Posttraumatic Stress Disorder
Dr. Khatib paused to ref lect on everything Paula had told him. As a group, her symptoms were rather diffuse and do not seem to center on any particular body system. With many illnesses, the symptoms center around a certain organ or certain body system (such as the respiratory tract). In Paula’s case, however, multiple body systems appear to be involved (e.g., pain in her lower back, dizzi-ness, trouble sleeping). Questioning Paula further, Dr. Khatib learned that none of these problems was present until a few months ago, which caused him to wonder about depression.
Dr. Khatib: Have you been feeling sad lately? Have you felt like crying?
Paula: “Yes . . . um, I’ve cried a few times . . .”
Dr. Khatib: Have you ever felt bad enough to consider hurting yourself?
Paula: [nervously] No!
Still thinking about depression, Dr. Khatib asked about social contact with her significant others.
Paula: I don’t see people or go out much. . . .
Dr. Khatib: The last time you were in here I believe there was someone you were dating?
Paula tensed noticeably in response to the question. She felt the butterf lies f luttering in her stomach but did not know what to do. “This man is a total stranger,” she thought. “What business does he have asking such personal ques-tions? All I want is a painkiller for my sore shoulder and maybe something to help me sleep better.” These thoughts f lew through Paula’s mind in response to Dr. Khatib’s question. She knew she should be honest, but did not know if she could trust this man. She also hated to think about “the events,” as she had come to categorize them in her mind. Sometimes, she almost convinced herself that if she did not think or talk about the events, she could forget they ever happened.
Dr. Khatib paused, giving Paula a chance to answer if she wanted to. He noticed that she seemed to be mulling things over in her mind, and he wanted her to have a chance to answer without further prodding from him. After several minutes, he rephrased the question and asked it again.
Dr. Khatib: Are you still dating that young man you were dating the last time you came in for a visit?
Paula: N-no.
Dr. Khatib: I see.
Paula: You see what? What could you possibly know about it?
Dr. Khatib: Nothing. I simply meant, I see that you are not dating him anymore because that is what you just told me.
Paula: Oh.
Paula H: Post-Traumatic Stress Disorder 181
Dr. Khatib: Is there anything you would like to tell me about that relationship?
Paula: I don’t know.
Dr. Khatib: You don’t know if there is anything about that relationship you want to tell me or you don’t know if you want to talk about it?
Paula: Both.
Dr. Khatib: I promise you, Paula, that anything you tell me stays in this room.
Why don’t you just think of a good place to start and just start talking? If you decide that you want to stop talking, I won’t pressure you to keep going.
Okay?
Paula: I don’t know.
Dr. Khatib: Talking about things is always better than holding them inside, don’t you think?
Paula: I guess so. Things hurt to talk about too, though.
Dr. Khatib: Remember what I said? If you start telling me anything about that relationship that you think I should know but decide you want to stop, I won’t pressure you. Okay?
Paula: I . . . I . . . I guess.
Paula teared up, looked away, and seemed to struggle with her emotions.
To Dr. Khatib, she appeared to be struggling between keeping her private life private and wanting desperately to share something. He knew to give her time to make the decision for herself. By not pushing and letting her be in control of the conversation, he gave her more of a sense that she can trust him.
When Paula looked back, tears were running down her face but she looked determined to tell him what she had, just moments ago, been uncertain she could reveal.
In a rush of emotion, Paula blurted out that Mark, the man she had been dat-ing, beat her severely on two occasions. The second time was 4 months ago. He left her house in a rage, and she hasn’t seen or heard from him since.
Dr. Khatib: Why haven’t you taken legal action against him?
Paula: I’m afraid of what Mark might do, and I don’t want to talk about what happened in front of anyone. I haven’t even told my parents, because I am afraid of what they might do. It’s possible they will blame me, since they did not like Mark and didn’t like how we used to go out drinking a lot. If I tell them, I’m afraid Mark might do something to hurt them, or even worse, that he will hurt Carly somehow.
Dr. Khatib asked if Paula had experienced any other medical and psychological problems recently, including alcohol and drug use (more than likely Dr. Khatib used the CAGE questionnaire already discussed in several other cases—such as the cases of Barbara M and Richard B—in this casebook). He referred Paula to a neurologist for a thorough examination.
Dr. Khatib was concerned that the dizziness and difficulty concentrating, while they might be due to anxiety over the severe traumas Paula experienced, could also have been caused by blows to her head. The neurologist did a men-tal status exam and performed other neurological tests. He found no physical abnormalities that would explain Paula’s symptoms, and after discussing the idea of psychotherapy at some length with Paula, referred her to Dr. Frank, a female psychologist who specializes in treating trauma.
The Diagnostic Interview
Dr. Frank was warm and cordial, but immediately got down to business. Because she knew why Paula was referred to her, she began by emphasizing how impor-tant it was for Paula to tell her everything that happened, and everything she thought and felt about it. (This is always useful in therapy, but it is especially difficult for people who have been through humiliating traumas like those Paula suffered.) Although Dr. Frank was ready to hear about everything, it took several sessions for Paula to give many details. (Noting this later, Paula explained that she did not really trust Dr. Frank to listen to all of it without becoming “turned off.”) Because it was the easiest way to start, Paula told Dr. Frank about her relation-ship with Mark. They met during a period of loneliness following her divorce.
At first, Paula felt f lattered by Mark’s attentiveness and his intense interest in her. Later she became disenchanted by what later seemed like warning signs.
For example, Mark was a heavy drinker and also regularly used marijuana. He showed a streak of cruelty toward a neighbor’s dog, and he sometimes drove dangerously, especially after drinking. He could be very self-centered, and he seemed to have rigid expectations about how Paula should behave.
Mark became jealous when Paula spent time working with a male fellow teacher on an after-school project. He could be sweet and romantic at times, but could also be hypercritical, belittling Paula to the point of embarrassing her in front of others. Mark also imposed rather petty conditions on their relationship.
He discouraged Paula from socializing with her fellow teachers after work, and sometimes listened in on her phone conversations. He insisted that she destroy all correspondence from her former husband, and consistently preferred that the two of them do things alone together. Eventually he objected even to Paula hav-ing more than brief phone conversations with her girlfriends.
Paula tried to end their relationship two or three times, but was not assertive about this: Her discomfort at making Mark unhappy and worries about loneli-ness made it hard to stick with this decision. Currently she was filled with doubt about her own role in bringing about Mark’s violent behavior towards her. She wondered if there was any truth to his claim that she bore some responsibility for instigating his loss of control.
Once Mark had finally left for good, Paula was overwhelmed with fear and anxiety. The unexpectedness of the two assaults, and the fact that each went on