By Markowitz, Joseph D
In this case report, an elderly combat veteran with a chronic course of post-traumatic stress disorder (PTSD) that was untreated for nearly 60 years was evaluated and treated with a combination of medication and graded exposure psychotherapy. To the best of our knowledge, there have been no reports on graded exposure in the elderly. The course of treatment lessened the key symptom domains of PTSD. Comorbid depression was also lessened. Although a single case report, it would appear that elderly patients do respond to psychotherapeutic techniques such as graded exposure therapy. Given the large percentage of the elderly population that has witnessed combat and due to the continuing military conflicts that the United States has been involved in over recent decades, treatments for PTSD in an aging population will be necessary. Introduction
It was only several years after the cannons of the American Civil War fell silent that Dr. Jacob Da Costa wrote an article describing “irritable heart” in former soldiers. A generation later, the phenomenon called “shell shock” was written about the horrific battles of World War I. Still later “combat neurosis” was used to describe this entity in World War II, until the Diagnostic and Statistical Manual of Mental Disorders III changed the name of this syndrome to post-traumatic stress disorder (PTSD). As PTSD became increasingly more relevant in the 20th century, figures in the field of psychology no less significant than Freud, Jung, and Piaget pondered the mechanisms of this disorder.1
At the dawn of the 21st century, PTSD continues to play an important role in the mental health care system. Temporally closer to our time will be the scourge of combat-related trauma victims of World War II, the Korean Conflict, and the Vietnam Conflict. Nonetheless, the generation that fought in the Persian Gulf War Conflicts and the War on Terror will quickly rise and present for treatment in increasing numbers over the coming years. Recent research has established that 25% of elderly men have experienced combat and that 50 to 70% of the general American population over a lifetime will experience a trauma meeting diagnostic criteria for PTSD.2 PTSD in the elderly population also has several distinguishing features that have been noted.
Despite the commonly held belief that PTSD symptoms ameliorate with age, retirement tends to worsen symptoms of PTSD.3 Factors involved in this are thought to be the loss of the ability to submerge the earlier trauma in the world of business or family life. Also, retirement age individuals experience other stressors such as the loss of friends to illness and death and a general decline in economic resources.3 Elderly patients with PTSD also are noted to suffer a greater burden of somatic complaints due to the illness.4 Anxiety disorders frequently affect the cardiovascular system, central nervous system, and endocrine system via the hypothalamic pituitary axis.4 Another aspect of PTSD in the elderly patient that bodes poorly is its persistence as a diagnosis.5
For the above reasons, as the general population continues to grow older, PTSD in the elderly will undoubtedly become more prevalent. Society will need newer and better treatment modalities as PTSD can prove to be a protracted and treatment-resistant disorder with significant morbidity, comorbidity in psychiatric and somatic health, and mortality.
Case Report
C.R. is an 82-year-old married Caucasian male with multiple medical problems who presented with a chief complaint of “nightmares and flashbacks of the Battle of the Bulge (Ardennes Offensive).”
History of Present Illness
C.R. served one term in the army from 1942 to 1946 in the European theater of World War II. He vividly remembers the campaign that began in the Ardennes Forest of Belgium during the winter of 1944 to 1945. During the interview, he expressed his fear of not surviving this battle and the horrors he experienced while in combat.
After his return from the war, he began re-experiencing explosions, witnessing dismembered or dead army soldiers, and running through the forests in the snow and ice. Another particularly disturbing memory that repeatedly surfaced was of a severely injured comrade asking for a “mercy killing” to “put him out of his misery.” He described these phenomena as “flashbacks” and stated that they occurred only occasionally since his discharge from active military duty in 1946 but intensified greatly during the early years of the Korean conflict.
