Marla is a 42-year-old Hispanic female who comes to the mental health clinic complaining of trouble sleeping, feeling "jumpy all of the time," and an inability to concentrate. These symptoms are causing problems for her at work where she is an accountant. When Marla entered my office, she was pleasant, but seemed visibly anxious. I greeted her with a comforting smile, and gestured to her to come into my office and take a seat. I made some polite conversation of an incidental nature with Marla, and proceeded to 'weave' the following questions into the conversation so I could draw some conclusions about her unsettled lifestyle.

 

Good morning, it's a pleasure to meet you, I'm Kerry. Will you tell me a little about yourself?

 

Marla introduced herself, smiling, and told me that she had been feeling anxious for sometime. She said that most of the anxious feelings she encounters, seem to happen during the time she is at work in her office. She was concerned about what might be wrong with her because the unsettling feelings had only started to happen over the past six to eight months and nothing significant had happened to her which could explain them. Prior to this disturbing period of her life she had been a carefree, happy-go-lucky type, who enjoyed going to work each morning. She seemed both alarmed and confused about what might be wrong with her, and was becoming glassy eyed when she referred to her job.

 

Is there a history if mental illness in your family Marla, and have you been previously diagnosed with a psychological disorder? If yes, what is the disorder, and are you currently taking medication for it?

Marla assured me that nobody in her family had suffered from any psychological disorder that she knew about, and again conveyed her concern as to why something like that could happen to her so suddenly, and for no apparent reason. She had not been abused or tormented, nor had she been the victim of any crime.

 

Are you physically unwell, and if so, have you been prescribed medicine for the condition? What kind of medicine do you take, and have you been following instructions provided by your doctor?

 

Marla had been to see her family doctor prior to my consultation with her; it was her physician's idea that she sees me to discuss her lifestyle more and to see if her feelings of being generally unwell were due to a psychological disorder. Marla has had a full physical examination in the past month and has been given a clean bill of physical health. Marla is not currently taking any medication.

 

Have you suffered any trauma; military deployment, a car accident, were you a victim of a crime, or have you been affected by a natural disaster or the death of a loved one?

 

Marla had already discounted being the victim of a crime, although I asked her again thinking it might make more sense to her if she had experienced an attack. She answered no, and no to the accident and death of someone close to her. She did however, mention that she had been caught up in the Hurricane Katrina disaster, but that was ages ago, and she did not consider that to be upsetting anymore; she had moved on comfortably with her life since then. Marla then paused, and mumbled something about Katrina, although she said it was nothing important when I asked her to repeat herself.

 

Marla, you indicated some problems with your sleeping pattern, would you tell me a little more about that? Is there any traumatic event that you recall which might be the cause of this problem?

 

Marla stated that her problems sleeping were becoming a nuisance. She was arriving at work on time, but was not feeling rested at all. She told me that getting to sleep was not a problem, but staying asleep was another matter. Marla said that this happened most nights, and she did, indeed, look very tired. She told me that if she could just sleep one whole night she would most likely be a whole new person and would not have troubles concentrating during her work day. Marla also admitted to having had some wine on several occasions, hoping it would make her sleep; it had not helped and she did feel weird about drinking alone so often.

 

Do you ever have waking recollections about a traumatic event, or do you have recurring nightmares about it?

 

I asked Marla if she had experienced any bad dreams; she quickly told me that she rarely dreams, or perhaps she simply does not recall the details of anything significant after being awake for a few moments. She did say however, that after waking up, she often felt overly anxious and could not explain why. She said that the feelings left her with an upset stomach and the shakes. She told me that she had taken a considerable number of days off work, and that her boss was becoming increasingly annoyed with her, although he never said anything directly. She also said that the more time she spent away from her office, the less she felt like going back. On the days when she did wake up feeling fine, she was more 'jumpy' as she got closer to work. I suggested that she keep a notepad and pencil on her bedside table and to jot down anything she recalled after waking. She agreed, although she told me that even when she could remember anything at all, it was not usually anything which caused her distress.

 

Do you lead an active social life with lots of friends?

 

Marla said she used to be quite the social butterfly; enjoying a dinner out with her friends at least once each week, and even a coupe of glasses of wine. She told me that since her sleep had been interrupted she had not felt like going out, and that she felt she should try to catch up on her sleep. She did not want her concentration, or lack of it, to jeopardize her job, and thought this was the best approach until she could resolve the problem. Her friends usually congregate at the same meeting place, and only on rare occasions do they visit each other at home. Marla thought for a few seconds, and was surprised to realize that it had been several months since she had dined out with her friends. She felt appreciative of their patience with her, but she often let the answering machine pick up their calls to her rather than enter into a conversation. She said she had lost interest in going out, and did not wish to discuss her concerns with her friends for fear she would be seen as a whiner.

