A “Cure” for Chronic Combat-Related Posttraumatic Stress Disorder Secondary to a Right Frontal Lobe Infarct: A Case Report
Abstract
CASE REPORT
The patient, a right-handed Vietnam combat veteran, presented initially at age 48 years for evaluation for admission to a PTSD rehabilitation program. He and his wife related a chronic history of arousal symptoms, including irritability, insomnia, and generalized anxiety, that had persisted since the end of the Vietnam War. On further questioning, the patient's wife described the patient's nightmares and intrusive recollections of the war, which had been present up to the time he suffered an acute cerebral infarct at age 45. At that time, the patient suddenly developed generalized weakness, headache, and a mild weakness on his left side that resolved over a period of several days.At the time of the initial psychiatric interview, the patient related a number of depressive symptoms, generalized anxiety, and periods of verbal and physical aggression in association with minor irritants. The patient denied any nightmares, intrusive recollections of the war, or any effort to avoid reminders of the war. His responses to these questions suggested very limited personal memory for most past events, including his war experiences. His presentation was notable for marked motor dysprosody, although sensory prosody was intact to bedside testing. Computed tomography of the head done at the time of the infarct revealed evidence of right frontal damage (Figure 1). A cerebral [99mTc]HMPAO SPECT scan completed 3 years after the initial infarct showed decreased rCBF in the right frontal cortex at the location of the infarct (Figure 2). Normalization of rCBF to a mean cerebellum rCBF value demonstrated a 43% reduction of right frontal rCBF compared with the left.Neuropsychological testing at the time of the interview 3 years after the infarct showed average intelligence, with a Wechsler Adult Intelligence Scale–Revised Full Scale IQ of 92 (Performance IQ=91, Verbal IQ=93), although individual subtest performances suggested disruptions in graphomotor efficiency, problem-solving speed, logical-sequential reasoning, and spatial cognition. Estimates of general memory functioning fell well below his measures of intellectual function, primarily because of retrieval difficulty in spontaneous and delayed free recall of narrative verbal information. Moderate dysfunction was noted on the Trail Making Test part B and the complex Tactual Performance Test. The patient completed the Autobiographical Memory Interview,10 obtaining scores on personal semantic events of 14.5/21 (childhood), 17.5/21 (adulthood), and 19/21 (recent), and on autobiographical incidents of 0/9 (childhood), 3/9 (adulthood), and 7/9 (recent). These results reveal a relative decrement in remote and past autobiographical memory function and an improved recall of more recent autobiographical material—a pattern similar to that in another reported case of acquired autobiographical memory impairment following a right frontal lobe infarct.9 The patient also completed the Davidson Trauma Scale, a self-report instrument for PTSD symptoms. His score on the intrusion (reexperiencing) subscale was 0; on the avoidance/numbing subscale, 39; and on the hyperarousal subscale, 29. The avoidance/numbing subscale score was entirely made up of his positive responses to questions about emotional numbing; he gave no positive responses to questions about avoidance of reminders.
DISCUSSION
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