Re-emergence of Symptoms of Posttraumatic Stress Disorder in a Homeless Woman

| November 8, 2007 | 0 Comments

by Ann Morrison, MD; and Beth McIlduff, MD

Dr. Morrison is Associate Professor of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, Ohio; Dr. McIlduff is a first-year resident in psychiatry at Northwestern, University in Chicago, Illinois; and Dr. Gillig is Professor of Psychiatry, Boonshoft School of Medicine. Wright State University, Dayton, Ohio.

Editor Note

All cases presented in the series “Psychotherapy Rounds” are composites constructed to illustrate teaching and learning points, and are not meant to represent actual persons in treatment.

Abstract

Posttraumatic stress disorder is commonly found in people experiencing homelessness; however, due to the high rates of other disorders, it may be undetected. In this article, we describe a woman previously recovered from depression and addiction who suffered from reactivation of traumatic symptoms following media exposure to Hurricane Katrina. Supportive psychotherapy with behavioral strategies are also described.

Key Words

posttraumatic stress disorder, reactivation, homelessness, natural disaster

Introduction

The importance of trauma and reactivation of traumatic experiences as a source of psychological distress has been of increased interest over the last several decades. Historically, combat stress has attracted a great deal of research interest, but more recently, reaction to natural and man-made disasters have been described extensively. Indeed, the psychological effects of Hurricane Katrina have already been reported.[1,2] There have also been descriptions of reactivation of symptoms (posttraumatic stress disorder or PTSD) when a traumatic event, such as a hurricane, occurs.
Hurricanes are common along the Gulf Coast of the United States. Many people have experienced more than one episode of displacement or devastation from these storms in the course of their lifetimes. We report the experience of a composite patient who, as a child, endured the peril of Hurricane Camille and then as a homeless adult in a Midwestern city experienced a recurrence of trauma symptoms following media exposure to the widespread coverage of Hurricane Katrina.

Case Presentation

Karen was a 49-year-old Caucasian woman who lived in the Midwest and who presented for treatment to our facility in the fall of 2005. Hurricane Katrina had just devastated the Gulf Coast, destroying cities, towns, and countryside and leaving thousands of people with no contact to family and friends. Images of flood waters, ravaged homes, and stranded people dominated the news on television, in newspapers, in magazines, and the internet. Karen began to become increasingly anxious about members of her family who lived on the Gulf Coast, lost sleep due to frightening dreams of drowning people, and experienced unusual irritability and more severe temper problems.

Prior to obtaining additional history, the patient was initially diagnosed as experiencing an adjustment disorder with anxious mood. This is because her symptoms occurred within three months of an identified stressor and impaired her social and occupational functioning. However, she was in fact experiencing PTSD, with a re-occurrence of major depressive disorder.

Karen had been homeless for several years. She was able to find and keep only occasional, short-term employment. She had a history of depression and substance use disorders (primarily alcohol dependence but also cocaine abuse), both of which were in remission. Despite difficulties accessing treatment, her depression had been treated successfully (until this point) with sertraline 100mg daily, and she had undergone rehabilitation for substance abuse and had been sober for two years. She was currently staying at a nearby shelter and was sustaining a long-term relationship with her boyfriend.

The recent stress of Hurricane Katrina was beginning to disrupt her daily life and threatened to jeopardize her sobriety. She was losing sleep at night and becoming somnolent during the day. She noticed that she was quickly annoyed by people, becoming angry and often losing her temper. She was getting into more arguments, which were escalating close to the point of violence. She believed that her sleep deprivation, anxiety, and anger were leading her to consider drinking again.

Practice Point: Mental Illness and Addiction Among Homeless Individuals

Karen, like many individuals experiencing homelessness, had prior struggles with depression and alcoholism. Rates of psychological illness reported by homeless people are high. Alcohol use problems are endorsed by 38 percent, 26 percent report other drug use, 39 percent report some form of mental health problem, and 20 to 25 percent have serious mental illnesses.[3] Co-occurring disorders are common among the homeless and are a risk factor for chronic homelessness. Up to 50 percent of people with serious mental illness who are homeless have a co-occurring substance use disorder.[3]

Supportive Therapy

Supportive therapy, as summarized by Kay and Kay,[4] provides psychological stabilization by strengthening the patient’s defenses and improving coping ability. Prevention of decompensation and regression by focusing on overcoming current problems is emphasized. Supportive techniques described by Kay and Kay and which we predicted would be helpful to Karen in dealing with her acute stress included empathic listening, measured advice and reassurance, and suggestions to improve coping skills. Her prior history of major depression and substance use as well as her homeless condition also influenced the choice of supportive therapy, as she had neither a sufficiently stable psychological state nor environment to utilize the learned techniques in therapy, which might lead to regression and risk further decompensation and relapse in an especially vulnerable individual.

