Case Study: PTSD Assessment and Intervention

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@Allce.com Counselortoolbox you. I'd like to welcome everybody to today's presentation on ptsd. Today we're going to be doing a case study using the PACER method. I am Dr. Donnelly Snipes. As they say on Law and Order. The following story is fictional and does not depict any actual person or event. So we're going to talk about this case. And I specifically chose a PTSD case that was not military related. You may be asking why. And the answer is because too many people assume that everybody in the military ends up with PTSD or everybody in the military, all the soldiers end up having some sort of mental health issue. And that's just not the case. So I didn't want to. Want to go on to perpetuate that. I want us to recognize that there are a lot more sources of ptsd and this particular case is sort of germane because the trauma for this person actually occurred around Christmas. So John is 48 years old. When he was 24, his house caught on fire due to faulty Christmas lights which were accidentally left on when the family went to bed. His wife and two children died in the fire. He is remarried and had three more children, 142 and 1412 and 9. And since the event, he continues to experience PTSD related symptoms. His wife, current wife, insisted he come to counseling after he was caught having another affair. Okay, so we've got some stuff going on and John is obviously not exactly a completely voluntary client. So let's kind of review what's what we're looking at for PTSD symptoms. Recurrent and intrusive distressing memories. When he sees things that remind him of Christmas or of fire, it triggers those memories of what happened that night. Recurrent distressing dreams in which he's surrounded by fire or he cannot save his family. And sometimes it's his, the family that perished, and other times it's the current family that is alive and he feels like he's reliving it again. Intense distress and exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event for him. He identifies some of these triggers as hearing sirens, smelling smoke, Christmas tree lights, Christmas trees themselves, carols, even fireplaces and barbecue grills. You know, fire near the house causes him intense distress and he recognizes that this is not, quote, normal, but he doesn't know how to deal with it. To date, you know, for the past 20 some odd years he's just tried to suppress it and you know, deal with it as best as he could. And we all know how far the, our knowledge of how to treat PTSD and the causes of PTSD has come in the last 20 years. So immediately after the trauma, of course he, you know, was referred for counseling and yada, yada, yada, but you know, it didn't seem to really help that much. He does still have efforts to avoid distressing memories, thoughts or feelings because he prohibits Christmas trees in the house. He just we're not going to put up Christmas trees, we're not going to decorate for Christmas. And he refuses to talk about the past, which is a little bit of a sticking point for his current family because that whole time period in his life is walled off. Persistent and exaggerated negative beliefs or expectations about oneself. I'm a bad person. That happened because I was being punished or I should have been able to save them. I should have remembered to turn off the lights. I should have. There's lots of shoulds, self blame and blaming others. You know, obviously there was the negative expectations about self, but there's also blaming others, blaming the manufacturer of the lights, blaming the manufacturer of the smoke detectors, blaming the fire department for not getting there fast enough. There's lots of blame. Trying to figure out some way to deal with all of this anger and guilt and remorse that, that he has persistent negative emotional state. He has a fear of another fire and a lot of anger, guilt and shame. He identifies, you know, he's well aware that he's experiencing these feelings. He's aware of these feelings to the extent that they are the superficial feelings, if you will. There's also a lot of other stuff that we'll get into. Feelings of detachment or estrangement from others, including his family. He has a hard time connecting with other people and he knows this. He recognizes that he doesn't feel that same sort of connection with them. Persistent inability to experience happiness, satisfaction or loving feelings. He says he just feels kind of numb. Irritable behavior and angry outbursts with little or no provocation. He tends to have reports that he tends to have a very short fuse, hypervigilance and exaggerated startle responses with when there's a noise, when there's, you know, something that startles him, even if it's not fire related, it stresses him out. And if a fire alarm goes off, that really stresses him out. And we all know that, you know, sometimes when the batteries start going low on our fire alarms, they'll start beeping. Well, that can set him off. Or if he has the windows open and the fire alarm, the smoke alarms go off, that also triggers an extreme response, problems with concentration and sleep disturbances. And we'll take sleep