创伤后应激

A Soldier Suffering from PTSD, Treated by Controlled Stress Exposition Using Virtual Reality and Behavioral Training Radosław Tworus, M.D., Ph.D., Sylwia Szymanska, M.A., and Stanisław Ilnicki, M.D., Ph.D. Abstract This article presents a case of posttraumatic stress disorder (PTSD) in a 30-year-old soldier of the Polish Military Contingent in Iraq who narrowly escaped death three times. The first time occurred when during a change of guard he was unintentionally shot by his colleague. The projectile penetrated the victim’s helmet, slid along its internal shell curvature, and left the shell causing only a scratch on the scalp skin. Another traumatic event was experienced by the soldier a month after the first incident. As a guard of honor, he was ‘‘shot’’ in the same rear head area with a cap of a cream tube, inadvertently stepped on by a colleague. The third event occurred a couple of days later, during a rocket attack on the Diwaniyah base. After this incident the soldier was evacuated to the Clinic of Psychiatry and Combat Stress in Warsaw. Multiform PTSDs that developed in this soldier are described in this work. The course of his comprehensive therapy during his two stays, with a total duration of 8 months, in the clinic is discussed. Also, a detailed description of the therapy controlled exposition to combat stressors in virtual reality (VR), supplemented with behavioral training consisting of desensitization of an aversive reaction to contact with a weapon at a shooting range is presented. The comprehensive treatment activities resulted in full remission of the PTSD symptoms. The soldier con- tinues his service in a logistic support unit. Introduction Posttraumatic stress disorder (PTSD) resulting fromtraumatic events experienced in battlefield poses a com- pletely new health problem for Polish military psychiatry and psychology. When PTSD was introduced into medical classifications, Poland was not participating actively in any military conflict. Therefore, we have little experience in the area of diagnostics and therapy of war trauma–related PTSD. Because Poland has been, for several years, actively engaged in military operations, previously in Iraq and cur- rently in Afghanistan, the number of patients suffering war- induced PTSD has been steadily growing. In the process of diagnostics and treatment of these disorders, we look mainly at experiences of the U.S. armed forces. In 2007, the Department of Psychiatry and Combat Stress of the Military Institute of Medical Services in Warsaw, in collaboration with the Virtual Reality Medical Center San Diego, Cali- fornia, launched attempts to use VR technology in PTSD treatment. Case Description Auto-anamnesis The case study is on a 30-year old private serving in the armed forces for 5 years as a career soldier. His mother’s pregnancy and childbirth were healthy. He was the eldest of seven brothers and sisters and was raised without parental supervision. His father, who did not have a permanent job, worked at casual jobs, abused alcohol, was combative, and used physical violence against other members of the family. His mother worked abroad for years in order to improve the difficult economic situation of the household. With the father dysfunctional as a parent and the physical absence of the mother, the patient had to organize his own life and those of his younger siblings; he continues to feel responsible for them today. He believes his childhood was a ‘‘big mistake’’; how- ever, he tried to play the role of a ‘‘strong and intrepid boy.’’ He says about himself, ‘‘I was putting on a mask to prevent any- body knowing what I felt.’’ A mediocre pupil, he finished both primary and vocational school on time without repeating any Department of Psychiatry and Combat Stress, Military Institute of Medical Services, Warsaw, Poland. CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING Volume 13, Number 1, 2010 ª Mary Ann Liebert, Inc. DOI: 10.1089=cyber.2009.0329 103 grade. Both at school and outside it, he displayed numerous behavioral problems: he was combative, aggressive, and auto- aggressive. His behavior often violated standards of the law, but he had never been punished either by the court or by administrative bodies. His attempts to start working and continue learning in a secondary school were unsuccessful. In 2000, he was called up into the army to serve as a conscript. He had no problems with adapting to conditions and requirements of the service. Having completed his ser- vice, he experienced trouble in finding a job near his place of residence and decided to join the army as a career soldier. He was assigned to a unit several hundred kilometers away from his homeplace and was serving as an RPG 7 gunner. He perceived military service as a tough job, but he liked his work. As he said, due to his rebellious nature, he experienced more problems than others, but nobody was able to ‘‘break’’ him. His superiors appraised him as a disciplined