The Psychosocial Context of Trauma in Treating PTSD Patients

Abstract

Ms. A was a tall, extremely thin, 42-year-old marriedwoman suffering from posttraumatic stress disorder(PTSD) and a major depressive disorder. After an auto-mobile accident 4 years earlier, she had developed psy-chiatric symptoms for the first time in her life. Her hus-band was driving when a woman pulled out from a stopsign and struck their car on the driver’s side. Ms. A re-membered screaming, “It’s going to hit us!” and thinkingshe was dying at the moment of colli-sion. Although her seat belt was buck-led, she was thrown to the front andside of the car. The driver’s side of thecar was smashed; her husbandclimbed out of the car through therear door to let her out. She was soshaken she was unable to stand; hehelped her sit down on the curb. Shehad severe neck and some shoulderpain that subsided slowly over severalmonths. Neither her husband nor theother driver was seriously injured.Ms. A’s recurrent nightmares aboutthe accident compromised her sleep.She had frequent distressing recollec-tions of the accident that she struggledto shut out. She fearfully avoided being in a car if shewas not the driver. She also avoided television and themovies because the frequent scenes of violent death up-set her. Although always a hard and reliable worker, Ms.A could not now concentrate on her job in customer re-lations for a manufacturing company. Depressed andtearful much of the time, sh e developed severe anorexiaand lost a great deal of weight. She lost all sexual desireand went through her day dully and mechanically. Shesaid her husband had tried to be supportive, but he feltrejected so that tension had developed between them.Ms. A had grown increasingly hopeless over her failureto improve; she often thought she would be better offdead. She considered suicide a sin but thought shewould be driven to it if she could not find relief from heranhedonia, affective “deadness,” loss of pleasure in herdaily activities, including her relationship with her chil-dren—a son of 23 lived at home and an older marrieddaughter was expecting her first child—a total loss of ap-petite, and recurrent nightmares about the accident.Ms. A had been receiving psychiatric treatment for sev-eral years with a combination of psychotherapy and med-ication from a psychiatrist who had experience in treatingPTSD. At the time she was first seen in our program, hertreatment included an antidepressant to reduce her de-pression and a sedative to help her sleep and diminish thefrequency of her nightmares. A behavioral approach wasemployed to induce her to eat more. This combination ofmedications had helped her sleep a little better, and hernightmares were less frequent, but her other PTSD symp-toms were no better, her mood had not improved signifi-cantly, and her appetite had not returned.Ms. A was the fourth of six children raised by hermother and grandparents on her grandfather’s farm inthe South. Her mother had never married, and severaldifferent men appear to have fathered her children.She said her mother, who worked making fabric in acotton mill, was devoted to all her children but was de-valued by her fundamentalist family,which included two uncles who wereBaptist ministers. Ms. A was regu-larly reminded of her illegitimacyand taught to be grateful that thegrandfather permitted the family tolive in his home. She was particularlyhurt by her grandfather’s angry,contemptuous disapproval of hermother.When Ms. A was 14, her mother leftthe farm and brought the childrennorth. She told them to tell theneighbors that their father had died.Much happier after the move, hermother went to work as a nurse’saide, and Ms. A attended a local highschool. During this period, she met her husband-to-be, ahigh school shop teacher, who was 7 years older thanshe. They married right after her graduation, and she im-mediately became pregnant. Ruefully, she remarkedthat she wished she had known more about birth con-trol, but her mother, who had died a year before the ac-cident, was not someone you could talk to about suchthings. Ms. A described her husband as an “ideal man”with whom she was happy before the accident. She saidhe was protective of her, but he was not someone to dis-cuss problems or feelings with.