 

Marla, are there certain situations you prefer to avoid because they cause you to feel anxious, or you feel as though you may be in danger?

 

Marla said she was happy enough to continue living her life as she always had, and I suspect that she did feel unsafe at times, although she did not continue with this part of her answer; instead she told me that her office felt uncomfortable to her on many occasions. She was not sure whether the air conditioner had been working properly or not, but she had been feeling rather hot and a little claustrophobic, and wished she could run away to somewhere cool to gather her thoughts. When I asked her if she had always had this intolerance for the hotter weather, she said she had not, and perhaps she was just getting old. Marla gave a little giggle at the thought!

 

Are you currently in a relationship Marla? If you were in a relationship which was terminated by the other party, how well do you think you coped?

 

Marla had a boyfriend, but he was currently oversees working on a research project. She had been in the relationship for four years, and she seemed very happy with her man. Marla said she had only been on casual dates before meeting Thomas, and that none of her dates had developed into a relationship. Marla made 'air-quotes' with her fingers when using the word 'relationship. When Marla spoke of her boyfriend, Thomas, however, her eyes smiled, but she confessed that she was not interested in getting married, even though Thomas was becoming insistent. She loves him, she said, but she just felt like it was not something she wanted to deal with at the moment.

 

Have you ever had suicidal thoughts?

 

Marla looked horrified when I asked her if she had had suicidal thoughts. I assured her it was a standard question and that I was not implying anything. She seemed afraid to continue with this part of the conversation for a moment, and then went on to express her sympathy for others who felt that way saying she could not imagine how sad they must be feeling to have such thoughts.

 

Posttraumatic Stress Disorder

 

Posttraumatic Stress Disorder can occur in some individuals who have been exposed to a life threatening situation, or a situation which they have witnessed in which another person is exposed to danger. The onset of symptoms with PTSD do not always happen immediately following the traumatic event, therefore the association between the symptoms and the initial event is often overlooked.

 

A person with PTSD will be hypervigilant, and can react to an unsettling situation with physiological symptoms such as upset stomach, headache, or dizziness. People with PTSD can also suffer from depression or panic disorder, although this is not always the case. Avoiding stimuli which can trigger an anxious reaction is normal for the PTSD sufferer, and many become withdrawn from social interaction with friends and family members. Some may also have problems continuing an intimate relationship, and angry outbursts for no particular reason can cause problems with interpersonal relationships, as well as jeopardizing one's employment.

Treatment for PTSD can be relatively straight forward, although not always easy for the patient to endure. Being taught how to effectively relax is paramount, and once this goal has been achieved, the process of systematic desensitization can gradually take place. The desensitization process involves confronting the stimuli which cause the patient to have an anxious episode. Oftentimes, the stimuli are a particular place, and for some it may be a certain situation which serves as an unconscious reminder of the traumatic event. The more a person is subjected to the offending place or situation, the less intense the fear becomes. This is achieved by implementing the relaxation strategies at the same time the stimuli are presented. The association between the relaxed state and the stimuli will eventually be achieved, disarming the stimuli and giving control back to the patient.

 

Being made aware of maladaptive responses to stimuli, patients are better able to identify which anxieties are due to the normal course of life, and which are patterns of irrational thinking related to their disorder. According to DSM-IV, PTSD can occur at any age, to either gender, and the onset of symptoms can be delayed by months or even years (DSM-IV, 1994, p.426).

 

According to Cognitive-Behavioral theorists, learned behaviors from conditioning can produce unsavory responses; both physically and psychologically. Unfortunately for the patient, these responses can occur whether it is their intent to react in such a way or not. In Marla's case, the association with the time Hurricane Katrina affected her life and her psychological and physiological response to her overheated office are one and the same. Learned behaviors can be unlearned, just as new and more effective behaviors can be adopted. Using classical conditioning, Marla can be taught new, positive behaviors to use when the offending stimuli is present, and not the unpleasant learned behaviors she has been using as her defense mechanism.

 

Marla's hypervigilance and feelings of anxiousness can alleviated and bought under control with practice, relaxation and frequent exposure to the offending stimuli, and in conjunction with Cognitive-Behavioral therapy, she may also benefit by taking an antidepressant (SSRI) such as Prozac, Zoloft or Paxil.

 

Reference

 

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994.

 

Faces of Abnormal Psychology, 2007. Posttraumatic Stress Disorder: Treatment Strategy. Retrieved July 4, 2009, from http://www.mhhe.com/socscience/psychology/faces