soldier who fulfills his duties well. In January 2007, he was deployed to Iraq within the 8th rotation of the Polish Military Con- tingent. The traumatic event As during his service in Poland, at the deployment he was a gunner. On March 9, 2007, during changing of the guards, he was unintentionally shot by his colleague. He was stand- ing nearby when the colleague, having changed the maga- zine, inadvertently reloaded the weapon and fired a ripple of three rounds. One projectile hit him at the right temple- occiput area. The bullet penetrated the helmet and, without damaging soft tissues of the head, slid along the internal helmet shell curvature up to the forefront area, where it cut the forehead skin at a length of approximately 3 cm and left a gap between the forehead bone and steel helmet shell. Bone tissues of the forehead area were not damaged. The shot was fired from a distance of approximately 60 cm. After the shot, he fell on the ground. He did not lose consciousness but suffered an acute response to stress: while he was lying on the ground, he claimed nothing wrong had happened to him, that he was fine, and he demanded that somebody take a picture of him. This behavior is known from reports of the witnesses; the patient himself does not remember it. Having been taken from the place of the accident, he re- ceived treatment in a field hospital. He continued to claim he felt fine; however, during the night, despite no brain damage symptoms, he could not sleep and he vomited several times. Ten days after that accident, he returned to his duties. However, he began to respond differently to the sound of weapon reloading, and he was more watchful in weapon handling. The accident triggered also a nervous motoric twitch of his head, right shoulder, and jaw. His thoughts often returned to the accident, and sleep disorders (difficulty falling asleep, shallow sleep, frequent wakefulness) as well as re- duced appetite occurred. The patient experienced another trauma 1 month after the first one. He was ‘‘shot’’ at the back of his head by a cap from cream tube. At that time, he was sitting on a broad wall and resting. Another soldier walking by stepped on a cream tube laying on the ground, and the tube burst. The cap and con- tents of the tube hit the patient precisely in the same place as the bullet had hit him a month before. The soldier felt an impact and ‘‘something’’ flowing down from his head. He grasped his head in this place and had an impression that the cold, sticky cream he touched with his hand was his blood. He even saw the blood color on his hand. Then he knelt down, trembling all over, and began to cry. He does not remember himself ever crying, even when he was a child. Two weeks after this incident, one of Polish soldiers was killed. When the patient participated in the funeral service, he had visions of his own death. Deep inside, he felt he could have been in the place of the killed one. He had an impression that ‘‘Death’’ had made a mistake, and this was the only reason he was not lying in the coffin. He felt Death was waiting for him, and it would rectify its previous mistakes. In the evening of the same day, a rocket attack was laun- ched on the Diwaniyah base. Just before the attack, the patient was going to the laundry, but he turned back because he had forgotten some of his things he wanted to wash. In that time, a large-caliber projectile hit the laundry building, destroying it completely and killing an American civil em- ployee. The patient’s life was saved only because he hap- pened to turn back. ‘‘I feel as if I have already exhausted my assignment of luck,’’ he said of this incident. On the night after the laundry explosion, the patient vomited. He felt he had evaded Death again, but it persistently tracked and fol- lowed him. The next day, he packed his things to prevent somebody else having to do so when he died. He wanted to be ready for his own death. He was preparing to meet it because he was convinced it would come soon. He called his brother in Poland, with whom he had been in conflict for a long time, to apologize to him for all bad things and to say farewell. From that time, PTSD symptoms developed quickly. The patient’s memory and concentration deteriorated. He was unable to recall many events or recognize people he was passing. He could not remember what ‘‘routes’’ should be used to reach various facilities in the base area, or he did not know how he had reached a particular place. The patient misplaced various small things, such as keys. He became more sensitive, quick-tempered, and even aggressive. After a psychological and psychiatric consultation, it was decided to send him back to Poland. The patient’s attitude toward this decision was a typical disease-related ambivalence: on one hand, he was decisively against the return, while on the other hand, he was convinced that without help, he would not be able to cope with his mental state. In the last days before being sent back to Poland, insomnia and vomiting occurred again, he felt a sensation that his stomach was squeezing, and he suffered intense headaches: ‘‘I feel like my skull is too tight, as if somebody is inflating a balloon inside my head.’’ Hospitalization Immediately after his return to Poland, the patient was admitted to the Clinic of Psychiatry and Combat Stress of the Military Institute of Medical Services and stayed there from April 29, 2007, to August 10, 2007. No symptoms of de- pression or psychosis were found upon admittance. The patient reported a feeling of increased internal tension and concerns about his ‘‘unpredictable and irrational’’ behavior patterns. He complained about chronic headaches, insomnia, nightmares associated with traumatic events from Iraq, and visions of his own death. The patient had visible twitches in the area of his jaw, head, and right shoulder, and he stut- 104 TWORUS ET AL. tered. Twitches and stuttering had not occurred before his deployment.1 The patient was at first distrustful of the personnel and all offered forms of help except medication; Citalopram, Car- bamazepine, Haloperidol, and Risperidone were used in the therapy. He tolerated the pharmacotherapy well and without objections; however, his attitude toward any forms of psy- chological help was skeptical. The patient was reluctant to talk about himself. When he decided to talk about himself and the causes and circumstances of hospitalization, his sensitivity increased even more; he was stressed and cursed frequently. During the collective psychotherapy sessions, each attempt to recall the traumatic event and focus on it in order to reconstruct the emotions triggered hardly with- standable fear. Symptoms of psychophysical overexcitation in the form of sleeping difficulties, frequent waking up in night, and strong fear reaction to stimuli associated with the trauma remained for approximately 3 months of the hospi- talization. Each time a medical helicopter landed at the hospital’s helipad, the patient responded with hunching, staring for a threat behind the windows, and sometimes even with a de- sire to hide under the hospital bed. Until the end of the hos- pitalization, he was unable to sit during everyday therapeutic sessions with his back turned to the windows. He felt he had to control everything that took place within his field of vision; however, he also sought isolation and tried to hide from other people. Because of this, despite that it was forbidden by in- ternal regulations, he covered the window in the door of his room in the clinic with a towel. The patient often experienced nightmares, described by him as ‘‘strange dreams.’’ He wrote poems showing his fascination with the mystery of Death. With time, he became much calmer. The decline of both tension and arousal was reflected in rarer use of vulgarisms as well as minimization of twitches in the area of the face and shoulder. The patient did not decide to participate in the exposure therapy using virtual reality (VR). After the first attempt he responded to the sound generated by the equipment with anxiety, tension, and vegetative arousal and left the VR therapy room. However, he agreed to work on incoming in- trusion thoughts, the first stage of therapy before an expo- sure to VR. The patient, by concentration on breathing and letting thoughts and images flow freely, was trying not to focus on them and thus not to amplify incoming intrusive thoughts. in this way, he was allowing for their spontaneous extinguishing and flowing away. He was discharged from the hospital with a diagnose of PTSD, in a balanced mental condition, and with a recom- mendation for continuing therapy as an outpatient of the mental health clinic. Also, Citalopram (60 mg=day), Risper- idone (1 mg=day) and Carbamazepine (600 mg=day) were recommended. Despite improvement achieved during the hospitalization, the patient was deemed unable to return to military service and needed to be examined by the Military Medical Commission. He was also responding with fear to the prospect of returning to military service. Less than 4 months later, during a control visit to the Mental Health Clinic of the Department of Psychiatry and Combat Stress, the patient was qualified again for hospitali- zation due to recurrence of PTSD symptoms. During a con- versation that preceded the qualification for hospital treatment, the psychiatric consultant noticed an increase in twitches that had been nearly completely eliminated during the previous hospitalization. Other attention-attracting fac- tors were the patient’s apathy, his amimic face, and his dis- tancing from all forms of social and everyday activities that seemed to be a mask for many suppressed negative emotions. These negative emotions were confirmed just by coincidence. When the patient was rising from a chair, a 35- to 40-cm-long bayonet fell out from an internal pocket of his jacket. He admitted that being in the street, among