser, & Drake, 1997). Further, individuals with PTSD may present symptoms that include dissociation, hallucinations, delusional and paranoid thinking, and bizarre behaviors, not unlike the spectrum of psychotic symptoms (Goodman,k Rosenberg, Mueser, & Drake, 1997). Thus, the level of uncertainty due to common symptom presentation in psychiatric disorders may reduce the likelihood of a PTSD diagnosis.

            Persons with severe and persistent mental illness (SPMI) are likely to have also experienced a traumatic event (Resnick, 1998). Mueser and her colleagues (1998) discovered that the existence of a least one traumatic event had occurred in 98% of persons with severe mental illness, yet PSTD was diagnosed in only 2% of them. Whether the person was exhibiting psychiatric disorders of a separate etiology, or the psychiatric disorders were related to a traumatic event in the person’s life, the rate of comorbidity  and PTSD appears to be high in those with severe mental illness (Mueser et. al., 1998). Psychiatric disorders that most commonly occur after a trauma include anxiety disorders, mood disorders, conversion disorders, postconcussion syndromes, dissociative disorders, and occasionally psychoses (Resnick, 1998).

            Person with a trauma history presenting concurrent psychiatric disorders still may be accurately assessed and diagnosed with PTSD (Mueser, Salyers, Rosenberg, Ford, Fox, & Carty, 2001) The presence of comorbidity has little impact on reliability and validity when using standardized assestment measures to measure PTSD and symptom severity (Mueser, Salyers, Rosenberg, Ford, Fox, & Carty, 2001). Mueser and colleagues (2001) administered the Trauma History Questionnaire (THQ; Green, 1996), the Clinician-Administered PTSD Scale (CAPS; Blake Weathers, Nagy, Kaloupek, Gusman, Charney, & Keane, 1996) to 16 women and 14 men who had a primary Axis I diagnoses of a severe and persistent mental illness, and a secondary diagnoses of PTSD. Innterrater, test-retest, and internal consistency reliabilities were found to be moderate to high in all instruments. Convergent validity was moderate on the initial assessment with the CAPS and PSL and stronger on follow-up interviews. Changes in traumatic categories and the severity scores of the PTSD measures were unrelated to the participant’s diagnosis and symptom severity ratings (Mueser, Salyers, Rosenberg, Ford, Fox, & Carty, 2001). Domestic violence and mental illness are a pretrauma and postrauma risk factor for PSTD (Brewin, Andrews, & Valentine, 2000; Morell & Ruben, 2001). Other pre-trauma risk factors include family mental illness, gender, acculturation, substance abuse, clinical depression, and lower education (Morell & Rubin, 2001). Post-trauma risk factors include anxiety, depression, dissociative characteristics, emerging symptoms of PTSD, social support network, substance abuse, and other life stress (Morell & Rubin, 2001).Brewin and colleagues (2000) suggested that three factors relating to events after the trauma convey the strongest risk for PSTD: greater trauma severity; lack of social support; and more life stress.

            The relationship among trauma severity, the type of trauma such as sexual and/or physical abuse, and the duration of the abuse have been linked to long-term behavioral problems in children (Cauffman, Feldman, & Waterman, 1998; Deary, Alistair, & Austin, 1998; Dubner & Motta, 1999). Sexually and physically abused children may receive diagnoses of anxiety disorders, depressive disorders, attention deficit-hyperactivity disorder, oppositional disorder, separation disorders, and psychosis (Cauffman, Feldman, & Waterman, 1998). Assessing PTSD is more difficult in asymptomatic children and in children with limited vocabulary and verbal skills (Cauffman, Feldman, & Waterman, 1998; Dubner & Motta, 1999). PTSD is more likely to be diagnosed in later adolescence and young adulthood, when PTSD-related symptomatology is more prevalent and verbalized (Dubner & Motta, 1999).

            In addition, depression and PTSD are highly related in trauma populations (Erickson, Wolfe, King, king, & Sharkansky, 2001). Research supports a bidirectional relationship between depression and PSTD, with initial PTSD symptoms “more strongly predictive of later depression than vice versa” (Erickson, Wolfe, King, king, & Sharkansky, 2001, pp. 3,12). The likelihood of depression leading to PSTD in young woman was almost as strong as that for PTSD predicting clinical depression. However, symptom management in trauma-exposed individuals may curtail the development of secondary disorders or attenuate the signs of early onset (Erickson, Wolfe, King, King, & Sharkansky, 2001).

Hypnosis seems to have revived in the clinical treatment of cases of stress and PTSD, physical and sexual abuse, eating disorders, addictions and sexual dysfunctions. This new vitality originates in the better knowledge of the origins and development of those pathological states. Now we can conceptualize them as constantly evolving in theoretical understanding and in the techniques to deal with them.

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