Conquering His Fears, One Step at a Time

Cases That Test Your Skills

Conquering his fears, one step at a time

Shani Stein, MD, Steven Friedman, PhD, and Abdul Elmouchtari, MD

MMr.r. Q ffearsears ccrossingrossing tthehe sstreet.treet. NNightmaresightmares aandnd fflashbackslashbacks How would you handle this case? ffueluel hishis phobia,phobia, andand a stutterstutter worsensworsens hishis anxietyanxiety andand blocksblocks Visit CurrentPsychiatry.com to input your answers and ccommunication.ommunication. WWhichhich pproblemroblem wwouldould yyouou aaddressddress fi rrst?st? see how your colleagues responded

CASE The big freeze Later in the evaluation, Mr. Q mentions that Mr. Q, age 34, is afraid to cross the street. As at age 10 he was struck by a car. The impact he steps off the curb, his legs “cramp up.” As fractured the left side of his skull and left leg, ® the cramping intensifi es and his feet stiff en, Dowdenand he temporarily Health lost consciousness. Media his heart races, he begins to sweat, and he Shortly after the accident, Mr. Q developed turns back for fear his legsCopyright will buckle Forin the personalmild memory anduse concentration only impairments street. While on the sidewalk, he stays within and a moderate stutter. He also experienced reach of a building or car in case he falls. nightmares, but they disappeared within days. Six months before presentation, Mr. Q He says he never received speech therapy walked to church during a blizzard, only to or other psychiatric treatment because his fi nd the church closed because of the storm. family did not have medical insurance. He returned home and shoveled snow for Mr. Q did not lose function after the 1 hour, during which he repeatedly leaned accident, but in college his stuttering led to forward and backward to dump the snow. diffi culty speaking in class and interacting The following Sunday, Mr. Q’s legs started socially. He suff ered panic attacks while on the to “hurt” as he crossed the street. Thinking he telephone or during job interviews. He now had severely injured himself while shoveling, mostly stays home, where he lives with his he began to fear street crossings. At work, parents and a nephew. He interacts only with he asked coworkers to help him cross over family members. to the subway. By spring, he had become During the evaluation, Mr. Q eff ortlessly so humiliated by his dependence that he walks around the therapist’s offi ce and stopped working. His phobia intensifi ed until reports no trouble walking at home. He says he presented to us at his family’s urging. the cramps almost never surface at home During evaluation, Mr. Q says he can cross because he feels “calm” with walls close by. only side streets and holds on to his father When trying to cross the street, he manages while crossing. His father, who is retired, spends to turn back without falling despite the much of his day helping his son get around. cramps. Complete physical exam by Mr. Q’s primary care physician reveals a possible Dr. Stein is a fourth-year psychiatric resident, Dr. Friedman pulled muscle in his right leg but no other is professor of clinical psychiatry, and Dr. Elmouchtari is medical problems. Neurologic exam results assistant professor of psychiatry, department of psychiatry, State University of New York Downstate Medical Center, Current Psychiatry are normal, ruling out nerve damage. Brooklyn. Vol. 6, No. 7 89 continued

