Treating Posttraumatic Stress Disorder: The Complexities of the Clinical Realm
Authors: Ulrich Schnyder
Journal: Psychotherapy and Psychosomatics (2024)

A number of evidence-based psychological and pharmacological treatments for posttraumatic stress disorder (PTSD) are available today [1‒5]. However, many trauma survivors do not have PTSD alone but suffer from various comorbidities. Moreover, patients' priorities frequently differ from their therapists' therapeutic strategies. In other words, clinical reality is usually much more complex than research evidence appears to suggest. Thorough training in trauma-focused psychotherapy [4] is essential, as is knowledge about effective pharmacological approaches. However, clinical wisdom may be as important. The therapist needs to be skilled in listening to their patient and building up a mutually trusting therapeutic relationship. They also must be able to honestly engage in shared decision-making while at the same time being straightforward in guiding the patient so that they can jointly develop consensus regarding the therapeutic steps to take [6‒8].John returns from work, tired, and a bit tense due to some minor stressors he had experienced in the office. On his way home, he buys 2 cheeseburgers. His fiancée, Anna, will visit and join him for dinner. When opening the front door of his apartment, the key gets stuck, so that John has to struggle a bit until he manages to release the key from the lock. Anna is there already, and he gives her a mouthful, accusing her of having created the problem with the door key. He drops the bag with the burgers on the kitchen table and tells her he is going to take a shower before dinner. When in the shower, he suddenly sees Anna entering the bathroom, gagging, looking at him with a strange expression, then collapsing. He jumps out, naked and wet, Anna lying on the ground motionless, lifeless. He shakes her, screams at her, to no avail. He runs to call the ambulance. In the kitchen, he sees that Anna has obviously taken a big bite from one of the cheeseburgers. He calls the ambulance a second time, asking them angrily why it takes them so long to come. After a felt eternity, the paramedics arrive, only to testify Anna's death.John is devastated. He cannot sleep. He cannot concentrate. He senses an unbearable restlessness. He consults his family doctor who puts him on sick leave. Yet John barely makes it through the first days in the immediate aftermath of Anna's tragic passing away due to what is known as "bolus death": the burger bite she had taken had gotten stuck in her throat, causing a vagal reflex, which had led to sudden cardiovascular arrest.Ten days after the event, I see John for the first time. He complains about insomnia and an extreme inner tension and restlessness. He feels guilty for not having been able to rescue his fiancée. He also reports frequent flashbacks and nightmares in which he reexperiences Anna's gagging, collapsing, and ultimately passing away. John fulfills the diagnostic criteria for acute stress disorder (ASD) [9]. I provide him with psychoeducation about typical acute stress responses in the aftermath of potentially traumatic events [10‒12]. I try to convey a confident, optimistic attitude, and suggest early intervention, combined with "watchful waiting." We agree on weekly appointments over the next couple of weeks (Fig. 1).John's ASD symptomatology fluctuates over the course of his days. In line with current guidelines on early intervention after trauma [1, 13], I try to apply elements of trauma-focused cognitive-behavior treatment [14], with limited success. John sees me as the PTSD expert, so he is very keen in learning about my views on the repercussions of potentially traumatic events and how to treat trauma-related psychological problems. He clearly idealizes me to some extent during these early sessions. However, I do not address John's positive transference at this point in time as it obviously helps building a trusting therapeutic relationship.Six weeks have passed since Anna's death. John feels somewhat stabilized. He has acquired a set of emotion regulation skills such as going for a walk when he is distressed. However, he still has frequent flashbacks and nightmares. He persistently avoids external reminders of Anna's death, such as visiting her grave at the cemetery. John keeps blaming himself for not having been able to save Anna's life. He is hypervigilant, has difficulties concentrating, and suffers from insomnia. In other words, John fulfills the diagnostic criteria for PTSD [9]. In addition, John has moderate major depressive disorder. He is in a depressed mood most of the time, experiences great loss of energy, and feels completely worthless.Of note, John does not feel sad about having lost Anna. Instead, he is constantly haunted by his guilt feelings. Whenever he is reminded of the incident, he immediately jumps to the idea of being responsible for her death. He spends hours ruminating: "If only I was a doctor, I could have applied the Heimlich maneuver, thus rescuing her!" (the Heimlich maneuver is a medical emergency procedure which can relieve foreign body airway obstruction if applied timely and properly). John's guilt feelings are additionally fueled by the little argument the couple had had upon his arrival at home: "If we had not argued over the problem with the door keys, she would not have been so stressed out, and thus would not have gagged on the burger bite!".John also suffers from a number of physical health