other people, he felt uncertainty and fear. Concerns about his own life and visions of his death emerged again. The patient was rehospitalized from November 26, 2007, to April 29, 2008. Upon his ad- mission to the clinic, the medication was changed to Sertra- line (200 mg=day), Haloperidol (2 mg=day), and valproic acid (600 mg=day). During this hospitalization, to the patient did not resist psychological aid as he had previously. He participated in everyday sessions of group therapy and weekly individual sessions when attempts were made to convince him he could also lead in the ‘‘dance with Death’’ he often spoke about since the traumatic events had occurred. The personnel tried to explain to the patient that he was not condemned for grace or disgrace of the ‘‘cold arms of Death,’’ as he used to say. The first anniversary of the day when he was shot, when he ‘‘escaped Death,’’ fell during this second hospitalization. The date was magical to him. He felt that something horrible would happen to him on this day. Despite this fear, per- suaded by the leading physician, the patient decided to walk out of the clinic on his own. To make him more assertive, he was given an anxiolytic medicine, Lorazepam, to be taken if he felt an attack of fear, helplessness, and feeling of ‘‘being lost.’’ The walk was successful, although the patient reported that he was walking as though hypnotized, on legs stiff from tension, dividing the route into small lengths in order not to return to the ward. While walking, he squeezed the Lor- azepam tablet so strongly that its shape was impressed in his skin and was visible for a long time after he let the tablet go. The patient was surprised that nothing wrong had happened to him. Gradually, he began to believe more strongly that it was he, rather than some invisible outside force, who could control his everyday life and functioning. After this event, the patient’s mental condition became balanced. The psychologist and psychiatrist in charge of di- rect therapy and psychotherapy began to notice that although the patient’s mental condition was stable and his behavior completely adjusted to everyday events, his condition was unnaturally static. Due to multimonth hospitalization and equally long psychotherapeutic actions, the patient had be- come a kind of ‘‘veteran’’ of the ward and the psychotherapy program. Although he actively participated in all therapeutic activities, they were not further improving his condition. The concern was that if he left the hospital and returned to ‘‘normal life,’’ the patient would again regress to the PTSD symptoms. Thus, a new plan of treatment was developed by the team. He was to undergo a cycle of VR sessions, twice weekly, and then to be exposed in vivo to effects consisting of a direct participation in shooting training. However, keeping in mind the patient’s negative attitude toward VR therapy, the team was concerned about his reac- tion to the therapy plan. In order to prevent a the patient’s withdrawal, this plan was presented to him as obligatory for COMBAT TRAUMA, PTSD, VR THERAPY, CASE STUDY, POLAND 105 qualification for discharge from the hospital. After this con- versation, the patient decided to undergo desensitization therapy by means of VR and to confront his fear of weapon handling in real life, at a military shooting range. After a 5- month psychiatric hospitalization, he declared he felt as he had before the traumatic event and decided to return to military service. VR exposure therapy VR exposure therapy was used according to standards of the Virtual Reality Medical Center, San Diego.2–5 Prior to the VR therapy, three sessions were provided to refresh the pa- tient’s concentration training by means of a method that was used during the first hospitalization. Although it may seem an easy skill, for a patient with intensely intrusive thoughts typical of PTSD symptoms, this is a tough task. The patient was becoming impatient and disheartened. However, con- tinuous monitoring of his results recorded by computer was helping him to persevere. VR stimulation was used from the fourth session forward. Altogether, 22 VR sessions were provided. The frequency was two 30- to 45-minuute sessions a week. The patient was connected to sensors measuring symptoms of autonomic arousal (body temperature, breath- ing frequency, and skin conductivity) while watching ‘‘Iraqi’’ pictures on the computer screen. Among other things, he listened to sounds of Iraqi civilians, shouts of soldiers and civilians, gunfire, and flying helicopters and was exposed to the sight of burning vehicles. The patient also saw onscreen data records of each session, which provided him with feedback on his own capabilities of affecting the measured results by techniques such as breathing control. It was im- portant that he learn to believed he could control what was happening to him. Rebuilding his belief enabled him to con- trol his symptoms, and he gained a stronger belief tha