|LETTER TO THE EDITOR
|Year : 2021 | Volume
| Issue : 2 | Page : 101-102
Using lorazepam-assisted interview to help with narrative exposure therapy in posttraumatic stress disorder: A case report
Lue- En Lee1, Chih- Min Liu2
1 Department of Psychiatry, College of Medicine, National Taiwan University Hospital, Taipei, Taiwan
2 Department of Psychiatry, College of Medicine, National Taiwan University Hospital; Neurobiology and Cognitive Science Center, National Taiwan University, Taipei, Taiwan
|Date of Submission||14-Feb-2021|
|Date of Decision||01-Mar-2021|
|Date of Acceptance||05-Mar-2021|
|Date of Web Publication||22-Jun-2021|
M.D., Ph.D Chih- Min Liu
No. 7, Chung-Shan South Road, Taipei 100
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Lee LE, Liu CM. Using lorazepam-assisted interview to help with narrative exposure therapy in posttraumatic stress disorder: A case report. Taiwan J Psychiatry 2021;35:101-2
|How to cite this URL:|
Lee LE, Liu CM. Using lorazepam-assisted interview to help with narrative exposure therapy in posttraumatic stress disorder: A case report. Taiwan J Psychiatry [serial online] 2021 [cited 2021 Dec 8];35:101-2. Available from: http://www.e-tjp.org/text.asp?2021/35/2/101/318957
In posttraumatic stress disorder (PTSD), retelling past trauma is a crucial step toward recovery. In this case report, we are illustrating a PTSD patient who benefited from lorazepam-assisted interview during narrative exposure therapy (NET).
| Case Report|| |
Ms. C is a 23-year-old college student patient. Having a mostly absent father and a high-expressed emotion mother, she has developed insecure attachment, and incapability of emotional expression. At age nine years, she was hospitalized for retrobulbar optic neuritis, with presentation of weakness of lower limbs and transient visual loss.
Since teenage, the patient had suffered from sexual assaults which led to chronic self-devaluation. During college years, she became a victim of repetitive intimate partner violence and coerced sex, and suffered from symptoms of flashbacks, nightmares, hypervigilance, and social avoidance. She had many psychiatric admissions for suicide attempts due to refractory depression and dissociation. Meanwhile, she re-enacted sexual trauma through intentional promiscuity. She had been diagnosed with major depressive disorder, PTSD with dissociative symptoms, and borderline personality disorder.
The patient continued to be suicidal despite receiving drug treatment and psychotherapy. In addition to main medication regimen of venlafaxine 150 mg, paroxetine 40 mg, and risperidone 2 mg per day, we started to give her NET during her tenth hospitalization. Unfortunately, Ms. C had difficulties telling the traumatic events, because exposure to traumatic memories triggered even more symptoms of dissociation and self-injury. Usually, she had depersonalization and derealization experiences for up to 80%–90% of the time, happening almost every day.
The patient received two sessions of lorazepam-assisted interview [Table 1] to enhance NET. In the first session, Ms. C described the first sexual assault which occurred when a classmate escorted her home. Thereafter, she depicted sexual assaults by that perpetrator throughout high school, while we explored her emotional responses. She felt shocked when he touched her. She was anxious and fearful for not knowing how to react. She became confused, shameful, and guilty, because she could not firmly resist him. She could not tell those assaults to her mother under distant emotional attachment, and blamed all faults to herself. But we gave her a chance for catharsis, and ventilated her feelings during the session.
The patient showed somatic complaints including dizziness and blurred vision in the following week, although the results of neurological and ophthalmological examination were all normal. Meantime, we observed her regressive behaviors that she identified her therapist as “mama.” The conversion-like presentations were symbolized as she re-enacted her bad childhood experiences, when she felt lonely and horrified during hospitalization for acute visual loss.
A week later, in the second session, the patient unveiled her childhood trauma of emotional neglect. She showed her big anger toward her mother, who chose to take care of her one-year-old sister at home during Ms. C's hospitalization, leaving her feel abandoned. After the second interview, her dizziness and blurred vision were gradually subsided, and frequency of dissociation markedly reduced to once or twice a week. In the following week, she denied suicide ideation, and started to express positive future plans. Her depressive symptoms were finally improved from a score of 29 to 16 in the Hamilton Depression Rating Scale . She was discharged home in three weeks after the second interview.
| Comment|| |
PTSD is associated with self-injury and suicidality, mediated by concurrent psychiatric condition including depression . Despite avoidance is one of the core symptoms , paradoxical phenomenon of behavioral repetitions and reenactments of past trauma is common .
For the presenting patient, the patient had insecure attachment, adolescent sexual trauma, and depression to cause pathological self-derogation, and further started the vicious cycle of repetitive victimization. Coping with the original trauma is the key to ending nightmares.
Anxiety-provoking traumatic memories are hypothesized to be dominated by sensory-perceptual information, and lack the integration with simultaneous cognitive and affective responses . Evidenced to effectively reduce PTSD symptoms, NET is a trauma-focused cognitive behavioral therapy in which patients are asked to tell their traumatic experiences and describe their emotions, thoughts, and physical responses in detail, aiming at re-integrating memories in the past and related emotional/physiological responses . But trauma narratives have been difficult owing to concomitant anxiety and dissociation.
Alternatively, drug-assisted interview is used in diagnosis and treatment of patients who have impaired verbalization abilities . With the aid of intravenous sedatives, patients might be able to reveal previously suppressed emotions. We explored such advantage, and tried to deal with resistance to discussion on traumatic experiences.
Evidence for the efficacy of drug-assisted interview in PTSD treatment has been scarce. In the absence of longitudinal studies, we do not have any information about follow-up prognosis, symptom severity, and recurrence rates. Nevertheless, our case report has provided an example of NET facilitated by lorazepam-assisted interview, which successfully relieved dissociative symptoms and reduced suicide risk of a PTSD patient. With more clinical studies, we suggest that the technique might be further used to manage complex PTSD. (The institutional review board at National Taiwan University Hospital approved this case report for publication (protocol number = 202101020RIND and date of approval = February 10, 2021), with the need to get an informed consent signed by the patient.)
| Financial Support and Sponsorship|| |
| Conflicts of Interest|| |
The authors declare no potential conflicts of interest in publishing this report.
| References|| |
Hamilton M: A rating scale for depression. J Neurol Neurosurg Psychiatry
1960; 23: 56-62.
Kryshinska K, Lester D: Post-traumatic stress disorder and suicide risk: a systemic review. Arch Suicide Res (London)
2010; 14: 1-23.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5).
Washington, DC: American Psychiatric Association, 2013.
Van der Kolk BA: The compulsion to repeat the trauma: re-enactment, revictimization, and masochism. Psychiatr Clin North Am
1989; 12: 389-411.
Lely J, Smid G, Jongedijk R, et al.: The effectiveness of narrative exposure therapy: a review, meta-analysis and meta-regression analysis. Eur J Psychotraumatol
2019; 10: 1-13.
Schauer M, Neuner F, Elbert T: Narrative Exposure Therapy. A Short-term Intervention for Traumatic Stress Disorders after War, Terror or Torture.
2nd ed. Göttingen, Germany: Hogrefe and Huber Publishers, 2011.
Leigh H, Streltzer JM: Special procedures: intravenous sedative interviews, Hoover test, and hypnosis. In: Handbook of Consultation-Liaison Psychiatry
. 2nd ed. New York: Springer, 2015: 403-10.