disturbances first. He doesn't sleep well. The initial trauma happened when he was sleeping. And ever since then, he doesn't remember having a good night's sleep. Which means, you know, he's probably got a lot of HPA axis activation, glucocorticoid resistance because of, you know, that chronic HPA axis activation and, you know, builds up buildup of adenosine in his brain and everything, which makes it harder for him to think clearly, harder for him to concentrate. Plus, when you're hypervigilant, when you are not filtering out the stimuli that other people filter out, you know, there's just so much input that it's hard to concentrate. So it makes sense. So when we're talking to him, on an average night, how much sleep do you get? He says he stays in bed for eight hours, but he doesn't sleep much. If he has a couple drinks before bed, he can sometimes get three or four hours of sleep. Okay, that's honest. On an average night, how many times do you wake up? He says five to six times. And then he's awake. You know, it's not like he wakes up, rolls over, and falls back to sleep. On an average night's sleep, how do you. After an average night's sleep, how do you feel? He says, tired. Well, that kind of makes sense looking at that sleep schedule. And he hasn't awakened feeling refreshed in years. As with everybody, we'll have him do a sleep hygiene assessment. This issue with drinking alcohol before bed will come up in the sleep hygiene assessment, and then we can talk about it at that point. Nutrition. He had his a full blood panel done about six months ago, testing his kidney and liver function, thyroid and vitamin D levels. There was no major problem. His nutrition was adequate. You know, it was your typical American diet. He says he eats whatever his wife cooks, but he forgets to eat a lot during the day. She's not home, she's out doing, you know, her thing. And when he's at work, he's not. He's also not remembering to eat. So he'll get up, get ready for work, go to work, come home, and he still hasn't eaten yet that day. Do you eat due to stress or for comfort when you're upset? He says, no, I have no appetite. When I get stressed out, you know, I Just, I get nauseous. Okay. Do you drink at least 64 ounces of non caffeinated, non alcoholic beverages each day? He says yes, but. And whichever conjunction you want to use, he does drink about 600 milligrams of coffee throughout the day. And that's just a rough estimate. You know, he said. He says he drinks coffee consistently throughout the day. You know, probably about a pot, which is about 600 milligrams. So we just kind of estimate there. He doesn't drink or. I'm sorry, he doesn't smoke. So we didn't have to worry about that. He doesn't have any problems or concerns about his weight or hypoglycemia. He hasn't had any weight changes recently. Now, you remember, this trauma was 20 years ago. So we're dealing with some persistent PTSD symptoms. I wouldn't expect significant weight changes unless he was having some issues with decompensation. His blood sugar was tested at that physical. No issues with that. But he does report gaining weight around his belly. Remember, that's a key or a clue that somebody may have high levels of stress, high levels of cortisol, and be developing what they call metabolic syndrome, which can lead to other physical health diseases. From a counselor's perspective, if they tend to gain weight around their midsection, we just want to file that back and think, okay, this may indicate persistent stress in this person's lifestyle, which is keeping their HPA axis, their threat response system, revved up, which is going to negatively impact their sleep, which will alter their gonadal hormone levels, it'll alter their thyroid hormone levels, and it'll alter all of their neurotransmitters. You know, HPA access is really pretty pivotal. So that's one of our visual clues that somebody may not be having, may not have optimal levels of neurotransmitters. What medications are you taking? He says he took Prozac for about six months, but he discontinued it last month. Last month because it wasn't helping, you know, the Prozac. A lot of people will comment that it revs them up. So he was already having difficulty sleeping. The Prozac just really didn't help. Another issue is Prozac is not one of the two SSRIs that has been identified as being effective with people with ptsd. That's another thing to consider in this article. It talks about particularly Zoloft being effective and Paxil being effective with. In people with ptsd. That's one of those things you just kind of want to File in the back of your mind. A lot of times talking to patients will give you an idea, if you've never been on these medications, about how the medication impacts them. You're not going to find it a lot of times in those generic write ups that you get from the pharmacist. If you ask people, you know, how do you feel when you're on this medication? Some of your SSRIs tend to make people feel very sleepy and others tend to be sort of neutral and others tend to rev you up. So it's important to know in general how medications affect people and encourage clients to talk with their doctor if they're taking this medication like Prozac. He