PSYCHIATRIC CASE FILES
Meet “Helena,” a 50-year-old woman with a history of PTSD and alcohol use disorders who is currently receiving substance use treatment at a local homeless shelter. This is her very first substance treatment program.
Helena experienced childhood sexual abuse at age 12 at the hands of a family member. She was then advised by her mother to keep the incident a secret and subsequently started struggling with academic performance, then dropped out of school at age 16. At the age 19, Helena got married to a physically and emotionally abusive husband and quickly had 2 children. Shortly after the birth of her second child, she started drinking alcohol to cope with the abuse. Once her youngest turned 18, Helena divorced her husband after 20 years of marriage. She received a small financial settlement after the divorce but had already exhausted her savings. Due to her alcohol use, she was unable to sustain employment. During this time, her alcohol use escalated and her relationship with her children became strained. After exhausting her financial resources, Helena was unable to purchase more alcohol and subsequently experienced significant alcohol withdrawal. She was then admitted to the medical unit for treatment. But during her inpatient stay, her apartment evicted her for nonpayment and she had to be discharged to a local shelter and substance use rehabilitation program.
Patient Presentation
After completing the first 30 days of her sobriety, Helena is seen by a psychiatrist. She is visibly anxious with significant psychomotor agitation. She reports difficulty with sleep initiation as well as sleep maintenance. She finds interacting with her peers uncomfortable and isolates herself when possible. During the visit, she reports significant irritability, primarily triggered by her peers and loud noises. She also reports having taken escitalopram in the past with poor effect. Additionally, Helena has some ambivalence about her alcohol use. While she understands that her use had escalated to an unhealthy level, she also reports that it was her primary means of coping with her anxiety. Without it, she reports a significant escalation of her symptoms. She worries about her ability to tolerate a substance use treatment program.
Treatment
Helena is initially started on sertraline for PTSD. She is also started on naltrexone for alcohol use disorder. Trazodone is used for sleep initiation difficulties.
Other treatment options aimed at addressing her anxiety such as hydroxyzine and gabapentin are discussed but declined by the patient due to a fear of daytime sedation. Topiramate is also discussed, as it has shown promise in patients with cooccurring PTSD and alcohol use disorder, although additional studies are needed. Ultimately, this medication is also omitted from the treatment plan due to the potential for cognitive deficits, which could impair her ability to participate fully in her substance use treatment program.
Challenges
Given her distrust of others and perceived failure of another selective serotonin reuptake inhibitor (SSRI), considerable time is spent in psychoeducation surrounding the role and effects of medications in her treatment plan.
Helena also reveals that she is having nightmares surrounding the physical abuse from her ex-husband. She reports that the dream frequency has not changed with the initiation of her other medications. Doxazosin is added for nightmares. While more research is needed in patients with comorbid PTSD and alcohol use disorder, doxazosin has had some promising results when studying these illnesses separately.
The shelter also helps Helena remain compliant with her medications via frequent reminders and scheduled medication times. She participates in cognitive behavioral therapy (CBT)-based substance use treatment classes, as well as group and individual therapy. She engages in prolonged exposure for her traumas. Over many weeks, Helena begins to trust her psychiatrist and engage in more peer support activities. Her emotional and physical reactivity improve. With the help of the shelter’s case manager, Helena is able to obtain work in the retail industry. As graduation approaches, she becomes more anxious. Her psychiatrist initiates a CBT-based model aimed at addressing her cognitive distortions surrounding her ability to be successful outside of a structured setting. Helena graduates from the substance treatment program and moves into an apartment.
She is followed closely by her psychiatrist after graduation. Immediately following her transition out of the shelter, the patient reports a recurrence of anxiety and sleep disturbance. In addition, she reports a relapse after being offered alcohol by a well-meaning neighbor. While initially struggling with significant shame and guilt, the patient is able to abstain from further use. Trazodone is transiently increased, and Helena continues to address her anxiety in therapy with positive effect.
After many months, Helena becomes romantically involved with a neighbor at her apartment complex. She reports an improvement in her anxiety and continued sobriety in the weeks following the start of their relationship. She is lost to follow up.
Helena returns to the clinic after 1 year. She reports that her boyfriend did not support her use of psychiatric medications and advised her to stop them. He soon became increasingly emotionally abusive, and the patient relapsed on alcohol. Two weeks ago, he sexually assaulted her after she declined to have intercourse. She has not yet told anyone about the assault, but ended the relationship. She reports feeling fearful, as he has remained a resident in her apartment complex.
Her psychiatrist provides emotional support while also encouraging the patient to report the assault to the police and consider seeking a restraining order in accordance with state law. She is also encouraged to obtain urgent gynecologic care and is given information about a local family violence shelter center. While the patient declines to report the incident to the police or seek resources from the family violence shelter, she does agree to seek gynecologic care. The patient restarts her medications and is able to taper off alcohol as an outpatient.
Note: This article originally appeared on Psychiatric Times.
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