Posttraumatic Stress Disorder 535
Edward was particularly bothered by the reexperiencing symptoms of PTSD. He
believed that the intrusive images were a sign that the PTSD was getting worse. He
expressed concern that the intrusive images and memories might eventually drive him
crazy. Their persistence as well as his sudden anger outbursts was proof that he had lost
all self- control. He was convinced that the PTSD meant he was a psychologically weak
or inferior person and that he was now “damaged goods” and of little use to the military
or any other potential employer. He blamed himself for being a victim of PTSD and
believed he would never get over its effects. He concluded he must have some preexisting
flaw to explain why he developed PTSD and others did not. He did not believe he could
ever overcome PTSD but with long-term therapy he might learn to manage its effects a
little better. He stated, “You [PTSD] have destroyed my life, quality of life, my normal
life and future.”
Edward tried his best to prevent or suppress the intrusive thoughts and memories
of Rwanda. He avoided any movies, books, or media presentations on Africa, and any
situations or people that reminded him of Rwanda. He isolated himself from social set-
tings and turned to alcohol abuse to drown his memories. In fact Edward developed a
comorbid alcohol dependence disorder because it suppressed the intrusive images and
memories and calmed his feelings of being overwhelmed and angry. In addition Edward
avoided public places and social interaction outside the work setting. He frequently
thought of suicide as the final solution to his pain. He experienced frequent dissociative
episodes where he could not account for periods of time while at work and he ruminated
on how he could have prevented the little girl’s disappearance. He tried to suppress
trauma memories by distracting himself and he tried hard to prevent the expression of
any strong emotion when talking about Rwanda. Ironically, of course, he did experi-
ence strong negative emotions such as anger, anxiety attacks, and deep dysphoria which
seemed to occur spontaneously and beyond his control. One of his adaptive responses
that became apparent in therapy was his ability to write about his thoughts and feelings.
He also read everything he could find about combat- related PTSD and trauma exposure
in order to better understand his own emotional state and he started a daily physical
exercise and well-being program.
Escape and avoidance were Edward’s main safety- seeking behaviors. When he
experienced anxious symptoms or an intrusive trauma- related image, he left the situa-
tion immediately. He spent much of his time outside of work, alone at home, drinking
and watching movies late into the night in order to distract himself and avoid sleep
which brought on nightmares. Later in therapy, Edward tried to use various relaxation
and meditation techniques to reduce anxiety and the reexperiencing symptoms, which
had limited success because they served a safety- seeking function.
Clinician Guideline 12.22
A cognitive case formulation for PTSD specifies (1) how the individual’s beliefs about self,
world, and others have been changed by the trauma; (2) how the trauma is remembered; (3)
the dysfunctional appraisals and beliefs about the trauma and its consequences; (4) the nega-
tive interpretations of intrusive trauma- related thoughts, images, and memories; and (5) the
maladaptive coping strategies used to suppress intrusive symptoms and minimize anxiety.