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Upon considering this confl ict, Mr. Q seems EVALUATION Flashing back to realize that his fear of street crossings Later in the evaluation, Mr. Q says that protects him from social situations. His whenever he considers or tries crossing a stuttering, however, confounds the evaluation street, he recalls his childhood vehicular because he has trouble communicating his injury and fears he will be struck again. symptoms. He has nightmares of being run over, and Mr. Q’s aff ect is constricted as he describes these nightmares and fl ashbacks have been his anxiety and fear. He says he feels limited occurring twice weekly since the snowstorm. and at times depressed by his inability to During the mental status examination, cross streets, yet shows little dysphoric aff ect Mr. Q is well related with fair to poor eye or mourning and seems unusually calm when contact, probably because of his stutter; discussing the problem. He appears relaxed he looks away from the speaker when his Clinical Point knowing that he can keep avoiding social stuttering intensifi es. His nightmares and situations. fl ashbacks suggest comorbid posttraumatic PPTSDTSD symptomssymptoms stress disorder (PTSD), although he has no ccanan developdevelop monthsmonths persistent symptoms of increased arousal. Mr. Q’s symptoms suggest: ttoo yearsyears afterafter He also shows no evidence of acute mood a) social anxiety tthehe precipitatingprecipitating b) panic disorder with agoraphobia disorder, psychosis, or cognitive disturbance. iincidentncident c) a specifi c phobia Mr. Q developed comorbid PTSD: a) after his childhood accident The authors’ observations b) after the snowstorm/injury Mr. Q’s history of fearing interviews and telephone conversations suggests social anxiety, and his fear and avoidance of The authors’ observations street crossings suggest a specifi c phobia. PTSD symptoms can develop months to Panic disorder with agoraphobia is not years after a precipitating incident,6,7 and present because the patient never experi- repeated trauma can make patients more enced spontaneous panic attacks. susceptible. Anxiety is more prevalent among per- Interestingly, Mr. Q briefl y suffered sons who stutter than in fl uent speakers.1,2 PTSD symptoms after the childhood acci- Persons who stutter: dent but had no full-blown symptoms until • more commonly report speech anxiety3 adulthood. In addition to triggering avoid- • are signifi cantly more uneasy in social ance behaviors, the muscle pull apparently situations and tend to avoid them4,5 reignited long-dormant PTSD symptoms • might not be motivated to eliminate (fl ashbacks, nightmares). barriers that thwart social interaction. Mr. Q suffered no other PTSD symp- Mr. Q’s stuttering has contributed to his toms. His stuttering might have signaled a isolation and enabled his phobia. Stutter- psychogenic anxiety disorder, rather than ing has caused signifi cant social discom- being an incidental fi nding that developed fort throughout his life, and staying home after acute brain trauma at age 10. protects him from that hardship. His fear Stuttering also might have contained Mr. of street crossings gives him a reason to Q’s PTSD symptoms for 24 years, until his stay home. snow-shoveling injury shattered that con- Worse, his stuttering makes it diffi cult tainment. Further, while shoveling in the to ascertain his symptoms or plan treat- street amid slippery conditions, he might ment because it takes him so long to fi nish have subconsciously feared he would have Current Psychiatry 90 July 2007 a sentence. trouble eluding an oncoming vehicle. Cases That Test Your Skills

Which symptoms would you treat first? Box 1 a) street-crossing phobia Mr. Q’s progress: b) speech impediment c) nightmares and fl ashbacks A step-by-step recap d) all symptoms at once Week 1—After much coaxing and encouragement, Mr. Q works through a leg cramp and takes 1 step off the curb, The authors’ observations fi rst with the therapist and then alone. We must address Mr. Q’s stuttering, phobia, Week 2—Mr. Q takes 2 steps into the and PTSD simultaneously to restore func- street—fi rst with the therapist and then tion. If we were to target his street-crossing alone—after repeated coaxing and phobia alone, we would face considerable despite leg cramping. resistance while exposing the underlying Month 1—Patient proceeds 4 steps into social phobia. the street unaccompanied. When his Clinical Point Supportive psychotherapy and expo- legs cramp, he intensifi es the cramp and Negative medical sure therapy—which would involve taking releases, then says ‘I can do this.’ Mr. Q to an intersection and guiding him Month 2—Patient walks 6 steps into the results can convince across—could help him overcome his fear street, fi rst with the therapist, then alone. a patient that of being run over. Cognitive-behavioral Month 3—Mr. Q walks 8 steps into the anxiety is causing his therapy (CBT) alone or with medications street, fi rst with the therapist, then alone. physical symptoms 8,9 also could help. Month 4—Patient begins crossing 1-way Mr. Q’s anxiety, however, is severe streets alone. After the therapist guides enough to keep him from trying exposure him to the center of a 2-way street, he therapy. Because staying home is his shield walks the rest of the way by himself. from social contact, he is not motivated to Month 5—Patient crosses a 2-way street leave his apartment. Although he presented unassisted. voluntarily, like many patients he is ambiv- Month 6—Mr. Q crosses busy alent toward exposure therapy. intersections near his church, where the Also, Mr. Q’s stutter makes it diffi cult to cramping began. engage him in conversation. His stuttering is so severe that we have trouble doing an target his anxiety with CBT, in vivo exposure, adequate CBT case formulation. At times his deep breathing/relaxation, speech therapy, speech is almost incomprehensible. and pharmacotherapy, all of which we start Improving Mr. Q’s speech is crucial to immediately. completing an assessment, decreasing his CBT. We plan therapy by having Mr. Q list 10 social anxiety, and motivating him to con- street crossings and rank them from least quer his fear of crossing streets. By address- fearful (side streets) to most fearful (busy ing his stuttering and phobia simultane- intersections). During cognitive interventions, ously, we can treat his anxiety on 2 fronts: we encourage him to recognize that his fears • the stuttering that stemmed from his might be protecting him from social situations, car accident at age 10 thereby prompting him to catastrophize his • the street-crossing phobia that devel- muscle cramps. oped after he pulled a leg muscle as an As part of Mr. Q’s psychoeducation, we adult. reiterate his negative physical examination results and point out that his childhood vehicular injuries might be perpetuating his TREATMENT 5-step approach fears. We work on getting him to recognize Negative medical results convince Mr. Q that that leg tightness does not predict falling and Current Psychiatry anxiety is holding him back. This allows us to getting hit by a car. Vol. 6, No. 7 91 continued Cases That Test Your Skills

