The authors’ observations
PTSD symptoms can develop months to years after a precipitating incident,6,7 and repeated trauma can make patients more susceptible.
Interestingly, Mr. Q briefly suffered PTSD symptoms after the childhood accident but had no full-blown symptoms until adulthood. In addition to triggering avoidance behaviors, the muscle pull apparently reignited long-dormant PTSD symptoms (fl ashbacks, nightmares).
Mr. Q suffered no other PTSD symptoms. His stuttering might have signaled a psychogenic anxiety disorder, rather than being an incidental finding that developed after acute brain trauma at age 10.
Stuttering also might have contained Mr. Q’s PTSD symptoms for 24 years, until his snow-shoveling injury shattered that containment. Further, while shoveling in the street amid slippery conditions, he might have subconsciously feared he would have trouble eluding an oncoming vehicle.
The authors’ observations
We must address Mr. Q’s stuttering, phobia, and PTSD simultaneously to restore function. If we were to target his street-crossing phobia alone, we would face considerable resistance while exposing the underlying social phobia.
Supportive psychotherapy and exposure therapy—which would involve taking Mr. Q to an intersection and guiding him across—could help him overcome his fear of being run over. Cognitive-behavioral therapy (CBT) alone or with medications also could help.8,9
Mr. Q’s anxiety, however, is severe enough to keep him from trying exposure therapy. Because staying home is his shield from social contact, he is not motivated to leave his apartment. Although he presented voluntarily, like many patients he is ambivalent toward exposure therapy.
Also, Mr. Q’s stutter makes it difficult to engage him in conversation. His stuttering is so severe that we have trouble doing an adequate CBT case formulation. At times his speech is almost incomprehensible.
Improving Mr. Q’s speech is crucial to completing an assessment, decreasing his social anxiety, and motivating him to conquer his fear of crossing streets. By addressing his stuttering and phobia simultaneously, we can treat his anxiety on 2 fronts:
- the stuttering that stemmed from his car accident at age 10
- the street-crossing phobia that developed after he pulled a leg muscle as an adult.
Mr. Q’s progress: A step-by-step recap
Week 1—After much coaxing and encouragement, Mr. Q works through a leg cramp and takes 1 step off the curb, first with the therapist and then alone.
Week 2—Mr. Q takes 2 steps into the street—first with the therapist and then alone—after repeated coaxing and despite leg cramping.
Month 1—Patient proceeds 4 steps into the street unaccompanied. When his legs cramp, he intensifies the cramp and releases, then says ‘I can do this.’
Month 2—Patient walks 6 steps into the street, first with the therapist, then alone.
Month 3—Mr. Q walks 8 steps into the street, first with the therapist, then alone.
Month 4—Patient begins crossing 1-way streets alone. After the therapist guides him to the center of a 2-way street, he walks the rest of the way by himself.
Month 5—Patient crosses a 2-way street unassisted.
Month 6—Mr. Q crosses busy intersections near his church, where the cramping began.
TREATMENT: 5-step approach
Negative medical results convince Mr. Q that anxiety is holding him back. This allows us to target his anxiety with CBT, in vivo exposure, deep breathing/relaxation, speech therapy, and pharmacotherapy, all of which we start immediately.
As part of Mr. Q’s psychoeducation, we reiterate his negative physical examination results and point out that his childhood vehicular injuries might be perpetuating his fears. We work on getting him to recognize that leg tightness does not predict falling and getting hit by a car.
Interventions Mr. Q found helpful—from most to least
In vivo exposure. During our first session, we walk Mr. Q to a 1-way street and—after much coaxing and guidance—lead him into taking 1 step off the curb. The following week, we guide him through a second step. For homework, we have him practice crossing streets daily, at first with family members and then alone. - Medications, which help him ‘feel calm’
- Relaxation breathing
- Saying ‘I can do it. I feel calm’ when legs cramp up in the street
- Soaking legs in warm water for 10 minutes twice daily
- Progressive muscle relaxation
- Cognitive intervention: internalizing that anxiety—not a medical problem —is holding him back
- Self empowerment exercise: further cramping his legs, then releasing them when they cramp up