just discontinued it. You know, he didn't go back to the doctor and go, hey, doc, this isn't working for me. He just said to himself, this isn't working for me. I'm not going to take it anymore. And, you know, it seems like he's probably got some underlying neurotransmitter disruption here. And because of the trauma and especially the enduring nature of the trauma symptoms, he may benefit from being on an SSRI like Paxil, which might help him sleep, or Zoloft, which is more neutral. He's also on statins for his cholesterol, and statins can contribute to mood symptoms. We do want to remember that, but, you know, he's on that for his cholesterol. And high cholesterol is also another sign of persistently activated HPA axis. He reports not having any chronic pain, so that's great. In terms of exercise, he plays golf. Well, that's good. That's sunlight. I like seeing sunlight and not sitting and netflix binging. He plays 18 holes on Saturdays and Sundays. The rest of the week. Nada. Okay, you know, that's not ideal for circadian rhythms, but at least he's getting some exercise. And he carries his clubs instead of riding in the golf cart, so he is getting some physical activity. How's your energy, mood and appetite after you play golf? He says, doesn't really affect me at all. It's just, it's something to do besides sit around the house. On his average day, his energy is low. You know, he reports he gets up, he goes through the motions, he does what he needs to do, but he's just flat. And so, you know, we're really looking at some symptoms here of concurrent persistent depressive disorder, which, remember, used to be called dysthymia in prior versions of the dsm. Have you had your thyroid levels tested lately? Well, Actually, he did, and they were in the normal range. His resting heart rate is 70, O2 sat is 98, and his blood pressure is fine right now. That's all good. Interestingly, he does report that his sex drive is pretty high. Okay, flat a lot of the rest of the time. Sex drive high? Where's that coming from? Has there been any change in your sex drive lately? He says no. He's over 45, but he hasn't had his sex hormones tested lately. Doesn't really see a need to. He says he engages in sexual activity daily or more often, if possible. And, you know, remember, one of the reasons he's here is because infidelity is an issue. So we want to take a look at what's the benefit of this behavior. How might infidelity or how might sexual activity be helping him cope with life? Does it give him a sense of being okay? Is it a sense of validation? Is it a neurotransmitter thing? What's going on? But those are all things we'll talk about in a little while. We do want to educate him about the impact of sex on testosterone and dopamine levels. When he. When people have sex, it typically initially rate or men, it typically initially raises those testosterone levels. So if he's feeling flat, you know, if his hormones are on that low level, lower end of the normal level, that might be helping him increase or rebalance those excitatory gonadal hormones. And you also have to remember that testosterone levels are related to serotonin, norepinephrine, and dopamine. If he has low serotonin levels, he may not have as much testosterone. But with any of our hormones or neurotransmitters, you can have deficiencies in multiple different ways. You can have failure to produce enough. So when you take a blood test or a urine test or whatever you're testing for, you know, however it's tested, it may show that it's in the normal range. And you're like, well, gosh, I guess there's no problem with that. But this is where hormones and neurotransmitters are kind of quirky. Because if you have. If your body's making enough and secreting enough, that's great. But if it doesn't get to where it's supposed to be, then you may test as having enough. But there's a. If there's a breakdown in the system and the receptors are not functioning, then you could still have problems. So that's one of those things that you kind of want to bear in mind, we're not going to argue with the physicians and stuff over it, but we do want to remember that serotonin or testosterone levels are impacted not only by how much is made, but also by how much is received by the, by the receptors once it's secreted. So, and do remember that you cannot, cannot, cannot, cannot test for neurotransmitters, your monoamines, your serotonin, norepinephrine, dopamine, glutamate, gaba, yada, yada. You cannot test for those with a urine or a blood test in terms of measuring how much is available in the brain, because the mono A means all of those have receptors throughout the body. So all you're getting with that measurement is an assessment of the level of monoamines, the neurotransmitters in the body. And if the receptors in, you know, from the neck down are working really well, but the receptors in the brain are not, you're not going to see that on the test. So that's one of those. Another one of those interesting things. Oh, and sorry, I'm off on a little tangent here, but with PTSD and with hypocortisolism, we've talked about glucocorticoid resistance. One of the things they found is in people who have altered HPA axis responses, there's