For many years, Dale had stayed away from crowded places, such as busy restaurants and amusement parks. Dale is unable to go on family vacations but find indescribable peace in the solitude provided by the mountains or woods when he is alone hunting. Generally sad and defeated, seemingly fatigued and always on guard as if someone is out to get him would be how relatives would describe Dale.
On the way to the V.A. his adult son probed with questions about how Dale was feeling. Dale confided in his son that he guessed he was down and maybe even depressed. He just could not put his finger on what was wrong that made him feel the way he did, but he never felt really positive about much. Dale began to disclose memories of abuse during his childhood and feeling harassed in the military. Dale described how his wife, Helen really loved him and he felt fortunate for that.
Although, Dale had never been diagnosed with any mental disorder, he never felt quite right. Dale believed that this was just the way he was made and that things could never be any better than his current state. Arriving to the Veteran’s Administrative Hospital (V.A.), Dale was anxious and broken. He had rarely expressed his emotions for years with exception to the explosive bouts he would display if he felt challenged by people or situations. Dale’s general method of operation was to withdraw and stew if adversity was present. This was not Dale’s first visit to the V.A. but would be the visit that really counted. Dale’s body language was comparable to that of most on this brisk day, shoulders crouched and head hunkered downward, as if to keep warm. Dale, however, carried himself in a similar posture often.
Once the in-take nurse called Dale’s name and began to ask questions regarding his well-being, he admitted to her that he did have some depression. She asked about suicidal thoughts, and Dale stated that he had not had any thoughts of dying or ending his own life. However, as the doctor asked those same questions, Dale admitted that he had indeed been experiencing thoughts about a diminished sense of his life’s importance as well as thoughts about ending his life. He just wanted to stop the pain.
History
Dale is a Caucasian male, 67 years of age. He has been married for 48 years with two adult children. As a young child, Dale was a member of a family of six with a vibrant mother and an alcoholic father. Dale was the youngest boy and had two sisters, also. Dale observed his older brother receiving extreme discipline at his father’s hand. Unforeseen was the pain that would ensue at the hand of Dale’s own father when his brother Duke was wise enough to escape. The father, George was no sleeping kitten when he was on a drunken binge. Instead, George would tear into a rage. When Duke was gone, Dale served as the surrogate, the whipping boy. Dale’s older brother, Duke, would often find respite at his Uncle Bobby’s house where he had cousins, and for the duration of his stay, Duke felt as though he was part of a fun-loving family. Dale did not hold it against Duke, even though Dale caught his father’s wrath in Duke’s absence. Dale was just too young to venture out on his own to get away
One would think that George’s anger would pass quickly, but it did not. Dale was not permitted to outwardly express his anguish. Often Dale would be whipped with his father’s leather belt, buckle and all, over and over. George, unleashing his rage, continued to strike Dale until he would no longer cry out, sometimes to the point of causing his small legs to bleed. It seemed that George’s anger was actually bolstered as though someone were adding fuel to a flame. Dale’s father would only seem satisfied of a job complete when he had totally crushed Dale’s spirit to the point of silence. Dale struggled through school, and he white-knuckled through many of the days. As years passed, Dale’s father seemed to successfully conceal his drunkenness from others in the community. In fact, George was elected to serve on the school board in their local community. By now, Dale was in the eighth grade, and while being at school was a safe haven from his father, the classwork and homework were difficult to concentrate on and to understand. Dale was holding on with a ‘D’ average, and this was unacceptable for a school board member’s child. This marked the time of a significant change in Dale’s life, as his father decided to ‘sign him out of school’ permanently. Dale was told that he was a ‘no good failure’ and to ‘go get a job.’ No one would give him a regularly paying job at his age except some of the local tobacco farmers. Dale worked so hard for the little pay he would get for priming tobacco, but felt thankful for the opportunity and the occasional good word he would receive for his effort.
By the time Dale was sixteen, he had been introduced to a young girl of seventeen, Helen. Helen and Dale were head over heels for each other and were married at the ripe age of eighteen and nineteen. Dale was a hard worker, determined to provide a good life for Helen. Helen, the product of a subservient mother and also an embezzling, alcoholic father, was not a developmentally mature individual but admired Dale’s work ethic and was the encouragement he needed.
Diagnosis
Dale is presenting symptoms of PTSD. His PTSD originates from early childhood trauma (physical abuse from his father) and from his service in foreign war. His symptoms are exacerbated by working in a maximum security prison, dealing with hardened individuals and heightened hypervigilance on a daily basis. Further, Dale experiences sleep disturbances in the form of recurrent dreams of being in battle, avoidance of settings, people and places, as well as, an inability to concentrate. Sometimes during the recurrent combat-related dreams, Dale has either hurt himself or his wife Helen. He never remembers any details of these episodes upon waking. Many times Helen must sleep in a separate room to avoid the possibility of being hurt unintentionally by Helen. Ultimately, Dale confesses that he is feeling down to the intake nurse, but he surprises his doctor when he answers a routine question regarding suicidal thoughts in the affirmative. This perpetuates a need for hospitalization. During the hospitalization, Dale is diagnosed with Post Traumatic Stress Disorder (PTSD).