Case Presentation, Continued

Brief supportive therapy along with increasing the dose of her current medication was chosen as the initial treatment modality for Karen. Supportive therapy was appropriate because she was suffering an acute crisis requiring immediate intervention. The disaster caused by Hurricane Katrina was rapidly and relentlessly capturing the attention of the media and she could not escape exposure to this information. By quickly providing understanding and validation of the emotions Karen was experiencing, her symptoms could find early relief. Karen was eager to begin therapy and very willing to undergo treatment.

While focusing on current stressors, during the first visits Karen also revisited her childhood in the rural South. She spoke with fondness of the region, and told stories of the character and life of the South. She also began remembering the hurricane of her childhood. The home in which she grew up completely flooded, and she was left with nightmares of unrelenting flood waters and drowning people. The nightmares, which were currently causing her to lose sleep, were similar. Then as now she saw faces of people underwater, and she was unable to save them. Today, feelings of helplessness from knowing that she was unable to reach out to her family caused her to feel guilty, worthless, and frustrated. The supportive technique of reassurance by balancing positive feelings of family and community support and the past successful recovery against the fear and helplessness experienced during the prior and present disasters helped Karen develop a better sense of control over her current problems and more optimism about the future. The therapist encouraged the telling of both the positive memories of her youth as well as the negative remembrance of her childhood flood. She began to understand the connection of her current symptoms to the anguish she felt as a child. To help her feel more proactive instead of helpless, the therapist was able to provide her with local charities and organizations raising money and supplies to send to the Gulf Coast and encouraged her to assist these groups.

Practice Point: Reactivation of Trauma

Once therapy began, the patient revealed additional trauma history from her childhood related to the hurricane she had survived. Karen survived Hurricane Camille at age 13 but she experienced frequent frightening nightmares and memories of heavy rain and floods for approximately two years following the hurricane. For three years after the storm, she would sleep in the attic rather than her first floor bedroom whenever there was severe weather. Later, as an older teenager, Karen would sometimes drink alcohol during periods when the nightmares briefly returned.

After graduating high school, Karen moved to the Midwest to attend college. Away from the yearly threat of tropical storms, Karen experienced a sustained remission of PTSD for nearly 30 years. However, her use of alcohol to cope with emotional or behavioral problems continued. In 2005, re-exposure to the massive flood caused by Hurricane Katrina, albeit through the media, resulted in Karen re-experiencing the nightmares and terrifying memories of her childhood.

Reactions in children and adolescents, including PTSD and depression, to natural disasters such as earthquakes, hurricanes and floods have been described.[5–8] Our patient experienced acute stress symptoms at age 13 immediately after Hurricane, Camille and continued to suffer some symptoms of PTSD over the next seven years. Katrina, with the enormous scale of the disaster and massive media coverage, reactivated this earlier trauma.

Reactivation of PTSD, primarily combat related, has been described.[9] However, even in these cases, the trigger is not always combat related and may not, as in the case of our patient, be directly witnessed by the individual.[10] Reactivation of PTSD in civilian survivors of war, the Holocaust, and sexual trauma has also been described.[11–13] No doubt the concern for and uncertainty about the fate of her family members enhanced the reactivation of symptoms.

Practice Point: Trauma and Homelessness

While Karen had a unique trauma and reactivation experience, trauma itself is common among people experiencing homelessness. Rates of trauma among the homeless individuals are staggering. Domestic violence is often a precipitant of homelessness for women with 22 to 50 percent of homeless women reporting that they left their last residence to escape domestic violence.[14] Ninety-two percent of homeless women experienced severe physical and/or sexual assault at some time in their lives.[14] While the rates of trauma and types of trauma experienced by homeless men may differ somewhat from women, in an Australian survey over 90 percent of homeless men also endorsed at least one event of trauma in their life.[15] A number of factors that put people at greater risk for homelessness are also correlated with higher rates of trauma. These include veteran status, history of being raised in foster care, mental illness, and substance use disorders. Unfortunately, given the multiple social and psychological problems with which many homeless individuals present, the role of trauma is often unidentified and untreated.

