Academic journal article Indo - Pacific Journal of Phenomenology

From Panic Disorder to Complex Traumatic Stress Disorder: Retrospective Reflections on the Case of Tariq

Academic journal article Indo - Pacific Journal of Phenomenology

From Panic Disorder to Complex Traumatic Stress Disorder: Retrospective Reflections on the Case of Tariq

Article excerpt

Abstract

This is a phenomenological-hermeneutic case study of Tariq who initially presented with panic disorder. It documents how, as therapy proceeded, the underlying meaning of his initial panic deepened as its roots in traumatic memories of childhood emerged. There were four spaced phases of treatment over four years. The first focused on anxiety management; the second was conceptualized within schema-focused therapy, and evoked and worked with childhood memories using inner child guided imagery; in the third and fourth phases insights gained led to an authentic re-engagement with family members in relationships that had been problematic. The panic attacks resolved and there were two dreams representing a reconfiguring of his relationship with his deceased father. The first two phases were the focus of an unpublished case study presented at a conference in 1995. This article incorporates material from that study and looks back at the case both in light of developments in phases two and three and also in light of theoretical developments in our understanding of complex trauma since the initial presentation.

Tariq approached me for treatment of panic attacks in the early 1990s. This was about the time that Judith Herman's (1992) Trauma and Recovery was published, although I did not read it myself until ten years later. In this book, she proposed the concept of complex posttraumatic stress disorder and provided some provisional criteria. She also pointed out that many clients presenting with emotional instability in various forms have a history of trauma that has not been recognized. "All too often," she observed, "neither patient nor therapist recognize the connection between the presenting problem and the history of chronic trauma" (Herman, 1992, p. 123). This turned out to be the case with Tariq.

When anxiety management interventions had limited impact, the focus of Tariq's treatment shifted to a series of traumatic childhood incidents. The case was conceptualized in terms of Young's (1990) schemafocused therapy and the case was written up for a conference presentation (Edwards, 1995). This article describes Tariq's clinical presentation and treatment, based on the original case study, as well as further information, obtained when Tariq returned to therapy over a year later. It also offers an interpretative reflection. Since Herman's (1992) book was written, a wealth of accessible literature has appeared (for example, Courtois & Ford, 2009) on the way in which repeated trauma can give rise to a range of clinical presentations. Young's (1990) schema-focused therapy has also evolved considerably. The single publication (Young, 1990), which was into its third edition a few years later (Young, 1999), was precursor to dozens of books and articles on what is now called schema therapy (van Vreeswijk, Broersen, & Nadort, 2012; Young, Klosko, & Weishaar, 2002). This has become a significant treatment for complex trauma presentations including borderline personality disorder (Farrell, Shaw, & Reiss, 2012; Farrell, Shaw, & Webber, 2009; Giesen-Bloo et al., 2007).

Schema-focused case formulation and intervention

Early maladaptive schemas (EMSs) are structures of emotionally charged memories and associated cognitions that developed in childhood in situations where basic needs were not met. These are the source of everyday cognitive distortions and irrational or intense emotional responses. EMSs are early, in that they are often laid down in early childhood, and maladaptive since they give rise to problematic symptoms either directly or because of dysfunctional coping that develops to keep them out of awareness. In schema-focused cognitive therapy, EMSs are assessed and then activated and restructured using imagery and dialogue techniques such as those developed in Gestalt therapy. Their incorporation into cognitive therapy had already been described in the 1990s by Young (1990) and the present author (Edwards, 1989, 1990). …

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