Dale’s diagnosis of PTSD, the symptoms are caused by the past traumatic stressors of his childhood and his time served in the Vietnam War while in combat. His symptoms have presented for many years and not only within the first month after the traumatic trigger events. Also, while Dale’s thoughts are reoccurring and are very intrusive, his thoughts are founded upon traumatic event triggers (Cohen, 2006). When considering PTSD as a diagnosis in the case of Dale, the best resource to utilize when investigating the validity of the diagnosis is the DSM-V. In the DSM-V (American Psychiatric Association, 2013, pp. 271-280), the diagnostic evaluation for PTSD is organized into six distinct criteria. The first criteria is that the patient has experienced exposure to an event that is considered traumatic and that included death, the threat of death or serious injury followed by a response of terror, intense fear or complete helplessness. Dale faced these both in his home life as a child as well as during his time in combat. The second criterion is that the trauma is re-experienced by the patient in at least one of five different manifestations. The first of the five manifestations is the stressful reoccurring and intrusive reliving of the trauma in thoughts, points of view or images. The second is the manifestation of the trauma in dreams. The third is to actually feel as if the traumatic event is occurring presently, even after waking from dreams or after consuming too much alcohol. A fourth manifestation is when the patient reacts with distress when exposed to a representation of the trauma whether the cues are internal or external. The fifth is how the patient’s body reacts to exposure to cues that manifest the past trauma. Dale experiences all of these manifestations, particularly in dreams and feeling as if he was back in battle or he had returned to his childhood home in the midst of the abuse he encountered there. Dale particularly deals with unhealthy psychological and physiological reactions to exposure to these past events such as after watching a war movie or after a particularly vivid dream of being back in Vietnam (APA, 2013).
The third criterion of PTSD (APA, 2013) is the patient’s avoidance of stimuli related to the past traumatic event. The patient must experience at least three of seven different manifestations of the avoidance or numbing towards certain life triggers of the past event. The patient will work hard to avoid thoughts or feelings or speaking about the past trauma. Secondly, the patient will avoid geographic locations or people that they associate with the trauma. Third, the patient may present with trouble in remembering the event(s). The fourth manifestation is loss of interest or disassociation from certain activities. The patient may feel estranged from people in their life. Sixth, the patient has a restriction of feelings, such as the inability to feel love or to care about someone or something. Lastly, the person will feel negatively about the future, as if they do not expect to be a part of normally expected life events like marriage or parenthood. In Dale’s life, he experiences all seven of these at one point or another. He has difficulty talking about his childhood and is visibly upset when he encounters questions about his time in Vietnam. He also goes out of his way to avoid people who may want to talk about serving in war. Both his troubled childhood and war trauma keep him from truly enjoying life’s major events, especially his ability to feel pride in himself for his involvement in life. The fourth criterion when diagnosing for PTSD is the increase of arousal that is exhibited in at least two of five distinct ways. The patient may have sleep difficulty. The person may have anger issues or be prickly and irritable. A third problem is difficulty with concentration or focus. The fourth consideration is the occurrence of hypervigilance. Last, the patient startles very easily and responds in an exaggerated way to being startled. Dale has always seemed to have problems with proper sleep patterns. He is always exaggerated in his response to being startled. Dale suffers with focusing in most all aspects of his life (American Psychiatric Association, 1994).
The final two criteria for the diagnosis of PTSD are also prevalent in Dale’s life. The duration of the symptoms discussed in the previous criterion persist for more than a month. Lastly, the symptoms the PTSD patient suffers with serve to impede life socially, in the workplace, in the home and most every aspect of life (DSM-V). Dale’s symptoms have been a part of his life for many years and they affectively serve to hinder his life in all aspects, particularly in his social life in dealing with relationships whether they are in the workplace, community or within his own family.
Patients who have PTSD may often contend with other disorders as well. Some examples of the most pervasive additional disorders that PTSD patients also have are Major Depressive Disorder, substance abuse and Obsessive-Compulsive Disorder. Scientists are studying why PTSD patients may also have an increased risk of social phobias, panic disorders and even agoraphobia. PTSD also shares a great deal with Borderline Personality Disorder in the form of common traits such as impulsive behavior, moodiness, trust issues, feelings of shame, low self-esteem and difficulty maintaining any stability in their relationships (Cohen, 2006).