issues: he has high blood pressure, is moderately overweight, and his blood glucose levels are borderline elevated. While focusing on the psychiatric and psychological aspects of his crisis, I am taking these physical issues into account, considering that the psychosocial stress John is currently exposed to may have elevated his preexisting allostatic load to allostatic overload [15].Now it seems to be the right time to start trauma-focused CBT. The core elements of evidence-based psychotherapy for PTSD include psychoeducation, emotion regulation training, imaginal exposure to the traumatic event, and cognitive restructuring [4, 12]. However, John is scared to death to engage in exposure treatment. He fears he would "go crazy" if he were to confront the dreadful moments of Anna's passing away. As much as I try to convince him that he would probably need exposure sessions, John categorically refuses to even give it a try.According to international guidelines [1, 13], I should start with exposure to address John's flashbacks and nightmares. John refuses. What should I do? I intuitively feel that by applying even more "arm-twisting," I might lose him. Sequential treatment [16] should take into account the patient's views. After all, the patient might sense that it is not (yet) the right time for exposure. I therefore decide to follow John's preference, and change plans accordingly. I would no longer urge him to undergo exposure therapy. Instead, I suggest to work on his guilt feelings. In addition, to address his depressed mood and persistent insomnia, I suggest mirtazapine 30 mg before going to bed. John accepts (Fig. 1).I emphasize that it seems justified for John to ask himself whether he could (and should) have done something to prevent Anna's death. After all, he had been the only person present when she collapsed in the bathroom! John explicitly thanks me for my willingness to talk about these issues. All others had symbolically or literally given him a pat on the back, trying in vain to talk him out of his guilt feelings and self-contempt. Over several sessions, we discuss his responsibility using the principles of Socratic dialog. John at first keeps obsessing about his guilt feelings. Slowly but steadily, however, he starts getting in touch with his underlying sadness and loneliness that seem even more difficult to tolerate. Anna and John had been a couple for 17 years. Their relationship had seen many ups and downs. Anna had suffered from severe recurring mental disorder. John had been looking after her when she went through her crises; however, he had also often been impatient with her and grumpy when he himself was distressed. Now, he deeply regrets having raised the "front door keys" issue with her. In retrospect, he realizes he had simply brought home tension from work. While she had been looking forward to a joint dinner, he had grumpily snapped at her.Gradually, John starts realizing that his obsessing about being responsible for her death not only generated enormous guilt feelings: it also offered him a certain illusion of having been in control of the situation. He starts facing and eventually accepting the fact that there was nothing he could have done, that the terrible sequence of events that had led to Anna's death had just simply been happening, a cruel twist of fate.After 10 sessions of Socratic dialog and cognitive restructuring, John has achieved a more realistic view of his role in his fiancée's passing away. He spends much less time ruminating about his guilt, instead mourning Anna. However, the traumatic memories still persist, almost as vividly as in the immediate aftermath of the tragic event. John is still haunted by nightmares from which he wakes drenched in sweat and suffers flashbacks on a daily basis.It is at this point in time that John comes up with an interesting idea: one of his dysfunctional beliefs had been that when calling the ambulance he had caused an unnecessary delay of the rescue operation. The receptionist had asked him whether Anna had diabetes or any preexisting cardiac problems, which she did not. John got angry, yelling that the receptionist should send the ambulance immediately, rather than "asking silly questions". Now John is wondering if he could somehow get hold of the audio recordings of the two phone calls he had made: he feels that by listening to these recordings, he might obtain objective information on how inappropriately he actually had behaved. I am not entirely convinced by this line of thought. Not knowing where this would lead us, I encourage John to give it a try anyway.Interestingly, this turns out much easier than expected: John brings 2 electronic audio files to the next therapy session. However, he is too scared to listen to the recordings. He asks if they can be transcribed, to which I agree.The following week, when merely looking at the transcript from the distance, John starts trembling and sweating. He feels like being the culprit in a court trial. The recordings would provide evidence that he is guilty of Anna's death. He would not be able to live with the final verdict. We discuss this, and it turns out that John is in fact ambivalent: while expecting his "death sentence," he also hopes for acquittal or at least for a mild verdict. After some negotiations, I start reading the transcript to him, realizing that this is going to be some kind of unconventional exposure session. John can hardly sit still and moans, breathing heavily, his heart pounding. I keep reading. John listens