Case Presentation, Continued

Karen spoke of becoming increasingly angry, frustrated, and annoyed with her peers. She would begin to talk about her nightmares and her worries since Katrina only to have her friends joke about them and downplay their significance. She began to isolate herself and chose not to put herself in situations that might escalate to violence. By listening to her stories, validating her emotions and providing positive support, the therapist was able to provide a safe outlet for Karen’s feelings. She was able to express her frustration and anger as well as recognize her anxiety and depression.

The therapist encouraged Karen to find a positive group of people to interact with instead of the negative atmosphere her peers were providing. Karen sought out a church group, and she found that participation in church activities made her feel calmer within herself and more patient with others. She went to the church group a couple times each week to either sit and reflect on her thoughts or talk with others who were willing to listen. She was also encouraged to increase her attendance at a 12-step group, such as Alcoholics Anonymous or Narcotics Anonymous, to once or twice a week. In therapy, to improve the relationship with her boyfriend and friends, she was encouraged to practice through role playing expressing emotions without escalating to abusive language or violence. As mentioned earlier, she was also encouraged to engage in activities to help others by working with local Gulf Coast relief efforts. These behavioral techniques enhanced the more general supportive therapy.

Practice Point: The Role of Trauma in the Life Course of Many Patients

Prior to the re-emergence of symptoms of anxiety and depression during media exposure about Hurricane Katrina, the role of trauma in shaping this patient’s life had not been fully appreciated by her or by prior therapists. Long-term follow-up of children and adolescents who survived the Buffalo Creek flood, for instance, suggests that more intensive interviewing may discover less obvious sequelae of trauma, such as numbing and avoidance.16 These symptoms, while less overt, may indeed contribute to an individual’s inability to fully function and integrate into society as an adult.

Given the high prevalence of trauma in the general population, and even higher rates in people experiencing homelessness and patients seeking psychiatric services, it is important to take a comprehensive history of each patient that includes questions about exposure to traumatic events, including natural disasters and accidents. While Karen may not have endorsed any current symptoms of PTSD prior to Hurricane Katrina, understanding her vulnerability may have allowed earlier intervention and may help explain her lack of progress in moving from homelessness. Her acute mood and substance use disorders had been in good control for approximately two years and yet she was still living in a shelter. The lack of social integration found in many individuals experiencing homelessness may be due not only to the more obvious symptoms of severe mental illness or active substance use, but also to the more subtle and and often intractable problems of numbing and avoidance, which may interfere with the social skills necessary to maintain successful employment and relationships.

Case Presentation, Continued

Over the first six weeks of therapy, Karen was able to make and keep four appointments. After these initial sessions, Karen showed improvement in her mood and anxiety, as well as diminished urge to drink. The next two sessions took place over a five-week period. Two additional monthly sessions occurred after which Karen resumed her earlier visit frequency of every three months. The antidepressant, sertraline, was increased to 150mg daily at the initiation of therapy. Approximately four months after starting therapy, Karen began working at a light assembly plant. She hoped that after working for a couple months, she would be able to move into an apartment. She continued to attend the church group and continued her long-term relationship with her boyfriend. She was able to contact her displaced family members by telephone. She had hopes that in the future she would be able to visit them when they had resettled in the Gulf.

Conclusion

Karen had several strikes against her when she was exposed by proxy through the media to the devastation of Hurricane Katrina. She had struggled with depression, addictions, and homelessness for many years. An early, active intervention, both pharmacologically and psychotherapeutically, resulted in a good outcome with restoration of wellbeing and a return to function over a relatively brief period of time. A key to this outcome was the identification of not only recurrent symptoms of major depression but also an appreciation of the effects of an earlier trauma. If the clinician’s cursory assessment of Karen’s problems were maintained as simply the nearly universal reaction of people seeing the suffering of others after the hurricane and flood or an adjustment disorder due to the stress of her family being in harm’s way perhaps would have caused the clinician to miss the opportunity to address and treat the effects that Karen’s childhood trauma were having on her now, 30 years after the initial event. Addressing the effects of trauma and vigorous treatment of the comorbid depression allowed Karen to move forward toward self sufficiency, including stable work and housing.

References

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Category: Anxiety Disorders, Mental Disorders, Mood Disorders, Neurology, Past Articles, Psychiatry, Psychotherapy Rounds, Sleep Disorders

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