Box 2 Speech therapy. The primary therapist Interventions Mr. Q found devotes 20 minutes of each session to speech helpful—from most to least therapy. She employs relaxation training and therapy techniques such as Easy Onset,10 1. Medications, which help him in which the patient stretches each sound, ‘feel calm’ syllable, or word for up to 2 seconds, allowing 2. Relaxation breathing him to speak at a smooth, slow rate. Mr. Q also 3. Saying ‘I can do it. I feel calm’ when practices these speech exercises at home. legs cramp up in the street After 6 weeks, Mr. Q’s stutter improves 4. Soaking legs in warm water for 10 slightly but he still has trouble communicating. minutes twice daily We refer him to a consulting speech therapist, 5. Progressive muscle relaxation who sees him twice weekly and leads Easy Clinical Point 6. Cognitive intervention: internalizing Onset and relaxation exercises. This gives us more time for supportive psychotherapy. Psychotropics with that anxiety—not a medical problem —is holding him back As his speech becomes more fl uent, Mr. relaxation exercises 7. Self empowerment exercise: further Q’s social anxiety and fear of street crossings can compromise cramping his legs, then releasing them decreases. exposure therapy when they cramp up Pharmacotherapy. We instruct Mr. Q to take but might be paroxetine, 20 mg/d, and clonazepam, 0.25 mg bid, 30 minutes before in vivo work to necessary if anxiety In vivo exposure. During our fi rst session, we manage his anxiety. We titrate clonazepam is severe walk Mr. Q to a 1-way street and—after much to 0.5 mg bid over 1 month. He responds coaxing and guidance—lead him into taking well to this regimen but fears he will become 1 step off the curb. The following week, dependent on it. we guide him through a second step. For During therapy, Mr. Q and the therapist homework, we have him practice crossing rank the above interventions from most streets daily, at fi rst with family members and to least therapeutic (Box 2) so that we can then alone. eff ectively treat him should he relapse. When his legs cramp up while trying to cross, we have him say out loud, “I can do it. The authors’ observations I feel calm;” this helps him proceed across Although Mr. Q’s case is unusual, we feel the street. We also teach self-empowerment our diagnostic and treatment methods can by having him purposely cramp up his legs, be applied to similar cases. His stutter, then release them to stop the cramping. however, prevented us from conducting Week by week, Mr. Q steps further into the a structured diagnostic interview—which crossing until—after 5 months of painstaking would have uncovered his symptoms in vivo therapy—he crosses the street both more quickly—or performing standard ways on his own. Two weeks later, he crosses manualized therapy. busier streets near his church with minimal Some data11 suggest that combination anxiety (Box 1, page 91). psychotropics and relaxation therapy can Deep breathing/relaxation. We teach Mr. compromise long-term exposure therapy Q progressive muscle relaxation and slow outcomes, as the patient’s fear could re- rhythmic breathing exercises, which he does turn once medication is stopped. Mr. Q’s before crossing streets to reduce his anxiety. anxiety was crippling, however, and had For homework, he practices these exercises to be addressed before we could consider and soaks his legs in warm water for 10 exposure therapy. minutes twice daily to relax his muscles and More research is needed on overcoming Current Psychiatry 92 July 2007 prevent cramping. patient communication barriers that can continued on page 99 Cases That Test Your Skills

