Categorizing Fear: The Role of Trauma in a Clinical Formulation

The problems in Hope’s treatment are worth highlighting. It appears that the first psychotherapists conducted a supportive, trauma-focused psychotherapy, presumably with a diagnosis of PTSD, while the physician was treating her for bipolar disorder. This probably contributed to her confusion. Like many individuals, Hope had difficulty understanding a model of mental life that divides her experience into “symptoms” to be reported to her physician and “problems” to be discussed with her psychotherapist. She became, understandably, increasingly frustrated with her physician and therapist as she remained ill for many months, and this reaction, along with depressive and anxiety symptoms, may have been misconstrued by the clinicians as a manifestation of borderline psychopathology. The complexity of her presentation, the presence of ongoing psychosocial stressors, and her inconsistent compliance with appointments all confounded the clinicians’ efforts. For all of these reasons, the recommendation that one clinician provide integrated care, and essentially become her primary physician, marks a turning point in the treatment course.

Research suggests that prominent dissociative symptoms are associated with both a history of childhood trauma and general psychopathology (1, 2), although dissociative problems can also occur in the absence of significant childhood trauma (3). Initially, Hope’s flashbacks and intermittent loss of reality testing were considered to be consistent with psychotic affective illness and may have further misled her clinicians toward a diagnosis of bipolar disorder. Such misdiagnosis is by no means uncommon among trauma patients. Using the Dissociation Evaluation Scale helped her psychiatrist reformulate her diagnosis in terms of trauma rather than psychosis, since Hope’s score was several standard deviations above the mean (a score above 30 suggests dissociative psychopathology and is typical of patients with PTSD) (4, 5).

This patient dissociates in response to extreme anxiety or fear, including that due to activation of associative memory networks by real and symbolic stimuli that evoke trauma memories. If extreme states are modulated through either psychotherapy or pharmacotherapy, dissociative symptoms may diminish. It is noteworthy that as will be shown, the dissociative symptoms improved as PTSD symptoms improved, without making dissociation a focus of treatment.

Taking a trauma history is important for any diagnostic evaluation and can facilitate the alliance by communicating the clinician’s interest in the whole person. Since disclosing traumatic events can provoke intense emotions of fear, anxiety, rage, or shame, the patient may not volunteer a trauma history. Clinicians can therefore specifically inquire about typical traumatic experiences and the patient’s reaction to them (6). In the National Comorbidity Survey, direct questioning about traumatic experiences led to a several-fold increase in the estimated lifetime prevalence of PTSD in the United States (7). If the patient reports a history of severe or recurrent trauma, the clinician can then assess the patient for diagnoses or clinical problems associated with severe trauma such as PTSD, dissociative disorders, major depression, borderline personality disorder, and prominent anniversary reactions.

Most patients feel relieved after disclosing traumatic experiences to a clinician who responds empathetically. However, individuals like Hope, who have never articulated such experiences, often need additional preparation and encouragement. An exploration of the patient’s fears regarding the disclosure can also be helpful. Individuals typically fear being overwhelmed with emotion, having a “breakdown,” or triggering an uncontrollable flood of horrible memories.

Particularly when recurrent trauma and its aftermath are viewed as the central feature of a patient’s problems, a list of diagnoses does not suffice to guide treatment. Significant traumatic experiences, particularly those perpetrated by family members, will almost certainly be relevant to a clinical formulation, in which the phenomenological presentation is integrated into an understanding of the meaning of the patient’s symptoms in the context of his or her life narrative.

When there have been multiple traumas over the life span, the individual’s characteristic adaptation to a predominantly hostile and unpredictable environment, and to attachments that are profoundly unreliable, will likely be observable in his or her approach to help seeking and capacity to make use of the clinician’s expertise. This is illustrated in Hope’s inconsistent and ambivalent engagement in treatment. However, Hope’s story also illustrates the fact that there is a wide range of outcomes to even severe childhood trauma. Her internal representation of dependent relationships certainly included fears of being exploited, betrayed, or treated with indifference. However, this view of others and the world did not entirely govern her behavior, since she was also described as likeable and engaging and showed no major manifestations of borderline or antisocial personality disorder.

In retrospect, the patient’s prominent irritability, mood instability, agitation, and decreased sleep were mistakenly formulated as symptoms of mixed mania rather than PTSD. Since most patients with PTSD also meet criteria for comorbid disorders (7), the initial presentation may be a complex mix of affective, anxiety, and PTSD symptoms. Similarly, one particular aspect of PTSD (e.g., affective instability, aggressive outbursts, severe insomnia, multiple somatic complaints) may dominate the clinical picture.