C.R. reported frequent nightmares since the early 1950s that were usually about themes of the war-dogs chasing him through the forest, bullets whizzing nearby and striking trees, and dismembered corpses. Commonly, the dreams had no substance but he woke up with feelings of dread and terror and usually sweating and shaking. C.R. reported that the nightmares occurred about two nights per week since that time. These dreams continued in frequency and intensity up to the time he presented for treatment over 50 years later. He described these symptoms as “something I thought was normal for people who had been in battle and would have to deal with for the rest of my life.” It was his opinion that the exposure to men in military service during the Korean conflict exacerbated his symptoms and established their permanence. The patient admitted that he had difficulties discussing the trauma of the Ardennes Offensive and avoided the topic with his family. In addition, he has avoided sports events and malls which disappointed his wife who enjoyed sports and shopping. He described being bothered by loud noises and had given up hunting many years ago as the combination of being in a wooded location with loud firearms exacerbated his symptoms and triggered “flashbacks.” C.R. reported that he becomes startled easily and spoke of sitting in the corners of restaurants so other patrons would not be directly behind him. One major reason for his seeking treatment was due to his noticing an increasing irritability that he was concerned over as he had several times verbally “snapped” at his wife. The symptoms C.R. discussed-re-experiencing phenomena, avoidance, and hyperarousability-met diagnostic criteria for PTSD.
Throughout this time, he experienced occasional depressive symptoms which were usually “mild” in the 4 to 5 out of 10 scale (1 being the worst mood he could ever imagine, 5 being the average mood most people have on a typical day, and 10 being the best mood he could imagine), but occasionally reaching 2 out of 10. He would then have decreased sleep, decreased concentration, poor energy, and guilt about surviving the war. He did maintain a normal appetite and sex drive. C.R. admitted to occasional suicidal thoughts but seriously doubted he would ever go through with the act. He had a plan once to drive his car off the road into a tree but emphasized that this thought had long since passed and he was able to contract for safety. Although the symptoms of PTSD and depression were present for many years, overall, these had worsened since C.R.’s retirement approximately a decade earlier. C.R. denied mania or psychotic symptoms except one episode of auditory and visual hallucinations when medically ill in the hospital. Several years before presenting to treatment, C.R. was in the hospital and saw a flashlight at the foot of the bed being held by someone he could not see. He believed he would soon be interrogated in a “military-like” manner. This was the first and only episode of auditory or visual hallucinations in C.R.’s life.
Past Psychiatric History
C.R. denied a history of psychiatric illness including hospitalizations, suicide attempts, or a history of physical or sexual abuse. He denied the use of cigarettes, drugs, or alcohol.
Past Medical History
As a child C.R. had a tonsillectomy and then as a young adult he had an appendectomy and a pilonidal cystectomy. Due to his time in the Ardennes Forest, he has bilateral peripheral neuropathy in his feet from frostbite and mild, bilateral sensorineural hearing loss. He has an extensive history of coronary artery disease with a quadruple bypass surgery, angioplasty, several catheterizations, and stent placements after suffering four myocardial infarctions. He has a 4-cm abdominal aortic aneurysm and suffers from hypertension.
Current medical pharmacotherapy includes 10 mg of ezetimibe in the morning, 75 mg of clopidogrel in the evening, 40 mg of sotalol daily, 60 mg of isosorbide mononitrate daily, 500 mg of acetaminophen/5 mg of hydrocodone-two tablets daily, one tablet of cetirizine in the evening, 40 mg of furosemide per day, potassium chloride tablets-20 milliequivalents twice daily, and 25 mg of hydroxyzine four times daily. He is allergic to aspirin and diltiazem.
Family History
C.R’s mother had a history of coronary artery disease and his father had diabetes mellitus. He had two brothers and four sisters, all with significant coronary artery disease. There is no history of psychiatric illness in any sibling.