continued from page 92 hamper treatment. Rapport with patients often makes or breaks psychiatric treat- Related Resources • Anxiety Disorders Association of America. www.adaa.org. ment, and communication problems can • Beck AT, Emery G, Greenberg RL. Anxiety disorders and prevent that connection. As clinicians, we phobias: a cognitive perspective. New York: Basic Books; 1985. must watch for linguistic, cognitive, and • Leahy RL, Holland SJ. Treatment plans and interventions for cultural impediments to treatment. depression and anxiety disorders. New York: Guilford Press; 2000. Drug Brand Names Clonazepam • Klonopin FOLLOW-UP ‘I can cross’ Paroxetine • Paxil Six months after presentation, Mr. Q crosses Disclosure all types of streets—from 1-way streets to 6- The authors report no fi nancial relationship with any lane intersections—with minimal anxiety. He company whose products are mentioned in this article or with manufacturers of competing products. has resumed his previous level of functioning Clinical Point and is searching for work. His stutter, though Acknowledgment The authors thank Michael Garret, MD, for his assistance in IIff severesevere aanxietynxiety greatly improved, is still audible. preparing this article. We see Mr. Q monthly. We stop paroxetine rresurfacesesurfaces whilewhile after 8 months but continue clonazepam to ttaperingapering aanxiolytics,nxiolytics, address his many underlying social anxieties. References 1. Ezrati-Vinacour R, Levin I. The relationship between anxiety rreturneturn toto previousprevious 1 By November—approximately 1 /2 years after and stuttering: a multidimensional approach. J Fluency Disord ddosageosage aandnd ttryry presentation—we have reduced clonazepam 2004;29:135-48. 2. Craig A, Hancock K, Tran Y, Craig M. Anxiety levels in people ttaperingapering aagaingain iinn to 0.5 mg each morning. We try reducing who stutter: a randomized population study. J Speech Lang the morning dose to 0.25 mg, but Mr. Q’s Hearing Res 2003;46:1197-206. aapproximatelypproximately 2 3. Cabel RM, Colcord RD, Petrosino L. Self-reported anxiety debilitating anxiety resurfaces. of adults who do and do not stutter. Perceptual Motor Skills mmonthsonths In December, we increase clonazepam to 2002;94:775-84. 4. Kraaimaat FW, Vanryckeghem M, Van Dam-Baggen R. 0.5 mg bid, then reduce it to 0.5 mg each Stuttering and social anxiety. J Fluency Disord 2002;27:319-31. morning 2 months later. In April, we cut 5. Stein MB, Baird A, Walker JR. Social phobia in adults with stuttering. Am J Psychiatry 1996;153:278-80. clonazepam to 0.25 mg each morning. So far, 6. Carty J, O’Donnell ML, Creamer, M. Delayed-onset PTSD: Mr. Q is functioning well. a prospective study of injury survivors. J Affect Disord 2006; 90:257-61. 7. Schnurr PP, Lunney CA, Sengupta A, Waelde LC. A descriptive The authors’ observations analysis of PTSD chronicity in Vietnam veterans. J Trauma Stress 2003;6:545-53. Patients who begin antistuttering inter- 8. Beck AT. Cognitive therapy and the emotional disorders. New vention as adults have a poorer speech York: International University Press; 1976. improvement prognosis than those who 9. Beck AT, Emery G, Greenberg RL. Anxiety disorders and phobias: a cognitive perspective. New York: Basic Books; 1985. start speech therapy in childhood.12 In 10. Hood SB, ed. Stuttering words, 3rd ed. Memphis, TN: Stuttering leaving his stuttering untreated for 24 Foundation of America; 1999. years, Mr. Q likely sacrifi ced quality of 11. Otto MW, Smits JA, Reese HE. Cognitive-behavioral therapy for the treatment of anxiety disorders. J Clin Psychiatry 2004; life. Speech intervention at an earlier age 65(suppl 5):34-41. might have improved his speech and 12. Curlee RF, Nielson M, Andrews G. Stuttering and related disorders of fl uency. New York: Thieme Medical Publishers; prognosis early on. 1993. Bottom Line Watch for symptoms of posttraumatic stress disorder (PTSD) in patients with severe anxiety. Ask about past trauma, as PTSD can surface years after the precipitating event. Concomitant psychotropics, cognitive-behavioral therapy, psychoeducation, Current Psychiatry and exposure therapy might be necessary if anxiety is debilitating. Vol. 6, No. 7 99