1 TRUST AFTER TRAUMA Joan Roig Llesuy, MD & Guest Discussant: Sonya Dinizulu,PhD

2 CASE CC: 34yo African American married Female referred to our clinic by Neurology clinic to assess for worsening mood symptoms after concussion. 9 months prior to her 1st visit with us she had a fall at work. After the fall she had been unable to return to work and was on medical leave under worker’s comp supervision.

3 TRAUMATIC EVENT Patient was at work welding and for no obvious reason stool collapsed. Fell forward, then tried to reach 2feet stool, fell backwards total and hit head and chest, unable to stand up for minutes. No LOC. A coworker took picture of her before helping. Transferred to hospital. Dx Concussion. 24h observation. In her way back to work 3days after accident she developed acute loss of vision and had to pull over the car. Work told her to refrain from returning until medical clearance given.

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7 Symptoms HPI Dizziness, neck pain and headaches. (improved after PT)Irritable mood, insomnia. Trouble concentrating, forgetfulness. Recurrent thoughts of unsafety/danger. Anhedonia/emotional numbness. Suicidal ideation with aborted attempt 6 months prior to our 1st appointment. Aggressive towards husband and others.

8 HPI (continuation) 3 months prior to her initial visit at our clinic with us her parents took her daughter to their place and her husband moved out of the house. She reports trouble doing tasks at the house. Needs parents to help her clean the house. Needs support going for groceries. Avoids social interactions. Beliefs she survived a threat, so “Karma is going to get me”. No psychosis, no manic symptoms.

9 Past psychiatric and medical historyNo past traumatic events. One prior outpatient psychiatric outpatient evaluation. Dx PTSD. No psychiatric hospitalizations No substance use. No family psychiatric history. No family traumatic events. Does not recall anybody that has gone thorugh truamatic experiences. Safe neighborhood.

10 Social history Born and raised in IL to married parents (Father retired welder). Youngest of 3 siblings (2 brothers: 1 fireman, 1 GM worker) No history of sexual nor physical abuse. “Okay” student at school (As and Bs), completed high school. 1 year phlebotomy technician training, then welder x 4years. Married for 4 years, with husband for 15 years. 1 daughter, 2 years old, who lives w husband & her parents. She lives alone in a 3 story house. Former president of neighborhood community.

11 Exam NRL exam normal MSE findings: In mild distress, anxious, fidgety, somewhat unkempt, reactive affect. Expresses embarrassment for not being able to return to work. Insomnia, nightmares. No hopelessness, denies suicidal ideation, plan or intent. MMSE 28/30. Missed 1 point memory and 1 point visuospatial.

12 TESTS CT Head: negative. Brain MRI: normal.Neuropsychological testing: inconclusive due to high anxiety. Other labs normal.

13 Diagnoses PTSD Major depressive disorder

14 Treatment Sertraline up to 200mg daily Prazosin 1mg qhs.Temazepam 45mg qhs for severe insomnia. Bupropion 200mg daily was added. Propranolol 60mg daily for headaches (NRL) Psychotherapy

15 Treatment course Seen weekly almost for 1 year.Prolonged exposed therapy+psychopahrmaclogy. Behavioral activation. Relaxation exercises. Partial improvement in depressive symptoms achieved. Persistent avoidance, hypervigilance, insomnia, anhedonia.

16 Treatment course (continuation)Some decrease in anger. Resumed driving. Able to hug family members. Improved social activities only minimally. Wearing makeup on each visit. Had sex with husband. Reluctance to start trauma focused therapies. Supportive family but rarely seen in clinic. Continues to push others away. Still far from being ready to return to work.

17 PROBLEMS DURING TREATMENTPERSISTENT AVOIDANCE Worried about what others might think of her. Worried about imminent danger. Avoids doing any activities supposedly unsafe. Worried about treatment plan of hierarchy of exposures. Example: bathroom avoidance Management: Behavioral activation Engage with family activities Imaginary exposure+relaxation during session

18 PROBLEMS DURING TREATMENTRELIVING TRAUMATIC EXPERIENCES Train encounter Re-experienced fall, panic. Management: Talk about it, resistance. Noticing hair loss, self-image change. INCREASED AWARENESS OF DEFICITS Family members visiting her house and noticing her “child” status. Frustration about not being able to go back at work overnight. Inability to enjoy spending time with daughter Daughter calls grandma “mama” Trigger for depressive thoughts/depersonalization/avoidance/anger Management: increase family exposure. Barriers.

19 Question: Why is treatment partially unsuccessful?Therapeutic relationship issues (engagement, trust) Cultural issues (African American and trauma) Gender role issues (male mostly work) Family dynamic issues (understanding, belongingness, burdensomness) Patient issues (depression, trauma) Missed/untalked re-experience of the trauma. Therapist issues

20 Welder Culture

21 SENSE OF HEROICITY/PRIDE

22 ACTION VS INSIGHT PROFESSION

23 PRIDE

24 MEN’S JOB

25 RISK TAKING

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28 GOALS of the talk (optional slide)Present a case to discuss characteristics and treatment of trauma-related disorders. Discuss options that might improve outcome after trauma treatment fails. Discuss therapy options available for trauma-relted disorders, and its challenges.

29 Joan Roig Llesuy, MD & Sonya Dinizulu, PhDTrust after trauma (Alternative first slide) Joan Roig Llesuy, MD & Sonya Dinizulu, PhD