a cortisol stress test that they can do and they inject a stimulant into the person's system and they look at the cortisol levels. Well, that's all well and good, and that'll give you a picture of one thing, but one of the studies I read when it was specifically looking at ptsd, found that cortisol levels differed in how much they increased. When you looked at the stress test with the injected serum versus a psychological stressor. So if you had somebody in your office and you were doing a, you were trying to figure out if they were hyper responsive to stress, if you did the chemical test, you would get. What they found was you got something that was, you know, looked pretty normal, you know, within normal range. But if you took that same person and exposed them to a psychological stressor, they dysregulated. So the body can actually tell the difference in some cases between these artificial stressors and actual stressors, especially in people with PTSD when that amygdala is still having difficulty. But now that's just one of those little quirky things that has no bearing on this particular case. But, you know, had you all captive physically, does he feel on edge and startle easily. Yes. He has a history of trauma. Yes. He has no autoimmune issues, no Crohn's disease, none of that. Never had a concussion. Doesn't have headaches, doesn't get migraines. He does drink liquor, and he drinks several drinks at night most nights of the week. So he would qualify as a heavy drinker. Remember that substance use disorder does not. There's a lot more to it than how much someone drinks. And people can be a heavy drinker without having substance use disorder. Do I think he has it? No. Does he gamble or play the lottery? No. So that's irrelevant. Affective. He says nothing makes him happy. He doesn't feel happy. He's just kind of, you know, his kids do good things and it's like, okay, you know, fine. So he's got this persistent flatness. And when I'm teaching in undergraduate classes, I kind of liken it to being like Eeyore. You know, he's not clinically depressed, but he's not happy either. He's not Tigger, he's not Piglet. He's not. So he's more the Eeyore. Just everything's fine. Whatever. He feels sad or depressed most days of the week. When asked what triggers it, he says, nothing in particular. I'm just. Blah. Sometimes just watching my kids makes me wonder what John and Julie, the two children who perished in the fire, makes me wonder what John and Julie would have been like. Okay, so even just seeing his kids, his current family, triggers traumatic responses. So it makes perfect sense why it's hard for him to connect with them because, you know, he loves them, but at the same time, it's triggering that grief. I feel stressed or overwhelmed zero to three days a week. I just. He says, I just don't have the energy to care enough to get stressed out about anything. It's just whatever. Anxious or worried, though, he identifies as most days of the week because he worries that something's going to have happen to his family. And what helps him feel better is just having them home where he can protect them. He feels like he needs to sort of helicopter in order to make sure that he keeps them safe. So he doesn't recapitulate the old trauma in terms of anger or resentment. He doesn't know what triggers it. He just acknowledges that he has a really short fuse. When the kids won't listen, he loses his temper. Well, let's think about that. That is very normal with somebody who has HPA axis dysregulation. That flat to furious we talked about a couple weeks ago when the body is exposed consistently to high levels of cortisol and glutamate. It starts blocking that out and saying, you know what, we're going to shut down some of those receptors because it's not good to stay this revved up this much. But when something does trigger that stress response, they go from. They emotionally dysregulate, they go from flat to furious. And he acknowledges that this is happening. When he feels angry, what helps him feel better? He says nothing. You know, after he gets angry, he blows his fuse and then he feels guilty about it, and then he goes and sulks and I feel guilty most days of the week. What triggers it? He says, there's always things reminding me of John, Julie and Sarah. Sarah was his first wife. What helps you feel better? He says nothing. In the past year, he has not had any major losses, but current stressors that are present. His wife gets mad at him when he loses his temper. He can't sleep like a normal person because of these quote, damn nightmares. Obviously he's having some marital problems because of his infidelity. But, you know, interestingly, that didn't come up. What's different when you're happy? He says he can't remember the last time he was happy. After he explodes, he says it doesn't take him a whole lot of time to calm down with that anger. But that anger is replaced by guilt and remorse for getting upset. What helps him calm down or stay calm? He identifies that, you know, if he just. When he gets angry, if he just lets it all out and yells, he feels better, faster, and he wouldn't have to yell if people would do what he tells them to do. You know, we'll take a look