The antidepressants prescribed in the first 2 years of treatment (bupropion, trazodone in low doses) do not have established efficacy in PTSD (9). Case reports have suggested that valproate may be helpful for prominent affective instability, hyperarousal, and aggressive outbursts (common in a subset of PTSD patients) in refractory PTSD. Thus, the partial benefit that Hope experienced with valproate, which encouraged the physician to persist with a treatment plan for bipolar disorder, may have been due to mood stabilization (10).

In contrast, Hope experienced a dramatic improvement with fluoxetine, consistent with controlled and open trials of selective serotonin reuptake inhibitors in PTSD for core symptoms and some types of dissociative symptoms (11, 12). The latter is of interest, since dissociation has traditionally been viewed as unresponsive to pharmacotherapy.

There is no evidence to date in support of the use of traditional neuroleptics in PTSD. However, olanzapine is an antagonist at dopamine and serotonin (5-HT_2A) receptors, as well as other receptor sites, which may explain the observed benefits for insomnia and hyperarousal.

Hope’s physician wisely identified her husband as a supportive figure and included him in the treatment plan. Involving a supportive family member in the treatment process can provide further validation of the patient’s reactions to trauma and enhance social support outside of the therapeutic relationship. In family therapy, the clinicians were able to model both and recommend more adaptive and constructive behavior for the patient and spouse. Individuals from abusive, neglectful family environments may have never experienced collaboration, openness, and constructive problem solving in intimate relationships. Similarly, the therapist can demonstrate a model of compassionate and informed understanding, as well as constructive limit setting if necessary, for the family members.

The psychosocial aspects of the last clinician’s work with Hope may be divided into several phases: 1) forming an alliance while simultaneously conducting an extended evaluation, 2) educating the patient about the formulation, 3) teaching behavioral interventions to manage anxiety, 4) conducting family therapy and problem-solving to promote a more successful adaptation to the patient’s chaotic environment, 5) reconstructing of a trauma narrative, and 6) exploring of conscious and unconscious meanings of traumatic experiences as they were continuing to influence her life.

The first several months of systematically investigating and addressing the patient’s problems following a medical model helped to solidify the treatment alliance.

The fact that the patient herself did not understand her problems as the consequence of multiple traumatic experiences is not uncommon in survivors of childhood trauma. Trauma-focused treatments with demonstrated efficacy in PTSD include an educational component in which the typical reactions to trauma are shared with the patient and illustrated in the patient’s own history and experience, 13). Education reassures the patient of the therapist’s knowledge and competence; normalizes the patient’s experience and thereby counters views of the self as weak or defective; identifies specific domains of symptoms and problems as a focus of treatment; and provides a credible, intuitively humane framework for both the psychotherapy and the patient’s self-understanding.

As illustrated in Hope’s treatment course, before productive exploration of the trauma, an alliance must be formed by establishing a professional relationship of relative safety and trust. This is important to counterbalance a tendency to misperceive exploration of the trauma as retraumatization. There may be a series of tests of the clinician’s persistence, concern, awareness of appropriate boundaries, ability to tolerate hearing about frightening experiences, and willingness to remain interested in the patient’s many complicated problems. For Hope, it appears that the eventually successful pharmacologic treatment was an additional, powerful proof of her physician’s competence to help her.

The technique of reconstructing a life narrative is particularly useful for patients with multiple, severe trauma. The technique essentially constitutes an extended exposure therapy treatment, which supports its efficacy but also raises important clinical issues, since exposure therapy is generally time limited because of its stressful nature. The clinician’s sensitivity to the patient’s ability to tolerate this endeavor, active support throughout the process, and flexibility can make the difference between a successful or disastrous trauma-focused therapy.

Hope’s decision not to join a therapy group of survivors of childhood sexual trauma is notable in this regard. She may have intuitively appreciated that such a group can be extremely taxing, and her ongoing struggles at home were difficult enough to tolerate. As the clinician recognized, the manifestation of negative transference at this point (i.e., fearing an angry, tyrannical response from the physician and loss of the relationship) in fact presented a valuable therapeutic opportunity. Recognizing her autonomy and responsibility for her own welfare and responding flexibly may have served as another corrective experience to counteract longstanding and understandable expectations of coercion and exploitation in dependent relationships.