Clinical Geriatrics

CASE PRESENTATION

Ms. N is a 64-year-old unmarried woman who came to her primary care physician with complaints of headaches and difficulty sleeping. Ms. N is employed as a legal secretary and chose Dr. R from the panel of physicians who participate in her employer’s health insurance plan. She has been her patient for the past 8 years, coming in annually for health maintenance visits. Dr. R has found it difficult to get to know Ms. N, as she does not engage readily in conversation. She is very meticulous about following up with appointments and is always very specific when describing her complaints. When Dr. R asked when the headaches began, Ms. N began crying. She told Dr. R that she has slept little since watching the first reports of the earthquake and tsunami in South Asia. When Dr. R tried to comfort her, Ms. N told her that she cannot keep the images of the dead children out of her head, often thinking that she sees herself among the piles of bodies

Dr. R asked if Ms. N has any family members who can be contacted. Ms. N told her that she was placed in a series of group homes and foster care since she was 8 years old after her parents were sent to prison for the beating and murder of her two younger brothers. Ms. N was the victim of severe emotional, physical, and sexual abuse from her parents. Her treatment in foster care was also at times traumatic. At the age of 14 she was placed in a boarding school run by a religious organization that was strict but provided consistency and the opportunity for Ms. N to complete high school and attend secretarial school. She has worked for the same law firm for the past 35 years, has never married, and lives a solitary life. Ms. N works long hours and feels safe when she is at the law firm. She reported that after the events of 9/11 she felt anxious, but was not as affected as she is now. Ms. N told the physician that the vivid pictures of children and the stories of so many people finding their dead relatives is “making her crazy,” but she also feels that she cannot escape the news coverage. Dr. R asked Ms. N if she had any suicidal thoughts. Ms. N responded that she would have killed herself long ago if she really wanted to. Dr. R made numerous telephone calls, arranging for Ms. N to be seen the next day by a psychiatrist, and gave her a prescription for a hypnotic medication. Ms. N went back to work, stating that she would rather be sitting at her desk than at home. She agreed to keep the appointment with the psychiatrist and to call Dr. R if her symptoms worsened.

DISCUSSION

Post-traumatic stress disorder (PTSD) is characterized by intense fear, helplessness, and horror that occur in response to a severe or extreme traumatic event.1 Patients often develop symptoms of hyperarousal, re-experiencing the trauma through images and flashbacks, and may try to avoid things that remind them of the experience. Symptoms of reduced involvement with others, restricted affect, and diminished interest in things also may occur, which results in patients being viewed as detached or distant. The resulting symptoms often become chronic, disabling, and interfere with the ability to function.1,2 The symptoms need only be present for 4 weeks to establish a diagnosis of PTSD; however, patients with the disorder often have active symptoms for an average of 5 years prior to diagnosis.3

Older adults have often lived through significant traumatic events including wars, illness, and loss of loved ones, and many have been the victims of violent crimes.4 Catastrophic events, such as the Oklahoma City bombings, September 11th terrorist attacks, and news coverage of worldwide tragedies, often trigger memories of past traumatic experiences. An older adult may have a past history of PTSD but recovered to return to normal functioning. Exposure to new trauma, even through television or newspaper coverage, may cause a relapse in symptoms.