Trauma Case Study: Civilian Narrative

(Please note that while every question or statement may not be shown below or match word-for-word the way the assessments are worded, there is enough information below to make an informed decision using the assessment instruments. After carefully reviewing the assessments and narratives several times, if you do not see a particular criteria or statement answered by the narrative, you can safely assume that it is not part of the diagnostic picture for this client.)

Rose is a 38-year-old married mother of three children (9, 7, and 2-years-old), and works full-time as pharmaceutical representative to various doctors and medical practices in her region. She typically drives anywhere between 700 to 1000 miles per week in a company-provided car. She is in good health, likes to run on her days off, and generally enjoys working in her yard and garden.

She came to the office about 30 minutes early and did a Beck Depression Inventory-2 (total score = 33, severe depression), and the Beck Anxiety Inventory (total score = 15, mild to moderate anxiety), as well as the usual required paperwork. Now she is in your office, sitting on the couch holding the small end pillow on her lap, and looking drawn, sad, and anxious. After doing a Mini-Mental Status Exam with her (total score = 28, normal cognitive functioning), you ask her what brought her here today?

She starts off with recounting how growing up her family moved around a lot due to her father being in the diplomatic core of the State Department. She has great memories of going to all kinds of different countries growing up, even though some of them were in places that are considered dangerous by most standards. For instance, once when she was around 10 years old and he was stationed in Turkey, a bomb destroyed a quiet street café a few doors down from their hotel where they were living at the time, and the family all were able to watch the carnage from their balcony. It was deemed a terrorist act, and she remembers the large number of dead bodies of adults and children laying in the street until the first responders came and started covering the dead while they were helping the injured. She remembers not being able to “take her eyes off the incredible amounts of blood everywhere, and she’ll have an occasional nightmare about the crying and screams of pain from that day.”

She also remembers being in Tokyo for a vacation when she was 12 when the city had a large, 7.1 earthquake as they were walking through the city. She recalls being dragged by her mom and dad to the middle of the street (as everyone else was doing) and crouching down low as windows shattered and parts of the masonry and some signs fell around them. But no one seemed to be physically injured that she could see, and although she was frightened that day, she also thought it was somewhat exciting. She does not recall any nightmares of that day, although sometimes when she hears or reads about an earthquake somewhere in the world, she will have a “flashback” to her experience.

Another event happened when she was around 15 years old when her father was stationed in Paris, France, during some of the demonstrations that took place over jobs and wages. She happened to be shopping with her mom and heard shouting and saw people running their way being “chased” by a cloud of smoke and police dressed in riot gear and carrying shields. She and her mom were able to get inside a small shop and watched with the other customers and shop owner as a large crown of people ran by, and few of them tripping and falling and being beat with truncheons by the police until they were either handcuffed and led away bleeding or managed to get up and run.

She remarks that she grew up and went to college and has “led a pretty boring life” (she says with a smile). She married her college sweetheart (he was finishing medical school at the time and just starting his residency) and she landed a job as a pharmacy technician in the local hospital. She discovered she had a “knack” for remembering all the different drugs and their interactions and side-effects so that often many of the medical staff would ask her opinion about different drugs and which may be better to use for patients to cause them the least amount of pain and discomfort. When she heard about the pharmacy representative job coming available, she applied and was hired largely based on the positive reviews the hospital doctors gave her. It also was a fairly large bump in pay, and she and her husband have lived a nice life in suburbia and enjoy spending time together as a family and taking care of all the “mom” things she says she loves doing.

Three weeks ago, she was driving home from a conference for her work when she “hit a slick spot on the highway” and “spun around and around like a top,” hitting several other cars until finally coming to a stop upside down in the drainage ditch beside the road. The top of the car was crushed against her neck and head, making it difficult to breathe, and she felt like she “was suffocating.” She said that feeling as if she couldn’t breathe “threw her into a panic attack” and “scared her more than anything that she has experienced in her life.” She said she thought she was “going to suffocate to death before help arrived” and just remembers seeing her “kids’ faces and how sad they were going to be without their mom.”

