47 Posttraumatic Stress Disorder

Name: Nick (Nicolas)
Source: The Deer Hunter (movie, 1976 )

Background Information

Nicolas (Nick) is a white male who seems to be in his late twenties. He lives in a small town where he has two long time friends, Michael and Steven. United States (U.S.) is still in war with Vietnam and Nick and his two friends plan to go to Vietnam War and protect their country but Steven is engaged and decides to get married before his departure to Vietnam. Nick and Michael go to Steven’s marriage ceremony and seem very happy and do not seem to have any physical or psychological complication; they dance, laugh, drink and enjoy the entire night. Nick’s behavior and attitude is normal and there are no observable sign of physical or mental illness associated with him. Michael is scared of going to Vietnam and very hopeless about returning back alive but Nick talks to Michael in several occasions and calms him down, promising that everything will be fine. Nick seems to be a very helpful individual in community as he lends a hand to people. Nick has a girl friend and would like to propose to her before going to Vietnam, so he proposes to his girlfriend at the end of the marriage ceremony and both decide to get married after Nick comes back from the War. After Nick’s plan for marriage, he also feels bad about going to Vietnam; he is emotionally connected to his fiancée and hard for him to leave. Before Nick and his friends depart to Vietnam, they decide to go for their last deer hunt, up in the mountains close to their town. “One shot” deer hunting is Michael’s favorite slang, meaning that he always wanted to catch a deer with only one shot. Michael successfully hunts a deer with only one shot and everybody enjoys the hunting that day. On the next day, they depart to Vietnam and face an unexpected battle with the Vietnamese army. It is not hard to see that they are all shocked in battle. Vietnamese soldiers attack them from all directions. After a couple of days, all three of them are taken captive in Vietnam. While captive, Nick, Michael and Steven are forced to play Russian roulette while their captors gambling on who will, or will not, blow out his brain. Russian roulette is a lethal game in which one bullet is placed in a revolver and participants (captives here) spin the cylinder, place the muzzle against their head and pull the trigger. This is a horrifying moment for Nick and his friends. Steven who is a newly married groom, shows extreme symptoms of stress and anxiety. Nick visibly disintegrates under the abuse and torture of their captors while Michael refuses to capitulate. Michael plans to free himself and his two other friends by requesting a three bullet Russian roulette game from his captors. He manages to kill the captors and runs away with Nick and Steven. An American helicopter shows up and transports Nick to army hospital, while Michael and Steven wait for the next helicopter.

Description of the Problem

While Nick is in the U.S. army hospital inside Vietnam, he displays mild symptoms of anxiety; insomnia, lack of appetite and anxiety, are among the major symptoms he displays. When a nurse comes and talks to him, he keeps staring at people who are brought to the hospital and does not talk to anyone. After about a month, he leaves the hospital and starts to have more severe symptoms of anger, especially when he is reminded of his time in Vietnam. He completely forgets that he has a fiancée or friends; he does not call his friends to see if they are still alive and seems detached from his social environment. He has a sense of a foreshortened future because he does not have a plan to go back home or do anything while he is in U.S. camp in Vietnam. Nick is very busy with his thoughts and does not communicate with his surroundings; social impairment is vivid at this point. He accidently visits a bar in that town where people gamble on playing Russian roulette. As soon as he enters the bar, he starts to have intrusive distressing recollections of the time when he was captive and forced to play this game. He experiences a high level of anxiety and anger. As he is watching a candidate place a revolver to his head, Nick grabs the revolver and passionately places it to his head and pulls the trigger. He disrupts the game and the gamblers kick him out, however on the next day as he is walking down a street, he reaches the same bar. He goes inside and sits in one of the empty seats designated for a Russian roulette player. Michael, who was more emotionally stable than Steven and Nick, shows only very mild symptoms of anxiety and goes back home. His friends and family welcome him but he goes back to Vietnam to bring Nick home. He meets Nick, however Nick does not show any emotion to him, so Michael tries to play Russian roulette with him in that bar to perhaps unfreeze Nick’s memory. Nick starts to communicate with Michael a little. However, Nick dies when he pulls the trigger in front of Michael.

Diagnosis

Based on the observed symptoms, the diagnosis for Nick fits well with Post-Traumatic Stress Disorder (309.81).

