Introduction

1.1 Presenting Complaint

Anna is a 42 year old female. She lives with her husband and 3 young children. She works part-time but has been having difficulty concentrating at work and is contemplating quitting her job.

Anna was referred for psychological services by her primary care physician. The physician referral stated “female patient in MVA two months ago, multiple injuries, experiencing recurring insomnia”. Anna, walking with the help of a cane, entered the office and sat down. “My doctor must think I’m losing my mind”, she said. When asked why her doctor recommended she meet with a psychologist, Anna reported that she was in a serious car accident where an oncoming car crashed into her at 50 mph. “Since the accident I haven’t been myself. I was in the hospital for 3 weeks with multiple broken bones and other severe injuries. I was taking a lot of pain medication but after I was discharged I stopped taking most of it because I didn’t like how it made me feel.” Anna reported that for the past month she has had difficulty sleeping. She takes at least 1 hour to fall asleep and if she wakes up during the night, it is extremely difficult to fall back to sleep. By the morning, she is exhausted, but has to get her kids ready for school and then go to her part-time job as a legal secretary. She reports having a difficult time concentrating at work because she “is so tired”. She expressed her desire to quit her job, but her husband encouraged her to make an appointment with her primary care physician before making any decisions.

When asked about the details of the car accident, Anna was quick to reply that she didn’t remember anything about the accident. After talking for some time about her injuries and stay in the hospital she revealed that had been experiencing some memories for the event itself. “The memories tend to come out in my dreams. I will finally fall asleep only to be awakened by seeing the car coming toward me and thinking, I’m going to die”. “All I could think about was the fact that my 3 children were going to have to grow up without a mother”. At this point, Anna was crying and shaking uncontrollably as she told her story. She reported that she had amnesia for the event for the first two weeks, but after that time, slowly began to remember specific details about the accident. She recalled driving on the highway and having to come to a sudden stop because of construction. As she slammed on the brakes, she looked in her rearview mirror only to see a SUV driving full speed and about the crash into the back of her car. Anna reported being paralyzed with fear and thinking she was about to die. Although she claims she does not remember the actual accident, she has experienced some flashbacks which consist of seeing a badly injured person being wheeled away on a stretcher. She later came to find out that the driver of the SUV was killed in the accident. Despite working very hard not to think about it, she can’t seem to help herself. “I just keep seeing it over and over again in my mind. Even though I tell myself it is over, I can’t shake the feeling. Sometimes, it actually feels like I’m being hit all over again.” When asked how her dreams and memories of the accident are related to her insomnia, Anna reported that she believed her sleep was worse because of the memories. After experiencing a vivid dream about the accident, her heart is racing, she is sweating, and is too scared to go back to sleep. She has not told her husband about the memories because she doesn’t want to burden him with anymore of her problems.

In addition to being exhausted and not able to concentrate at work, Anna reported feeling as though she didn’t have any more love to give to her husband and children. This feeling was particularly upsetting to her because she reported that she knew she loved her family, but that she couldn’t feel the love anymore. She claimed to feel guilty about having to work so hard to “put on a happy face” and demonstrate her love. She believes that these behaviors have contributed to her feeling tired all the time too.

The lack of feelings were confusing for Anna, because while she had a hard time experiencing loving feelings toward her children, she also recognized that she was much more anxious about their safety now. “Having the accident made me realize that there really is danger all around us and that your life could be over any minute”. She reported worrying about her children when she was not with them. The most difficult time for Anna is when her children are being driven in a car. When asked how she feels when she is driving her children, she reported that she has not driven since the accident and is “terrified to get behind the wheel of a car”. She will ride as a passenger in the car if her husband is driving but she spends the entire time looking around to make sure no one is going to crash into them. She stated that her drive home from work every afternoon is particularly grueling because she refuses to allow her husband to drive on the highway where the accident occurred. As a result, it takes much longer to get home each day, which means more time on the road leading Anna to feel more anxious about being involved in another accident.

Anna believed that if she could just get more sleep at night that she would have more strength to “fight off the memories”. She described herself as a strong person with good values and is surprised that she hasn’t been able to just “get over this” like other people do. Her hope was to just get a few sleeping pills from her primary care physician, but he insisted she attend this appointment first.

1.2 Social/Family History

Anna is the oldest of three children and was raised primarily by her mother. Her parents separated when she was 6 years old and were divorced by the time she was 8 years old. She remembers her mother spending what seemed like weeks on the couch, unable to complete the most basic tasks. During these “sad spells”, Anna felt pressure step-up and take care of her younger sister and brother the best she could. She grew up with limited contact with her father, but could remember occasions where she would spend the weekend at his house. She remembered feeling scared and alone but was afraid to cry because her father would get very angry and tell her to “just suck it up”. Through her adolescence, she described feeling confused about how to deal with stressful situations because her mother seemed to dwell on things whereas her father seemed to never even think about it.

During her college years, Anna began to drink heavily. She recalled that the drinking was primarily with her friends and never significantly interfered with her daily functioning. By the end of college, she had cut down her drinking and today she only drinks occasionally. Since her car accident, Anna has not had any alcohol because she believes it will make her feel out of control just as the pain medication in the hospital did. She reported that she is trying so hard to keep her life in control right now that she has had no desire to take anything (alcohol or medication) that will lead to her feeling different.

Growing up Anna always had a number of friends and she enjoyed spending time with them. Her outgoing personality made it easy to make new friends. However, she reported that prior to the car accident she was feeling somewhat isolated as she was not able to spend time with her friends as much as she would like. “Between working and driving kids to and from activities, no one has time to get together”. She recognized that her busy life has played a role in her changing friendships, but expressed some sadness that she doesn’t feel as though she has many people she can confide in now after the accident.

Anna has been married to her husband for 13 years and described him as a “caring person and very good father”. She describes her husband as very concerned about her since the accident. He reportedly thinks she may be having psychological problems, which annoys her and makes it less likely that she confides in him. She reported some significant marital stress about 3 years ago but attributes that to the children being more demanding of their time and not having enough time for each other. They attended some marital therapy which she reported helped them learn to communicate better and find ways to reconnect. Anna denied ever receiving any other psychological services.

1.3 Multiple-Choice Questions