at those skills. Cognitively, his concentration's awful. Nothing has changed recently. He thinks, you know, lack of sleep for 20 years, depression, I don't know, that might be contributing to it. His memory's awful. And he says it just. He hasn't been the same since the fire. When you think about your life, the world, other people do, you tend to feel angry, suspicious or hopeless. And he says he feels angry, guilty and depressed. He doesn't hold a lot of ill will towards other people, but he just doesn't know why. He has a lot of survivor's guilt. He doesn't know why he's still on this planet. He doesn't know what he's supposed to do. Since his. His vision of the perfect life, you know, got destroyed 20 years ago, have you always felt this way? No, the fire changed how he saw everything. He frequently judges or criticizes himself, which we've seen, and he doesn't think that he needs to be perfect to be likable or lovable. But for the past 20 years, he recognizes he's thrown himself into his work in order to avoid feeling feelings and to stay busy. He says his negative self talk came from being raised to take pride in his work and his self racist, which means constantly striving to improve. So I'm hearing a little bit of staying at work in order to avoid feeling feelings, but I'm also hearing a little bit of staying at work to constantly strive and improve and fulfill those expectations that he was raised with in terms of cognitive distortions. He has a lot of all or none thinking. So finding, helping him find exceptions. He focuses on small aspects of things instead of the bigger picture. He struggles with expecting life to be fair. You know, it's not fair that he experienced the tragedy that he did. He struggles with taking things too personally. And so he needs to consider alternate explanations and often focuses on the negative and ignores the positive. Instead of focusing on how well his family, his current family is doing and how much they love him, he is still focused, stuck, if you will, focusing on how he perceives himself to have failed. His first family. Hardiness. There was just not much to work with. So leaving that aside, he said, you know, I just. I don't know. You know, there's nobody that I really confide in. You know, obviously, if he quits cheating on his wife, that would help, but he wasn't real motivated to participate in that activity. So. Okay, time management, he said his time management's great. He throws himself into work or projects. He is a perfectionist. You know, he likes to take pride in his work and tends to get irritable if it's not perfect. But he doesn't feel he procrastinates at all. Do you feel safe most of the time? He says, no. You know, no. I'm always concerned that there's going to be a fire if I'm with my family and I'm in a safe place, which for him means also being awake. He can feel safer, but he's always sort of on edge, concerned that something bad's gonna happen. His first family, he doesn't understand why that happened. So he's worried that, you know, it may not be a fire this time. It may be a stray bullet, it may be a tornado, who knows? But. But he's worried that that's going to happen again. So he has difficulty feeling safe. Are you able to have peace and quiet when you want it and when you sleep? He says, oh, yeah. And that goes back to having that short fuse. People walk on eggshells around him. During the day. He's able to access natural light. He makes his room totally dark when he sleeps, but he does watch television until it's time for him to go to bed. So he's exposed to that blue light. He's not exposed to much in terms of noxious smells, triggering smells, the smell of burning wood. He lives in an area that gets cold in the winter. And when people start using their fireplaces, you know, if you're in one of those areas, you know how going outside during those times now, I love that space. I don't have, you know, obviously don't have traumas associated with that. But you can go outside and you can smell people running their fireplaces and smell that burning wood. And for him, that is extremely triggering, happy, relaxing, energizing smells. Coffee. He loves coffee. The gym, air fresheners. You know, he doesn't mind what sights our triggers. For him, fire, whether it's in a fireplace or a barbecue grill or anything like that, fire is a trigger. Anything Christmas. And we know that Christmas starts, you know, anymore in July. And, you know, they have the Christmas ornaments out and the Christmas toys and the Christmas this and the Christmas that. And that can be really traumatic for people who have traumas, if you will, around the holiday season. And a lot of our clients do. It may not be something as traumatic as losing your family in a fire, but a lot of our clients have traumas that are associated with the holidays, even if they don't. And I know we're off the case study again, but even if they don't have a trauma that occurred right around the holiday, if they have a recent loss, then remember at least a year, if not three to five years of holidays without that person can also. The holidays can also trigger a sense of melancholy. Just kind of bear that in the back of your mind when you're identifying