A. The person has been exposed to a traumatic event in which both of the following have been present:
1. The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
2. The person’s response involved intense fear, helplessness, or horror
Nick’s symptoms certainly meet above characteristics as Nick experienced and witnessed an event in Vietnam which he was threatened to death (by the Russian roulette game). He has intense fear and feelings of hopelessness while being captive in Vietnam (Background information).
B. The traumatic event is persistently re-experienced in one (or more) of the following ways:
1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. NOTE: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
2. Recurrent distressing dreams of the event. NOTE: In children, there may be frightening dreams without recognizable content.
3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). NOTE: In young children, trauma-specific reenactment may occur.
4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
Nick re-experienced very intense psychological distress when he observed people who were gambling on players (playing Russian roulette) in a bar. In there, he acted as if he was a captive in Vietnam and therefore took the gun from one of the players and after he pointed the gun toward his head, pulled the trigger. So he was exposed to external cues which symbolized an aspect of the traumatic event in Vietnam. Therefore he qualifies for more than one of above conditions (3, 4 and 5).

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. Efforts to avoid activities, places, or people that arouse recollections of the trauma
3. Inability to recall an important aspect of the trauma
4. Markedly diminished interest or participation in significant activities
5. Feeling of detachment or estrangement from others
6. Restricted range of affect (e.g., unable to have loving feelings)
7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

As it was mentioned in the background information, Nick showed no interest in any activity or in friendships. He was certainly detached from his social environment and also had no feelings of love. When his friend Michael showed up to take Nick back home, Nick did not show any interest and was not passionate about his fiancé. Therefore, he met four of above conditions (4, 5, 6 and 7).

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hypervigilance
5. Exaggerated startle response

Nick clearly shows outburst of anger in several scenes of the movie. He also had difficulty concentrating when his friend Michael tried to remind him of his fiancé and home. Unfortunately it was not shown in the movie whether Nick has difficulty sleeping. But his condition meets above criteria (2 and 3).

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than one month.
Nick had above symptoms for more than one month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Nick’s symptoms reveal an intense social impairment as well impairment in his interpersonal relationship. Therefore his symptoms meet this criterion. Nick’s condition is a representation of an acute PTSD.

Accuracy of Portrayal

Nick’s symptoms were well demonstrated to portray Post Traumatic Stress Disorder (PTSD). Nick experienced intense and horrifying moments in Vietnam in which he was threatened with death through Russian roulette. He observed and watched other prisoners die. Therefore, the war portrayed an accurate condition which could be the cause of PTSD. However, this movie showed Nick revisit the bar (while he is suffering from PTSD) and playing Russian roulette over and over again. Although Nick showed intense anger toward this game, PTSD patients mostly avoid experiences that remind them of their stressful event. Therefore, this part of the movie does not accurately resemble the condition of a PTSD patient, while all other symptoms are well matched with PTSD. Overall, there was an accurate portrayal of a person’s descent into PTSD.

Treatment

PTSD is highly comorbid with other anxiety problems and as such it would be beneficial to control the anxiety before starting other treatments. Therefore the primary treatment action for Nick would be to start a low dosage of an anti anxiety medication such as escitalopram (Lexapro) after a full medical examination. Once pharmaceutical treatment begins, the next level of treatment for Nick would be Prolonged Exposure (PE) therapy. This therapy will help Nick to decrease distress about his trauma and approach trauma-related thoughts, feelings, and situations that he is avoiding due to the distress. In the first part of prolonged exposure therapy, Nick needs to be educated about his disorder and common trauma reactions. This would allow Nick to learn and become more familiar about his symptoms and better understand treatment goal and process. The second part of the treatment is to train Nick how to have long breath and relax. One of the symptoms of PTSD, especially in Nick’s case, is abnormal breathing habits when the patient is scared or anxious. This part of treatment will help Nick to overcome his distress by breathing differently. Real world exposure practice is the third part of this treatment in which Nick is exposed to Russian roulette game (without any bullets) over and over again. Such in vivo exposure helps Nick’s trauma related distress to lessen over time. In the last part of prolonged exposure therapy, therapist should talk to Nick while he is exposed to Russian roulette game. This helps to unfreeze Nick’s memory and to let him communicate about his experience and memories with therapist and not being afraid of his memories. Talking through the trauma can also help therapist to identify Nick’s negative thoughts about past event and help to modify his negative thoughts, allowing him to make sense of what happened and have fewer negative thoughts about the trauma. Family therapy is also recommended for Nick since he no longer seeks any friendship and does not have any emotions for his fiancée. Family therapy can help the Nick’s friends and fiancée understand what they are going through, and help them work through relationship.