Treatments
When considering Dale’s difficulties, particularly the symptoms that he deals with on a daily basis involving his PTSD, certain approaches to psychotherapy must be considered in formulating a treatment strategy. One theory is to expose PTSD patients to their past trauma while in a group of peer patients. This therapy program is known as Group-Based Exposure Therapy (GBET). This psychotherapy treatment method is a cognitive-behavioral therapy that relies on the progressive sharing of experiences between PTSD patient peers in a safe setting. Dale has been involved in the process of GBET. He is a member of a peer group that has shared traumatic combat experiences (Ready et al., 2008). Further, through the implementation of this group-based exposure therapy, there is strong evidence that Dale’s PTSD symptoms can be greatly impacted. For instance, in one article (Ready et al., 2012), there is such a significant decrease in participants’ symptoms that as many as 78 percent of veterans no longer meet the criteria for the diagnosis for posttraumatic stress disorder according to the DSM-V. GBET can be structured and carried out in multiple formats. The most common method, and the main structure of Dale’s GBET, is to have each patient share their war stories, stories of the traumatic events that have shaped their existence, within the group. Over time, the patients forge relationships with one another that perpetuate increasing comfort levels with sharing and dealing with the traumas each have faced. Accompanying the times of group sharing, the individual patients develop a taped account of their own trauma stories that they listen to many times on a set schedule. These continued exposures work to create a more healthy way of dealing with the trauma moving forward. The times of group sharing enable the patients to belong to a group of people who can relate to their experiences and struggles. Their reactions to one another help to make the troubled behaviors of their lives become more normalized and therefore more easily dealt with over time and continued exposures (Ready et al., 2012).
A second therapy strategy is to utilize an integrative model or a combination of two or more theories in order to treat a patient in a more holistic way. A therapist may utilize the strengths of a cognitive-behavioral treatment like GBET and combine that with another therapy approach such as Expressive Arts Therapy. The patient in this type of integrative treatment has even greater opportunity for self-expression while still performing a role of helping their peers with their problems (Cohen, 2006).
In the case of Dale, an integrative model has proven to be a therapy model that has produced positive results. Upon his diagnosis of PTSD, Dale began to explore an integrative treatment that combined aspects of GBET and Expressive Arts Therapy. Dale had never written about his feelings before, but during his time of hospitalization, he wrote a poem about his time serving as a combat veteran in Vietnam. He expressed more in the lines of his poems than he had expressed verbally in the many years since the time he served his country. It was a major breakthrough in treating Dale and also demonstrated a positive result from his exposure therapy as well, in that he was outwardly expressing his trauma and how it made him feel. In addition to the poem, Dale also began painting his recollections of the past. He has continued to share these memories through painting scenes from those times and places that he served in combat, but nothing from his childhood trauma (Kaiser et al. 2005). The outlet that these two types of expressive arts have created for Dale has made him more open to sharing in the group setting. Expressive Art therapy, although some might consider it fringy has proven to provide a set of effective characteristics in its use with patients with PTSD. These characteristics include the provision of relaxation, a medium to share feelings in a non-verbal form, as well as providing a containment area for the entire trauma causing material that allows the patient to feel a sense of control over them (Sandmire, Gorham, Rankin & Grimm, 2012). Further, Expressive Art therapy provides a means of symbolic expression allows an externalization of the traumatic memories and also creates an opportunity to experience the pleasure of creativity and creation and the accompanying building of self-esteem while fostering positive re-establishment of a higher level of social interaction (Collie et al., 2006).
Beyond the traditional GBET method, another cognitive-behavioral exposure therapy has emerged that utilizes technology in an interesting way. Virtual Reality Exposure Therapy utilizes technology to simulate the actual past exposure events. The patient is able to relive past events in a virtual world. An example of what this could be like would be to have virtual exposures that simulate the sights and sounds of his combat experiences in Vietnam, including the reproduction of the Huey helicopter sounds, as they were utilized a great deal in the overall war strategy in Vietnam (Rothbaum et al., 1999). Dale’s group is supposed to create an audio reenactment of a war experience as well as each one presenting orally to the group their most fear provoking experience. Part of each group member’s commitment to the purpose of the group is to expose him or herself through listening to their recording a select number of times.
