Case 30

Case of Post-traumatic Stress Disorder as a Result of Childhood Sexual Abuse

Objective:  To illustrate the long term sequelae of childhood sexual abuse.

Narrative Case

Susan, who was aged 55 years, came to the medical review panel as her long term disability had been refused by her work disability insurance.  The review panel had difficulty in understanding the reason for her inability to work as there was no clear cut history in her medical record.  She was working as a care aide at a long term facility when she felt too anxious and depressed to work.

The review panel had the opportunity to interview Susan and find out the details of her disability.

Susan had been attending her general practitioner for ten years but felt uncomfortable in telling him about the sexual abuse she suffered as a child. [1] It was only when she was referred to a female psychiatrist that she was able to open up about her past.  She had a brother who was having sexual intercourse with her since the age of 12 years and although her mother knew about it, she did nothing to stop it. [2] Throughout her teenage years, she found herself partying and would overuse alcohol, smoke marijuana and use a bit of heroin.  She was devastated to find she had contracted hepatitis C.  She married young to get out of the house, but her husband was both verbally and physically abusive.  She really could not leave him as she had three young children and no means of support. [3]

As the children grew older, she was able to get a job as a care aide and finally left her husband.  She had a few boyfriends but they had drug and alcohol problems and were abusive towards her. [4] They blamed her for not being interested in sex but she found it difficult to enjoy intercourse without intrusive memories of her sexual abuse as a child. [5]

Work was becoming difficult.  She felt anxious all the time.  She was constantly tired due to nightmares and was surprised that the sexual abuse by her brother still turned up in these nightmares after all the years.  At work, she had found it difficult to concentrate as thoughts kept swirling around her head.  When the family of a patient complained about her care of their mother, she decided she could no longer work.  She went to her doctor and was prescribed antidepressants but did not find them helpful.  She found it difficult to complete the paperwork for the long term disability and when this was turned down she did not know what she was going to do.

Learning Points

[1]  Patients often present to their general practitioner but do not know how to bring up the topic of sexual abuse.  Likewise, physicians are often not sure how to ask, for fear that they do not know the proper management.

[2]  As a child she felt helpless and trapped.  If her own mother would not stand up for her, what was she to do.

[3]  Getting out of the house and away from the toxic environment is so important, that the choice of a husband is often poor and the selection is of one who continues to abuse her.

[4]  Due to low self-esteem, she chose partners who perpetuated her low self-esteem, treating her as if she was deserving of abuse.

[5]  Due to her PTSD, she tried to avoid sexual activity as it brought back the childhood memories of abuse.

Background Information

  1.  In the Diagnostic and Statistical Manual of Mental DisordersIV (Text Revision)(DSM-IV-TR), the diagnostic criteria for PTSD are:

A: Exposure to a traumatic event. This must have involved both (a) loss of “physical integrity”, or risk of serious injury or death, to self or others, and (b) a response to the event that involved intense fear, horror, or helplessness (or in children, the response must involve disorganized or agitated behaviour). (The DSM-IV-TR criterion differs substantially from the previous DSM-III-R stressor criterion, which specified the traumatic event should be of a type that would cause “significant symptoms of distress in almost anyone,” and that the event was “outside the range of usual human experience.”

B: Persistent re-experiencing. One or more of these must be present in the victim: flashback memories, recurring distressing dreams, subjective re-experiencing of the traumatic event(s), or intense negative psychological or physiological response to any objective or subjective reminder of the traumatic event(s).

C: Persistent avoidance and emotional numbing. 

This involves a sufficient level of:

  • avoidance of stimuli associated with the trauma, such as certain thoughts or feelings, or talking about the event(s)
  • avoidance of behaviours, places, or people that might lead to distressing memories as well as the disturbing memories, dreams, flashbacks, and intense psychological or physiological distress
  • inability to recall major parts of the trauma(s), or decreased involvement in significant life activities
  • decreased capacity (down to complete inability) to feel certain feelings
  • an expectation that one’s future will be somehow constrained in ways not normal to other people.

D: Persistent symptoms of increased arousal not present before. These are all physiological response issues, such as difficulty falling or staying asleep, or problems with anger, concentration, or hypervigilance. Additional symptoms include irritability, angry outbursts, increased startle response, and concentration or sleep problems.[18]

E: Duration of symptoms for more than 1 month. If all other criteria are present, but 30 days have not elapsed, the individual is diagnosed with Acute stress disorder.

F: Significant impairment. The symptoms reported must lead to “clinically significant distress or impairment” of major domains of life activity, such as social relations, occupational activities, or other “important areas of functioning”.

  1.  Posttraumatic Stress Disorder (PTSD) will be included in a new chapter in DSM-5 on Trauma- and Stressor-Related Disorders. This move from DSM-IV, which addressed PTSD as an anxiety disorder, is among several changes approved for this condition that is increasingly at the centre of public as well as professional discussion.

The diagnostic criteria for the manuals next edition identify the trigger to PTSD as exposure to actual or threatened death, serious injury or sexual violation. The exposure must result from one or more of the following scenarios, in which the individual:

  • directly experiences the traumatic event;
  • witnesses the traumatic event in person;
  • learns that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); or
  • experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related).

The disturbance, regardless of its trigger, causes clinically significant distress or impairment in the individuals social interactions, capacity to work or other important areas of functioning. It is not the physiological result of another medical condition, medication, drugs or alcohol.

Changes in PTSD Criteria

Compared to DSM-IV, the diagnostic criteria for DSM-5 draw a clearer line when detailing what constitutes a traumatic event. Sexual assault is specifically included, for example, as is a recurring exposure that could apply to police officers or first responders. Language stipulating an individuals response to the eventintense fear, helplessness or horror, according to DSM-IVhas been deleted because that criterion proved to have no utility in predicting the onset of PTSD.

DSM-5 pays more attention to the behavioural symptoms that accompany PTSD and proposes four distinct diagnostic clusters instead of three. They are described as re-experiencing, avoidance, negative cognitions and mood, and arousal.

Re-experiencing covers spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks or other intense or prolonged psychological distress. Avoidance refers to distressing memories, thoughts, feelings or external reminders of the event.

Negative cognitions and mood represents myriad feelings, from a persistent and distorted sense of blame of self or others, to estrangement from others or markedly diminished interest in activities, to an inability to remember key aspects of the event.

Finally, arousal is marked by aggressive, reckless or self-destructive behaviour, sleep disturbances, hypervigilance or related problems. The current manual emphasises the flightaspect associated with PTSD; the criteria of DSM-5 also account for the fightreaction often seen.

The number of symptoms that must be identified depends on the cluster. DSM-5 would only require that a disturbance continue for more than a month and would eliminate the distinction between acute and chronic phases of PTSD.

 

References:

 

  1.  http://en.wikipedia.org/wiki/DSM-IV_codes

 

  1.  http://www.dsm5.org/Documents/PTSD%20Fact%20Sheet.pdf

 

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