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A case of complex post traumatic stress disorder

Treating “complex post traumatic stress disorder (PTSD)” is perhaps the most challenging task that a psychologist can encounter in his career. In this condition, patients usually suffer from an established but often unknown personality disorder when they experience a traumatic situation.

This gives rise to a complex interplay of two conditions, such as either the PTSD activates the personality disorder or the personality disorder intensifies the PTSD.

In a recent case, a truck driver who faced serious physical injuries in a single vehicle accident was assessed. Assessment revealed that he was suffering from a pre-morbid antisocial personality disorder.

The truck driver had become an impulsive, aggressive man because of his painful childhood where he was been subjected to rejection and violence. For the fear that he might again face rejection, he kept people away from himself throughout his adult life projecting violent tendencies and a biker image. This gradually led to the build-up of suspicion, distrust, and resentment in him towards almost every person he met in his life.

When he met the accident, he went through the classic post-trauma symptoms of re-experiencing avoidance and hyper arousal. With these, he also sensed the feeling of anger burning within him towards his employer, the doctors who operated on him, the police who probed the accident, and the insurance company that had given him the coverage. He kept his anger underground: he said, “If I don’t maintain the rage they will screw me, just like people have screwed me all my life.”

The two-directional influence from post-traumatic stress disorder to personality disorder and vice versa renders the case highly complex. To proceed, I had to understand where to involve, what the focus should be, and what should be logical therapeutic objectives.

The main goal of the treatment was to modify his thoughts and behaviours and not to find a solution for all of his problems.

People with personality disorders need to alter their thoughts and behaviours, such as inflexibility, resentment, impulsiveness, compulsiveness, and propensity towards interpersonal conflict. Taking all this in consideration the trauma specific therapy is designed to help people to regulate and manage their intrusive thoughts and memories and come back, if physically possible, to the pre-trauma levels of functioning.

In order to make this possible, it is important for clients to have strong motivation as well as basic skills. But, unfortunately, brief interventions do not allow sufficient time for implementing the required changes. Even then, psychologists revisit the basics of therapy for clients which include:

  • A sound therapeutic relationship emphasizing the significance of team-work
  • A complete evaluation of the client’s existing problems and background
  • A perfect analysis of the client’s past behavioural patterns, their present experiences, which in turn, help in creating a future plan
  • A practical therapeutic approach, usually cognitive behavioural in nature, to bring about real change in client’s thoughts and behaviours
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