Mental health articles

PTSD Case Study Examples about one person. Mr F was a prison officer in a small town in the west of England. At six feet four inches, he was a big strong man, fond of playing rugby for a local team and drinking with his mates. He was happily married with two young children. He had no history of mental health problems, and looking at him one would imagine him as an archetypal ‘good coper’. However, his history of PTSD showed that even ‘good copers’ may develop significant mental health problems.

Long-term antecedents

As is often the case with PTSD, there were very few long-term antecedents for Mr F’s development of PTSD. He had no history of mental health problems and was happily married with his wider family also around for support. He was happy at work, and had no work or home-related problems.

Short-term antecedents

The trigger to Mr F’s PTSD was a simple event. He was walking a group of prisoners down a flight of steps in an isolated stairwell, when he slipped and fell. Against prison regulations (as a result of his shift being short-staffed), he was on his own in the stairwell with no fellow prison officers. As a consequence, the prisoners took the opportunity to knock him to the ground, and began to beat and kick him around the body and head. The force of his beating was such that he was briefl y knocked unconscious. The last thought he remembers before losing consciousness was that he was going to die. He was taken to the prison wing, before being sent home to recover from his injuries. Over the next few months he experienced a signifi cant number of fl ashbacks to the incident, feeling the force of the blows to him and experiencing the fear of dying. Many occurred at night, while in bed. Every fl ashback was terrifying, and in the hour following them he had to get out of bed and try and watch television or read a book to help him calm down. He regularly had two or more fl ashbacks per night. As a consequence he became increasingly exhausted. In addition, he spent much of the day mulling over the causes and consequence of the attack. He would spend many hours (‘A day may disappear’) looking out of a house window dwelling on the attack. He believed that both the prisoners were to blame – as they had, he believed, tried to kill him – as well as his fellow prison offi cers who had allowed the incident to occur. The prison service was unsympathetic to his condition, writing frequent letters asking when he would return to see the prison occupational health physician, threatening to reduce his pay, and so on. He began to believe that these letters were a deliberate form of harrassment. As a result of these various processes his mood became increasingly depressed. He was able to engage with his wife and son for brief periods in the day – helping prepare breakfast, for example – but found these periods increasingly diffi cult to manage and he became increasingly isolated even within the family home. He also isolated himself from the home, spending hours away in peaceful places – including local graveyards – dwelling on the events and their consequences. He was unable to go into any area where he believed there would be prison offi cers or ex-prisoners, as he was unsure how he would be able to cope with the sight of them, expecting to be extremely frightened, but also angry and possibly expressing his anger. In a relatively small town, this severely limited where he was able to go.

Formulation

Mr F had a signifi cant post-traumatic response. The critical factor in its development was his belief that he was going to die as a result of his beating. He continued to hold this belief, believing that it was only the somewhat late intervention by his colleagues that prevented him dying in the incident. This continued catastrophic belief helped maintain his anxieties. His response to the incident was typical, if rather stronger than, most responses in PTSD. He experienced the three key symptoms of PTSD: fl ashbacks when his mind was unoccupied, pre-occupation and rumination on the originating incident, and heightened arousal. His depression stemmed from the nature of his beliefs, including the belief that some prisoners wanted him dead and that the institution for whom he worked and his work colleagues cared little for his well-being. These beliefs were maintained by his avoidance of colleagues who did try to visit him at home following the incident: visits which tailed off over time as they were apparently unwanted. In addition, his rumination constantly focused on his negative beliefs about the incident and how close to death he had been, and his anger towards the prison service. Accordingly, although he chronically ruminated about the incident, he had failed to normalize or reappraise it into something less threatening, both of which may have reduced the frequency and severity of his fl ashbacks. The time spent dwelling on these negative thoughts combined with exhaustion due to lack of sleep and his dislocation from his family and friends led to depression, and a vicious cycle of rumination, fl ashbacks, avoidance of positive aspects of life, low mood, rumination  .  .  .  and so on.

Intervention

Mr F had severe PTSD and depression (a relatively common co-morbidity). The usual treatment for PTSD involves either exposure or EMDR. Some individuals prefer the latter particularly as if they fi nd it diffi cult to focus on the distressing issues for a prolonged time or to verbalize their thoughts. However, Mr F was unwilling to utilize either approach. In addition, his belief that he could have died in the incident was unshakeable. Accordingly, initially, he and his therapist took another approach. Instead of focusing on the PTSD symptoms, they focused on reducing his rumination, his depression and avoidance of feared situations. One strategy for this was to plan things to do in the day that broke him out of his ruminations, and began to normalize his day. His daily plans, for example, involved sitting with his family watching television, walking the dog with his wife, and going out for drives or (when they occurred) watching rugby matches with his brother. The aim was to reduce the time he spent ruminating, and provide a number of rewarding/ enjoyable experiences each day. In addition, he began a graded exposure to places in the town that he had begun to avoid for fear of meeting ex-cons or colleagues. In preparing for this, he rehearsed how he would respond to seeing such individuals – using relaxation and breathing techniques he was taught, and using self-instruction to calm himself. He also used the relaxation and breathing exercises to help him calm down following any fl ashbacks he had, particularly at night. This approach took several weeks before he began to feel less depressed and more able to go into town. He also experienced several setbacks when he received letters from the prison service, which he now considered to be a form of harassment. Once he began to feel less depressed and more engaged with his family (including his brother), therapy began to focus on reducing the trauma-related symptoms. As he was already ruminating frequently on the trauma (and he had successfully reduced the time spent ruminating) therapy involved EMDR rather than an exposure programme. This was gradually introduced as his tolerance to the images increased. In addition, he engaged in cognitive therapy, reappraising the role of his colleagues more positively (some had, for example, visited him at home after the incident – so they had shown concern for him). In addition, while he continued to believe that the prisoners who attacked him had wanted him dead, he was able to defuse some of these thought, entertaining the idea that they perhaps wanted to hurt rather than kill him, and that the attack was not personal but one which any offi cer might have experienced if the occasion presented. Depersonalizing the attack was important as it reduced his feelings of threat and shame (‘I was so hated by the prisoners that they wanted to kill me’) that had been triggered by the attack. Recovery occurred, but not quickly, and despite normalizing his life away from the prison, Mr F was unable to work at the prison.

Tags: case study, PTSD