trauma triggers and working with clients and helping them plan or understand why they might have more moodability beginning in, you know, August, because, you know, a lot of people don't draw the connection. And some days he says church triggers his. Triggers his thoughts and his moods and makes things worse because Christmas was a religious holiday for him. And, you know, celebrating the birth of his Lord and savior also happened on the same day that he lost his entire family. What sounds are triggers? Fire crackling fire alarms, sirens and sadly enough. Little kids laughing or playing, because that throws him back where he's remembering what it sounded like when his kids laughed and played. And then he starts lamenting about how he'll never hear that again. Are you able to keep your environment at a temperature you find comfortable? Yes. Great. So we have that one under control. Do you feel you're capable, loving, and deserving? He says, no, I failed as a father and a husband, so why, you know, why. Why do I deserve to be happy? Do you have healthy relationships or regular fear of abandonment? He knows his relationships are not healthy, and he says, maybe she is better off if she does leave me. Okay, so that might be another indication for the infidelity. You know, maybe he's trying to push his family away so he doesn't have to be reminded of his prior tragedy. He doesn't have to be hurt again if they. Something disastrous happens. You know, I'm just kind of thinking, obviously during the assessment, I'm not thinking out loud. I'm just filing all this away for when I write my comprehensive assessment. Can you effectively identify and communicate feelings and thoughts and get your needs met? He says, no, I don't know what I feel or think most of the time and just fly off the handle. Which goes back to what he identified at the beginning as just feeling flat and numb all the time. He's either numb or he's furious. There's no middle ground, and it doesn't seem like there's any other, you know, significant feelings. Do you have a social support group that can provide practical assistance and emotional support? He says his wife tries, but she just. She doesn't get it. And in a way, she also triggers it because she reminds him of the fact that, you know, this is round number two. So John experienced a significant loss in trauma after the fire. He threw himself into his work. He's tried counseling a couple of times, but it doesn't seem to help. He's not sleeping well. He uses alcohol to help himself get to sleep at night and try to block out the nightmares. And he seems to be using sex and the risk involved with his affairs to maybe increase dopamine and endorphins, which reduce stress as well as provide feelings of pleasure and help him feel something. He also, as I said, may be using it to subconsciously push away this current family so he doesn't have to experience the loss of control or the pain and loss of control that comes with the devastation that he experienced with his first family. If he's pushing them away, then he's in control of what's going on to a certain extent. What are we going to do? Well, let's start out with the basics because as I said, he's not a voluntary client. He's here because his wife made him. But let's start figuring out what can we pull. And remember, all of these things are interrelated. I want you to think of it, if you haven't heard the analogy before, like a woven blanket or a sweater, that it's all these strings are woven together and as soon as you start pulling one, eventually the whole blanket will unravel. But as you start pulling one, it starts making little air holes in the blanket or in the sweater so it's lighter and more air can get in and you can breathe easier. So, you know, that's kind of what we're looking for with him at this point. We want to help him improve sleep to reduce fatigue, irritability and difficulty concentrating. Referral back to a psychiatrist specializing in PTSD for consideration of a new medication. You know, nothing against his primary care physician. However, he's got enough going on right now that I think it would be beneficial to have a psychiatrist actually take a look at it because psychiatrists are more aware of the vast array of different pharmacological interventions that might be available and might be able to identify one of those that would not only address some of his PTSD and persistent depressive disorder symptoms, but also help him sleep. We want to help him improve his relationship with his wife and kids so he feels satisfied in his current situation. So we're going to explore his motivations for and benefit of the affairs. That's going to take some time. We'll explore his relationship with his wife and kids now and how that's impacted by his prior trauma and really start having having him look at how that trauma is impacting him and figuring out how he can live in the end, accept the fact and feel the hurt or know that it hurts to have that prior loss and still get joy and love and whatever. Interacting with his. With the three kids that he does have now and will help him identify what he wants his current relationships to look like. He says he hasn't really felt much of