intently. He senses an intense pain in his chest. When we approach the end of the first phone call, John starts crying. It takes him quite a while to regain his composure.The recording shows that John had in fact been very agitated when making the call. The receptionist had asked a number of questions about Anna's health condition. Toward the end of the call, John had shouted at the receptionist, who in turn had kept his professional composure. By no means had John's behavior caused any delay in the rescue procedure. In fact, at the time of the second call, the paramedics had already been on their way to John's place. According to the rescue service's files, they had arrived 8 min after John's first call. John realizes that he himself had been his merciless judge without taking into account the evidence.John is much relieved. His self-designed exposure session had taken him directly back into the core scene of the traumatic event. He is exhausted but also proud of having survived exposure! During the following sessions, John reads the transcript himself, and finally, he listens to the audio recording. Again, he is very much emotionally involved. After the third "exposure" session, John declares himself "only partially guilty": He now recognizes that he had actually upset Anna in the first place when arguing with her over the front door keys. Once she had collapsed in the bathroom, he had done all in his power to save her life, given that he actually is not a doctor but an IT specialist. Sadly, this had not been enough to rescue her.Shortly thereafter, John no longer suffers from any significant intrusions. His hyperarousal symptoms have decreased significantly, and he is also in a better mood. The exposure sessions not only significantly reduced John's reexperiencing symptoms. They also yielded substantial cognitive change which in turn helped him to better understand the biographical origins and impact of his cognitive schema of being in control as a guarantee for success in life. He is now able to link this to experiences in childhood and adolescence, particularly to his father's frequent and unpredictable outbursts of anger which John had been extremely scared of.John visits Anna's grave, crying, mourning. He starts putting his apartment in order. He joins a self-help group for people who had lost a partner. There, he finds people with whom he can share his feelings and have in-depth conversations about how to cope with the loss and to find new meaning in life.When I see him for a follow-up assessment 1 year after Anna's death, John no longer fulfills the diagnostic criteria for PTSD and depression. He has stopped psychotropic medication. He has resumed work. He goes out seeing friends. He is still very sad about having lost Anna, though.John keeps asking for an appointment once or twice a year. It is only when I see him 7 years after Anna's death that John tells me he had finally been able to dispose of the rest of her cheeseburger which he had been keeping in his deep freezer for so many years.Over many years now, trauma-focused therapy has been concerned to a large extent with helping trauma survivors "to regain control over their emotional responses" [17], particularly their intrusions. So far, so good. However, such an attitude implicitly conveys a potentially problematic message, namely, that everything in life can be controlled. As a matter of fact, bad things do happen: we fall ill, lose a loved one, experience physical violence. For John, it was crucial to understand that he had experienced a cruel twist of fate. While toward the end of therapy he regained control over his intrusions, it was probably even more important for him to learn to accept that he had had virtually no control over the unfolding of events on the day when Anna passed away. Moreover, he learned to distinguish between things on the one hand that are potentially controllable, and things on the other hand that are beyond his control, that have to be accepted and coped with, along with the pain and suffering they may bring about.I myself as John's therapist had to learn my lesson as well: I had a hard time initially to accept that John refused to engage in exposure therapy. When I finally stopped insisting but started listening to John's concerns, and later also to his "outlandish" idea to retrieve the audio files, things turned for the better, and John started recovering. I am most grateful to John to have taught me this lesson. He had played an active role in the design of his sequential treatment [18]. He had also influenced the timing of my interventions in a positive way (Fig. 1). I learned that an intervention that is properly done, but poorly timed, may be of little value. An intervention needs to develop and mature in order to unfold its optimal effect. For a more detailed description of this case study, see Online Supplementary Material (for all online suppl. material, see https://doi.org/10.1159/000538954).Good therapists are aware of their own limitations. They tailor psychotherapy individually and sequentially [18] to each patient's situation, taking into account their psychopathological status as well as their resources, their allostatic load [15], as well as their resilience. And they humbly accept their own failures.This article is based on a case example that was previously published in a book chapter [19].The author has no conflicts of interest to declare.This study was not supported by any sponsor or funder.Ulrich Schnyder conceived and wrote the entire manuscript.