Many patients do not improve in psychiatric treatment because they are improperly or inadequately medicated (1) . A smaller but significant number who are medicated properly do not improve until their serious psychosocial problems are addressed (2) . The case of “Ms. A” illustrates this point.
Case Description
Treatment
Discussion
Sleep disturbances have been considered the hallmark of posttraumatic stress disorder for decades (3) . Since insomnia has been observed in 90% of PTSD cases (4) and nightmares related to the trauma in 70% (with or without comorbid depressive disorder [5] ), this is understandable. Both pharmacologic and psychotherapeutic approaches to the disorder have concentrated on improving sleep and reducing nightmares.
Pharmacotherapy, primarily with antidepressants, has been shown to have beneficial effects in improving sleep and reducing nightmares in patients with PTSD (6, 7) . So too have various forms of trauma-focused cognitive behavior therapy, ranging from exposure therapy, which seeks to desensitize the patient to the traumatic experience, to cognitive-processing therapy, which seeks to change the patient’s perception of the experience, often through teaching patients to restructure the nightmares (8, 9) . According to meta-analyses of psychotherapy trials for PTSD, 67% of the patients who complete treatment no longer meet criteria for PTSD (10) . Interpersonal psychotherapy, which focuses on current social and interpersonal functioning in treating PTSD, has had comparable results (11) .
There is also some evidence that in treating PTSD, a combination of both medication and psychotherapy is better than either alone (12) and stronger evidence that in the treatment of depressed patients, a combined approach is preferable (2, 13, 14) . Before implementing a treatment intended to reduce a patient’s nightmares, it would seem desirable first to attempt to understand the nightmare in the context of the patient’s traumatic experience. The specific content of the nightmare itself, which tends to be ignored, can be a valuable help in this process (15) .
In about half of the cases, patients’ dreams exactly recapitulate the trauma; in the other half, there will be some alteration in what actually occurred (16) . We often see patients whose recurrent nightmares are related to the trauma but involve features that express both guilt and the need for punishment (17) . Discussing the nightmares with patients reveals that guilt reflects something the patient feels in connection with the trauma. The guilt may be connected to the patients’ believing they had done something wrong or, as in Ms. A’s case, their thinking of doing something they felt was wrong or, more commonly, their having done something they felt was wrong during the traumatic event.
Ms. A, raised in a constricted fundamentalist home, was made to feel she was a bad illegitimate child who should expect little and deserved to suffer as the daughter of a promiscuous mother. This self-attitude provided the emotional framework for understanding her reaction to the automobile crash. Emotionally and otherwise abused children often grow up thinking they deserve to suffer and feel long-term guilt. But knowing her background alone would not have been sufficient to help Ms. A without knowing about, and being able to help her deal with, the events preceding the car crash. Exploring the nightmare led her to feel free to reveal these events.
Ms. A said she never had anyone to talk to, particularly referring to her mother and her husband, but implicitly including her first psychiatrist. She was grateful for the minimal relief the medication the psychiatrist prescribed provided but seemed relieved to be talking about herself without focusing on her eating, sleeping, or medications. She appeared to see her first therapist as a milder version of her grandfather and her husband, insensitive to her feelings but someone to whom she should be grateful for whatever she received since she deserved no better.
Dr. P, on the other hand, seems to have been perhaps the first paternal figure in her life whom she saw as understanding and supportive. Their therapeutic alliance, which recent research has shown to be a critical factor in the progress in any psychotherapy and pharmacotherapy (18), was certainly a key factor in Ms. A’s progress, enabling her to tell Dr. P about the “evil thoughts”—fantasies of adultery and resentment of her husband—she had just before the accident. The crash seemed to her like a divine judgment coming down on her. Dr. P’s interest in her recurrent nightmare, the content of which had been ignored by her first therapist, deepened their rapport. With his help, Ms. A came to see that thinking of an affair was an understandable reaction to her husband’s insensitive, overbearing behavior.
Although it might have been possible to uncover the source of the guilt that underlay her condition without the help of the dream, it would have been difficult. It would have required psychotherapy that was not so exclusively focused on symptom reduction that what was driving the symptoms was ignored. It is not warranted, however, to conclude that medication played no role in her recovery. The symptomatic relief she was receiving from the medications when she began therapy with Dr. P, even if not great, may have played a role in making her more accessible to psychotherapy.
Bringing to light the events that preceded the accident was a necessary first step in Ms. A’s improvement, but it was also necessary to help her deal with her husband more effectively. Gradually, she became more self-assertive and less obsequious. In some ways, she saw Dr. P as treating her as she wished her husband would treat her. That led to some anxiety when after 5 months treatment was ending, but she was able to resolve it, and when Dr. P last heard from her, she was doing well and had no further nightmares.
In evaluating what was responsible for the success of psychotherapy with Ms. P, it should be kept in mind that despite her chronic PTSD symptoms, severe depression, and painful childhood, Ms. A had more strength and resiliency than many patients who have the disorder. Before the development of PTSD, she was a relatively high-functioning individual despite inhibitions and conflicts centering around self-esteem, difficulties in self-assertion, and repressed sexuality. She had no history of substance abuse, personality disorder, or impulsive or self-destructive behavior. She raised two children who appeared to be well adjusted and to whom she was devoted. Starting on a clerical level, she had risen to a responsible administrative position at work, where her performance had been appreciated, and her confidence had been growing.
Beyond the issue of PTSD, however, Ms. A’s case is a reflection of what appears to be an increasing tendency to treat symptoms while neglecting the psychosocial problems of patients. Although the relative value of split treatments versus integrated treatment, conducted by one psychiatrist, or team treatment have yet to be evaluated, the trend toward split treatments in which a psychiatrist concentrates on symptoms and prescription writing and leaves psychosocial problems to an auxiliary therapist contributes to the problem (19) .
Yet we see the same problem among the many psychiatrists who employ an eclectic approach that incorporates psychopharmacology with cognitive behavior and interpersonal techniques, with varying degrees of reliance on psychodynamic principles (20) . Moreover, the psychiatric history forms commonly used in hospitals have often become symptom checklists that provide no picture of patients’ lives but seem aimed simply at matching symptoms with medications to address them. Such forms do not provide a helpful training experience for residents entering practice. The profession is increasingly recognizing that all psychiatrists need both psychosocial and psychopharmacological knowledge and skill in order to treat patients as well as their symptoms (21) .
Footnotes
Received July 18, 2007; revision received Oct. 2, 2007; accepted Oct. 5, 2007 (doi: 10.1176/appi.ajp.2007.07071144). From Suicide Prevention International. Address correspondence and reprint requests to Dr. Hendin, Suicide Prevention International, 1045 Park Ave., New York, NY 10028; [email protected] (e-mail).
All authors report no competing interests.
References
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