Dale is finally receiving the treatment he has desperately needed for many years. His integrative treatment regimen including Group Based Exposure Therapy with some Virtual Reality Exposure, Expressive Arts Therapy, periodic talk therapy and the use of medications to treat his symptoms is working to improve his life. Dale’s wife Helen and his two children, grandchildren and even the community are all stakeholders, beneficiaries of the PTSD treatment. They are all finally experiencing Dale in new and exciting ways as he is able to live his life truer to the person he really is and not the person who has suffered dealing with the devastating impact of PTSD since childhood. Dale continues to explore new ways to express himself including his continued use of expressive arts such as writing, painting and music. His doctors continue to work with Dale to provide a set of medicines that work well together and with minimal side-effects. Dale is looking forward to future planned experiences such as visiting the National Vietnam Memorial in Washington, D.C. with a group of fellow Vietnam veterans who are also being treated for Post-traumatic Stress Disorder. Dale is finally able to share about his past war experiences with his family who appreciate so much the sacrifices he has made for them and the United States.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Cohen, H. (2006). Associated Conditions of PTSD. Psych Central. Retrieved on October 1, 2014, from http://psychcentral.com/lib/2006/associated-conditions-of-ptsd/
Cohen, H. (2006). Differential Diagnosis of PTSD Symptoms. Psych Central. Retrieved on October 2, 2014, from http://psychcentral.com/lib/2006/differential-diagnosis-of-ptsd-symptoms/
Collie, K., Backos, A., Malachiodi, C., Spiegel, D. (2006). Art therapy for combat-related PTSD: Recommendations for research and practice. Art Therapy: Journal of the American Art Therapy Association, 23(4), 157-164.
Kaiser, D., Dunne, M., Malchiodi, C., Feen, H., Howie, P., Cutcher, D., et al. (2005). Call for art therapy research on treatment for PTSD. American Art Therapy Association White Paper.
Ready, D. J., Sylvers, P., Worley, V., Butt, J., Mascaro, N., & Bradley, B. (2012). The impact of group-based exposure therapy on the PTSD and depression of 30 combat veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 4(1), 84-93. doi:10.1037/a0021997
Ready, D., Thomas, K., Worley, V., Backscheider, A., Harvey, L., Baltzell, D. and Rothbaum, B. O. (2008), A field test of group based exposure therapy with 102 veterans with war-related posttraumatic stress disorder. J. Traum. Stress, 21: 150–157.doi: 10.1002/jts.20326
Rothbaum, B. O., Hodges, L., Alarcon, R., Ready, D., Shahar, F., Graap, K., Pair, J., Hebert, P., Gotz, D., Wills, B. and Baltzell, D. (1999), Virtual reality exposure therapy for PTSD Vietnam veterans: A case study. J. Traum. Stress, 12: 263–271.doi: 10.1023/A:1024772308758
Sandmire, D., Gorham, S., Rankin, N., & Grimm, D. (2012). The influence of art makingon anxiety: A pilot study. Art Therapy: Journal of the American Art TherapyAssociation, 29(2): 68-73. doi: 10.1080/07421656.2012.683748
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Cohen, H. (2006). Associated Conditions of PTSD. Psych Central. Retrieved on October 1, 2014, from http://psychcentral.com/lib/2006/associated-conditions-of-ptsd/
Cohen, H. (2006). Differential Diagnosis of PTSD Symptoms. Psych Central. Retrieved on October 2, 2014, from http://psychcentral.com/lib/2006/differential-diagnosis-of-ptsd-symptoms/
Collie, K., Backos, A., Malachiodi, C., Spiegel, D. (2006). Art therapy for combat-related PTSD: Recommendations for research and practice. Art Therapy: Journal of the American Art Therapy Association, 23(4), 157-164.
Kaiser, D., Dunne, M., Malchiodi, C., Feen, H., Howie, P., Cutcher, D., et al. (2005). Call for art therapy research on treatment for PTSD. American Art Therapy Association White Paper.
Ready, D. J., Sylvers, P., Worley, V., Butt, J., Mascaro, N., & Bradley, B. (2012). The impact of group-based exposure therapy on the PTSD and depression of 30 combat veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 4(1), 84-93. doi:10.1037/a0021997
Ready, D. J., Thomas, K. R., Worley, V., Backscheider, A. G., Harvey, L. A. C., Baltzell, D. and Rothbaum, B. (2008), A field test of group based exposure therapy with 102 veterans with war-related posttraumatic stress disorder. J. Traum. Stress, 21: 150–157.doi: 10.1002/jts.20326
Rothbaum, B. O., Hodges, L., Alarcon, R., Ready, D., Shahar, F., Graap, K., Pair, J., Hebert, P., Gotz, D., Wills, B. and Baltzell, D. (1999), Virtual reality exposure therapy for PTSD Vietnam veterans: A case study. J. Traum. Stress, 12: 263–271. doi: 10.1023/A:1024772308758
Sandmire, D., Gorham, S., Rankin, N., & Grimm, D. (2012). The influence of art making on anxiety: A pilot study. Art Therapy: Journal of the American Art Therapy Association, 29(2): 68-73. doi: 10.1080/07421656.2012.683748
All About Trauma 
I like the format for presenting the symptoms. It is very readable and easy to understand
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Thanks, Dr. Dave!
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