While it took rescue vehicles about 30 minutes to reach her and another 30 minutes to get her out of the vehicle safely (“they were worried that my neck or back was broken”), she said it “felt like a lifetime,” and that she “wasn’t going to make it.” Surprisingly, she only had bruises, and sprains in her neck and shoulders, but no broken bones. She was taken to the hospital and kept overnight for observation due to the way she landed on her head and neck, but was released to her husband the next day, with a follow-up appointment two days later with a neurological specialist. He thought it was amazing that she did not have major injuries, and all the tests he gave her came out negative. He sent her home with a prescription for pain killers and muscle relaxers and set another appointment for two weeks later. After the second appointment, again she passed with a “clean bill of health,” and the specialist recommended that she call him for an appointment if she had any problems appear.

She then begins to relate that about two weeks ago she started to have repeated dreams of the crash, especially “hanging upside down” that has bothered her quite a bit. That started causing her to get up at night (after the dream) several times per week because “who can sleep after a nightmare like that!” It has also started making her delay going to bed because she “never knows when the dream will happen.” This has caused her to “feel tired all the time now” and “only getting three or four hours of sleep.” And while the dreams are bad enough, she also started having daily memories or “flashbacks” of the accident that have caused considerable distress when she is at work, sometimes to the point of having to either go calm down in the bathroom, take a walk outside, or take a sick day to try and help her “get the thoughts and images of the crash” out of her mind. She says it has become too painful to think about, and if she does, she starts to feel panicky, so she just wants to avoid them at all costs. When family and friends ask how she is doing, she just wants to “switch the topic as fast as possible” so she doesn’t have to “relive it all over again.” She says that while she “does not want to commit suicide or anything like that,” she does have recurring thoughts of death and dying and how close it came to happening to her when she is sitting alone.

When she does relate aspects of the accident (while she is sitting there with you), she seems to be taking short, quick breaths and sweat is breaking out on her forehead. She says that even just talking about it here makes her feel as if she “can’t breathe,” that her “chest hurts,” and that she “feels like she wants to throw up.” She holds up her hands and says, “look how I’m shaking.” She says this only happens when she is thinking about the accident, and “not just out of the blue for no reason.” You ask how often this occurs and she responds, “only about three to five times a week; I’m getting better at not letting it ruin my day.”

When asked what other feelings she seems to be having, she says, “that’s just it! I’m not really feeling anything like I used to. We all used to be so close, but I just feel emotionally numb. I don’t even want to hug or play with my two-year-old.” She looks at you and says, “what kind of mother says things like that?” She continues: “I’ve always loved being the ‘mom in the stands’ to cheer my kids on as they play their sports, but now I just want to stay home and not be around anyone. Not only that, but I find myself being irritable and snapping or yelling at the kids for every little thing.” She turns and looks out the window and quietly adds: “we used to do so many things together, but now they don’t want to be around me that much . . ., and I just don’t want to be around them, either. We used to go hiking about every three weeks, but I just do not find that relaxing anymore, and would rather stay home.” She notes that this emotional distance has put a big strain on her marriage. Her husband “has been amazing through all of this, but now I can tell he is afraid it will never be over, and he feels helpless because there is nothing he can do.” She says she is “beginning to feel useless and guilty that she’s not being the wife and mother she should be.” She also adds that “I’ve lost 10 pounds over the last month because I just don’t feel like eating at all. My clothes do not fit very well anymore.”

When asked about how this is affecting her job, she remarks that “it is just about the same there, too.” Her coworkers are “really great,” but have been asking her why “she looks so sad and tearful lately?” On some days it “is not much of a problem,” but on others, “I can’t concentrate on what I need to work on for my clients, and my accounts are getting behind.” She says she feels like she “just doesn’t have the energy to do everything she needs to do.” When she is driving, she relates that she “is extremely focused for any bad spots in the road” or on other “cars getting too close to hers,” causing her to grip the steering wheel so tight her “hands hurt after about 30 minutes of driving.”

She did think it was interesting that she “has never been afraid of driving again, just having an accident.” She says she does get hesitant when she gets close to where the accident occurred and finds herself “slowing down as she sees the spot where she went off the road and vividly remembers going into the ditch.” She looks at you smiling and remarks, “you must think I’m really crazy, don’t you?” Then she looks at you more seriously and asks: “Am I going crazy? I must be crazy. I should be over this by now. I think I’m ruined forever, aren’t I?”