anything for 20 years and he's had multiple affairs. His current wife is with him, but she said she's not going to stick around if he keeps having affairs. So we want to figure out, if you're here, obviously because you don't want this marriage to end, what do you want this relationship to look like in order to Feel content or in order to be able to express what you need and get your needs met. Well, we want to improve anger management skills to reduce his angry outbursts. So identify and explore the function of his anger triggers. Going to have him keep a log of those anger triggers for a few weeks and we'll look at what those things mean in terms of loss of control and maybe explore it in terms of the initial trauma represented, what it represented a gross loss of control and, and you know, he had no control over that fire and he looks back and he shoulda coulda, wouldas. However, in that moment he was powerless to save his family and now he doesn't like to feel powerless at all. He holds on with, you know, white knuckles in order to try to keep control of things, try to keep people safe. We want to enhance his mindfulness and early identification of anger. Help him identify when he feels that bubbling inside of his gut before he gets to the point where he's enraged. So if he tells his kid to do something and they don't do it, you know, before he flies off the handle, you know, what's the gap there? And you know, identify. He tells his kid to do something. Now he needs to practice his deep breathing, his belly breathing skills in order to not allow himself to start getting upset right away if Junior doesn't comply immediately. And we'll develop anger coping skills using psychological flexibility, helping him identify what a rich and meaningful life looks like. Helping him identify what skills and tools help him manage his anger now. Help him identify what risk factors or what vulnerabilities make him more likely to be cranky. You know, some days he's flat, other days he's furious. What things make him more likely to be even more short tempered? Is it lack of sleep? Is it when he's drinking alcohol? What is it? So he can choose which behaviors to use in order to help him move towards that rich and meaningful life. We're going to look at reducing PTSD symptoms, developing resources to enable him to deal with distress upon cue exposure. There's a lot of cues and even. Well, the next step is refer him to an EMDR therapist to help process trauma. I'm a big believer in emdr. There's a couple of other therapies that are out there now that are like tapping, that are gaining a lot of really positive exposure. However, helping him develop some foundational skills to deal with distress when he starts to feel triggered will give him a sense of control over his body which he hasn't had for a long time. And we will address negative self talk and self blame with cognitive processing therapy. You know, I'm not EMDR certified. I'm not going to do that part. But that doesn't mean we can't, you know, the EMDR therapist and I can't work collaboratively with him. And we're going to work on helping him grieve the loss of his families so he can integrate it into his life. Because right now it's this thing and he's kind of stuck there reliving that day over and over and over again. He closes his eyes and he's still reliving that day. We'll discuss how grieving the loss doesn't necessarily mean forgetting his family. He has a lot of survivor grief. He's also afraid that he'll forget if he doesn't do it. He also, you know, feels like he should, quote, should be punished because he didn't rescue them, because he didn't turn the lights off. We're going to address a lot of those shoulds and, and what grieving actually means and might mean for him. We'll explore using narrative therapy to help him integrate the loss. He loves writing and loves reading, so that's not a problem for him. And I'm going to encourage him to write a novel or a screenplay to integrate the loss, starting back from when he met his first wife, working all the way through. And then we're going to talk about how those things integrate and how this current chapter or season or whatever it is, however he chooses to write it, how he can integrate the events of the past into this character, yet still allow the character to remain the protagonist in the situation. I may have have him write letters to his wife and his children, the current family, to express his feelings to them. I may also have him write his letters to his first wife and his children, all of whom are deceased, to express his feelings to them. And we may do go through a grief ritual, which I found some of those to be very helpful. And I'm going to encourage him to get involved in a survivors of grief support group. This is not a survivors of suicide support group. It is kind of difficult to actually find straight up grief support groups, especially for people who've experienced traumatic grief. There are a lot of grief support groups that are mainly people whose spouses have, you know, passed on, you know, due to cancer or heart attack or something like that. Or you've got the survivors of suicide group. But there's not a lot of grief groups that are specifically