Psychosocial History
C.R. reported an uneventful childhood in rural South Carolina with no history of physical or sexual abuse. He interacted well with siblings and peers and had friends. C.R. graduated from college after his military service, went on to complete seminary, and was a minister for 44 years before retirement. After retirement, he volunteered in a hospital chaplaincy service. Currently, he enjoys woodshop. He has been married for 56 years and has two daughters and multiple grandchildren. Mental Status Examination
Mental status examination upon initial consultation demonstrated an 82-year-old Caucasian male who appeared younger than his stated age. His speech was normal in rate and volume. He described his mood as “okay” and his affect was mildly blunted. He was cooperative, coherent, and his stream of thought was goal directed. He denied suicidal or homicidal ideation. He denied auditory or visual hallucinations. He was not hypervigilant or paranoid. His insight and judgment were good. Cognitively, he was of above-average intelligence with preserved mental functioning based on his fund of knowledge and vocabulary. He was aware of the date, location, and current events. C.R. was able to spell the word “grape” forward and backward, do serial mathematical calculations, and was able to recall three items immediately and after 5 minutes.
Clinical Course
Treatment for C.R. was initiated with sertraline at 25 mg per day and after several days increased to 50 mg per day. He was not able to tolerate this medication due to fatigue and discontinued it on his own volition. Upon return visit, we agreed to a trial of 10 mg of escitalopram per day which also caused fatigue and we reduced the dose to 5 mg per day. This dose was effective and well tolerated. Initially, his mood symptoms began to show improvement, including his sleep, energy, and concentration, while the number of nightmares and flashbacks, as well as the severity of the avoidance and hyperarousability, remained constant.
A discussion on the theory of graded exposure therapy and its potential to lead to a brief worsening of symptoms before improvement was undertaken and C.R. agreed to begin this treatment.6 Graded exposure is a technique used to overcome maladaptive anxiety by having the patient approach the feared situation gradually through a hierarchy of anxiety-provoking scenes developed by the both physician and patient.7 As each level is mastered, more intense anxiety provoking scenes are graduated to until there is a relative desensitization to the material disturbing the patient.7 As a first step, C.R. attained a long article in the mail from a World War II veteran’s group to which he belongs of the history of his battalion during the Ardennes Offensive and its relation to other units including the rationale of troop and supply movements. The reading of this took several hours and was described as a difficult, yet tolerable and helpful, experience. Next, for several sessions, we discussed his personal experiences at the Battle of the Bulge from December 16th to December 21st 1944 and had detailed discussions of the events of the engagement and his feelings surrounding various situations. Initially, the topics covered were of the least emotionally upsetting (e.g., his position and a general description of the landscape and troop movements). C.R. was asked to only superficially describe his experiences and, when comfortable with one event, to continue to progress to more graphic and traumatizing experiences (e.g., the decision to “storm” a home and the events that occurred once inside). Painful memories were spoken about first in the office until some sense of mastery was acquired over them by the patient. At that point, he made a cassette tape recording of himself discussing these experiences in detail to be listened to daily for at least 1 month for habituation. C.R. was instructed to only make the tapes of the previously discussed experiences until the most traumatic experiences (e.g., the request of a friend for a “mercy killing” and seeing dismembered corpses of fellow soldiers) were mastered. Concurrently, the frequency of nightmares decreased from approximately two weekly to one every 2 to 3 weeks and the number of flashbacks decreased from approximately five weekly to two to three every 2 weeks. After approximately 2 to 3 more months of medication treatment, he reported only the occasional nightmare and flashback. C.R. described less sensitivity to disturbing stimuli and less arousal but still noted avoidance symptoms. Nonetheless, by the end of treatment he began to have less avoidance as evidenced by his attending two crowded church bazaars without difficulty.
Discussion
PTSD is a common syndrome estimated to affect 1 in 12 adults at some time during their lives although 50 to 70% of people are exposed to traumatic experiences. Approximately 20% of those exposed to traumatic situations develop PTSD.8 PTSD must be a diagnosis of concern for the clinician since it is an anxiety disorder commonly comorbid with other anxiety disorders, affective disorders, substance abuse disorders, and suicide.9 When combined with the fact that the suicide rate increases in elderly males, particularly elderly Caucasian males, PTSD proves to be a condition that must be closely monitored.
