492 TREATMENT OF SPECIFIC ANXIETY DISORDERS
seared into Edward’s mind. He remembered the throngs of refugees afraid and
hungry walking along the roads or gathering around their trucks seeking food
and security. He could still smell the air of rotting and decaying corpses that
hung over the countryside and the images of hundreds of women and children
hacked to death in churches and village meeting halls. He recalled the scenes
of mass graves and dead bodies floating in the river. He could still see the face
of a little 5-year-old girl he befriended at an orphanage whom he suspects was
later murdered by the Rwandan Patriotic Army (RPA). He relived the fear of
approaching checkpoints where he was substantially outnumbered by young
intoxicated Rwandan soldiers armed with automatic weapons and machetes.
Edward could see the toll that the tour was having on himself and his fellow
soldiers. He witnessed the suicide of one of his comrades, who shot himself
outside the Kigali stadium.
When Edward returned to Canada, he immediately assumed a normal
workload of tasks and duties. In fact, 4 years later he accepted a final 9-month
tour of duty in Bosnia in charge of landmine clearance. Though he did not
witness any trauma, the work was intense, stressful, and highly dangerous. He
returned from that tour with no energy, no interest in life, depressed, hopeless,
cynical, feeling angry and out of control, withdrawn and alienated from others.
Over the next several years Edward was able to function at work, but his men-
tal and emotional state was deteriorating. He became increasingly depressed,
irritable, anxious, easily frustrated, and withdrawn. He frequently had anger
outbursts at home that frightened his wife and daughters. He became more and
more socially anxious, and finally refused to have any social contact outside his
work setting. Most nights and weekends he sat alone, watching TV and drink-
ing until intoxicated. He had great difficulty sleeping, waking frequently with
nightmares about Rwanda. In 2002 his wife and daughters finally left him, and
several months later his wife filed for divorce. Out of a sense of desperation,
and with the encouragement of his family, Edward overcame his stigma about
mental health services and initiated a request for psychiatric and psychological
treatment.
An initial assessment revealed that Edward met diagnostic criteria for sev-
eral Axis I disorders: chronic PTSD, as well as alcohol dependence and major
depression recurrent. Administration of the SCID module for PTSD revealed
that his Rwanda experience qualified as a Criterion A traumatic event. In addi-
tion Edward had several reexperiencing symptoms including (1) recurrent,
intrusive thoughts and images of Rwandan crowds and the little girl, (2) recur-
rent nightmares, (3) flashbacks of the Rwandan crowds or intrusive images of
the little girl with a gorilla dressed in a RPA uniform, and (4) intense shaking,
trembling, and nervousness when exposed to reminders of Rwanda. He devel-
oped extensive avoidance of anything that reminded him of Rwanda includ-
ing a certain stretch of highway close to his community as well as crowded
stores and malls. He had little interest in social activities, and felt detached and
unable to empathize with others. He also experienced increased arousal symp-
toms like difficulty falling asleep, anger outbursts, and difficulty concentrating
including episodes of dissociation. On the Beck Depression Inventory–II he
scored 40 and endorsed the statement of having suicidal thoughts but would
not carry them out.
Edward began a lengthy treatment of individual CBT as well as numer-
ous combinations of medications interspersed with a 4-week PTSD recovery