targeted toward traumatic loss. So it's a little bit more challenging to find an appropriate group. But I will encourage him to do it, even if it is just going to a grief support group that is mainly people who've lost their loved ones to natural causes because he did lose his loved ones. And even people who lose their loved ones to cancer, for example, can still be triggered and they can still, they're still going to have those reminiscent feelings and the exacerbation of symptoms around holidays. They're still going to, you know, occasionally smell their loved ones perfume and be back in that situation or have to go into a hospital and smell that smell that they smelled during one of the worst days, weeks, months of their life and it triggers them again. So they can relate to some extent. But, you know, I would continue to look for a trauma survivors support group. Sleep. The doctor put John on Paxil to be taken in the evening. This has helped him start sleeping through the night and has also reduced his evening drinking considerably because he doesn't want to be out of it if something happens during the night. Alcohol is a depressant. Paxil is an antidepressant that tends to make you very sleepy. They are very contraindicated to combine, however some people do. But he recognizes that not only is it not good to combine them, but he feels it would put him in a place where his family would be too vulnerable. So that's kind of a double win there because alcohol helps you fall asleep and sleep initially. But as the alcohol leaves your system, sleep becomes progressively impaired. Since he's not drinking alcohol before he goes to bed anymore, that's one sleep disruptor that's gone. Plus we've added, or the doctor has added the Paxil, which is helping him sleep. He reports he's not having as many nightmares and tends to be waking up less in the last half of the night since he started the new medication, which again, I think he's waking up less in the last half of the night because he's not drinking. I'm not going to split hairs. He's waking up less and that's a good thing. Alrighty. Adult night night terrors and Paroxetine. So we want to look at the impact of adult night terrors on, on Paxil. And they found that Paxil can be super effective at helping people who have night terrors. Okay. So PTSD causes a variety of physical, cognitive, emotional and interpersonal alterations to protect the person from future trauma and everything with this client, as I'm learning about it, all of the behaviors that Seem problematic, if you will. I look at it through the lens of in what way does this help him protect himself from experiencing that trauma again, whether it's experiencing another fire or. Or in what ways does it protect him from being reminded and triggered? You know, we don't want to see something that is going to trigger the worst memory that we have, so we may do what we can to push that away too. Until the trauma is integrated, the HPA axis, the stress response system, will often stay activated, and the person will have exaggerated responses to reminders of the trauma. You can see with this client, reminders have been, you know, grossly generalized. The laughter of children triggers him. You know, you hear that a lot of places. You hear that in Walmart. You hear that in church. You hear that outside your own house when you check the mail. We want to help him start dealing with and integrating this trauma. So. And degeneralizing or desensitizing himself to some of these overly generalized traumas. Persistent activation of his HPA axis can lead to sleep deprivation, irritability, anger. That hypocortisolism that we were talking about, which alters the levels of testosterone, thyroid hormones, and neurotransmitters. Testosterone tends to make men feel more virile, and they really don't have another way of conceptualizing that. But studies have shown that testosterone is associated with that. Since he feels so much like a failure, since he feels like he let his first family down, it could be that trying to bump up those testosterone levels are. Is a way of trying to make himself feel virile again. I don't know. Thyroid hormones and neurotransmitters are also altered when the HPA axis is out of whack. Sexual activity, remember, and risk taking, which, you know, having an affair is risky, can both increase dopamine. Additionally, when he's pursuing these affairs, you know, that initial, you know, month, three months in a relationship, there's that element of lust or the new flush of excitement in a relationship, which may be another reinforcing factor in that. In that activity, because, again, it's allowing him to feel something. It's important to explore all behaviors and symptoms through the lens of how might this be a reaction to the trauma, HPA axis dysfunction, or, you know, just something totally different? But we do want to regularly reflect on the fact that until trauma is effectively integrated, it is going to have significant systemic impacts on the person. Between writing notes, filing insurance claims, and scheduling with clients, it can be hard to stay organized. That's why I recommend therapynotes. 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