Some authors have postulated the underdiagnosis of this syndrome in patients due to both clinical inattention on the part of health care providers and a culture of denial among the generation of World War II and Korean era combat veterans.10
Because PTSD is likely to be a chronic condition, it would be helpful to have an idea of the typical course the illness follows. Contrary to widespread belief that the syndrome uniformly diminishes in severity over time, it is more likely to show an early decrease in symptoms, with a heightening of symptoms later in life.2 This seems to be the course that C.R.’s psychopathology followed. Table I represents a diagram of events believed to be increasingly intense in traumatic nature, and possibly more likely, to result in PSTD.
Combat exposure, including duration and intensity, is known to predict PTCD. This could be complicated by the more community- driven psychosocial stressors such as recent conflicts in the Middle East. It has been reported that combat veterans can have significant increases in symptomatology at times when reminders of warfare abound.11
Treatment of PTSD continues to evolve and has entered an exciting new phase of development. Selective serotonin reuptake inhibitors clearly are the first-line drugs for treatment and appear effective in both the core symptomatology of PTSD and the very frequent comorbid depression.9 The paradigm shift to the utilization of graded exposure treatment has proven very promising for a large number of sufferers of PTSD and should be considered either as a primary treatment or to consolidate gains made with pharmacotherapeutic measures, especially when fear is the predominant PTSD emotion and avoidance is the primary coping mechanism.6 When fear is not the predominant coping mechanism (e.g., shame, guilt, or disgust), graded exposure therapy may be less likely to be successful. Another valuable lesson learned from this case is that, contrary to a popular belief among some mental health professionals, the elderly can benefit from psychotherapeutic interventions.8 Although there is little published data on controlled trials of psychotherapy with the elderly, relaxation therapy, cognitive therapy, cognitive behavioral therapy, and psychodynamic psychotherapy, all have been associated with positive outcomes in elderly patients with mood and anxiety disorders.12-14 Relaxation therapy typically involves the tensing and relaxing of progressive muscle groups while attention is focused on different sensations associated with tension and relaxation. Sometimes an element of guided imagery is added in which a patient is directed to have calming visions and physical sensations. In cognitive therapy, distorted thoughts at times of anxiety or depression are rigorously identified.
Evidence for and against these thoughts is collected and the patient is encouraged to challenge the maladaptive thoughts. Cognitive behavioral therapy incorporates cognitive therapy with elements of relaxation training or the exposure therapy mentioned above. Psychodynamic psychotherapy focuses on conflicts from childhood and earlier adulthood and analyzes patient defense mechanisms to affect long-term changes in patient behavior. This usually proves to be an intense therapy to better understand oneself and more adaptively relate to the environment. C.R. responded well to the selective serotonin reuptake inhibitor medication and to exposure therapy, reporting dramatic relief of symptoms in a fairly short amount of time. Another aspect of his personality likely to have been beneficial to his recovery was his religious faith and career. Religious faith, it has been noted, can help people transcend their embeddedness in their own personal suffering and provide a purpose for suffaring.1 After the war, C.R. likely used his experiences of seeing the worst in mankind to try to bring some hope and good will to his “corner of the world.”
Conclusions
PTSD is a common psychiatric disorder and it can persist for many years after the trauma occurred. Due to the many conflicts and tragedies of the 20th century, it is hard to imagine anything but an epidemic of PTSD in America and around the world. Screening the elderly who present with depression, especially those with a past history of military service, should be a standard practice. Medication and psychotherapy are likely to be beneficial to the majority of patients and should be discussed with patients. When fear is the predominant emotion and avoidance is the primary coping mechanism, exposure therapy may demonstrate great usefulness. Hopefully, the future will deliver new and better treatments for this common and potentially devastating psychiatric disorder.
References
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Guarantor: Joseph D. Markowitz, MD
Contributor: Joseph D. Markowitz, MD
Department of Neuropsychiatiy and Behavioral Science, University of South Carolina School of Medicine, 15 Medical Park, Columbia, SC 29203.
This manuscript was received for review in January 2006. The revised manuscript was accepted for publication in July 2006.
Reprint & Copyright (c) by Association of Military Surgeons of U.S., 2007.
Copyright Association of Military Surgeons of the United States Jun 2007
(c) 2007 Military Medicine. Provided by ProQuest Information and Learning. All rights Reserved.
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